Title:
Pheochromocytoma Induced Cardiogenic Shock Treated with Impella 5.5
Introduction
:
45 F presented with respiratory failure and shock to a referral facility emergency department. A rapid transfer process was utilized to a tertiary care hospital. Patient suffered two PEA cardiac arrests, required five inotropes/vasopressors with refractory hypotension, multiorgan failure and TTE revealed EF 5-10%. Bilateral adrenal gland masses raised suspicion for pheochromocytoma. Shock protocol was followed and Impella 5.5 was implanted. Patient had complete neurologic recovery, was discharged home with EF 60-65% after 21 days and will have outpatient surgery.
Clinical Case:
45 F presented to referral facility emergency department and was rapidly transferred due to critical condition. She had tachypnea, tachycardia, elevated lactic acid and complained of epigastric pain and vomiting for two days prior to arrival. Her workup at the referral facility included an abdominal CT scan that showed a 6 cm x 5.1 cm by 6 cm mass on the left adrenal gland, 1.7 cm mass on right adrenal gland, soft tissue mass on left buttock and in left breast. Upon arrival to tertiary center, patient required intubation and suffered two PEA cardiac arrests with 10 minutes of CPR. Five inotropes and vasopressors were utilized with continued refractory hypotension. Post arrest labs revealed Creatinine 1.22, AST 1,261, ALT 1,147 and lactic acid 13.2. Therapeutic hypothermia was not initiated due to observed neurologic function. Impella 5.5 was placed via right axillary approach with calculated CPO and PAPI 1.21 and 0.27 respectively. Post implant, patient required only one inotrope. Over the next 48 hours, her CPO increased from 1.21 to 1.52 off inotropic support, PAPI increased from 0.27 to 2.89, and lactic acid decreased to 1.3 from 13.2. Plasma norepinephrine level was 3,775 pg/mL (80-520 ph/mL) and plasma epinephrine was 2,515 pg/mL (10-200 pg/mL) consistent with diagnosis of pheochromocytoma. Creatinine remained elevated and patient required hemodialysis. Impella was explanted after 6 days and extubation occurred on day 7. Her post explant TTE reveal EF of 60-65%. She remained neurologically intact and discharge labs revealed Creatinine 2.75, AST 49, ALT 53. She was discharged home with alpha and beta blockade, outpatient dialysis scheduled but not anticipated to be needed with renal recovery and plan for outpatient adrenalectomy.
Discussion:
NCSI algorithm created a foundation for AMI cardiogenic shock that can be utilized for different phenotypes including non-cardiac causes of cardiovascular collapse such as pheochromocytoma.