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Images and Case Reports in Heart Failure

What a Headache

Rare Neuroendocrine Indication for Cardiopulmonary Bypass for Severe Left Ventricular Dysfunction and Shock

James D. Newton, MBChB, MRCP; Shahzad Munir, BSc, MBChB, MRCP; Ravinay Bhindi, MBBS, PhD, FRACP, FESC and Oliver Ormerod, DM, FRCP

From the Department of Cardiology, John Radcliffe Hospital, Oxford, UK.

Correspondence to James Newton, MBChB, MRCP, Department of Cardiology, John Radcliffe Hospital, Headington, Oxford, OX3 9DU, UK. E-mail jdn1@le.ac.uk

An extract of the first 250 words of the full text is provided, because this article has no abstract.

	Introduction

 
A 45-year-old male presented with 2 days of nausea, sweating, and abdominal pain. Examination revealed tachycardia, hypertension, diaphoresis, widespread crepitations, and diffuse abdominal tenderness. Profound hypotension developed, despite intravenous fluids, and was treated with noradrenaline and dobutamine; hypoxia required endotracheal intubation, followed by chest radiograph, which demonstrated extensive pulmonary edema. Echocardiography revealed severe global left ventricular systolic impairment, with an estimated ejection fraction of only 10% (Data Supplement Movies I and II). The patient was transferred to our hospital for the consideration of intraaortic balloon counterpulsation or left ventricular assist device support or both. An intraaortic balloon pump was inserted, and inotropic support was changed to adrenaline with modest improvement. Examination revealed a large mobile nonpulsatile mass in the left paraumbilical region, confirmed as a paraganglionoma on computed tomography (Figure 1). -Blockade with phentolamine was commenced because an irreversible agent, such as phenoxybenzamine, was unsuitable in an unstable patient. Unopposed -blockade resulted in severe reflex tachycardia, and β-blockade with intravenous esmolol precipitated critical hypotension. Recurrent atrial fibrillation and worsening pulmonary edema indicated that the patient was unlikely to survive with conservative treatment; yet, the risks of conventional surgical resection without autonomic blockade were considered prohibitive. The only option for a successful outcome was to provide the patient with an artificial circulation and remove the tumor. Femoro/femoral bypass was rejected as this form of support would be unable to provide for the potential need for very high flow rates. The patient underwent cardiopulmonary bypass following a midline sternotomy. The . . . [Full Text of this Article]