Hemodynamic Challenges in Pheochromocytoma Resection: A Case Report

Document Type

Conference Proceeding - Restricted Access

Publication Date

5-9-2025

Abstract

Pheochromocytomas are rare catecholamine-secreting tumors, with an incidence of 2-8 cases per million annually. These tumors cause excessive catecholamine release, leading to hypertension, tachycardia, and hypermetabolic states. This case highlights the challenges of managing a large adrenal pheochromocytoma (>10 cm) in a patient with hypertrophic cardiomyopathy (HCM) suspected to be secondary to his tumor. Preoperative and intraoperative, catecholamine surges led to a hyperdynamic heart, obstructing the left ventricular outflow tract (LVOT) via systolic anterior motion (SAM) of the mitral valve. Post-tumor removal, cardiovascular collapse required cautious use of inotropes and pressors. Despite his comorbidities, the patient required pressors at doses exceeding standard protocols, underscoring the need for tailored management strategies.

A 47-year-old male with a 6-year history of poorly controlled hypertension, type 2 diabetes, and stage 3a chronic kidney disease presented with fatigue, tremors, diaphoresis, and newly elevated liver function tests (LFTs). Abnormal liver ultrasound results prompted his primary care physician to order a computed tomography (CT) scan, which revealed a 13.2 x 13.8 x 12.1 cm left adrenal mass with modest enhancement. Elevated plasma metanephrines (110 nmol/L, 122x normal) and normetanephrines (77 nmol/L, 154x normal) confirmed the diagnosis of pheochromocytoma. Preoperative evaluation identified a new systolic murmur. Echocardiography showed HCM with asymmetric interventricular septal hypertrophy, moderate SAM of the mitral valve, and LVOT obstruction with a peak gradient of 59 mmHg. HCM was attributed to catecholamine exposure, with follow-up planned post-surgery. Multidisciplinary perioperative collaboration involved oncologic surgery, cardiology, anesthesiology, and critical care.

Preoperative optimization included alpha-blockade, beta-blockade, and calcium channel blockers to stabilize blood pressure, reduce cardiac remodeling, and counteract catecholamine-induced LVOT obstruction. During surgery, invasive monitoring with an arterial line, central venous catheter, and transesophageal echocardiography (TEE) guided management. Severe hypertensive surges (BP > 260/110 mmHg) during tumor manipulation were controlled using short-acting beta-blockers and vasodilators. Post-resection, cardiovascular collapse required high-dose vasopressors and inotropes, including phenylephrine, norepinephrine, epinephrine, vasopressin, and angiotensin II. Intraoperative TEE confirmed no significant LVOT obstruction despite high vasopressor doses. The patient was extubated on postoperative day (POD) 1, and inotropic agents were preferentially weaned. All remaining pressors were weaned by POD 2. The patient was discharged in stable condition with no signs of residual hemodynamic instability.

This case illustrates the complexity of managing pheochromocytomas, especially in patients with coexisting conditions like HCM. Multidisciplinary perioperative care facilitated safe tumor resection and recovery. The patient's tolerance of supraphysiologic vasopressor and inotropic support, despite his HCM, was likely due to a physiologic adaptation and acquired tolerance to catecholamines. This case highlights the unpredictable physiologic conditions in patients with pheochromocytomas.

Comments

2025 Research Day Corewell Health West, Grand Rapids, MI, May 9, 2025. Abstract 1689

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