2 CASE REPORT
A 53-year-old male was admitted after occurrence of dyspnea for two weeks and repeated transient cerebral ischemic attacks of right hemiplegia occurred over a 4-day period. The patient was extremely obese, with body weight of 130 kg and BMI of 44.2. He was prescribed immunosuppressive medication for pyoderma gangrenosum and had type 2 diabetes mellitus, hypertension, sleep apnea syndrome, and history of ablation. Blood pressure (BP) was 133/92 mm Hg, pulse was 119/minute, and respiratory rate was 30/minute with an O2 saturation of 94% via nasal cannula at 3 L/minute. Chest radiography findings showed pulmonary congestion. Transthoracic echocardiography revealed a 2.7×9-mm mobile mass on the noncoronary cusp of the aortic valve, which initiated IE. Based on mobile mass with neurological dysfunction and heart failure progression, there was no time to wait and an emergency AVR was performed.
Upon admission to the operating room, BP was 200/103 mmHg, then rose during endotracheal suction to 342/167 mmHg in association with sinus tachycardia at 105/minute (Figure 1). Initially, improper medication administration was suspected and all medications were replaced, though hypertensive crisis recovery was not obtained. We decided to continue the operation because of heart failure progression and neurological complications. However, even with administration of routine anti-hypertensive drugs (nitroglycerin, nicardipine), a steady hemodynamic condition was difficult to maintain due to repeated BP elevation and the hypertensive crisis continued after initiation of cardiopulmonary bypass (CPB). It was then noted that a retroperitoneal mass had been seen at a previous hospital examination, which led us to suspect a pheochromocytoma (Figure 2A) and an intermittent intravenous infusion of phentolamine was started. After finishing the AVR procedure, CPB was weaned with intravenous phentolamine and phenylephrine for stabilization of BP, with a continuous infusion of both phentolamine and norepinephrine needed at the end of the operation. Vegetation was noted on the left-ventricular side of the noncoronary cusp. A 25-mm mechanical valve (Masters 25-mm prosthesis, Abbott St. Jude Medical, St. Paul, USA) was implanted in an intra-annular position.
In the early postoperative period, noradrenaline combined with phentolamine was still required, due to intermittent hypotension, then after discharge from the intensive care unit antihypertensive medication was stopped due to continued orthostatic hypotension symptoms. A close examination for possible pheochromocytoma was performed one month after the operation by an endocrinologist, which showed urinary metanephrine plus normetanephrine at 4.2 mg/day (reference 0.15-0.41 mg/day) and free noradrenaline at 343 μg/day (31-160 μg/day). Additionally,123I-metaiodobenzylguanidine scintigraphy revealed abnormal accumulation in the left adrenal gland (Figure 2B) and a diagnosis of pheochromocytoma was confirmed. After six weeks of antimicrobial treatment, the patient was transferred to a rehabilitation hospital (postoperative day 56) and scheduled for adrenalectomy after recovery of general condition.