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.