The perils of beta-blockade and the promise of venoarterial extracorporeal membrane oxygenation in managing low-output heart failure in thyroid storm: a case report

Thyroid storm is a rare endocrine emergency that requires prompt recognition and treatment to reduce the high morbidity and mortality associated with the disease. A subset of patients with thyroid storm develop the grave complication of thyrotoxicosis-induced low-output heart failure, the severity of which ranges from subclinical to life-threatening. These patients present a therapeutic challenge because the initiation of beta-adrenergic blockade, a cornerstone of therapy in thyroid storm, disrupts the hyperadrenergic state that plays a compensatory role in maintaining cardiac output and may lead to cardiogenic shock. We present a case of a young healthy man who presented to the emergency department in thyroid storm, which was his first clinical presentation of Graves’ disease. He was treated with beta-blockers prior to recognition of his subclinical low-output heart failure and he decompensated into cardiogenic shock necessitating inotropic and vasopressor support. He was ultimately treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock which enabled him to recover normal left ventricular function while his thyroid hormone levels normalized. Screening for underlying thyrocardiac disease and cautious administration of rate controlling agents can prevent treatment-induced cardiogenic shock. Early intervention with VA-ECMO may provide the best clinical outcome for patients presenting with thyrotoxicosis-induced low-output heart failure.