Extracorporeal membrane oxygenation for pheochromocytoma-induced cardiogenic shock

Mechanical Circulatory Support Strategies in Takotsubo Syndrome with Cardiogenic Shock: A Systematic Review

BACKGROUND

Takotsubo syndrome is, by definition, a reversible form of acute heart failure. If cardiac output is severely reduced, Takotsubo syndrome can cause cardiogenic shock, and mechanical circulatory support can serve as a bridge to recovery. To date, there are no recommendations on when to use mechanical circulatory support and on which device is particularly effective in this context. Our aim was to determine the best treatment strategy.

METHODS

A systematic literature research and analysis of individual patient data was performed in MEDLINE/PubMed according to PRISMA guidelines. Our research considered original works published until 31 July 2023.

RESULTS

A total of 93 publications that met the inclusion criteria were identified, providing individual data from 124 patients. Of these, 62 (50%) were treated with veno-arterial extracorporeal life support (va-ECLS), and 44 (35.5%) received a microaxial left ventricular assist device (Impella). Eighteen patients received an Impella CP and twenty-one an Impella 2.5. An intra-aortic balloon pump (IABP) without other devices was used in only 13 patients (10.5%), while other devices (BiVAD or Tandem Heart) were used in 5 patients (4%). The median initial left ventricular ejection fraction was 20%, with no difference between the four device groups except for the IABP group, which was less affected by cardiac output failure (p = 0.015). The overall survival was 86.3%. Compared to the other groups, the time to cardiac recovery was shorter with Impella (p < 0.001).

CONCLUSIONS

Though the Impella treatment is new, our analysis may show a significant benefit of Impella compared to other MCS strategies for cardiogenic shock in Takotsubo syndrome.

Catecholamine-induced hypertensive crises: current insights and management

Phaeochromocytomas and paragangliomas (PPGLs) release catecholamines leading to catecholamine-induced hypertensive (CIH) crises, with blood pressure greater than or equal to 180/120 mm Hg. CIH crises can be complicated by tachyarrhythmias, hypotension, or life-threatening target organ damage while treatment remains undefined, often requiring co-management between endocrinologists and cardiologists. Furthermore, biochemical diagnosis of a PPGL as a cause of a CIH crisis can be difficult to identify or confounded by comorbid conditions, potentially resulting in misdiagnosis. Here, we combine relevant evidence, 60 years of collective clinical experience, insights derived from assessing over 2600 patients with PPGL, and supplementary outcomes from 100 patients (treated at the National Institutes of Health) with a CIH crisis to inform diagnosis and treatment of CIH crises. Recognising that disparities exist between availability, cost, and familiarity of various agents, flexible approaches are delineated allowing for customisation, given institutional availability and provider preference. A CIH crisis and its complications are readily treatable with available drugs, with effective intervention defining an avenue for mitigating consequent morbidity and mortality in patients with PPGL.

Pheochromocytoma-induced cardiogenic shock: A multicentre analysis of clinical profiles, management and outcomes

OBJECTIVE

There is still uncertainty about the management of patients with pheochromocytoma-induced cardiogenic shock (PICS). This study aims to investigate the clinical presentation, management, and outcome of patients with PICS.

METHODS

We collected, retrospectively, the data of 18 patients without previously known pheochromocytoma admitted to 8 European hospitals with a diagnosis of PICS.

RESULTS

Among the 18 patients with a median age of 50 years (Q1-Q3: 40-61), 50% were men. The main clinical features at presentation were pulmonary congestion (83%) and cyclic fluctuation of hypertension peaks and hypotension (72%). Echocardiography showed a median left ventricular ejection fraction (LVEF) of 25% (Q1-Q3: 15-33.5) with an atypical- Takotsubo (TTS) pattern in 50%. Inotropes/vasopressors were started in all patients and temporary mechanical circulatory support (t-MCS) was required in 11 (61%) patients. All patients underwent surgical removal of the pheochromocytoma; 4 patients (22%) were operated on while under t-MCS. The median LVEF was estimated at 55% at discharge. Only one patient required heart transplantation (5.5%), and all patients were alive at a median follow-up of 679 days.

CONCLUSIONS

PICS should be suspected in case of a CS with severe cyclic blood pressure fluctuation and rapid hemodynamic deterioration, associated with increased inflammatory markers or in case of TTS progressing to CS, particularly if an atypical TTS echocardiographic pattern is revealed. T-MCS should be considered in the most severe cases. The main challenge is to stabilize the patient, with medical therapy or with t-MCS, since it remains a reversible cause of CS with a low mortality rate.

Pheochromocytoma Crisis Rescued by Veno-Arterial Extracorporeal Membrane Oxygenation and Continuous Renal Replacement Therapy

Pheochromocytoma is a rare catecholamine producing adrenal tumor. Pheochromocytoma crisis is a life-threatening condition inducing multiple organ failure and hemodynamic instability caused by too much catecholamines produced from pheochromocytoma. We report a 59-year-old woman with pheochromocytoma crisis rescued by veno-arterial extracorporeal membrane oxygenation (VA-ECMO), continuous renal replacement therapy (CRRT), and interval tumor resection. In June 2020, the patient was taken to our institution complaining of headache and left lower back pain. The patient developed cardiopulmonary arrest while at the emergency department. After extracorporeal cardiopulmonary resuscitation, the patient required VA-ECMO for hemodynamic support, and subsequently CRRT for catecholamine removal and acute kidney injury. After 1 month of hemodynamic management, the patient underwent left adrenalectomy. The postoperative course was uneventful and she was discharged on postoperative day 23. CRRT would be a safe and feasible option for catecholamine control in patients with acute kidney injury in pheochromocytoma crisis.

The importance of perioperative and complication management in the treatment of pheochromocytoma crisis with venoarterial extracorporeal membrane oxygenation (V-A ECMO): a case report and review of the literature

PURPOSE

In this article, we aimed to elaborate on perioperative and complication management in treatment of pheochromocytoma crisis with extracorporeal membrane oxygenation (ECMO).

MATERIAL AND METHODS

We report a case of relatively rare grant paraganglioma-induced pheochromocytoma crisis leading to severe circulatory failure, treated with venoarterial extracorporeal membrane oxygenation (V-A ECMO) as a bridge to curative adrenalectomy. Weaning of ECMO was followed by successful surgical removal of the tumor, and patient survival. However, distal ischemia of the cannulated leg occurred during ECMO operation, which eventually led to amputation. In addition, the patient developed new cerebral infarction and left hemiplegia, half a month after paraganglioma resection.

CONCLUSIONS

We believe that patients with pheochromocytoma crisis, who cannot maintain blood circulation, are eligible for V-A ECMO treatment. Moreover, care should be taken to prevent thrombosis and individualized and precise blood pressure management targets. Early detection and treatment of thrombosis is imperative to long-term prognosis of patients with ECMO.

The ABCDE approach to difficult weaning from venoarterial extracorporeal membrane oxygenation

Venoarterial extracorporeal membrane oxygenation (VA ECMO) has been increasingly applied in patients with cardiogenic shock in recent years. Nevertheless, many patients cannot be successfully weaned from VA ECMO support and 1-year mortality remains high. A systematic approach could help to optimize clinical management in favor of weaning by identifying important factors in individual patients. Here, we provide an overview of pivotal factors that potentially prevent successful weaning of VA ECMO. We present this through a rigorous approach following the relatable acronym ABCDE, in order to facilitate widespread use in daily practice.

Cardiogenic shock among cancer patients

Sophisticated cancer treatments, cardiovascular risk factors, and aging trigger acute cardiovascular diseases in an increasing number of cancer patients. Among acute cardiovascular diseases, cancer treatment, as well as the cancer disease itself, may induce a cardiogenic shock. Although increasing, these cardiogenic shocks are still relatively limited, and their management is a matter of debate in cancer patients. Etiologies that cause cardiogenic shock are slightly different from those of non-cancer patients, and management has some specific features always requiring a multidisciplinary approach. Recent guidelines and extensive data from the scientific literature can provide useful guidance for the management of these critical patients. Even if no etiologic therapy is available, maximal intensive supportive measures can often be justified, as most of these cardiogenic shocks are potentially reversible. In this review, we address the major etiologies that can lead to cardiogenic shock in cancer patients and discuss issues related to its management.

Paraganglioma-induced inverted takotsubo-like cardiomyopathy leading to cardiogenic shock successfully treated with extracorporeal membrane oxygenation

Paragangliomas are rare neuroendocrine tumors that originate in the chromaffin cells of the adrenal medulla or lymph nodes. Paragangliomas manifest in rare cases as catecholamine crisis, leading to heart failure, intracranial hemorrhage, renal failure, arrhythmias, pulmonary edema, or multisystem failure. Takotsubo cardiomyopathy is also called apical ballooning syndrome or stress cardiomyopathy. Left ventricular dysfunction with apical hyperkinesis and basilar and midventricular akinesis in the absence of coronary artery disease is highly suggestive of a variant of stress cardiomyopathy (inverted takotsubo cardiomyopathy). Herein, we report the case of a 69-year-old man with an unknown retroperitoneal paraganglioma who suffered from cardiogenic shock due to inverted takotsubo cardiomyopathy. He was treated with venoarterial extracorporeal membrane pulmonary oxygenation (ECMO) in combination with an intra-aortic balloon pump. After the restoration of cardiac function, a successful transition to curative retroperitoneal paraganglioma resection was performed. We conclude that ECMO is a valuable option for undiagnosed endocrine emergencies, helping to restore cardiac function and allowing sufficient time for further accurate diagnosis and specific treatment.

Case Report: Early Resection of Pheochromocytoma in a Patient With Cardiogenic Shock Due to Pheochromocytoma-Induced Cardiomyopathy With Extracorporeal Life Support

Background

Pheochromocytoma-induced cardiomyopathy is a rare but potentially life-threatening complication of pheochromocytoma. It mimics the patterns of stress-induced cardiomyopathy. In severe cases, patients can develop refractory cardiogenic shock, which might require mechanical circulatory support.

Case Presentation

We presented a case of 54-year-old female who developed refractory cardiogenic shock, following an elective orthopaedic surgery complicated by cardiac arrest, requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. After urgent coronary catheterisation revealed normal coronary arteries, further evaluation of the aetiology of cardiogenic shock revealed pheochromocytoma. With a diagnosis of pheochromocytoma-induced cardiomyopathy, the patient had accelerated preoperative alpha adrenergic blockade preparation for a total of 6 days and subsequently had the tumour removed under VA-ECMO support. Postoperatively, the patient recovered well and was off ECMO support and extubated a few days later.

The optimal management of pheochromocytoma-induced cardiomyopathy, especially for severe cases, is still unclear. Indeed, some cases will require mechanical circulatory support to allow left ventricular function recovery. But our case also showed that it was possible to introduce alpha blockade safely whilst the patient is on VA-ECMO and has the pheochromocytoma removed with VA-ECMO support after accelerated preoperative preparation.

Successful Management of Pheochromocytoma Crisis with Cardiogenic Shock by Percutaneous Left Ventricular Assist Device

Therapeutic strategy utilizing mechanical circulatory supports in patients with pheochromocytoma-related cardiogenic shock remains unestablished. We had a 51-year-old man with acute decompensated heart failure due to pheochromocytoma crisis. He received a percutaneous left ventricular assist device-supported alpha-blocker and intensive fluid infusion therapy, which ameliorated impaired end-organ dysfunction, maintaining hemodynamics and achieving cardiac recovery, followed by the successfully scheduled adrenalectomy. Early suspicion of pheochromocytoma and Impella-supported disease-specific medical management might be a promising bridge to surgery strategy.

Pheochromocytoma Crisis Presenting With ARDS Successfully Treated With ECMO-Assisted Adrenalectomy

Objective

Pheochromocytoma (PCC) crisis caused by acute catecholamine release from an adrenal PCC or extra-adrenal paraganglioma can be difficult to diagnose and may require an unconventional management strategy to achieve good outcomes. We describe a case of PCC crisis presenting with acute respiratory distress syndrome (ARDS) that resolved with stabilization on veno-venous (VV) extracorporeal membrane oxygenation (ECMO) during adrenalectomy.

Case Description

A 30-year-old man with a history of severe alcohol use disorder and a prior hospital admission for alcohol withdrawal syndrome presented with sudden-onset hemoptysis, altered mental status, and severe dyspnea that rapidly deteriorated to ARDS requiring ECMO support. He demonstrated hemodynamic collapse after cannulation for VV-ECMO and stabilized after conversion to veno-arterial-ECMO, but ARDS persisted and he developed acute renal failure. Computed tomography without contrast done as part of work-up for a presumed infection revealed a 6.9 × 6.4 cm right adrenal mass suspicious for pheochromocytoma. Plasma and random urine metanephrine levels were markedly elevated. ARDS persisted despite α- and β-adrenoreceptor blockade, and he underwent laparoscopic right adrenalectomy with VV-ECMO support. Pathology confirmed PCC with intermediate risk for malignancy. Postoperatively, he was weaned off respiratory and renal support within 10 days, showed rapid clinical improvement, and was discharged 1 month later.

Conclusion

This case highlights diagnostic and management challenges associated with patients with PCC crisis presenting with ARDS. A multidisciplinary team approach is critical to identifying appropriate treatment strategies.

Extracorporeal life support for phaeochromocytoma-induced cardiogenic shock: a systematic review

INTRODUCTION

Phaeochromocytoma is a catecholamine-secreting tumour associated with clinical presentation ranging from paroxysmal hypertension to intractable cardiogenic shock. Extracorporeal life support, in veno-arterial mode, application in refractory acute heart dysfunction is sharply increasing worldwide. However, its clinical utility in phaeochromocytoma-induced cardiogenic shock remains still unclear.

METHODS

A systematic review of published reports was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Statement. Searches were accomplished on PubMed, Embase and Google Scholar to identify articles describing the use of extracorporeal life support in the setting of phaeochromocytoma-induced cardiogenic shock (PROSPERO: CRD42019125225).

RESULTS

Thirty-five reports, including 62 patients supported with extracorporeal life support because of intractable phaeochromocytoma crisis, were included for the analysis. Almost all the subjects underwent peripheral cannulation for extracorporeal life support. The median duration of the mechanical circulatory support was 5 days, and most of the patients recovered normal myocardial function (left ventricular ejection fraction ⩾50%). In-hospital survival was 87%. Phaeochromocytoma was removed surgically during extracorporeal life support in 10 patients (16%), while in the remaining after haemodynamic stabilization and weaning from the mechanical support.

CONCLUSION

Successful management of phaeochromocytoma-induced cardiogenic shock depends on prompt recognition and immediate treatment of shock. In this scenario, extracorporeal life support may play a significant role allowing cardiac and end-organ recovery and giving time for accurate diagnosis and specific treatment.

Life-Saving Emergency Adrenalectomy in a Pheochromocytoma Crisis with Cardiogenic Shock

Cardiogenic shock during a pheochromocytoma crisis is a life-threatening disorder. This case report illustrates a 49-year-old male with profound cardiogenic shock, extreme hemodynamic instability (systolic blood pressure ranging from 45 up to 290 mmHg in a cyclic pattern), and progressive multiple organ failure in the presence of a unilateral adrenal mass. Emergency adrenalectomy led to rapid hemodynamic stabilization. Histological investigation confirmed the diagnosis of pheochromocytoma. This case indicates that emergency adrenalectomy, although usually not considered first choice, is a valid option in cardiogenic shock and extremely fluctuating hemodynamics due to a pheochromcytoma-induced catecholamine storm.

Fast myocardial recovery ensured by the combined use of V-A ECMO and IMPELLA CP in cardiogenic shock related to a pheochromocytoma crisis

BACKGROUND

Pheochromocytoma is a rare catecholamine-secreting tumor derived from chromaffin cells in the adrenal glands. An excessive stimulation of cardiac myocytes, when pheochromocytoma 'crisis' occurs, lead to myocardial damage with cardiogenic shock.

AIM OF THE STUDY

We present the case of a A 28-year old female patient admitted with signs of severe cardiogenic shock. She was successfully supported with extracorporeal membrane oxygenation (ECMO) combined with IMPELLA CP heart pump (Abiomed Danvers, MA), for left ventricular unloading. Mechanical circulatory support (MCS) was used to favour myocardial recovery and avoid cardiac remodeling.

RESULTS

A very fast recovery was observed. The ECMO was discontinued after four days. The IMPELLA-CP was safely removed after six days. A completely myocardial recovery was observed.

CONCLUSIONS

Use of MCS might find an indication in case of PCC as a bridge to myocardial recovery.

Temporary circulatory support for cardiogenic shock

Cardiogenic shock can occur due to acute ischaemic or non-ischaemic cardiac events, or from progression of long-standing underlying heart disease. When addressing the cause of underlying disease, the management of cardiogenic shock consists of vasopressors and inotropes; however, these agents can increase myocardial oxygen consumption, impair tissue perfusion, and are frequently ineffective. An alternative approach is to temporarily augment cardiac output using mechanical devices. The use of these devices-known as temporary circulatory support systems-has increased substantially in recent years, despite being expensive, resource intensive, associated with major complications, and lacking high-quality evidence to support their use. This Review summarises the physiological basis underlying the use of temporary circulatory support for cardiogenic shock, reviews the evidence informing indications and contraindications, addresses ethical considerations, and highlights the need for further research.

Mechanical circulatory support for Takotsubo syndrome: a systematic review and meta-analysis

BACKGROUND

Cardiogenic shock occurs in 10%-15% of patients with Takotsubo syndrome (TS). For several reasons catecholamines, and especially inotropes, should be avoided in TS. Temporary mechanical circulatory support (MCS) appears attractive as bridge-to-recovery, but prospective studies are lacking. Here we analyze the available literature on MCS use in patients with TS.

METHODS AND RESULTS

PubMed/Medline was systematically screened until December 2019. 18 studies reporting pooled data of 5629 TS patients, of whom 227 had received MCS, were considered for a qualitative synthesis. 81 articles from 2003 through 2019 reporting individual data of 93 MCS cases were included in a meta-analysis. Median age was 57 (IQR: 43-68) years, 83.9% were women, and a physical trigger could be identified in 74.1% of cases. Median left ventricular ejection fraction (LVEF) before MCS was 20% (IQR: 15-25) and comparable between groups defined by MCS device. An apical TS type was present in 76.1% of cases. The overall number of publications on MCS for TS increased over time, as did those using veno-arterial extracorporeal membrane oxygenation (V-A ECMO) and Impella, while those using intra-aortic balloon pump declined. MCS-related complications were not regularly reported. Median time on MCS was 3 (IQR: 2-7) days, with an overall survival of 94.6%.

CONCLUSIONS

MCS for TS-related shock is increasingly reported, with a growing use of V-A ECMO and Impella. Currently available clinical data support this approach. Prospective studies are needed to evaluate safety and efficacy of different devices as well as timing of MCS in this special patient population.

Cardiogenic shock in cancer

Cardiogenic shock (CS) is increasingly recognized in patients with malignancies, while cancer is independently associated with worse prognosis in CS. A number of conditions may lead to CS in cancer, including acute coronary syndromes, cardiomyopathy, takotsubo syndrome, myocarditis, pulmonary embolism, tamponade, and cardiac herniation. In these conditions, CS may be related to cancer itself or to cancer therapy, including surgery, chemotherapy, or radiotherapy. Given the significantly improved overall survival of patients with malignancies, the early recognition and proper management of CS in cancer become increasingly important. In the present paper, we review the available evidence on CS in patients with malignancies and highlight issues related to its management.

Inverted takotsubo syndrome complicated with cardiogenic shock requiring veno-arterial extracorporeal membrane oxygenation in a patient with bilateral pheochromocytoma: a case report

Background

Takotsubo syndrome (TS) is characterized by a transient left ventricular (LV) dysfunction and rarely presents with cardiogenic shock (CS). Inverted TS (ITS) is a rare entity associated with the presence of a pheochromocytoma.

Case summary

We present a case of a young woman was admitted to the emergency department due to intense headache, chest discomfort, palpitations, and breathlessness. An ITS secondary to a pheochromocytoma crisis presenting with CS was diagnosed. The patient was managed with veno-arterial extracorporeal membrane oxygenation, until recovery of LV function. On the 35th day of hospitalization, open bilateral adrenalectomy was performed.

Discussion

Takotsubo syndrome patients presenting with CS are challenging and clinicians should be aware of underlying causes. Specific triggers such as pheochromocytoma should systematically be considered particularly if ITS was presented. Extracorporeal life support devices could provide temporary mechanical circulatory support in patients with TS on refractory CS and help to manage complex cases with TS due to pheochromocytoma.

Clinical features, complications, and outcomes of exogenous and endogenous catecholamine-triggered Takotsubo syndrome: A systematic review and meta-analysis of 156 published cases

Innumerable physical stress factors including externally administered catecholamines, and pheochromocytomas and paragangliomas (PPGLs) have been reported to trigger Takotsubo syndrome (TS). A systematic search of PubMed/MEDLINE identified 156 patients with catecholamine‐induced TS up to December 2017. Data were compared within the catecholamine‐induced TS cohort, but some comparisons were also done to a previously published large all‐TS cohort (n = 1750). The mean age was 46.4 ± 16.4 years (72.3% women). The clinical presentation was dramatic with high complication rates in (68.2%, n = 103; multiple complications 34.6%, n = 54). The most common TS ballooning pattern was apical or mid‐apical (45.2%, n = 69), followed by basal pattern (28.8%, n = 45), global pattern (16.0%, n = 25), mid‐ventricular (8.3%, n = 13), focal (0.6%, n = 1), and unidentified pattern (1.9%, n = 3). There was an increase in the prevalence of apical sparing ballooning pattern compared to all‐TS population (37.7% vs 18.3%, P < .00001). Higher complication rates were observed in TS with global ballooning pattern compared to apical ballooning pattern (23/25, 92% vs 38/65, 58.5%; P = .0022). Higher complication rates were observed in patients with age < 50 years than patients >50 years (73/92, 79.3% vs 29/56, 51.8%, P = 0.0009). Recurrence occurred exclusively in patients with PPGL‐induced TS (18/107 patients, 16.8%). PPGL‐induced TS was characterized by more global ballooning's pattern (22/104, 21.2% vs 3/49, 6.1%, P = 0.02), and lower left ventricular ejection fraction (25.54 ± 11.3 vs 31.82 ± 9.93, P = 0.0072) compared to exogenous catecholamine‐induced TS. In conclusion, catecholamine‐induced TS was characterized by a dramatic clinical presentation with extensive left ventricular dysfunction, and high complication rate.

Mechanical thrombectomy in acute ischemic stroke patients under venoarterial extracorporeal membrane oxygenation

BACKGROUND

Use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in adult patients to treat refractory cardiogenic shock has increased in recent years, and ischemic stroke is the most frequent VA-ECMO-induced cerebrovascular complication. No adult case of mechanical thrombectomy (MT) has been reported.

METHODS

Retrospective observational study of hospital medical records of patients who received circulatory support with VA-ECMO with acute ischemic stroke treated with MT, from 2006 to 2018.

RESULTS

Two adult patients on VA-ECMO with acute ischemic stroke treated with MT were found. Both cases were successfully treated.

CONCLUSION

These cases illustrate the feasibility of performing MT in adult patients on ECMO.

Adrenergic Downregulation in Critical Care: Molecular Mechanisms and Therapeutic Evidence

Catecholamines remain the mainstay of therapy for acute cardiovascular dysfunction. However, adrenergic receptors quickly undergo desensitization and downregulation after prolonged stimulation. Moreover, prolonged exposure to high circulating catecholamines levels is associated with several adverse effects on different organ systems. Unfortunately, in critically ill patients, adrenergic downregulation translates into progressive reduction of cardiovascular response to exogenous catecholamine administration, leading to refractory shock. Accordingly, there has been a growing interest in recent years toward use of noncatecholaminergic inotropes and vasopressors. Several studies investigating a wide variety of catecholamine-sparing strategies (eg, levosimendan, vasopressin, β-blockers, steroids, and use of mechanical circulatory support) have been published recently. Use of these agents was associated with improvement in hemodynamics and decreased catecholamine use but without a clear beneficial effect on major clinical outcomes. Accordingly, additional research is needed to define the optimal management of catecholamine-resistant shock.

A case of catecholamine-induced cardiomyopathy treated with extracorporeal membrane oxygenation

A 55-year-old female patient was presented with severe dyspnea due to sudden onset of heart failure (ejection fraction (EF) <10%). Echocardiogram showed a takotsubo pattern with an akinetic apical segment. Coronary angiography did not reveal any obstructive disease. She became hypotensive which was refractory to conventional pressor agents. Catecholamine-induced cardiomyopathy was suspected after the CT scan of the abdomen showed a 4 cm necrotic right adrenal mass consistent with pheochromocytoma (PHEO). Venous arterial extracorporeal membrane oxygenation and α blockers were initiated. There was a rapid improvement in cardiac function with EF normalising in 1 week. Subsequently, β-blockers were added and right adrenalectomy was done 3 weeks after the admission. She did extremely well after surgery with her blood pressure normalising without the need for antihypertensive therapy. Genetic evaluation revealed no pathogenic mutations implicated in the development of PHEO.

Catecholamine-Induced Cardiomyopathy in Pheochromocytoma: How to Manage a Rare Complication in a Rare Disease?

Pheochromocytomas and paragangliomas (PHEOs) are rare neuroendocrine tumors. Clinical manifestations include different cardiovascular signs and symptoms, which are related to excessive secretion of catecholamines. Catecholamine-induced cardiomyopathy in PHEO (CICMPP) is a rare but dreaded complication of PHEO. Once patient is diagnosed with this condition, the prognosis is worse and a surgical risk is much higher than expected. This article focuses on how catecholamines affect the heart and the pathophysiologic mechanism of CICMPP. The cardiovascular responses to catecholamine depend mostly on which catecholamine is released as well as the amount of catecholamine that is released. The acute release of norepinephrine and epinephrine from PHEO increases heart rate, systemic vascular resistance, myocardial contractility, and reduces venous compliance. The excessive adrenergic stimulation by catecholamine results in severe vasoconstriction and coronary vasospasm, myocardial ischemia, and subsequently damage, and necrosis. Chronically elevated catecholamine levels lead to significant desensitization of cardiac β-adrenoceptors. The increased levels of the enzyme β-adrenoceptors kinase (βARK) in the heart seems to mediate these biochemical and physiological changes that are consistently correlated with attenuated responsiveness to catecholamine stimulation. Through these mechanisms different types of cardiomyopathy (CMP) can be formed. This review discusses extensively the 3 types of cardiomyopathies that can be present in a PHEO patient. It also provides the clinical presentation and diagnostic and therapeutic algorithm in managing patients with CICMPP.

Mechanical circulatory devices in acute heart failure

PURPOSE OF REVIEW

Temporary circulatory support (TCS) with short-term mechanical circulatory support (MCS) devices is increasingly used as a salvage therapy for patients with refractory cardiogenic shock. This article provides an overview of current devices, their indications and management, and discusses results of recent case series and trials.

RECENT FINDINGS

Percutaneous active MCS devices (Impella, TandemHeart…) and venoarterial extracorporeal membrane oxygenation (VA-ECMO) are utilized as a bridge to 'decision' that includes weaning after cardiac function recovery, transplantation, long-term MCS and withdrawal in case of futility. VA-ECMO is considered the first-line TCS since it allows rapid improvement in oxygenation, is less expensive, and is also suitable for patients with biventricular failure. Combining Impella or intra-aortic balloon pump support with ECMO might decrease left ventricular pressure and improve outcomes. Sepsis-associated cardiomyopathy, massive pulmonary embolism, arrhythmic storm and Takotsubo-like cardiomyopathy are among emerging indications for TCS.

SUMMARY

TCS have become the cornerstone of the management of patients with cardiogenic shock, although the evidence supporting their efficacy is limited. VA-ECMO is considered the first-line option, with a growing number of accepted and emerging indications. Randomized clinical trials are now needed to determine the respective place of different MCS devices in cardiogenic shock treatment strategies.

Paraganglioma presenting as stress cardiomyopathy: case report and literature review

Pheochromocytoma/paraganglioma (PPGL) are neuroendocrine tumors that can secrete catecholamines. The authors describe a challenging case who presented as stress cardiomyopathy and myocardial infarction (MI). A 76-year-old man, with a medical history of Parkinson's disease, type 2 diabetes mellitus, hypertension, dyslipidaemia and a previous inferior MI in 2001, presented to the emergency department due to chest pain, headaches and vomiting. He also reported worsening blood glucose levels and increasing constipation over the preceding weeks. BP was 185/89 mmHg (no other relevant findings). EKG had ST segment depression in leads V2-V6, T troponin was 600 ng/L (<14) and the echocardiogram showed left ventricular hypokinesia with mildly compromised systolic function. Nevertheless, he rapidly progressed to severe biventricular dysfunction. Coronary angiogram showed a 90% anterior descendent coronary artery occlusion (already present in 2001), which was treated with angioplasty/stenting. In the following days, a very labile BP profile and unexplained sinus tachycardia episodes were observed. Because of sustained severe constipation, the patient underwent an abdominal CT that revealed a retroperitoneal, heterogeneous, hypervascular mass on the right (62 × 35 mm), most likely a paraganglioma. Urinary metanephrines were increased several fold. 68Ga-DOTANOC PET-CT scan showed increased uptake in the abdominal mass (no evidence of disease elsewhere). He was started on a calcium-channel blocker and alpha blockade and underwent surgery with no major complications. Eight months after surgery, the patient has no evidence of disease. Genetic testing was negative for known germline mutations. This was a challenging diagnosis, but it was essential for adequate cardiovascular stabilization and to reduce further morbidity. Learning points: PPGL frequently produces catecholamines and can manifest with several cardiovascular syndromes, including stress cardiomyopathy and myocardial infarction. Even in the presence of coronary artery disease (CAD), PPGL should be suspected if signs or symptoms attributed to catecholamine excess are present (in this case, high blood pressure, worsening hyperglycaemia and constipation). Establishing the correct diagnosis is important for adequate treatment choice. Inodilators and mechanical support might be preferable options (if available) for cardiovascular stabilization prior to alpha blockade and surgery. Laboratory interference should be suspected irrespective of metanephrine levels, especially in the context of treated Parkinson's disease.

Extracorporeal membrane oxygenation in pheochromocytoma-induced cardiogenic shock

Extracorporeal membrane oxygenation has been extensively used for cardiopulmonary support in cardiogenic shock. However, its clinical value in the management of pheochromocytoma crisis remains unclear. We report a rare case of life-threatening cardiogenic shock managed with peripheral venoarterial extracorporeal membrane oxygenation combined with endovascular left ventricular venting, in a 40-year-old female patient, in the setting of unknown adrenal pheochromocytoma. We highlight the life-saving role of extracorporeal membrane oxygenation in undiagnosed endocrine emergencies, allowing cardiac and end-organ recovery, and giving time for accurate diagnosis and specific treatment in such unusual situations.