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headache and palpitations of 24-h duration&#46; Upon arrival&#44; she was having a hypertensive emergency &#40;180&#47;100&#41;&#44; hypoperfusion with hyperlactacidemia and hypoxemic respiratory failure&#46; 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 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The echocardiogram showed the presence of severe left ventricular &#40;LV&#41; hypokinesia that spared the apical segments and one ejection fraction &#40;EF&#41; of 17&#37; &#40;<a class="elsevierStyleCrossRef" href="#sec0015">video 1</a>&#41;&#46;</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&#44; the patient was transferred to our center&#44; where axillary&#8211;femoral veno-arterial &#40;VA&#41; ECMO support was provided immediately&#46; This improved multi-organ dysfunction&#44; the amines where completely removed&#44; and the patient showed a tendency toward arterial hypertension&#46; The catecholamines in urine test was conducted &#40;metanephrine and normetanephrine&#41; that confirmed levels 10&#8211;20 times higher than the value of reference&#59; also&#44; the CT scan was reviewed and confirmed the diagnosis of pheochromocytoma &#40;PHC&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">After six &#40;6&#41; days of ECMO support and clinical improvement&#44; the severe ventricular dysfunction was still there&#46; Since ventricular device support weaning was not an option&#44; the PHC surgical approach was decided&#44; through multidisciplinary approach&#44; without ECMO removal&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Prior to the intervention&#44; only conditioning therapy during 4 days with phenoxybenzamin and esmolol was possible and a slight improvement of ventricular function was observed &#40;LVEF 25&#37;&#41;&#46; The surgery conducted was one right suprarenalectomy procedure but while the tumor was being manipulated&#44; the patient suffered from a new adrenergic crisis that worsened the LVEF &#40;15&#37;&#41; and after the resection of the tumor&#44; she suffered a new episode of serious hypotension that required complete ECMO support in order to keep optimal perfusion&#46; During the following days&#44; the patient&#39;s left ventricular function improved and ECMO support was withdrawn twelve &#40;12&#41; days later&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">As associated complications&#44; the patient suffered heparin-induced thrombopenia that lead to argatroban anticoagulant therapy during the ECMO support therapy&#59; respiratory infection due to <span class="elsevierStyleItalic">Escherichia coli</span> and <span class="elsevierStyleItalic">Aspergillus</span> spp&#46; that resolved with targeted antimicrobial therapy&#59; and serious tetraparesis with motor-axonal damage that slowly recovered with physical therapy&#46; Forty days after hospital admission&#44; the patient was transferred to her floor&#44; and forty-nine days later she was discharged from the hospital&#46; The echocardiographic study conducted looked normal and the anatomopathological study conducted confirmed the diagnosis of PHC&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Stress cardiomyopathy &#40;SC&#41;&#44; also known as Tako-Tsubo syndrome&#44; has widely been reported in the medical literature&#59; its onset is usually an acute one imitating an acute coronary syndrome &#40;ACS&#41; and is usually associated with emotional stress&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> For its diagnosis in the echocardiography&#44; segmental alterations of its contractility beyond the territory of a coronary artery can be found&#44; making it necessary to rule out the presence of coronary disease&#44; myocarditis or PHC&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> It usually has good prognosis&#44; only 10&#37; of the patients develop cardiogenic shock and less than 5&#37; die from it&#46;<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&#44; even more rare with an inverted Tako-Tsubo syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#44;7</span></a> If we take a look at the cases reported so far&#44; we will see that PHC-induced SC is more common among young patients&#44; is not usually related to stress factors as factors triggering this condition&#44; and is associated with much more complications &#40;cardiogenic shock&#44; arrhythmias and even cardiac arrest&#41;&#46;<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&#44; often&#44; only based on case series&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8&#44;9</span></a> In the multicenter registry conducted in France by Sauneuf et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> from January 2000 through December 2015&#44; 34 cases were reported&#44; out of which only 14 &#40;41&#37;&#41; required VA-ECMO support for hemodynamic stabilization&#46; These patients were in a more serious condition&#44; their hospital stays were longer&#44; and they required more support therapy &#40;amines and mechanical ventilation&#41;&#44; and in up to five &#40;5&#41; cases complications associated with ECMO support were reported&#46; Yet despite all this&#44; 75&#37; of the patients survived and all of them recovered their ventricular function without the need for a transplant or any other ventricular support&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In this group of patients&#44; it is recommended that PHC surgery is postponed for a few weeks&#44; once prior conditioning therapy has been implemented correctly&#44; being exeresis with ECMO mechanical circulatory support exceptional&#46; In our case&#44; 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&#46; The surgery with ECMO controlled the hemodynamic alterations anticipated with the manipulation of the tumor&#44; both in the catecholaminergic discharge and in the vasoplegia-induced profound posterior shock and new profound decline of myocardial contractility&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The clinical course of arterial hypertension and systolic dysfunction&#44; and the atypical echocardiographic presentation lead us to review the findings of the CT scan that was the diagnostic modality of PHC&#46; The catecholamines in urine test usually takes a few days or even weeks&#44; which is an inviable delay in extreme cases like ours&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In patients with PHC-induced SC&#44; the use of ECMO support has some risks too&#44; it is a measure of optimal circulatory support that allows myocardial and organ recovery and helps hemodynamically during tumor resection&#46;</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&#46;</p></span></span>"
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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
L. Martin-Villena,
Corresponding author
, Y. Corcia-Palomoa, S. Escalona-Rodrigueza, A. Roldan-Reinaa, D. Acosta-Delgadob, R. Martin-Bermudeza
a UGC Medicina Intensiva, Hospital Universitario Virgen del Rocio, Sevilla, Spain
b UGC Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
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headache and palpitations of 24-h duration&#46; Upon arrival&#44; she was having a hypertensive emergency &#40;180&#47;100&#41;&#44; hypoperfusion with hyperlactacidemia and hypoxemic respiratory failure&#46; 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 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The echocardiogram showed the presence of severe left ventricular &#40;LV&#41; hypokinesia that spared the apical segments and one ejection fraction &#40;EF&#41; of 17&#37; &#40;<a class="elsevierStyleCrossRef" href="#sec0015">video 1</a>&#41;&#46;</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&#44; the patient was transferred to our center&#44; where axillary&#8211;femoral veno-arterial &#40;VA&#41; ECMO support was provided immediately&#46; This improved multi-organ dysfunction&#44; the amines where completely removed&#44; and the patient showed a tendency toward arterial hypertension&#46; The catecholamines in urine test was conducted &#40;metanephrine and normetanephrine&#41; that confirmed levels 10&#8211;20 times higher than the value of reference&#59; also&#44; the CT scan was reviewed and confirmed the diagnosis of pheochromocytoma &#40;PHC&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">After six &#40;6&#41; days of ECMO support and clinical improvement&#44; the severe ventricular dysfunction was still there&#46; Since ventricular device support weaning was not an option&#44; the PHC surgical approach was decided&#44; through multidisciplinary approach&#44; without ECMO removal&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Prior to the intervention&#44; only conditioning therapy during 4 days with phenoxybenzamin and esmolol was possible and a slight improvement of ventricular function was observed &#40;LVEF 25&#37;&#41;&#46; The surgery conducted was one right suprarenalectomy procedure but while the tumor was being manipulated&#44; the patient suffered from a new adrenergic crisis that worsened the LVEF &#40;15&#37;&#41; and after the resection of the tumor&#44; she suffered a new episode of serious hypotension that required complete ECMO support in order to keep optimal perfusion&#46; During the following days&#44; the patient&#39;s left ventricular function improved and ECMO support was withdrawn twelve &#40;12&#41; days later&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">As associated complications&#44; the patient suffered heparin-induced thrombopenia that lead to argatroban anticoagulant therapy during the ECMO support therapy&#59; respiratory infection due to <span class="elsevierStyleItalic">Escherichia coli</span> and <span class="elsevierStyleItalic">Aspergillus</span> spp&#46; that resolved with targeted antimicrobial therapy&#59; and serious tetraparesis with motor-axonal damage that slowly recovered with physical therapy&#46; Forty days after hospital admission&#44; the patient was transferred to her floor&#44; and forty-nine days later she was discharged from the hospital&#46; The echocardiographic study conducted looked normal and the anatomopathological study conducted confirmed the diagnosis of PHC&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Stress cardiomyopathy &#40;SC&#41;&#44; also known as Tako-Tsubo syndrome&#44; has widely been reported in the medical literature&#59; its onset is usually an acute one imitating an acute coronary syndrome &#40;ACS&#41; and is usually associated with emotional stress&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> For its diagnosis in the echocardiography&#44; segmental alterations of its contractility beyond the territory of a coronary artery can be found&#44; making it necessary to rule out the presence of coronary disease&#44; myocarditis or PHC&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> It usually has good prognosis&#44; only 10&#37; of the patients develop cardiogenic shock and less than 5&#37; die from it&#46;<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&#44; even more rare with an inverted Tako-Tsubo syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#44;7</span></a> If we take a look at the cases reported so far&#44; we will see that PHC-induced SC is more common among young patients&#44; is not usually related to stress factors as factors triggering this condition&#44; and is associated with much more complications &#40;cardiogenic shock&#44; arrhythmias and even cardiac arrest&#41;&#46;<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&#44; often&#44; only based on case series&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8&#44;9</span></a> In the multicenter registry conducted in France by Sauneuf et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> from January 2000 through December 2015&#44; 34 cases were reported&#44; out of which only 14 &#40;41&#37;&#41; required VA-ECMO support for hemodynamic stabilization&#46; These patients were in a more serious condition&#44; their hospital stays were longer&#44; and they required more support therapy &#40;amines and mechanical ventilation&#41;&#44; and in up to five &#40;5&#41; cases complications associated with ECMO support were reported&#46; Yet despite all this&#44; 75&#37; of the patients survived and all of them recovered their ventricular function without the need for a transplant or any other ventricular support&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In this group of patients&#44; it is recommended that PHC surgery is postponed for a few weeks&#44; once prior conditioning therapy has been implemented correctly&#44; being exeresis with ECMO mechanical circulatory support exceptional&#46; In our case&#44; 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&#46; The surgery with ECMO controlled the hemodynamic alterations anticipated with the manipulation of the tumor&#44; both in the catecholaminergic discharge and in the vasoplegia-induced profound posterior shock and new profound decline of myocardial contractility&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The clinical course of arterial hypertension and systolic dysfunction&#44; and the atypical echocardiographic presentation lead us to review the findings of the CT scan that was the diagnostic modality of PHC&#46; The catecholamines in urine test usually takes a few days or even weeks&#44; which is an inviable delay in extreme cases like ours&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In patients with PHC-induced SC&#44; the use of ECMO support has some risks too&#44; it is a measure of optimal circulatory support that allows myocardial and organ recovery and helps hemodynamically during tumor resection&#46;</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&#46;</p></span></span>"
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