Case Report:
A 28-year old female was admitted to our Hospital with ventricular
arrhythmia, hypotension and respiratory failure secondary to pulmonary
oedema. Blood pressure was 70 ⁄ 40 mmHg with heart rate being 130 beats
/ min and significant ST elevation in V1-V3 leads. Despite inotropic and
vasoconstrictor support (noradrenaline 0.05 μg/kg/min and dobutamine 10
μg/kg/min), the echocardiogram revealed a poor biventricular function
(left ejection fraction [EF] < 25%). Blood test
documented elevated troponin-I levels (54,7 ng/mL). Because of the
worsening hemodynamic instability and metabolic acidosis, mechanical
ventilation was started and a V-A ECMO device was implanted through the
surgical cannulation of the right femoral artery (Return, 17 French
BIO-MEDICUS TM cannula) and the right femoral vein
(Access, 21 French Multi–Stage BIO-MEDICUS cannula).
A 9 French reperfusion cannula was distally inserted in the main femoral
artery to prevent limb ischemia. Therefore, the unloading of the LV was
obtained by inserting an IMPELLA-CP, through the left femoral artery. A
trans-aortic 2,5 L/m flow was obtained. Heparin was continuously
administrated to maintain activated clotting time between 150 and 200
sec. An emergency coronary angiography detected patent coronary
arteries. An endomyocardial biopsy was also performed to exclude acute
myocarditis. The urinary catecholamine levels were several times higher
than normal; Epinephrine 2980 µg/day (normal range2-14 µg/day);
Norepinephrine 3876 µg/day (normal range 230-120 µg/day); Homovanillic
acid 75 mg/day (normal renage <15 mg/day); Vanilmandelic acid
85,5 mg/day (normal range<8 mg/day). A subsequent abdominal
computed tomography revealed the presence of a 5 cm nodular lesion
within the left adrenal gland [Fig. 1], highly suggestive for the
diagnosis of pheochromocytoma. A pharmacological therapy comprehensive
of alpha- and beta-blockade was therefore started. A very fast recovery
was observed and the weaning from ECMO was started after only 24 hours
of full support; the patient was discontinued from ECLS on day 4. The
IMPELLA-CP was then switched to 1,5 L/m flow, on day 5. On day 6, it was
safely removed [Fig 2] and a completely recovery of EF was
assessed by echocardiographic evaluation (EF > 60%). The
patient underwent adrenalectomy 3 weeks after the initial emergency
presentation and the histological examination confirmed the diagnosis of
pheochromocytoma. The post-procedural course was uneventful and
10 days later the patient was discharged from our department.