Pheochromocytoma crisis treated with veno-arterial extracorporeal membrane oxygenation and urgent adrenalectomy—case report

Abstract

A 61-year-old woman, presented to the Emergency Department (ED) with respiratory failure and cardiogenic shock following a face lift surgery earlier that day. Her intraoperative course included highly labile blood pressure (BP) and heart rate (HR). Initial investigation revealed severe global left ventricular (LV) failure with sparing of the base, high levels of troponin-I and bilateral chest infiltrates, without electrocardiographic evidence of acute myocardial ischemia. Her condition quickly deteriorated to severe hypoxemia and refractory shock. Peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was installed during resuscitation, resulting in rapid hemodynamic stabilization, normalization of lactate levels and restoration of normal urinary output. Laboratory investigation and computed tomography (CT) revealed a round lesion with a hypodense core in the left adrenal gland, and high blood levels of epinephrine and norepinephrine, supporting a diagnosis of pheochromocytoma. The patient gradually recovered and was weaned from ECMO support on day 5, but continued to experience repeated, life threatening, events of hemodynamic instability. Following a multidisciplinary discussion that included intensivists, endocrinologists, anesthetists and surgeons, urgent adrenalectomy was successfully performed. The patient made a full recovery and was discharged home. This case emphasizes the role of ECMO as a life-saving mean in cases of potentially reversible cardiogenic shock, and triggers the discussion as to the optimal timing and safety of adrenalectomy in cases of pheochromocytoma crisis.