Key result
Staged open AVR followed by adrenalectomy enables successful management of critical AS with pheochromocytoma.
Why the study?
The optimal order and timing of surgical aortic valve replacement and pheochromocytoma resection in patients with critical aortic stenosis and symptomatic pheochromocytoma remains controversial.
Case Report (n=1)
No
This case report demonstrates the feasibility of performing open AVR followed by adrenalectomy in a patient with critical aortic stenosis and symptomatic pheochromocytoma, despite significant perioperative hemodynamic volatility.
May inform staged management of rare concurrent critical aortic stenosis and pheochromocytoma; leaves open safety, sequencing, and generalizability.
BACKGROUND: Pheochromocytoma is a rare medical condition caused by catecholamine-secreting tumor cells. Operative resection can be associated with significant hemodynamic fluctuations due to the nature of the tumor, as well as associated post-resection vasoplegia. To allow for cardiovascular recovery before surgery, patients require pre-operative alpha-adrenergic blockade, which would be limited in the setting of co-existent severe aortic stenosis. In this report, we describe a patient with severe aortic stenosis and symptomatic pheochromocytoma. CASE PRESENTATION: ) was found to have a highly active 4 × 4 cm left adrenal pheochromocytoma. Alpha-adrenergic blockade for his pheochromocytoma was limited by syncope in the setting of his aortic stenosis. Open aortic valve replacement (AVR) was performed, followed by adrenalectomy the next day. The perioperative course for each surgical procedure was hemodynamically volatile, exacerbated by severe alcohol withdrawal. During the adrenalectomy, cardiogenic and vasoplegic shock developed immediately after securing the vascular supply to his tumor. This shock was refractory to vasopressin and methylene blue, but responded well to angiotensin II and epinephrine. After both surgeries were completed, his course was further complicated by severe ICU psychosis, ileus, fungal bacteremia, pneumonia/hypoxic respiratory failure and atrial fibrillation. He ultimately recovered and was discharged from the hospital after 38 days. CONCLUSION: To our knowledge, this is the first report of surgical AVR and pheochromocytoma resection in a patient with critical aortic stenosis. The appropriate order and timing of surgeries when both these conditions co-exist remains controversial.
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Feinstein et al. (2021) conducted a case report in Symptomatic pheochromocytoma and critical aortic stenosis (n=1). Staged open aortic valve replacement followed by open adrenalectomy was evaluated. A staged procedure of open aortic valve replacement followed by open adrenalectomy was successfully performed in a patient with critical aortic stenosis and symptomatic pheochromocytoma.
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