Scientific Letter
Extracorporeal membrane oxygenation support in a patient with pheochromocytoma stress myocardiopathy
Soporte con membrana de oxigenación extracorpórea en paciente con miocardiopatía de estrés secundaria a feocromocitoma
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Martin-Villen, Y. Corcia-Palomo, S. Escalona-Rodriguez, A. Roldan-Reina, D. Acosta-Delgado, R. Martin-Bermudez" "autores" => array:6 [ 0 => array:4 [ "nombre" => "L." "apellidos" => "Martin-Villen" "email" => array:1 [ 0 => "luis.martin.exts@juntadeandalucia.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Y." "apellidos" => "Corcia-Palomo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "S." "apellidos" => "Escalona-Rodriguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "A." "apellidos" => "Roldan-Reina" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "D." "apellidos" => "Acosta-Delgado" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "R." "apellidos" => "Martin-Bermudez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "UGC Medicina Intensiva, Hospital Universitario Virgen del Rocio, Sevilla, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "UGC Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Soporte con membrana de oxigenación extracorpórea en paciente con miocardiopatía de estrés secundaria a feocromocitoma" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1269 "Ancho" => 1000 "Tamanyo" => 173591 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">TAC thoraco-abdominal CT scan with contrast with bilateral alveolar occupation imaging and right suprarenal hyperuptaking lesion.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cardiopulmonary support with extracorporeal membrane oxygenation (ECMO) support is a more and more common practice of Intensive Care Units (ICU) these days.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> According to the ELSO (Extracorporeal Life Support Organization) registry conducted back in 2016, ECMO support was used in more than 2000 adult patients with cardiac conditions and with an average survival of 42%.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Since ECMO support se is implemented when all the other usual therapeutic approaches have been tried, having this level of cardiopulmonary support available is a very important leap forward in the management of patients with refractory cardiogenic shock.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We hereby present the case of a 41-year-old woman without any prior significant clinical history who presented to the ER with clinical manifestations of general discomfort, headache and palpitations of 24-h duration. Upon arrival, she was having a hypertensive emergency (180/100), hypoperfusion with hyperlactacidemia and hypoxemic respiratory failure. The thoraco-abdominal CT scan conducted confirmed the presence of bilateral alveolar occupation and one 4<span class="elsevierStyleHsp" style=""></span>cm-hyperuptaking lesion in the arterial phase in her right suprarenal gland (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The echocardiogram showed the presence of severe left ventricular (LV) hypokinesia that spared the apical segments and one ejection fraction (EF) of 17% (<a class="elsevierStyleCrossRef" href="#sec0015">video 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Being the situation cardiogenic shock and multi-organ dysfunction with need for invasive mechanical ventilation and support with noradrenaline and dobutamine at high doses, the patient was transferred to our center, where axillary–femoral veno-arterial (VA) ECMO support was provided immediately. This improved multi-organ dysfunction, the amines where completely removed, and the patient showed a tendency toward arterial hypertension. The catecholamines in urine test was conducted (metanephrine and normetanephrine) that confirmed levels 10–20 times higher than the value of reference; also, the CT scan was reviewed and confirmed the diagnosis of pheochromocytoma (PHC).</p><p id="par0020" class="elsevierStylePara elsevierViewall">After six (6) days of ECMO support and clinical improvement, the severe ventricular dysfunction was still there. Since ventricular device support weaning was not an option, the PHC surgical approach was decided, through multidisciplinary approach, without ECMO removal.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Prior to the intervention, only conditioning therapy during 4 days with phenoxybenzamin and esmolol was possible and a slight improvement of ventricular function was observed (LVEF 25%). The surgery conducted was one right suprarenalectomy procedure but while the tumor was being manipulated, the patient suffered from a new adrenergic crisis that worsened the LVEF (15%) and after the resection of the tumor, she suffered a new episode of serious hypotension that required complete ECMO support in order to keep optimal perfusion. During the following days, the patient's left ventricular function improved and ECMO support was withdrawn twelve (12) days later.</p><p id="par0030" class="elsevierStylePara elsevierViewall">As associated complications, the patient suffered heparin-induced thrombopenia that lead to argatroban anticoagulant therapy during the ECMO support therapy; respiratory infection due to <span class="elsevierStyleItalic">Escherichia coli</span> and <span class="elsevierStyleItalic">Aspergillus</span> spp. that resolved with targeted antimicrobial therapy; and serious tetraparesis with motor-axonal damage that slowly recovered with physical therapy. Forty days after hospital admission, the patient was transferred to her floor, and forty-nine days later she was discharged from the hospital. The echocardiographic study conducted looked normal and the anatomopathological study conducted confirmed the diagnosis of PHC.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Stress cardiomyopathy (SC), also known as Tako-Tsubo syndrome, has widely been reported in the medical literature; its onset is usually an acute one imitating an acute coronary syndrome (ACS) and is usually associated with emotional stress.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> For its diagnosis in the echocardiography, segmental alterations of its contractility beyond the territory of a coronary artery can be found, making it necessary to rule out the presence of coronary disease, myocarditis or PHC.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> It usually has good prognosis, only 10% of the patients develop cardiogenic shock and less than 5% die from it.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The onset of PHC as a SC is a rare entity in the medical literature, even more rare with an inverted Tako-Tsubo syndrome.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6,7</span></a> If we take a look at the cases reported so far, we will see that PHC-induced SC is more common among young patients, is not usually related to stress factors as factors triggering this condition, and is associated with much more complications (cardiogenic shock, arrhythmias and even cardiac arrest).<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The use of ECMO as a life support measure in patients with PHC-induced cardiogenic shock is scarce and, often, only based on case series.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8,9</span></a> In the multicenter registry conducted in France by Sauneuf et al.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> from January 2000 through December 2015, 34 cases were reported, out of which only 14 (41%) required VA-ECMO support for hemodynamic stabilization. These patients were in a more serious condition, their hospital stays were longer, and they required more support therapy (amines and mechanical ventilation), and in up to five (5) cases complications associated with ECMO support were reported. Yet despite all this, 75% of the patients survived and all of them recovered their ventricular function without the need for a transplant or any other ventricular support.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In this group of patients, it is recommended that PHC surgery is postponed for a few weeks, once prior conditioning therapy has been implemented correctly, being exeresis with ECMO mechanical circulatory support exceptional. In our case, an urgent surgical approach was decided given the slight improvement of cardiac dysfunction and the complications occurred during ECMO that would not allow an optimal pharmacological protection. The surgery with ECMO controlled the hemodynamic alterations anticipated with the manipulation of the tumor, both in the catecholaminergic discharge and in the vasoplegia-induced profound posterior shock and new profound decline of myocardial contractility.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The clinical course of arterial hypertension and systolic dysfunction, and the atypical echocardiographic presentation lead us to review the findings of the CT scan that was the diagnostic modality of PHC. The catecholamines in urine test usually takes a few days or even weeks, which is an inviable delay in extreme cases like ours.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In patients with PHC-induced SC, the use of ECMO support has some risks too, it is a measure of optimal circulatory support that allows myocardial and organ recovery and helps hemodynamically during tumor resection.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interests associated with this article whatsoever.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Martin-Villen L, Corcia-Palomo Y, Escalona-Rodriguez S, Roldan-Reina A, Acosta-Delgado D, Martin-Bermudez R. Soporte con membrana de oxigenación extracorpórea en paciente con miocardiopatía de estrés secundaria a feocromocitoma. Med Intensiva. 2018;42:566–568.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0075" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0015" ] ] ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1269 "Ancho" => 1000 "Tamanyo" => 173591 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">TAC thoraco-abdominal CT scan with contrast with bilateral alveolar occupation imaging and right suprarenal hyperuptaking lesion.</p>" ] ] 1 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 1185152 "Video" => array:2 [ "mp4" => array:5 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Soporte mecánico con membrana de oxigenación extracorpórea veno-arterial (ECMO-VA): evolución a corto y a largo plazo tras la retirada de la asistencia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 11 | 16 |
| 2024 October | 38 | 48 | 86 |
| 2024 September | 36 | 38 | 74 |
| 2024 August | 46 | 47 | 93 |
| 2024 July | 35 | 31 | 66 |
| 2024 June | 38 | 44 | 82 |
| 2024 May | 33 | 22 | 55 |
| 2024 April | 50 | 37 | 87 |
| 2024 March | 49 | 30 | 79 |
| 2024 February | 51 | 37 | 88 |
| 2024 January | 35 | 39 | 74 |
| 2023 December | 39 | 34 | 73 |
| 2023 November | 43 | 39 | 82 |
| 2023 October | 38 | 33 | 71 |
| 2023 September | 32 | 37 | 69 |
| 2023 August | 27 | 12 | 39 |
| 2023 July | 31 | 32 | 63 |
| 2023 June | 21 | 15 | 36 |
| 2023 May | 39 | 31 | 70 |
| 2023 April | 32 | 21 | 53 |
| 2023 March | 45 | 35 | 80 |
| 2023 February | 57 | 33 | 90 |
| 2023 January | 44 | 14 | 58 |
| 2022 December | 58 | 34 | 92 |
| 2022 November | 60 | 32 | 92 |
| 2022 October | 61 | 33 | 94 |
| 2022 September | 53 | 28 | 81 |
| 2022 August | 35 | 50 | 85 |
| 2022 July | 35 | 32 | 67 |
| 2022 June | 30 | 23 | 53 |
| 2022 May | 45 | 35 | 80 |
| 2022 April | 35 | 28 | 63 |
| 2022 March | 38 | 49 | 87 |
| 2022 February | 37 | 38 | 75 |
| 2022 January | 39 | 34 | 73 |
| 2021 December | 48 | 54 | 102 |
| 2021 November | 74 | 41 | 115 |
| 2021 October | 111 | 82 | 193 |
| 2021 September | 42 | 36 | 78 |
| 2021 August | 43 | 44 | 87 |
| 2021 July | 46 | 24 | 70 |
| 2021 June | 51 | 30 | 81 |
| 2021 May | 61 | 41 | 102 |
| 2021 April | 127 | 82 | 209 |
| 2021 March | 99 | 24 | 123 |
| 2021 February | 107 | 27 | 134 |
| 2021 January | 72 | 33 | 105 |
| 2020 December | 58 | 24 | 82 |
| 2020 November | 36 | 20 | 56 |
| 2020 October | 29 | 27 | 56 |
| 2020 September | 86 | 20 | 106 |
| 2020 August | 76 | 17 | 93 |
| 2020 July | 51 | 19 | 70 |
| 2020 June | 44 | 14 | 58 |
| 2020 May | 75 | 12 | 87 |
| 2020 April | 22 | 14 | 36 |
| 2020 March | 42 | 14 | 56 |
| 2020 February | 71 | 27 | 98 |
| 2020 January | 41 | 18 | 59 |
| 2019 December | 51 | 20 | 71 |
| 2019 November | 42 | 28 | 70 |
| 2019 October | 45 | 18 | 63 |
| 2019 September | 39 | 18 | 57 |
| 2019 August | 58 | 31 | 89 |
| 2019 July | 29 | 18 | 47 |
| 2019 June | 17 | 11 | 28 |
| 2019 May | 37 | 29 | 66 |
| 2019 April | 21 | 16 | 37 |
| 2019 March | 4 | 8 | 12 |
| 2019 February | 0 | 5 | 5 |
| 2019 January | 1 | 10 | 11 |
| 2018 November | 0 | 2 | 2 |
| 2018 October | 0 | 1 | 1 |
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