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Pheochromocytoma Detected During Anesthesia Induction
LETTER TO THE EDITOR
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graphy is unique in that it combines both a physical skill in optimal image acquisition as well as an intellectual understanding of cardiac physiology, interpretation of data and application in patient management, and appreciation for echocardiography’s limitations and pitfalls. We agree that the use of simulation has great potential. It helps beginners better understand cardiac anatomy and anatomic-echocardiography correlations, but its development is very complex. Today, simulators only offer a limited aspect of necessary skills and applications for complete training in echocardiography. There is no color or spectral Doppler offered, and few realistic pathologies are provided by the simulator to train clinicians. The development of simulators for echocardiography is a very exciting field, but, currently, their capabilities cannot provide a true and full training experience for beginners. Because of these limitations, echocardiography is best mastered the old-fashioned way, with time, effort, face-to-face interaction, hands-on training, and practice on human models and full real echocardiography systems. Perhaps soon, the simulators will offer all aspects of clinical echocardiography. Tara R. Brakke, MD, FASE* Georges Desjardins, MD, FRCPC† Sasha K. Shillcutt, MD, FASE* Daniel P. Vezina, MD, MS, FRCPC† Candice R. Montzingo, MD, FASE* *Department of Anesthesiology University of Nebraska Medical Center Omaha, NE †Department of Anesthesiology University of Utah Salt Lake City, UT REFERENCES 1. Canty DJ, Royse CF: Audit of anaesthetist-performed echocardiography on perioperative management decisions for non-cardiac surgery. Br J Anaesth 103:352-358, 2009 2. Manecke GR Jr, Vezina DP: Perioperative transthoracic echocardiography: “Universal acid”? J Cardiothorac Vasc Anesth 23:447-449, 2009 3. Cowie B: Focused cardiovascular ultrasound performed by anesthesiologists in the perioperative period: Feasible and alters patient management. J Cardiothorac Vasc Anesth 23:450-456, 2009 4. O’Halloran TD, Kannam JP: Preoperative transthoracic echocardiography: When is it useful? Int Anesthesiol Clin 46:1-10, 2008 5. Maytal R, Bose R, Warraich H, et al: Transthoracic echocardiographic simulator: Normal and the abnormal. J Cardiothorac Vasc Anesth 25:177-181, 2011 doi:10.1053/j.jvca.2011.05.005
palpitations, and chest pain are nonspecific and may be absent. Surgical procedures under general anesthesia can result in high morbidity and mortality in patients with undiagnosed pheochromocytoma.1 There are few case reports in the anesthesia literature regarding undiagnosed pheochromocytoma suspected during anesthesia induction because of hemodynamic instability.2,3 In one case report, surgery was completed, and later the patient developed multiorgan failure and cardiac hypokinesis.1 We present a case of hemodynamic instability during anesthesia induction in which the surgical procedure was aborted because of suspected undiagnosed pheochromocytoma. A 60-year-old man with severe aortoiliac occlusive disease was scheduled for aortobifemoral bypass graft surgery under general anesthesia. He had well-controlled hypertension, peripheral vascular disease, asbestosis, and oral carcinoma requiring radical neck dissection and radiation. He was taking aspirin, simvastatin, and valsartan. His preoperative 2-dimensional echocardiogram showed a normal ejection fraction and valvular function. After standard anesthesia monitors were applied, a right radial arterial catheter was placed, and anesthesia was induced with midazolam, fentanyl, propofol, and tracheal intubation facilitated with succinylcholine. A right internal jugular triplelumen catheter then was inserted to administer vasopressors, if needed, and to monitor volume status. Induction was complicated by severe hemodynamic instability; wide swings in the blood pressure responded poorly to positional changes, volume administration, and vasopressor/vasodilator administration (Fig 1). The patient had taken his morning dose of angiotensin receptor blocker, which may cause hypotension but not hypertension. An intraoperative transesophageal echocardiogram was performed to exclude myocardial ischemia, massive pulmonary embolus, hypovolemia, and left ventricular outflow obstruction. An undiagnosed pheochromocytoma then was suspected, and the procedure was aborted. Pheochromocytoma later was confirmed by elevated plasma catecholamine levels and radiographic studies. The patient was started on ␣-adrenergic blockers and later underwent successful laparoscopic adrenalectomy and aortofemoral bypass. This case shows the importance of a systematic approach to unexplained hemodynamic instability during anesthesia. Pheochromocytoma has been described as a great mimic and may only manifest during induction. Common causes of hemodynamic instability should be ruled out first. Barotrauma can be 250 200 150
Pheochromocytoma Detected During Anesthesia Induction
SBP DBP
100
Mean HR
50
Pheochromocytoma is a rare neuroendocrine tumor of the adrenal gland, with an incidence of 0.05% to 0.2% in hypertensive patients. Symptoms including hypertension, headache,
0 7:54 7:58 8:03 8:04 8:10 8:14 8:18 8:23 8:30 8:35 8:40 8:43 8:47 8:51 8:56 9:00 9:04 9:09 9:20 9:29 9:40 9:42 9:44 9:45
To the Editor:
Fig 1. Hemodynamic instability. (Color version of figure is available online.)
e44
LETTERS TO THE EDITOR
excluded by the absence of an increase in peak airway pressure and normal gas exchange; anaphylaxis, by the absence of bronchospasm and other cutaneous changes; hyperthyroidism, by a lack of significant tachycardia, arrhythmias, and hyperthermia; and carcinoid, by the absence of tricuspid valve involvement on transesophageal echocardiography as well as other typical signs. The decision to abort surgery and investigate the possibility of pheochromocytoma may have been a lifesaver because the mortality of patients undergoing major surgery with unrecognized pheochromocytoma is more than 80%. Vikas Kumar, MBBS Jerry Spivey, MD Mary Arthur, MD Manuel Castresana, MD Department of Anesthesiology Medical College of Georgia Augusta, GA
Fig 1. TEE: midesophageal 4-chamber view showing color Doppler across the bioprosthetic mitral valve with severe regurgitation jet (A). See Video 1. (Color version of figure is available online.)
REFERENCES 1. Siddik-Sayyid SM, Dabbous AS, Shaaban JA, et al: Catastrophic cardiac hypokinesis and multiple-organ failure after surgery in a patient with an undiagnosed pheochromocytoma: Emergency excision of the tumor. J Cardiothorac Vasc Anesth 21:863-866, 2007 2. Heindel SW, Maslow AD, Steriti J, et al: A patient with intracardiac masses and an undiagnosed pheochromocytoma. J Cardiothorac Vasc Anesth 16:338-343, 2002 3. Holldack HJ: Induction of anesthesia triggers hypertensive crisis in a patient with undiagnosed pheochromocytoma: Could rocuronium be to blame? J Cardiothorac Vasc Anesth 21:858-862, 2007 doi:10.1053/j.jvca.2011.05.011
Intraoperative Detection of a Stuck Bioprosthetic Mitral Valve Leaflet Causing Severe Mitral Regurgitation To the Editor: The use of transesophageal echocardiography (TEE) is becoming an essential and integral part of the management during cardiac surgery. Recent practice guidelines from the society of cardiovascular anesthesiologists task force on TEE recommended that for adult patients without contraindication, TEE should be used in all cardiac surgeries (eg, valvular surgeries, both repair as well as replacement).1 TEE is used in repair cases to assess the adequacy of repair and to rule out any valvular stenosis, whereas in valve replacement cases it is used to assess the adequacy of deairing before weaning from cardiopulmonary bypass (CPB) and the prosthetic valve function after coming off CPB. However, debate still persists about its routine use in valve replacement cases particularly in our Indian subcontinent. We present a case of mitral valve replacement in which the use of TEE led to an early diagnosis of a stuck leaflet and prevented a potential fatal complication. A 63-year-old male patient admitted with a diagnosis of triple-vessel coronary artery disease as well as severe mitral
regurgitation (MR). Preoperative transthoracic echocardiography revealed flail posterior mitral leaflet because of ruptured chordae with an ejection fraction of 35% and regional wall motion abnormality. The patient was scheduled to undergo coronary artery bypass graft surgery and mitral valve replacement. He was stabilized using intra-aortic balloon pump support a day before surgery. The patient was induced using a standard opioid-based technique. Intraoperative TEE confirmed the preoperative diagnosis. However, we found moderate MR, which could be caused by the effect of anesthetic drugs and an intra-aortic balloon pump. The mitral valve was replaced using a 27-mm Perimount bioprosthetic mitral valve (Carpentier-Edwards, Irvibe, CA). While preparing to wean from CPB, TEE was performed to assess the adequacy of deairing. Color Doppler was also used to assess bioprosthetic mitral valve function and to see any regurgitant or paravalvular jet. At partial CPB flow, TEE revealed a severe regurgitation jet across the bioprosthetic mitral valve (Fig 1 and Video 1 [supplementary videos are available online]). A detailed transesophageal echocardiographic examination revealed that 1 leaflet of the bioprosthetic valve was immobile leading to severe MR (Figs 2 and 3 and Video 2). The surgeon was informed about the findings. Full-flow CPB was reinstituted immediately to inspect the bioprosthetic mitral valve. Cardioplegia was administered. While inspecting the bioprosthetic MV, a loop of suture was found along the strut of the bioprosthetic valve restricting the mobility of one leaflet, resulting in severe regurgitation. The problem was rectified, and the patient was weaned from CPB on moderate inotropes. The postoperative course was uneventful. An intraoperative stuck mitral valve is a relatively rare but fatal complication after mitral valve replacement. It is reported more commonly with metallic prosthetic valves than bioprosthetic valves. An intraoperative stuck valve can occur because of obstruction by mitral subvalvular apparatus and mechanical obstruction by suture.2 A delay in the detection of a stuck valve may result in myocardial distension, hemodynamic deterioration, and sometimes failure to wean
e43
graphy is unique in that it combines both a physical skill in optimal image acquisition as well as an intellectual understanding of cardiac physiology, interpretation of data and application in patient management, and appreciation for echocardiography’s limitations and pitfalls. We agree that the use of simulation has great potential. It helps beginners better understand cardiac anatomy and anatomic-echocardiography correlations, but its development is very complex. Today, simulators only offer a limited aspect of necessary skills and applications for complete training in echocardiography. There is no color or spectral Doppler offered, and few realistic pathologies are provided by the simulator to train clinicians. The development of simulators for echocardiography is a very exciting field, but, currently, their capabilities cannot provide a true and full training experience for beginners. Because of these limitations, echocardiography is best mastered the old-fashioned way, with time, effort, face-to-face interaction, hands-on training, and practice on human models and full real echocardiography systems. Perhaps soon, the simulators will offer all aspects of clinical echocardiography. Tara R. Brakke, MD, FASE* Georges Desjardins, MD, FRCPC† Sasha K. Shillcutt, MD, FASE* Daniel P. Vezina, MD, MS, FRCPC† Candice R. Montzingo, MD, FASE* *Department of Anesthesiology University of Nebraska Medical Center Omaha, NE †Department of Anesthesiology University of Utah Salt Lake City, UT REFERENCES 1. Canty DJ, Royse CF: Audit of anaesthetist-performed echocardiography on perioperative management decisions for non-cardiac surgery. Br J Anaesth 103:352-358, 2009 2. Manecke GR Jr, Vezina DP: Perioperative transthoracic echocardiography: “Universal acid”? J Cardiothorac Vasc Anesth 23:447-449, 2009 3. Cowie B: Focused cardiovascular ultrasound performed by anesthesiologists in the perioperative period: Feasible and alters patient management. J Cardiothorac Vasc Anesth 23:450-456, 2009 4. O’Halloran TD, Kannam JP: Preoperative transthoracic echocardiography: When is it useful? Int Anesthesiol Clin 46:1-10, 2008 5. Maytal R, Bose R, Warraich H, et al: Transthoracic echocardiographic simulator: Normal and the abnormal. J Cardiothorac Vasc Anesth 25:177-181, 2011 doi:10.1053/j.jvca.2011.05.005
palpitations, and chest pain are nonspecific and may be absent. Surgical procedures under general anesthesia can result in high morbidity and mortality in patients with undiagnosed pheochromocytoma.1 There are few case reports in the anesthesia literature regarding undiagnosed pheochromocytoma suspected during anesthesia induction because of hemodynamic instability.2,3 In one case report, surgery was completed, and later the patient developed multiorgan failure and cardiac hypokinesis.1 We present a case of hemodynamic instability during anesthesia induction in which the surgical procedure was aborted because of suspected undiagnosed pheochromocytoma. A 60-year-old man with severe aortoiliac occlusive disease was scheduled for aortobifemoral bypass graft surgery under general anesthesia. He had well-controlled hypertension, peripheral vascular disease, asbestosis, and oral carcinoma requiring radical neck dissection and radiation. He was taking aspirin, simvastatin, and valsartan. His preoperative 2-dimensional echocardiogram showed a normal ejection fraction and valvular function. After standard anesthesia monitors were applied, a right radial arterial catheter was placed, and anesthesia was induced with midazolam, fentanyl, propofol, and tracheal intubation facilitated with succinylcholine. A right internal jugular triplelumen catheter then was inserted to administer vasopressors, if needed, and to monitor volume status. Induction was complicated by severe hemodynamic instability; wide swings in the blood pressure responded poorly to positional changes, volume administration, and vasopressor/vasodilator administration (Fig 1). The patient had taken his morning dose of angiotensin receptor blocker, which may cause hypotension but not hypertension. An intraoperative transesophageal echocardiogram was performed to exclude myocardial ischemia, massive pulmonary embolus, hypovolemia, and left ventricular outflow obstruction. An undiagnosed pheochromocytoma then was suspected, and the procedure was aborted. Pheochromocytoma later was confirmed by elevated plasma catecholamine levels and radiographic studies. The patient was started on ␣-adrenergic blockers and later underwent successful laparoscopic adrenalectomy and aortofemoral bypass. This case shows the importance of a systematic approach to unexplained hemodynamic instability during anesthesia. Pheochromocytoma has been described as a great mimic and may only manifest during induction. Common causes of hemodynamic instability should be ruled out first. Barotrauma can be 250 200 150
Pheochromocytoma Detected During Anesthesia Induction
SBP DBP
100
Mean HR
50
Pheochromocytoma is a rare neuroendocrine tumor of the adrenal gland, with an incidence of 0.05% to 0.2% in hypertensive patients. Symptoms including hypertension, headache,
0 7:54 7:58 8:03 8:04 8:10 8:14 8:18 8:23 8:30 8:35 8:40 8:43 8:47 8:51 8:56 9:00 9:04 9:09 9:20 9:29 9:40 9:42 9:44 9:45
To the Editor:
Fig 1. Hemodynamic instability. (Color version of figure is available online.)
e44
LETTERS TO THE EDITOR
excluded by the absence of an increase in peak airway pressure and normal gas exchange; anaphylaxis, by the absence of bronchospasm and other cutaneous changes; hyperthyroidism, by a lack of significant tachycardia, arrhythmias, and hyperthermia; and carcinoid, by the absence of tricuspid valve involvement on transesophageal echocardiography as well as other typical signs. The decision to abort surgery and investigate the possibility of pheochromocytoma may have been a lifesaver because the mortality of patients undergoing major surgery with unrecognized pheochromocytoma is more than 80%. Vikas Kumar, MBBS Jerry Spivey, MD Mary Arthur, MD Manuel Castresana, MD Department of Anesthesiology Medical College of Georgia Augusta, GA
Fig 1. TEE: midesophageal 4-chamber view showing color Doppler across the bioprosthetic mitral valve with severe regurgitation jet (A). See Video 1. (Color version of figure is available online.)
REFERENCES 1. Siddik-Sayyid SM, Dabbous AS, Shaaban JA, et al: Catastrophic cardiac hypokinesis and multiple-organ failure after surgery in a patient with an undiagnosed pheochromocytoma: Emergency excision of the tumor. J Cardiothorac Vasc Anesth 21:863-866, 2007 2. Heindel SW, Maslow AD, Steriti J, et al: A patient with intracardiac masses and an undiagnosed pheochromocytoma. J Cardiothorac Vasc Anesth 16:338-343, 2002 3. Holldack HJ: Induction of anesthesia triggers hypertensive crisis in a patient with undiagnosed pheochromocytoma: Could rocuronium be to blame? J Cardiothorac Vasc Anesth 21:858-862, 2007 doi:10.1053/j.jvca.2011.05.011
Intraoperative Detection of a Stuck Bioprosthetic Mitral Valve Leaflet Causing Severe Mitral Regurgitation To the Editor: The use of transesophageal echocardiography (TEE) is becoming an essential and integral part of the management during cardiac surgery. Recent practice guidelines from the society of cardiovascular anesthesiologists task force on TEE recommended that for adult patients without contraindication, TEE should be used in all cardiac surgeries (eg, valvular surgeries, both repair as well as replacement).1 TEE is used in repair cases to assess the adequacy of repair and to rule out any valvular stenosis, whereas in valve replacement cases it is used to assess the adequacy of deairing before weaning from cardiopulmonary bypass (CPB) and the prosthetic valve function after coming off CPB. However, debate still persists about its routine use in valve replacement cases particularly in our Indian subcontinent. We present a case of mitral valve replacement in which the use of TEE led to an early diagnosis of a stuck leaflet and prevented a potential fatal complication. A 63-year-old male patient admitted with a diagnosis of triple-vessel coronary artery disease as well as severe mitral
regurgitation (MR). Preoperative transthoracic echocardiography revealed flail posterior mitral leaflet because of ruptured chordae with an ejection fraction of 35% and regional wall motion abnormality. The patient was scheduled to undergo coronary artery bypass graft surgery and mitral valve replacement. He was stabilized using intra-aortic balloon pump support a day before surgery. The patient was induced using a standard opioid-based technique. Intraoperative TEE confirmed the preoperative diagnosis. However, we found moderate MR, which could be caused by the effect of anesthetic drugs and an intra-aortic balloon pump. The mitral valve was replaced using a 27-mm Perimount bioprosthetic mitral valve (Carpentier-Edwards, Irvibe, CA). While preparing to wean from CPB, TEE was performed to assess the adequacy of deairing. Color Doppler was also used to assess bioprosthetic mitral valve function and to see any regurgitant or paravalvular jet. At partial CPB flow, TEE revealed a severe regurgitation jet across the bioprosthetic mitral valve (Fig 1 and Video 1 [supplementary videos are available online]). A detailed transesophageal echocardiographic examination revealed that 1 leaflet of the bioprosthetic valve was immobile leading to severe MR (Figs 2 and 3 and Video 2). The surgeon was informed about the findings. Full-flow CPB was reinstituted immediately to inspect the bioprosthetic mitral valve. Cardioplegia was administered. While inspecting the bioprosthetic MV, a loop of suture was found along the strut of the bioprosthetic valve restricting the mobility of one leaflet, resulting in severe regurgitation. The problem was rectified, and the patient was weaned from CPB on moderate inotropes. The postoperative course was uneventful. An intraoperative stuck mitral valve is a relatively rare but fatal complication after mitral valve replacement. It is reported more commonly with metallic prosthetic valves than bioprosthetic valves. An intraoperative stuck valve can occur because of obstruction by mitral subvalvular apparatus and mechanical obstruction by suture.2 A delay in the detection of a stuck valve may result in myocardial distension, hemodynamic deterioration, and sometimes failure to wean