Extracorporeal membrane oxygenation for pheochromocytoma-induced cardiogenic shock View Full Text


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Article Info

DATE

2016-11-28

AUTHORS

Guillaume Hekimian, Fatima Kharcha, Nicolas Bréchot, Matthieu Schmidt, Cécile Ghander, Guillaume Lebreton, Xavier Girerd, Christophe Tresallet, Jean-Louis Trouillet, Pascal Leprince, Jean Chastre, Alain Combes, Charles-Edouard Luyt

ABSTRACT

BackgroundPheochromocytoma, a rare catecholamine-producing tumor, might provoke stress-induced Takotsubo-like cardiomyopathy and severe cardiogenic shock. Because venoarterial-extracorporeal membrane oxygenation (VA-ECMO) rescue of pheochromocytoma-induced refractory cardiogenic shock has rarely been reported, we reviewed our ICU patients’ presentations and outcomes.MethodsAll pheochromocytoma-induced refractory cardiogenic shock cases managed with VA-ECMO (January 2007–March 2015) were prospectively included and reviewed. We also performed a systematic review on this topic.ResultsNine patients (7 women, 2 men; 31–51 [median, 43 (IQR 36–49) years old]) were included; none had a previously known pheochromocytoma. Six of them had medical histories suggestive of the diagnosis: palpitations and headaches for several months for four, multiple endocrine neoplasia syndrome type 1 for one and recurrent Takotsubo disease for one; at hospital admission, all were hypertensive despite cardiogenic shock. Three others had an identified surgical triggering factor. All nine patients rapidly developed refractory cardiogenic shock with very severe left ventricular (LV) impairment (LV ejection-fraction range 5–20%; LV outflow-tract velocity–time integral range 3–8 cm). Seven patients’ abdominal computed tomography scans showed pheochromocytoma-suggestive adrenal gland tumors (no scan during ICU stay for 2). Despite VA-ECMO implantation, three patients died of refractory multiple organ failure. For the six others, myocardial function improved and ECMO was removed 3–7 days post-implantation; α- and β-blockers were progressively introduced. Five survivors underwent pheochromocytoma excision 3 weeks–4 months post-ICU discharge, with satisfactory outcomes. One patient, whose pheochromocytoma was diagnosed 1 year after the index event, underwent uneventful surgical adrenalectomy. Systematic review retrieved 40 cases of pheochromocytoma-induced cardiogenic shock requiring mechanical support (mostly ECMO), with a mortality rate of 7%. Pheochromocytoma was removed surgically after mechanical support weaning in 31 patients and during mechanical support in 5. Four were not operated.ConclusionsPheochromocytoma is a rare but reversible cause of cardiogenic shock amenable to VA-ECMO rescue. Adrenal gland imaging should be obtained for all patients with unexplained cardiogenic shock. Lastly, it might be safer to perform adrenalectomy several weeks after the initial catastrophic presentation, once recovery of LV systolic function is complete. More... »

PAGES

117

Identifiers

URI

http://scigraph.springernature.com/pub.10.1186/s13613-016-0219-4

DOI

http://dx.doi.org/10.1186/s13613-016-0219-4

DIMENSIONS

https://app.dimensions.ai/details/publication/pub.1052046857

PUBMED

https://www.ncbi.nlm.nih.gov/pubmed/27896787


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11 schema:description BackgroundPheochromocytoma, a rare catecholamine-producing tumor, might provoke stress-induced Takotsubo-like cardiomyopathy and severe cardiogenic shock. Because venoarterial-extracorporeal membrane oxygenation (VA-ECMO) rescue of pheochromocytoma-induced refractory cardiogenic shock has rarely been reported, we reviewed our ICU patients’ presentations and outcomes.MethodsAll pheochromocytoma-induced refractory cardiogenic shock cases managed with VA-ECMO (January 2007–March 2015) were prospectively included and reviewed. We also performed a systematic review on this topic.ResultsNine patients (7 women, 2 men; 31–51 [median, 43 (IQR 36–49) years old]) were included; none had a previously known pheochromocytoma. Six of them had medical histories suggestive of the diagnosis: palpitations and headaches for several months for four, multiple endocrine neoplasia syndrome type 1 for one and recurrent Takotsubo disease for one; at hospital admission, all were hypertensive despite cardiogenic shock. Three others had an identified surgical triggering factor. All nine patients rapidly developed refractory cardiogenic shock with very severe left ventricular (LV) impairment (LV ejection-fraction range 5–20%; LV outflow-tract velocity–time integral range 3–8 cm). Seven patients’ abdominal computed tomography scans showed pheochromocytoma-suggestive adrenal gland tumors (no scan during ICU stay for 2). Despite VA-ECMO implantation, three patients died of refractory multiple organ failure. For the six others, myocardial function improved and ECMO was removed 3–7 days post-implantation; α- and β-blockers were progressively introduced. Five survivors underwent pheochromocytoma excision 3 weeks–4 months post-ICU discharge, with satisfactory outcomes. One patient, whose pheochromocytoma was diagnosed 1 year after the index event, underwent uneventful surgical adrenalectomy. Systematic review retrieved 40 cases of pheochromocytoma-induced cardiogenic shock requiring mechanical support (mostly ECMO), with a mortality rate of 7%. Pheochromocytoma was removed surgically after mechanical support weaning in 31 patients and during mechanical support in 5. Four were not operated.ConclusionsPheochromocytoma is a rare but reversible cause of cardiogenic shock amenable to VA-ECMO rescue. Adrenal gland imaging should be obtained for all patients with unexplained cardiogenic shock. Lastly, it might be safer to perform adrenalectomy several weeks after the initial catastrophic presentation, once recovery of LV systolic function is complete.
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17 schema:keywords BackgroundPheochromocytoma
18 ECMO
19 LV systolic function
20 ResultsNine patients
21 Takotsubo
22 VA-ECMO
23 VA-ECMO implantation
24 admission
25 adrenal gland imaging
26 adrenal gland tumors
27 adrenalectomy
28 cardiogenic shock
29 cardiogenic shock cases
30 cases
31 catastrophic presentation
32 catecholamine-producing tumors
33 cause
34 days
35 diagnosis
36 discharge
37 disease
38 events
39 extracorporeal membrane oxygenation
40 factors
41 failure
42 function
43 gland tumors
44 headache
45 history
46 hospital admission
47 imaging
48 impairment
49 implantation
50 index event
51 left ventricular impairment
52 mechanical support
53 medical history
54 membrane oxygenation
55 months
56 months post-ICU discharge
57 mortality rate
58 multiple endocrine neoplasia syndrome type 1
59 multiple organ failure
60 myocardial function
61 organ failure
62 outcomes
63 oxygenation
64 palpitations
65 patient presentation
66 patients
67 pheochromocytoma
68 post-ICU discharge
69 presentation
70 rare catecholamine-producing tumor
71 rate
72 recovery
73 refractory cardiogenic shock
74 rescue
75 reversible causes
76 review
77 satisfactory outcome
78 scans
79 severe cardiogenic shock
80 severe left ventricular impairment
81 shock
82 shock cases
83 stress-induced takotsubo
84 support
85 surgical adrenalectomy
86 survivors
87 syndrome type 1
88 systematic review
89 systolic function
90 tomography scan
91 topic
92 tumors
93 type 1
94 unexplained cardiogenic shock
95 ventricular impairment
96 week 4
97 weeks
98 years
99 β-blockers
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