Pheochromocytoma presenting as inverted Takotsubo cardiomyopathy

Metanephrine and normetanephrine associated with subclinical myocardial injuries in pheochromocytoma and paraganglioma

Objective

To analyze the correlation between metanephrine and normetanephrines (MNs) and subclinical myocardial injuries (SMI) diagnosed by low left ventricular global longitudinal strain (LV GLS) in patients with pheochromocytoma and paraganglioma (PPGL).

Methods

Seventy-six patients who underwent surgery for pheochromocytoma or paraganglioma from September 2017 to April 2022 were examined. All the patients enrolled had normal left ventricular ejection fraction (LVEF) and myocardial injury biomarkers including cardiac troponin I and B-natriuretic peptide. Univariate analysis and multivariate analysis were performed to evaluate the association of MNs and subclinical myocardial injury (SMI)(defined as LV GLS<18).

Results

LV GLS of 13(17.11%) PPGL patients was less than 18. The percentage of patients with elevation of single hormone (metanephrine, normetanephrine, 3-methoxytyramine) or any one of MNs was not significantly correlated with SMI (P=0.987, 0.666, 0.128 and 0.918, respectively). All MNs elevation was associated with SMI (OR: 11.27; 95% CI, 0.94—135.24; P= 0.056). After adjusting for age, All MNs elevation was significantly correlated with SMI (OR: 16.54; 95% CI, 1.22—223.62; P= 0.035).

Conclusion

MNs might be an important factor influencing myocardial function. All MNs elevation might indicate SMI. If all MNs elevated, LV GLS measurement was recommended for PPGL patients to detect SMI in the absence of decrease LVEF or other heart disease in clinical practice.

Rare Metabolic and Endocrine Diseases with Cardiovascular Involvement: Insights from Cardiovascular Magnetic Resonance - A Review

The identification of rare diseases with cardiovascular involvement poses significant diagnostic challenges due to the rarity of the diseases, but also due to the lack of knowledge and expertise. Most of them remain underrecognized and undiagnosed, leading to clinical mismanagement and affecting the patients' prognosis, as these diseases are per definition life-threatening or chronic debilitating. This article reviews the cardiovascular involvement of the most well-known rare metabolic and endocrine diseases and their diagnostic approach through the lens of cardiovascular magnetic resonance (CMR) imaging and its prognostic role, highlighting its fundamental value compared to other imaging modalities.

Takotsubo cardiomyopathy as an overlooked cause of cardiac arrest in a patient undergoing ureteral stenting: a case report and literature review

Takotsubo cardiomyopathy (TC) is a rare disease with unclear etiology that is characterized by wall motion abnormalities of the left ventricle. We report a 64-year-old woman who presented with cardiac arrest 6 hours after ureteral stenting, with no history of heart disease. Notably, she had a urinary tract infection preoperatively. TC was diagnosed with characteristic apical ballooning on the left ventriculogram. The hemodynamics and cardiac function recovered quickly within 1 day after conservative treatment and controlling the infection. TC should be considered when a patient presents with decreased cardiac function after ureteral stenting, especially in patients with potential concurrent infection. A review of the literature documenting cases of TC related to urological surgery in the past decade was conducted using PubMed. The results were summarized in a table.

Protocol for presurgical and anesthetic management of pheochromocytomas and sympathetic paragangliomas: a multidisciplinary approach

OBJECTIVE

To offer a practical guide for the presurgical and anesthetic management of pheochromocytomas and sympathetic paragangliomas (PGLs).

METHODS

This protocol was based on a comprehensive review of the literature and on our own multidisciplinary team's experience from managing pheochromocytoma and sympathetic PGLs at a referral center.

RESULTS

Patients with pheochromocytomas and sympathetic paragangliomas (PGLs) may develop potentially life-threatening complications, especially during surgical procedures. A complete biochemical, radiological, genetic, and cardiological assessment is recommended in the preoperative stage as it provides an evaluation of the risk of surgical complications and malignancy, allowing individualization of the presurgical treatment. Treatment with α-blockade and proper volume expansion in the preoperative stage significantly reduces the perioperative morbidity. During surgery, the anesthesiologist should look for a deep anesthetic level that inhibits the cardiovascular effects of catecholamines to minimize the risk of intraoperative complications.

CONCLUSIONS

An optimal presurgical evaluation of pheochromocytomas/ sympathetic PGL requires a multidisciplinary approach, including a complete hormonal, radiological, cardiac, genetic, and functioning evaluation in most cases. A proper preoperative evaluation in combination with strict blood pressure and heart rate control, and blood volume status optimization, will significantly reduce the risk of intraoperative and perioperative complications. In those patients who unfortunately develop intraoperative complications, the role of the anesthesiologist is essential since the selection of the appropriate management has a direct impact on morbimortality reduction.

Takotsubo syndrome: State-of-the-art review by an expert panel - Part 1

Takotsubo syndrome (TTS) is an acute cardiac condition independent of epicardial coronary obstruction that mimics acute coronary syndrome and is characterized by acute heart failure with reversible ventricular motion abnormalities. This consensus paper is the result of a multinational effort aiming to summarize the current state of the art on TTS. Experts in the field provide a thorough and detailed review of this syndrome. Several novel and unique sections are emphasized in this document, including the current state of the art on genetics of takotsubo syndrome, microRNAs (miRs), racial differences, role of cardiac spectroscopy and intracoronary imaging, as well as mechanical circulatory support. In part 1 of this two-part manuscript, we discuss how TTS came to be known, several patterns and forms it can take in patients, epidemiology and pathophysiology of the syndrome, and clinical presentation.

Takotsubo cardiomyopathy in a patient with ileus: a case report

Background

Takotsubo cardiomyopathy (TCM) is a form of stress-induced cardiomyopathy featured by the dilatation of the apex of the left ventricle during systole. Whereas the pathogenesis of this disorder is not well understood, it usually occurs after an emotional or physical stress such as acute asthma, surgery, chemotherapy, and stroke. However, its occurrence in ileus patients is rarely reported. We hereby report probably the first case of TCM after ileus in the literature and discuss its implications.

Case presentation

An 85-year-old man was brought to the Emergency Department due to vomiting, abdominal pain, and no stool passages for 2 days. His abdomen was markedly distended, and ileus pattern was observed in the plain film of abdomen. Electrocardiogram showed right axis deviation, poor R-wave progression, and diffuse ST-segment elevation in the anterior leads, and cardiomegaly was observed by roentgenogram. A ventriculography showed an ejection fraction of 33% and confirmed the apical dilation consistent with TCM. He was treated with medication and discharged without remarkable adverse events. A follow-up transthoracic echocardiogram 4 months later showed normalization of his left ventricular systolic functions.

Conclusion

The precise mechanisms of the development of TCM are still unknown, but it is widely believed that it is triggered by the catecholamine surge produced in response to stress. This case demonstrated that such a stress can be of various forms, including ileus and other conditions that may lead to severe abdominal pain, and highlight the importance of awareness in diagnosing this rare but potentially lethal condition.

Perioperative Management of Pheochromocytoma

Pheochromocytomas are rare neuroendocrine tumors that produce and store catecholamines. Without adequate preparation, the release of excessive amounts of catecholamines, especially during anesthetic induction or during surgical removal, can produce life-threatening cardiovascular complications. This review focuses on the perioperative management of pheochromocytoma/paragangliomas, initially summarizing the clinical aspects of the disease and then highlighting the current evidence available for preoperative, intraoperative, and postoperative anesthetic management.

A case of reverse takotsubo cardiomyopathy caused by an eating disorder

Takotsubo cardiomyopathy is an acquired transient cardiomyopathy that causes severe systolic dysfunction in the absence of coronary disease. Here we present a case of reverse takotsubo cardiomyopathy. A 67-year-old female was admitted for weakness and falls due to severe malnutrition. During her stay she was diagnosed with an eating disorder. She also developed chest pain during her hospitalization and was taken urgently for catheterization which showed normal coronary arteries with akinetic basal and inferior walls and hyperkinesis of the apex. Her ejection fraction decreased to 25% from 60% five days previously. She was diagnosed with reverse takotsubo. She was placed on an appropriate heart failure regimen and eventually transferred to inpatient rehabilitation. In its typical form, takotsubo causes apical ballooning due to hyperkinetic basal and inferior wall motion and apical hypokinesis. Reverse takotsubo causes a depressed basal segment with apical hyperkinesis usually brought on by severe emotional or physical stress. Our case is the first documented report of an eating disorder causing the reverse type of takotsubo cardiomyopathy. <Learning objective: The reader will be able to recognize stress-induced cardiomyopathy in the right clinical setting and understand that there are different variants of this condition that can present with multiple different wall motion abnormalities.>.

Acute systolic heart failure and uncontrolled hypertension: what is the missing link?

Pheochromocytoma is a rare tumor in adults, with an estimated annual incidence of 0.8 per 100,000 persons. Cardiomyopathy is an uncommon presentation of such a rare disease. Serious cardiovascular complications of these tumors are related to potent effects of secreted catecholamines. The mechanism of pheochromocytoma-related cardiomyopathy is not well understood but it is likely due to the effect of excess catecholamines and their oxidation products which have been found to have a direct toxic effect on the myocardium. We describe below a case of a 70-year old female with uncontrolled hypertension and new onset acute systolic heart failure, who on further evaluation was noted to have pheochromocytoma-related cardiomyopathy. Pheochromocytoma should be strongly considered in the differential diagnosis of non-ischemic cardiomyopathy for a patient with elevated blood pressures relative to severity of cardiac dysfunction.

A case of unusual acute coronary syndrome

Pheochromocytoma is a rare tumor that usually develops ahead of the neuroectodermal chromaffin cells of the adrenal medulla, but it may arise anywhere within plexus of sympathetic adrenergic nerves. Headache, palpitations, tremor, excessive sweating, abdominal pain, and hypertensive paroxysm are the common clinical presentations of the tumor, but it has also been reported several cardiac symptoms.

Endomyocardial biopsy in a patient with hemorrhagic pheochromocytoma presenting as inverted Takotsubo cardiomyopathy

A 29-year-old female patient presented with shock and dyspnea due to heart failure and pulmonary edema. Echocardiography indicated excessive contraction limited to the left ventricular apex and akinesis of the basal and middle ventricle, which were confirmed by emergency left ventriculography. The finding was diagnostic of inverted Takotsubo cardiomyopathy. An abdominal computed tomography scan showed a tumor in the left adrenal gland with a central low-density area, and the plasma and urinary catecholamines were strikingly elevated. Taken together, these findings suggested the presence of a hemorrhagic pheochromocytoma. A myocardial biopsy in the very acute stage on the day of admission revealed neutrophilic infiltration and contraction-band necrosis, which was indistinguishable from the previously reported pathology in the acute phase of idiopathic Takotsubo cardiomyopathy without pheochromocytoma. The diagnosis of pheochromocytoma in this case was confirmed 7 weeks later by surgical removal of the left adrenal gland with massive hemorrhage at the center of the pheochromocytoma. The marked similarity of the endomyocardial pathology between this case and cases with idiopathic Takotsubo cardiomyopathy strongly points to catecholamine excess as a common causality for Takotsubo cardiomyopathy with or without pheochromocytoma.

Takotsubo-like cardiomyopathy in pheochromocytoma

BACKGROUND

Takotsubo Cardiomyopathy (TTC) is commonly triggered by acute illness, physical or emotional stress and has been associated with elevated catecholamine levels. TTC has also been associated with pheochromocytoma (TTC-pheo).

METHODS

We performed a computer assisted search of the electronic databases Medline, Scopus and Google Scholar from 1965 to January 2011. All case reports with reported TTC-pheo were selected and compared to a recent review by Gianni et al. which examined primary TTC (TTC-primary).

STATISTICS

Data analysis was performed using SPSS version 18. Chi-square test of Fisher's exact test was used as appropriate to compare categorical data.

RESULTS

38 cases of TTC-pheo were retrieved from literature and compared to 254 cases of TTC-p. Chest pain was the most common presentation in both groups. The TTC-pheo patients were on average 18 years younger than patients with TTC-p (p<0.01). Only a minority of TTC-pheo patients presented with classical features of pheochromocytoma including hypertension (52.6%), headache (28.9%), palpitations (31.6 %), and diaphoresis (26.3%). In TTC-pheo complications rates were higher compared to TTC-p, including cardiogenic shock (34.2% vs. 4.2%, p<0.01) and heart failure (46.7% vs. 17.7%, p<0.01). Antecedent stressors were less common in TTC-pheo. About one-third of TTC-pheo patients presented with the inverted pattern, which compared to the apical pattern, was associated with higher complication rates, including, cardiogenic shock, heart failure, acute renal failure and arrhythmias.

CONCLUSIONS

Although rare, pheochromocytoma should be considered in the differential diagnosis of TTC especially in younger patients presenting without antecedent stressors and a high complication rate. The similarities in the clinical features and outcomes in patients with TTC-p and TTC-pheo point to a similar underlying cardiac pathophysiologic process at the time of the acute presentation.