From Hypertensive Surge to Shock: Pheochromocytoma–triggered Takotsubo Requiring Impella and Va–ecmo

Background Takotsubo syndrome may follow an abruptadrenergic discharge; pheochromocytoma–related forms are uncommon but tend to be severe, with ischaemia/vasospasm, pulmonary oedema, arrhythmias and shock. Case presentation A 57–year–old woman with long–standing paroxysmal hypertension and a 5–cm right adrenal mass wasadmitted for morpho–functional assessment of suspectedpheochromocytoma. During the diagnostic pathway, shortly after corticosteroid exposure, she suddenly developed a fulminantadrenergic crisis (extreme hypertension, tachyarrhythmias), rapidly progressing to acute pulmonary oedema, severe lacticacidosis, hyperosmolar coma and cardiogenic shock. ECG showeddiffuse repolarization abnormalities with deep T-wave inversionand QTc prolongation. Transthoracic echocardiographydemonstrated mid–apical akinesia with basal hyperkinesis(Takotsubo pattern) and LVEF ∼25%; coronary angiographyexcluded obstructive disease. Despite vasoactive support, she required Impella left–ventricular assistance and escalation to veno–arterial ECMO. The course was complicated by sustainedventricular tachycardia and ventricular fibrillation, treated with lidocaine, esmolol and defibrillation, and later by an episode of atrial fibrillation. Emergent adrenalectomy under mechanicalsupport removed a pheochromocytoma, after which blood–pressure lability eased and ventricular function began to recover(LVEF 35% on step–down). She was discharged stable on guideline–directed heart–failure therapy and scheduled for cardiacMRI. Conclusions This case illustrates a clinically relevant “double hit”: diagnostic work–up (and potentially steroids) acting as the spark for catecholamine storm and Takotsubo syndrome, with malignant arrhythmias and multiorgan failure.In suspectedpheochromocytoma, clinicians should actively avoid precipitants, ensure early alpha–blockade, and use beta–blockers only after adequate alpha–control. Early transfer to centres able to providerapid mechanical circulatory support and definitive tumourresection can be lifesaving