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DP31: SUCCESSFUL LVAD IMPLANTATION AS DESTINATION THERAPY IN A PATIENT WITH A FUNCTIONAL PHEOCHROMOCYTOMA
David A Rios Pineda1; Manuela Rodriguez Giraldo1; Daniel Buitrago2; Junaid Raja2; Andres Laserna, MD, MSc2
1Icesi University; 2University of Miami
Introduction: Perioperative management of functional pheochromocytoma combined with advanced heart failure requiring left ventricular assist device (LVAD) implantation presents extraordinary challenges. Catecholamine mediated myocardial injury precipitates cardiogenic shock in approximately 11% of pheochromocytoma cases, while traditional 7-14 day alpha blockade protocols may precipitate circulatory collapse in patients dependent on high systemic vascular resistance. Literature regarding LVAD placement with unresected pheochromocytoma is sparse. We present a case of successful durable LVAD implantation as destination therapy in a patient with an incidental, unresected functional pheochromocytoma.
Case Description: A 46 year old man with obesity (BMI 40.9), non-ischemic cardiomyopathy, and Stage D heart failure (LVEF 10–15%, INTERMACS 3) presented for advanced heart failure evaluation. Right heart catheterization confirmed low cardiac output (CI 1.38, PAPi 3.23). Due to obesity, heart transplantation was contraindicated, necessitating LVAD as destination therapy. Abdominal CT incidentally revealed a 2.5 cm right adrenal mass with plasma metanephrines elevated >3× upper limit of normal, confirming functional pheochromocytoma.
Preoperative stabilization included doxazosin 2 mg for seven days. Milrinone was switched to dobutamine to reduce vasoplegia risk. Anesthesia was induced with midazolam, fentanyl, and etomidate, avoiding ketamine and morphine, maintained with sevoflurane and remifentanil. Monitoring included dual arterial lines, pulmonary artery catheter, and transesophageal echocardiography.
HeartMate 3 LVAD implantation was completed following 98 minutes of cardiopulmonary bypass. Despite intratracheal milrinone (25 mcg/kg), weaning attempts revealed refractory hypotension and severe right ventricular dysfunction. Echocardiography demonstrated severe global right ventricle (RV) hypokinesis, RV distension, and volume dependent left ventricle (LV) decompression at LVAD flows of 5 L/min. Given persistent hemodynamic instability (CI 2.0 L/min/m²) despite high dose epinephrine and inhaled nitric oxide, a temporary CentriMag right ventricular assist device (RVAD) with integrated oxygenator was initiated. The patient was transferred to cardiovascular ICU with HeartMate 3 at 5400 rpm and RVAD at 3200 rpm.
The patient was extubated on postoperative day 2. Following echocardiographic confirmation of improved RV function, the RVAD was successfully decannulated on postoperative day 11. The patient was discharged home on hospital day 51, ambulating independently with stable hemodynamics. Outpatient follow up was arranged for durable LVAD management and planned adrenalectomy.
Discussion: This case demonstrates that durable LVAD implantation can be performed in patients with unresected functional pheochromocytoma using abbreviated alpha blockade, meticulous anesthetic selection, and advanced hemodynamic monitoring with readiness for early mechanical RV support. The coexistence of pheochromocytoma and LVAD creates unique hemodynamic challenges: catecholamine surges increase systemic vascular resistance, dramatically reducing centrifugal pump flow and precipitating ineffective LV unloading, while catecholamine induced pulmonary vasoconstriction increases RV afterload, predisposing to RV failure.
By stabilizing the patient with durable LVAD support first, subsequent elective adrenalectomy can be performed under optimized hemodynamic conditions with mechanical circulatory backup. This case challenges traditional perioperative paradigms and suggests that in selected patients, durable LVAD implantation as destination therapy is feasible despite the presence of an unresected functional pheochromocytoma.
