Pheochromocytoma-induced cardiomyopathy is modulated by the synergistic effects of cell-secreted factors

Targeting Left Ventricular Mechanics In Patients With Pheochromocytoma/Paraganglioma: An Updated Meta-analysis

BACKGROUND

Numerous studies targeting left ventricular (LV) systolic function by measuring LV ejection fraction (LVEF) in patients with pheochromocytoma and paraganglioma (PPGL) either failed to reveal any impairment of this parameter or found a super-normal systolic function compared to essential hypertensives or normotensive controls. To provide an updated piece of information on LV systolic dysfunction in the PPGL setting, we performed a meta-analysis of speckle tracking echocardiography (STE) studies investigating LV mechanics via global longitudinal strain (GLS), a more sensitive index of LV systolic function than LVEF.

METHODS

A computerized search was performed using PubMed, OVID, EMBASE, and Cochrane library databases from inception until September 30, 2022. Full articles reporting data on LV GLS and LVEF in patients with PPGL and controls were considered suitable.

RESULTS

A total of 252 patients with PPGL and 187 controls were included in 6 studies. LV GLS was worse in the pooled PPGL group than in the control group (-17.3 ± 1.2 vs. -20.0 ± 0.6) with a standard means difference (SMD) of 1.13 ± 0.36 confidence interval (CI: 0.43-1.84, P = 0.002), whereas this was not the case for LVEF (67.3 ± 1.9 and 66.4 ± 1.6%, respectively), SMD: 0.12 ± 0.03, (CI: -0.41/0.65, P = 0.66). A meta-regression analysis in PPGL patients showed an inverse relationship between adrenergic activity and GLS (P < 0.0001).

CONCLUSIONS

Our findings suggest that early changes in LV systolic function not detectable by conventional echocardiography in the PPGL setting can be revealed by STE; therefore, STE implementation in the workup of patients with PPGL may improve the detection of subclinical systolic dysfunction.

A Comprehensive Outlook on Dilated Cardiomyopathy (DCM): State-Of-The-Art Developments with Special Emphasis on OMICS-Based Approaches

Dilated cardiomyopathy (DCM) remains an enigmatic cardiovascular disease (CVD) condition characterized by contractile dysfunction of the myocardium due to dilation of the ventricles. DCM is one of the major forms of CVD contributing to heart failure. Dilation of the left or both ventricles with systolic dysfunction, not explained by known causes, is a hallmark of DCM. Progression of DCM leads to heart failure. Genetic and various other factors greatly contribute to the development of DCM, but the etiology has still remained elusive in a large number of cases. A significant number of studies have been carried out to identify the genetic causes of DCM. These candidate-gene studies revealed that mutations in the genes of the fibrous, cytoskeletal, and sarcomeric proteins of cardiomyocytes result in the development of DCM. However, a significant proportion of DCM patients are idiopathic in nature. In this review, we holistically described the symptoms, causes (in adults and newborns), genetic basis, and mechanistic progression of DCM. Further, we also summarized the state-of-the-art diagnosis, available biomarkers, treatments, and ongoing clinical trials of potential drug regimens. DCM-mediated heart failure is on the rise worldwide including in India. The discovery of biomarkers with a better prognostic value is the need of the hour for better management of DCM-mediated heart failure patients. With the advent of next-generation omics-based technologies, it is now possible to probe systems-level alterations in DCM patients pertaining to the identification of novel proteomic and lipidomic biomarkers. Here, we also highlight the onset of a systems-level study in Indian DCM patients by applying state-of-the-art mass-spectrometry-based “clinical proteomics” and “clinical lipidomics”.

Evaluation of β-adrenergic ligands for development of pharmacological heart failure and transparency models in zebrafish

Cardiovascular toxicity represents one of the most common reasons for clinical trial failure. Consequently, early identification of novel cardioprotective strategies could prevent the later-stage drug-induced cardiac side effects. The use of zebrafish (Danio rerio) in preclinical studies has greatly increased. High-throughput and low-cost of assays make zebrafish model ideal for initial drug discovery. A common strategy to induce heart failure is a chronic β-adrenergic (βAR) stimulation. Herein, we set out to test a panel of βAR agonists to develop a pharmacological heart failure model in zebrafish. We assessed βAR agonists with respect to the elicited mortality, changes in heart rate, and morphological alterations in zebrafish larvae according to Fish Embryo Acute Toxicity Test. Among the tested βAR agonists, epinephrine elicited the most potent onset of heart stimulation (EC₅₀ = 0.05 mM), which corresponds with its physiological role as catecholamine. However, when used at ten-fold higher dose (0.5 mM), the same compound caused severe heart rate inhibition (-28.70 beats/min), which can be attributed to its cardiotoxicity. Further studies revealed that isoetharine abolished body pigmentation at the sublethal dose of 7.50 mM. Additionally, as a proof of concept that zebrafish can mimic human cardiac physiology, we tested βAR antagonists (propranolol, carvedilol, metoprolol, and labetalol) and verified that they inhibited fish heart rate in a similar fashion as in humans. In conclusion, we proposed two novel pharmacological models in zebrafish; i.e., epinephrine-dependent heart failure and isoetharine-dependent transparent zebrafish. We provided strong evidence that the zebrafish model constitutes a valuable tool for cardiovascular research.

Subclinical cardiac damage in cancer patients before chemotherapy

Cancer and cardiovascular diseases, including heart failure (HF), are the main causes of death in Western countries. Several anticancer drugs and radiotherapy have adverse effects on the cardiovascular system, promoting left ventricular dysfunction and ultimately HF. Nonetheless, the relationship between cancer and HF is likely not unidirectional. Indeed, cancer and HF share common risk factors, and both have a bidirectional relationship with systemic inflammation, metabolic disturbances, and neurohormonal and immune activation. Few studies have assessed the impact of untreated cancer on the heart. The presence of an active cancer has been associated with elevated cardiac biomarkers, an initial impairment of left ventricular structure and function, autonomic dysfunction, and reduced exercise tolerance. In turn, these conditions might increase the risk of cardiac damage from chemotherapy and radiotherapy. HF drugs such as beta-blockers or inhibitors of the renin–angiotensin–aldosterone system might exert a protective effect on the heart even before the start of cancer therapies. In this review, we recapitulate the evidence of cardiac involvement in cancer patients naïve from chemotherapy and radiotherapy and no history of cardiac disease. We also focus on the perspectives for an early diagnosis and treatment to prevent the progression to cardiac dysfunction and clinical HF, and the potential benefits of cardioactive drugs on cancer progression.

A case of pheochromocytoma presenting with cardiopulmonary arrest

A 33-year-old woman complained of sudden chest pain and intense headache. She was unconscious and underwent defibrillation for ventricular fibrillation in the ambulance. In the emergency room, she was placed on an artificial respirator. Diffuse wall hypokinesis and decreased left ventricular ejection fraction (31%) were identified on transthoracic echocardiography, and an intra-aortic balloon pump was inserted to address the cardiogenic shock. A mass was identified in the right adrenal gland on abdominal ultrasonography. Since a pheochromocytoma was suspected, doxazosin and carvedilol were administered. Blood and urinary norepinephrine and dopamine levels were elevated, confirming the pheochromocytoma diagnosis, and right adrenalectomy was performed 23 days after the initial hospitalization. After surgery, the left ventricular wall motion and left ventricular ejection fraction had improved to 62% on echocardiography. Blood and urinary norepinephrine and dopamine levels also decreased to within the normal range. This case highlights that the patient returned to normalcy and recovered to a transient myocardial disorder or malignant arrhythmia after cardiopulmonary arrest due to early diagnosis of and accurate treatment for pheochromocytoma. <Learning objective: Pheochromocytomas secrete excessive levels of catecholamines that may cause cardiac dysfunction, including fatal arrhythmias. It is necessary for the transient hypertension and fatal arrhythmia appearance to consider the possibility of pheochromocytoma. The decreased cardiac function may be reversible with resection of the tumor. Therefore, early diagnosis and treatment can be lifesaving in such cases. Pheochromocytomas provide an interesting model to evaluate the vulnerability of the myocardium to adrenergic stimulation, such as in cases of takotsubo cardiomyopathy or catecholamine-induced cardiomyopathy.>.

Extra-adrenal pheochromocytoma presenting as inverse takotsubo-pattern cardiomyopathy treated with surgical resection

Pheochromocytoma is a rare catecholamine-secreting tumour that is typically located in the adrenal medulla or along the sympathetic ganglia. The typical symptoms are episodic in nature and include tachycardia, sweating and headache. These tumours can present as transient, reversible cardiomyopathy similar to takotsubo cardiomyopathy (TCM). TCM is characterised by transient hypokinesis of the left ventricular apex and is typically induced by emotional stress. We describe the case of a 26-year-old woman with a medical history significant for headaches who presented initially to her family physician with nausea, vomiting, headache and hypertension. She was started on lisinopril 10 mg daily. One week later, she presented to the emergency department with substernal severe chest pressure. Her troponin level was elevated. Coronary angiogram showed normal coronary arteries and left ventriculogram showed inverse TCM pattern. Serum catecholamines were very elevated confirming pheochromocytoma. She was successfully treated with alpha-blockers followed by surgical resection.

Pheochromocytoma Crisis in the ICU: A French Multicenter Cohort Study With Emphasis on Rescue Extracorporeal Membrane Oxygenation

OBJECTIVES

To describe the characteristics, management, and outcome of patients admitted to ICUs for pheochromocytoma crisis.

DESIGN

A 16-year multicenter retrospective study.

SETTING

Fifteen university and nonuniversity ICUs in France.

PATIENTS

Patients admitted in ICU for pheochromocytoma crisis.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

We included 34 patients with a median age of 46 years (40-54 yr); 65% were males. At admission, the median Sequential Organ Failure Assessment score was 8 (4-12) and median Simplified Acute Physiology Score II 49.5 (27-70). The left ventricular ejection fraction was consistently decreased with a median value of 30% (15-40%). Mechanical ventilation was required in 23 patients, mainly because of congestive heart failure. Vasoactive drugs were used in 23 patients (68%) and renal replacement therapy in eight patients (24%). Extracorporeal membrane oxygenation was used as a rescue therapy in 14 patients (41%). Pheochromocytoma was diagnosed by CT in 33 of 34 patients. When assayed, urinary metanephrine and catecholamine levels were consistently elevated. Five patients underwent urgent surgery, including two during extracorporeal membrane oxygenation. Overall ICU mortality was 24% (8/34), and overall 90-day mortality was 27% (9/34). Crude 90-day mortality was not significantly different between patients managed with versus without extracorporeal membrane oxygenation (22% vs 30%) (p = 0.7) despite higher severity scores at admission in the extracorporeal membrane oxygenation group.

CONCLUSIONS

Mortality is high in pheochromocytoma crisis. Routinely considering this diagnosis and performing abdominal CT in patients with unexplained cardiogenic shock may allow an earlier diagnosis. Extracorporeal membrane oxygenation and adrenalectomy should be considered as a therapeutic in most severe cases.

Pheochromocytoma resection: Current concepts in anesthetic management

Pheochromocytoma represents very significant challenges to the anesthetist, especially when undiagnosed. These chromaffin tissue tumors are not uncommon in anesthetic practice and have varied manifestations. The perioperative management of these tumors has improved remarkably over the years, in conjunction with the evolution of surgical techniques (open laparotomy to laparoscopic techniques and now to robotic approaches in the present day). This review attempts to comprehensively address the intraoperative and postoperative issues in the management of these challenging tumors with an emphasis on hemodynamic monitoring and anesthetic technique.

Pathologic and Cardiovascular Characterization of Pheochromocytoma-Associated Cardiomyopathy in Dogs

Pheochromocytoma-associated catecholamine-induced cardiomyopathy is a well-known entity in man, nonhuman primates, and mice but has not been described in dogs. In this retrospective study, 9 dogs were identified with pheochromocytomas and concurrent cardiovascular pathology observed histologically ( n = 6), echocardiographically ( n = 4), and/or electrocardiographically ( n = 5). Cardiac lesions included multifocal cardiomyocyte necrosis with contraction bands, cardiomyocyte degeneration, myocardial hemorrhage, lymphohistiocytic myocarditis, and interstitial fibrosis. Clinical procedures, including electrocardiographic and echocardiographic examinations, Doppler blood pressure measurement, and auscultation, were available for 5 dogs and consistently revealed concentric or mixed (eccentric and concentric) ventricular hypertrophy. Additional changes observed included arrhythmias, systemic hypertension, and heart murmurs. The myocardial lesions observed in this series of dogs are similar to those observed in humans with pheochromocytoma-associated catecholamine-induced cardiomyopathy. Since the clinical manifestations of catecholamine-induced cardiac disease are amenable to medical treatment, recognition of this cardiomyopathy has the potential to reduce morbidity and mortality in dogs with pheochromocytoma.

Loss of syndecan-1 induces a pro-inflammatory phenotype in endothelial cells with a dysregulated response to atheroprotective flow

Fluid shear stresses are potent regulators of vascular homeostasis and powerful determinants of vascular disease progression. The glycocalyx is a layer of glycoaminoglycans, proteoglycans, and glycoproteins that lines the luminal surface of arteries. The glycocalyx interacts directly with hemodynamic forces from blood flow and, consequently, is a prime candidate for the mechanosensing of fluidic shear stresses. Here, we investigated the role of the glycocalyx component syndecan-1 (sdc-1) in controlling the shear stress-induced signaling and flow-mediated phenotypic modulation in endothelial cells. We found that knock-out of sdc-1 abolished several key early signaling events of endothelial cells in response to shear stress including the phosphorylation of Akt, the formation of a spatial gradient in paxillin phosphorylation, and the activation of RhoA. After exposure to atheroprotective flow, we found that sdc-1 knock-out endothelial cells had a phenotypic shift to an inflammatory/pro-atherosclerotic phenotype in contrast to the atheroprotective phenotype of wild type cells. Consistent with these findings, we found increased leukocyte adhesion to sdc-1 knock-out endothelial cells in vitro that was reduced by re-expression of sdc-1. In vivo, we found increased leukocyte recruitment and vascular permeability/inflammation in sdc-1 knock-out mice. Taken together, our studies support a key role for sdc-1 in endothelial mechanosensing and regulation of endothelial phenotype.

Pheochromocytoma presenting as acute decompensated heart failure reversed with medical therapy

A 26-year-old woman presented to hospital with acute chest pain, hypertension, tachycardia and an elevated serum creatinine. She developed respiratory distress requiring endotracheal intubation and mechanical ventilation. She progressed to multiorgan failure due to decompensated congestive heart failure. Echocardiography demonstrated global hypokinesis and an ejection fraction of <10%. Her cardiac function improved with fluid resuscitation and β blockade, and she was eventually discharged home. She was readmitted a few days later with pancreatitis after presenting with nausea, abdominal pain and hypertension. During hospitalisation she had paroxysms of headache, nausea and diaphoresis associated with hypertension and tachycardia. A CT scan of her abdomen revealed an adrenal mass and serum metanephrine studies confirmed the diagnosis of pheochromocytoma. After fluid resuscitation and sympathetic blockade her ejection fraction improved to 55%. The patient underwent an uneventful adrenalectomy and made a complete recovery.

Adrenergic signaling polymorphisms and their impact on cardiovascular disease

This review examines the impact of recent discoveries defining personal genetics of adrenergic signaling polymorphisms on scientific discovery and medical practice related to cardiovascular diseases. The adrenergic system is the major regulator of minute-by-minute cardiovascular function. Inhibition of adrenergic signaling with pharmacological beta-adrenergic receptor antagonists (beta-blockers) is first-line therapy for heart failure and hypertension. Advances in pharmacology, molecular biology, and genetics of adrenergic signaling pathways have brought us to the point where personal genetic differences in adrenergic signaling factors are being assessed as determinants of risk or progression of cardiovascular disease. For a few polymorphisms, functional data generated in cell-based systems, genetic mouse models, and pharmacological provocation of human subjects are concordant with population studies that suggest altered risk of cardiovascular disease or therapeutic response to beta-blockers. For the majority of adrenergic pathway polymorphisms however, published data conflict, and the clinical relevance of individual genotyping remains uncertain. Here, the current state of laboratory and clinical evidence that adrenergic pathway polymorphisms can affect cardiovascular pathophysiology is comprehensively reviewed and compared, with a goal of placing these data in the broad context of potential clinical applicability.

Pheochromocytoma and paraganglioma

Pheochromocytoma is a very special kind of tumor full of duplicity. On the one hand it represents its own microworld with unique clinical, biochemical and pathological features, while on the other it constitutes a tremendously significant part of whole body system, playing a vital role for practically every organ system. It has a very special character - sometimes like a child it can be sweet and predictable, while at times it can behave like a deadly wild beast, crashing and tearing everything on its path in a fierce rage. It also consists of the amazingly intelligent neuroendocrine cells that possess a magical ability to make miraculous substances of many kinds. But most of all, it is a system that is able to drive our curiosity and the itch of "Cogito, ergo sum" to limitless depths and year by year it still amazes us with new and unexpected discoveries that move our understanding of multiple pathways and metabolic events closer to the ultimate truth. Recent discoveries of succinate dehydrogenase (SHD) and prolyl hydroxylase (PHD) mutations, for example, propelled our understanding of neuroendocrine tumorigenesis as a whole, as well as physiology of mitochondrial respiratory chain and phenomenon of pseudohypoxia in particular. Good old discoveries make their way from dusty repositories to shine with new meaning, appropriate for the current level of knowledge. This acquired wisdom makes us better physicians - knowing the specific expression makeup of catecholamine transporters, GLUTs and SRIFs allows for better tailored imaging and therapeutic manipulations. There are still long ways to go, keeping in mind that pheochromocytoma is but so very special, and we are optimistic and expect many great things to come.