Laparoscopic adrenalectomy for pheochromocytoma in a patient recovering from catecholamine cardiomyopathy
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The stem
A 48-year-old woman, 70 kg and 165 cm, is scheduled for laparoscopic right adrenalectomy for a 5 cm pheochromocytoma. The surgeon says the tumor sits against the inferior vena cava.
Ten weeks ago she came to the emergency department with chest pain, pulmonary edema and a blood pressure of 210/120. Her troponin rose, coronary angiography showed normal arteries, and her echocardiogram showed an ejection fraction of 25% with apical ballooning. CT found a right adrenal mass, and her plasma normetanephrine was 14 times the upper limit of normal. She was diagnosed with catecholamine-induced cardiomyopathy and treated for heart failure.
Endocrinology started phenoxybenzamine and titrated it over three weeks; metoprolol was added after that for a resting heart rate of 110. She has followed a high-salt diet with about 3 L of fluid a day, and her furosemide was stopped six weeks ago. She has no other history. Her brother had thyroid cancer at 35.
Medications: phenoxybenzamine 20 mg three times daily, metoprolol succinate 50 mg daily, lisinopril 5 mg daily.
Allergies: none known.
- Seated blood pressure 118/72, heart rate 64; standing 102/64, heart rate 78; she has a stuffy nose and is mildly light-headed on standing
- SpO2 98% on room air, temperature 36.7 °C; airway Mallampati 2
- Hemoglobin 12.9 g/dL (14.8 at presentation); creatinine 0.8 mg/dL; potassium 4.0 mEq/L
- Fasting glucose 104 mg/dL (168 at presentation); HbA1c 6.1%
- NT-proBNP 160 pg/mL (4,800 at presentation)
- ECG: sinus rhythm 64, T-wave inversions resolved, QTc 440 ms
- Transthoracic echo last week: ejection fraction 55%, normal wall motion, mild mitral regurgitation