Management of an acute catecholamine-induced cardiomyopathy and circulatory collapse: a multidisciplinary approach

Abstract

A phaeochromocytoma (PC) is a rare, catecholamine-secreting neuroendocrine tumour arising from the adrenal medulla. Presenting symptoms of this rare tumour are highly variable but life-threatening multiorgan dysfunction can occur secondary to catecholamine-induced hypertension or hypotension and subsequent cardiovascular collapse. High levels of circulating catecholamines can induce an acute stress cardiomyopathy, also known as Takotsubo cardiomyopathy. Recent studies have focused on early diagnosis and estimation of the prevalence of acute stress cardiomyopathy in patients with PC, but very little is reported about management of these complex cases. Here, we report the case of a 38-year-old lady who presented with an acute Takotsubo or stress cardiomyopathy and catecholamine crisis, caused by an occult left-sided 5 cm PC. The initial presenting crisis manifested with symptoms of severe headache and abdominal pain, triggered by a respiratory tract infection. On admission to hospital, the patient rapidly deteriorated, developing respiratory failure, cardiogenic shock and subsequent cardiovascular collapse due to further exacerbation of the catecholamine crisis caused by a combination of opiates and intravenous corticosteroid. An echocardiogram revealed left ventricular apical hypokinesia and ballooning, with an estimated left ventricular ejection fraction of 10-15%. Herein, we outline the early stabilisation period, preoperative optimisation and intraoperative management, providing anecdotal guidance for the management of this rare life-threatening complication of PC.

Learning points: A diagnosis of phaeochromocytoma should be considered in patients presenting with acute cardiomyopathy or cardiogenic shock without a clear ischaemic or valvular aetiology.Catecholamine crisis is a life-threatening medical emergency that requires cross-disciplinary expertise and management to ensure the best clinical outcome.After initial resuscitation, treatment of acute catecholamine-induced stress cardiomyopathy requires careful introduction of alpha-blockade followed by beta-blockade if necessary to manage β-receptor-mediated tachycardia.Prolonged α-adrenergic receptor stimulation by high levels of circulating catecholamines precipitates arterial vasoconstriction and intravascular volume contraction, which can further exacerbate hypotension. Invasive pressure monitoring can aid management of intravascular volume in these complex patients.

Figure 1

(A) A coronal section of the contrast-enhanced CT thorax performed on day 1 of admission and demonstrates bilateral pseudonodular opacities with ground glass changes, in keeping with pulmonary oedema, (B) A coronal section of the abdomen on the same CT exam and the 5-cm left-sided adrenal mass is highlighted by the white arrow. (C) The electrocardiogram demonstrating non-specific t-wave changes, a prolonged QT interval and a sinus tachycardia. (D) The intraoperative monitoring and the additional medications administered over the period of surgery.

Figure 2

Images (A) and (B) display the apical 4 chamber view in end diastole and end systole The basal anteroseptal, basal inferolateral and basal inferior segments had reasonable contractility, and the mid-inferior segment was hypokinetic. The remaining segments were severely hypokinetic/akinetic. Visually estimated LVEF = 10–15%. (C and D) Cardiac MRI showed improvement in LV systolic function with no myocardial oedema on T2-weighted sequences (Fig. 2C), and no late gadolinium enhancement to suggest myocardial fibrosis (Fig. 2D).