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CLEAR FILTERS
CARDIOGENIC SHOCK MANAGEMENT – A PARTICULAR CASE
Session:
Casos Clinicos
Speaker:
Rita Ataíde Silva
Congress:
CPC 2020
Topic:
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Theme:
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Subtheme:
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Session Type:
Comunicações Orais
FP Number:
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Authors:
Rita Ataíde Silva; Natália Noronha; Pedro Epifânio; Mónica Rebelo
Abstract
<p><strong>INTRODUCTION: </strong>Pheochromocytoma is an infrequent tumor that induce excess of circulating catecholamines. Its onset as cardiogenic shock is exceptional.</p> <p><strong>CASE REPORT: </strong>We report the case of a 14-year-old girl with no relevant personal or family history, brought to the emergency department due to a 3-month history of hyperhidrosis, dry cough, new-onset dyspnea and abdominal discomfort. On physical examination she had hypertension (132/91mmHg) and tachycardia (140bpm), diaphoresis and hepatomegaly. An abdominal ultrasound showed a suspect mass above left kidney. Paediatric Cardiology evaluation was requested. Transthoracic echocardiogram showed dilated cardiomyopathy, an ejection fraction (EF) of 15% and a thrombus in the left ventricle. The girl was admitted to an Intensive Care Unit and further investigation confirmed the presence of a pheochromocytoma. She went into cardiogenic shock, which was difficult to manage given the excessive circulating catecholamines. After initiating phenoxybenzamine, milrinone and levosimendan with no significant improvement, it was decided to start her on extracorporeal membrane oxygenation (ECMO) in order to achieve clinical stabilization and enable surgery. She later underwent tumor resection, complicated by infection and hemorrhage, which culminated in splenectomy. ECMO was removed 9 days after surgery. Medical management of heart failure relied on renin-angiotensin-aldosterone blockers and beta-blockers, slowly titrated as tolerated. However, tachycardia subsisted. She was started on ivabradine (even though its use is not consensual in paediatric age), with good response. Her malnourishment state (25% weight loss) and psychological deterioration were also difficult to manage, requiring a multidisciplinary and holistic approach. She was discharged 62 days after the surgery. </p> <p>Presently, a year after the initial presentation, her cardiac function has recovered fully (EF 59%). She is asymptomatic and leads a normal life without restrictions, maintaining anti congestive medication.</p> <p><strong>CONCLUSION:</strong> The reversibility of the myocardial affection after adrenalectomy has been described in cases of mild myocardial damage, but a few cases present as cardiogenic shock requiring ECMO. This was a very challenging case of dilated cardiomyopathy given the contraindication of standard vasoactive drugs. The need to resort to ECMO to support anesthesia had several risks but was lifesaving. Full recovery was possible with rigorous management of drugs.</p>
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