Endocrine Abstracts

Introduction: Catecholamine-induced cardiomyopathy (CIC) is a stress-induced heart dysfunction caused by excessive catecholamines. It often presents insidiously, as left ventricular dysfunction without significant obstructive coronary artery disease. Patients presenting with dilated cardiomyopathy and heart failure should be screened for phaeochromocytoma. Adrenalectomy remains the gold standard treatment in patients with CIC with intraoperative mortality of 4% versus 22% with conservative management.

Case details: A 57-year-old man with established hypertension and dilated cardiomyopathy presented following a fall and was noted to have a heterogenous 4 cm adrenal lesion on CT imaging. Biochemical testing revealed plasma metadrenaline 7 times upper normal limit (3379pmol/l) consistent biochemically with phaeochromocytoma, later confirmed by MIBG. Cardiac assessment revealed significant systolic and diastolic dysfunction with ejection fraction (EF) of 10%. Reversing Atrial Fibrillation (AF) with amiodarone allowed adequate alpha-blockade using doxazosin, though EF remained unchanged. The profound cardiac impairment initially led the first adrenal multiple multidisciplinary team (MDT) to deem him unfit for adrenalectomy. However, this decision was challenged by the endocrinologist prompting further MDT discussions including Cardiology, Surgery, ITU, Anaesthesiology and Endocrinology, which ultimately supported proceeding at a tertiary centre. Surgery was preplanned by cardiac intensivists and anaesthetists with extracorporeal membrane oxygenation (ECMO) on standby and potential escalation to cardiac transplant. He underwent open adrenalectomy with complete pheochromocytoma resection without surgical complications. At eight weeks post-surgery catecholamines normalised and EF improved to 20%. Six-month follow-up ECHO is awaited. Genetic testing for causes of cardiomyopathy/phaeochromocytoma were negative.

Summary: Surgery remains the definitive treatment for pheochromocytoma, though often limited by frailty, comorbidities, and surgical risk. This case showed improvement in CIC following adrenalectomy. Surgery should be pursued when feasible, even with severe cardiac impairment, utilising an MDT approach at a specialised tertiary centre. Even in the absence of post operative improvement in cardiac function, adrenalectomy may enable cardiac transplantation.