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G. Todorov ,St.Toshev, B.Mioljevikj-Miserliovska, R.Miserliovski, Second Surgical Department Department of General Surgery, University Hospital „Alexandrovska”, Sofia, Bulgaria P. Tzaneva Second Surgical Department , Department of Anaesthesiology and Intensive Care, University Hospital „Alexandrovska”, Sofia, Bulgaria CLINICAL CASE-2
A 52 years old female, who had a crisis increase in blood pressure to 170/100 in the past Pheochromocytoma is a rare catecholamine producing tumor arising from chromaffin cells year, accompanied by pallor, sweating, palpitations. Attacks have a duration of 10 minutes, 1-2 in the adrenal medulla or in other paraganglia of the sympathetic nervous system. Typical times a week. Being under no attacks she had a normal to low blood pressure. clinical findings include headache, palpitation, excessive sweating and paroxysmal hypertension. The best confirmatory test for diagnosis is to measure free catecholamines or Ultrasonographic evidence of tumor formation with 65/40mm size in the right adrenal gland. their degradable products in a 24 h urine collection. Elevated levels of metanefrins in 24 hours urine, respectively metanefrin 1305ng (normal<350) Laparoscopic removal of the tumor has gained wide popularity in recent years because of and normetanefrin 2509 ng (normal<600) were found. After two weeks of preoperative its clear advantages: lower consumption of analgesics, shorter hospital stay and quicker preparation with Doxazosin 2x 0,5 mg / d she was hospitalized for surgery. During the recovery. Adequate alfa blockade in preoperative period is of high importance in preventing dissection of the tumor with laparoscopic technique the patient developed severe arrhythmia life-threatening complications such as hypertensive crisis, arrhythmias, pulmonary edema, and sudden desaturation to 80%. Cyanosis and venous stasis of the neck appeared. After the myocardial ischemia provoked by released of high levels catecholamines while manipulating the tumor. In addition preoperative preparation may include beta-blocker with a short effect operation in the background of persistent hypoxemia, the patient was removed in the intensive (Esmolol) or calcium blocker (Nicardipin) . care unit intubated , on spontaneous ventilation through a T-piece with the submission of O2, / The operation poses serious challenges for the surgical team and especially the anesthetist SatO2 92% /. Hemodynamic parameters were stabilized with volume expansiors and infusion to ensure strict control and monitor maintenance of vital functions. The operation is performed under general anesthesia with endotracheal intubation and generally takes place in two stages. In the first an hypertensive crisis and severe arrhythmias are observed due to uncontrollable levels of catecholamines released from handling the tumor. During this stage powerful, short acting vasodilators (Phentolamine, Naniprus) and antiarrhythmics are applied. After the clamping the v.centralis and the interruption of venous drainage of the tumor the operation enters into second stage of arterial hypotension. It is recommended fluid resuscitation and vasopressors. In the early postoperative period hemodynamic parameters and blood sugar are monitored. Catecholamine levels are restored to normal within a few days Within the period of 2002 - 2012 46 pheochromocytomas were removed retroperitoneoscopically in our clinic. We present two cases, complicated with unilateral A working diagnosis of acute heart attack was made. From the X-ray - data for inhomogeneous pulmonary edema and severe left ventical dyskinesis, described in literature as reversible shadowing of the left lung half, with ECG evidence of negative T waves in lead I, aVL, V3- V6. The echocardiography showed dyskinesia of the middle and top segments of the LV. EF- 35%. Laboratory evidence of elevated enzymes (CPK 543; MB 26; troponin-0, 408) was found. In the backround of heparinoterapy and inotropic support pulmonary changes underwent rapid reversal. The patient was extubated after seven hours the operation. The left We performed total adrenalectomy in all of the patients.Mean operative time was 63 min ventriculography found hypokynesis of the apex and hyper contractility of the basal segments. (range 30-240 min). The estimated blood loss was 30 ml (range 0-550 ml). We have not Coronary angiography excluded obstructive coronary disease. On the six day after the established a significant dependence of the operative time on the gender (p=0.787), localization operation after resolution of ECG changes, enzyme abnormalities and fully stabilized of the pathological process (left or right adrenal) (p=0.615), size of the tumor lesion (p=0.460), even on BMI.Perioperative major complications for the whole series of pheochromocytoma cases were 8.6 %,with mortality rate – 0%. Major - 8,6%
This two clinical cases demonstrate the same complications occurred during laparoscopic conversion to open procedure due to intraoperative
cardiovascular instability in pheochromocytoma Acute unilateral pulmonary edema- Possible mechanisms of occurrence are:
- unilateral pulmonary edema and severe left ventrical
-Cardiogenic-based transient acute cardiac dysfunction. Ultrasonography in patients revealed evidence of impaired contractility and reduced LVEF. Minor – peritoneal tear, pneumoperitoneum
Postoperative complications, 4.35 %
-Due to severe cardiogenic postcapilar venous spasm, abnormal alveolocapilar permeability and - Postoperative hemorrhagia, no hemotransfusion required
severely elevated pulmocapilar hydrostatic pressure induced by high levels of catecholamines. The position on the operating table - left lateral position in “Jackson “ position probably is an We present two cases, complicated with unilateral pulmonary edema and severe left ventical additional component that contributes to significant changes in pulmonary vascular pressures. dyskinesis, described in literature as reversible Takotsubo cardiomyopathy. Transient cardiomyopathy type Takotsubo. This syndrome is first reported in the Japanese
population by Hikaru Sato et al (1) described in 1991. Clinically resembles acute miocardial infarction(AMI), serum enzymes are mild to moderately elevated, and coronary angiography is A 37 years old man, who in the last six years complained about a crisis increases in blood normal. Ultrasound showed severe left ventricular dyskinesia (apical ballooning and hyper pressure 230/105, palpitations, headache, sweating. He observed lost of weight (10kg in one contractility of the basal segments).The image resembles a trap for octopus-"takotsubo". Within year). Treatment with antidepressants and antihypertensive had no effect. Metanefrines in 24h a few days to weeks changes undergo reversal with a favorable outcome. It is a rare finding, urine were measured ten times above normal values, respectively metanefrin 3350ng (normal although in the past decade, however, the number of published reports of patients presenting <350) and normetanefrin 4325ng (normal <600). On CT a heterogeneous formation was found in with this syndrome has steadily increased. Several investigations assessed the prevalence of the right adrenal -29/36mm in size. After a 14 days preoperative preparation with Doxazosin tako-tsubo cardiomyopathy. Serial studies reported a prevalence of 1.0–2.0% among patients 8mg / d he was admitted for elective laparoscopic adrenalectomy. with acute coronary syndrome.There is a strong predominance of postmenopausal women. The first part of the operation until the interruption of the venous drainage of the tumor occured The accurate pathogenetic mechanisms has not been clearly established. Several theories have with large variations in blood pressure and severe arrhythmias requiring discontinuation of the been proposed: excessive sympathetic stimulation (7-13) , metabolic impairment and stunning manipulation on the formation. To maintain hemodynamics Naniprus infusion of 3-8mg / h and (4-6). microvascular dysfunction (14) , and low estrogen levels (15). Catecholamine surge Lidocain 1,5 mg / min was applied. After the ligation of v centralis ,desaturation / SatO2 89-90% definitely plays a role, but the way it affects myocardial function has not been clarified. The / occured, accompanied by severe hypotension in the absence of peripheral pulses, progressive decrease of the pulse rate, strongly deformed ventricular complexes and dilated unresponsive pupils. Despite the forced fluid resuscitation and infusion of Dopamine 8-20 g/kg/min ,the condition progressively deteriorated The operation was aborted and cardiopulmonary resuscitation was carried out to stabilize the hemodynamics. Pupils remain dilated and Perioperative management of patients with pheochromocytoma is a great challenge for the surgical team and the anaestesiologist, requiring a After the operation the patient was transferred in intensive care unit intubated , (IPPV, FiO2 = functions. Operative treatment should be done only in highly specialized clinics with 100%) with persistent volume substitutuion and infusion of Dopamine 15-20 g / kg / min. experienced teams in both endocrine and laparoscopic surgery. Cerebroprotectives , stimulation of diuresis and antithrombotic therapy were applied . 30 minutes after admitting the patient recovered consciousness and began to execute commands. Desaturation persisted. The left lung was completely overshadowed with decompensated 1. Sato H, Tateishi H, Uchida T, et al. Takotsubo type 1. cardiomyopathy due to multivessel spasm. In: Kodama K, Haze K, Hon M, ds. Clinical aspect of myocardial injury: fromischaemia to heart failure. Tokyo: Kagakuhyouronsya, 1990;56-64. Japanese. 2 Stollberger C, Finsterer J, Schneider B. Tako-tsubo-like left ventriculardysfunction: clinical presentation, instrumental findings, additional cardiac and non-cardiac diseases and potential pathomechanisms. Minerva Cardioangiol acidosis and severe hypoxemia(PH 7,17; PaO2 9,14; PaCO2 6,48; BE -11,2; Sat 89%). 2005;53:139–45. 3 Ito K, Sugihara H, Kawasaki T, et al. Assessment of ampulla (takotsubo) cardiomyopathy with coronary angiography, two-dimensional echocardiography and 99mTc-tetrofosmin myocardial single photon emission computed Ultrasonography, performed several hours later found reduced ejection fraction of 40% (baseline tomography. Ann Nucl Med 2001;15:351–5 4. Bybee KA, Murphy J, Prasad A, Wright RS, Lerman A, Rihal CS,et al. Acute impairment of regional myocardial glucose uptake in the apical ballooning (takotsubo) syndrome. J Nucl Cardiol 2006;13:244-50. 5. Dorfman T, Aqel R, Allred J, Woodham R, Iskandrian AE. Takotsubo cardiomyopathy induced by treadmill exercise testing: An insight into the pathophysiology of transient left ventricular apical (or midventricular) ballooning in 58%), expanded volumes and dimensions of cardiac ventricle with diffuse hypokinesia. There the absence of obstructive coronary artery disease. J Am Coll Cardiol 2007;49:1223-5 6. Ito K, Sugihara H, Kinoshita N, Azuma A, Matsubara H. Assessment of Takotsubo cardiomyopathy (transient left ventricular apical ballooning) using 99mTc-tetrofosmin, 123I-BMIPP,123I-MIBG and 99mTc-PYP myocardial SPECT. Ann Nucl Med 2005;19:435-45. was a laboratory evidence of elevated enzymes (CPK 542; MB 35; Troponin 0,955). 7. Ueyama T, Kasamatsu K, Hano T, Yamamoto K, Tsuruo Y, Nishio I.Emotional stress induces transient left ventricular hypocontraction in the rat via activation of cardiac adrenoceptors: A possible animal model of „tako-tsubo‟ cardiomyopathy. Circ J 2002;66:712- 8. Ueyama T, Hano T, Kasamatsu K, Yamamoto K, Tsuruo Y, Nishio I. Estrogen attenuates the emotional stress-induced cardiac responses in the animal model of Tako-tsubo (Ampulla) cardiomyopathy. J Cardiovasc Pharmacol 18 hours after surgery, after the control X-ray control on which spotted shadow in the lower and 2003;42:S117-9. 9. Villareal RP, Achari A, Wilansky S, Wilson JM. Anteroapical stunning and left ventricular outflow tract obstruction. Mayo Clin Proc 2001;76:79-83. 10. Burgdorf C, von Hof K, Schunkert H, Kurowski V. Regional alterations in myocardial sympathetic innervation in patients with transient left-ventricular apical ballooning (Tako-Tsubo cardiomyopathy).J Nucl Cardiol a smoller one in the middle lung in the left lung were establishes, and with normalized values 2008;15:65-72. 11. Akashi YJ, Barbaro G, Sakurai T, Nakazawa K, Miyake F. Cardiac autonomic imbalance in patients with reversible ventricular dysfunction takotsubo cardiomyopathy. QJM 2007;100:335-43. 12. Pavin D, Le Breton H, Daubert C. Human stress cardiomyopathy mimicking acute myocardial syndrome. Heart (Brit Cardiac Soc)1997;78:509-11. arterial blood gas analysis with hemodynamic parameters stabilized, the patient was extubated . 13. Sato M, Fujita S, Saito A, Ikeda Y, Kitazawa H, Takahashi M, et al. Increased incidence of transient left ventricular apical ballooning(so-called „Takotsubo‟ cardiomyopathy) after the mid- Niigata Prefecture earthquake. Circ J 2006;70:947-53. 14. Kurisu S, Sato H, Kawagoe T, Ishihara M, Shimatani Y, Nishioka K, et al. Tako-tsubo-like left ventricular dysfunction with STsegment elevation: A novel cardiac syndrome mimicking acute myocardial infarction. Am Heart J Permanent improvement of the situation in the following days was established . The patient was 2002;143:448-55. 15. Dorfman TA, Iskandrian AE, Aqel R. An unusual manifestation of Tako-tsubo cardiomyopathy. Clin Cardiol 2008;31:194-200. 16.Gautam PL, Kaul TK. Pheochromocytoma-anaesthetic considerations. J Anaesth Clin Pharmacol 2002; 18(3): 232-247. dismissed on the fifth postoperative day after a normal X-ray control. 17. Hessel EA, London MJ. Takotsubo (stress) cardiomyopathy and the anesthesiologist: enough case reports. Let‟s try to answer some specific questions! Anesthesia-analgesia 2010; 110(3): 674-679. 18. Miyazawa I, Wada A, Sugimoto T, Nitta N, Horie M. Emerging acute unilateral pulmonary edema in a patient with pheochromocytoma. Int


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