Surgical anesthesia in a patient with a pheochromocytoma crisis supported by ECMO：A Case Report

Surgical anesthesia in a patient with a pheochromocytoma crisis supported by ECMO：A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Surgical anesthesia in a patient with a pheochromocytoma crisis supported by ECMO：A Case Report minjuan chen, wei yan, zhihai yang, tao hong, lingling jin, donghang Cao This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4835108/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 20 Dec, 2024 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted 20 You are reading this latest preprint version Abstract Pheochromocytoma is rare in the clinic, and patients with pheochromocytomas mainly present with headache, high blood pressure and sweating. Patients who develop a pheochromocytoma crisis are particularly rare. This report describes the case of a patient in a pheochromocytoma crisis who presented with severe cardiogenic shock, acute respiratory failure, and acute coronary syndrome, who ultimately underwent surgery under general anesthesia with the support of ECMO, and who was discharged healthy. Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Pheochromocytoma is a rare endocrine tumor in which the adrenal medulla or paraganglia pheochromocytoma cells secrete large amounts of catecholamines, and the typical clinical manifestations are persistent or flareup hypertension, severe headache, palpitations and excessive hormone-induced sweating. However, in clinical practice, the symptoms of pheochromocytoma are easily confused with those of other diseases, leading to a misdiagnosis or a missed diagnosis by clinicians, and the risk of death is very high once the optimal treatment time is missed. Clinical data The patient was a 64-year-old female. The patient was healthy and had no previous history of heart disease, hypertension, diabetes, etc. She was admitted to the hospital at 16:50 on November 9, 2023, complaining of "palpitations accompanied by nausea and vomiting for 1 day and dyspnea for 20 hours". One day prior, the patient suddenly experienced heart palpitations with radiating pain in both lower limbs without obvious inducement and was treated in a local hospital. Enhanced abdominal CT revealed that "the left adrenal area is occupied by a rich blood supply, in which a pheochromocytoma should be considered", and no special treatment was given. At 17:00 on the same day, the patient suddenly experienced nausea and vomiting, chest tightness and obvious shortness of breath, headache and dizziness, and the staff of the local hospital considered the diagnosis of a "myocardial injury". Routine blood tests revealed the following: troponin-I (24.998 ng/ml), BNP (1806 ng/ml), and lactic acid (9.0 mmol/L). Lung CT indicated the presence of “diffuse exudative changes in both lungs,” indicating diffuse pulmonary edema in both lungs. Acute left heart failure was diagnosed, and no significant improvement was observed after 40 mg of furosemide was given as an intravenous diuretic medication and 5 mg of morphine was given as an intravenous pain medication. The patient gradually became confused, her oxygenation was difficult to maintain, and assisted ventilation with a tracheal intubation ventilator was performed. CT examination of the head and chest indicated the following: "Ischemic changes in both lateral ventricles and the hemi-oval center. Diffuse exudative changes in both lungs indicating pulmonary edema in both lungs”. It was difficult to maintain the stability of the patient’s circulatory system after administering large doses of vasoactive drugs, so the patient was transferred to our hospital for further treatment. The patient was admitted to the ICU of our hospital through the outpatient department with the following characteristics: 1. pheochromocytoma, 2. shock, 3. acute heart failure, and 4. acute respiratory failure. After admission, the patient's body temperature was 38.7°C, her heart rate was 148 breaths/min, her respiration rate was 20 breaths/min, and her blood pressure was 108/68 mmHg (epinephrine at 1.5 µg/kg/min and norepinephrine at 1.2 µg/kg/min were continuously pumped). With ventilator support treatment, her blood oxygen saturation was 93% (the oxygen concentration was 100%), and her consciousness was not clear. The pupils on both sides were abnormally large, with a diameter of approximately 2.5 mm on the left side and 2 mm on the right side. The pupillary light reflexes on both sides had disappeared, she had decreased breathing sounds in both lungs, and wet rales were heard in both lungs. Blood gas analysis and blood tests revealed the following: pH, 7.27; plasma lactate, 10.5 mmol/L; bicarbonate concentration, 14.4 mmol/L; oxygen partial pressure, 65 mmHg; oxygenation index, 65 mmHg; white blood cell count, 26.51×109/L; neutrophil count, 91.4%; NT proBNP, 14079 pg/ml; glucose, 26.02 mmol/L; creatinine, 233 µmol/L; alanine aminotransferase, 751 U/L; aspartate aminotransferase, 951 U/L; free methoxynorepinephrine, 15511.60 ng/L; free methoxyepinephrine, 4205.70 ng/L; and free metoxyadrenaline substance, 18717.30 ng/L. A bedside color Doppler ultrasound indicated "left ventricular enlargement; reduced left cardiac function, and an LVEF, of 20%”. The diagnoses based on the findings of the electrocardiogram were as follows: "1; sinus tachycardia (heart rate, 145 beats/min), 2; frequent atrial premature beats, 3; lambda waves, 4, indoor block, 5; and ST-T changes". The admission diagnoses were as follows: "1, cardiogenic shock 2, acute respiratory failure 3, acute coronary syndrome 4, pheochromocytoma 5, sepsis 6, acute liver insufficiency, and 7, acute renal insufficiency". At 19:45 on November 9, due to severe cardiogenic shock, the patient underwent EMCO catheter insertion through the right femoral vein-left femoral artery route. The EMCO rotation speed was 3300 rpm, the flow rate was 3.0 L/min, the inhaled oxygen concentration was 100%, and the respirator inhaled oxygen concentration was 50%. A protective lung ventilation strategy was implemented, which included the setting of a small tidal volume of 6 ml/kg. When PEEP was set with optimal oxygen therapy, the patient’s percutaneous oxygen saturation increased to 98%. Coronary angiography at 23:20 showed that the LM, LAD, LCX and RCA were normal. The patient’s vital signs were maintained with the support of ECMO, but the patient still needed a constant rate infusion of 0.25 µg/kg/min norepinephrine to maintain circulation after symptomatic treatment, such as stomach protection, kidney protection, anti-shock therapy and anti-infection therapy. Considering that surgical resection of the tumor or subtumor embolization was the best means of treatment at this stage, a multidisciplinary consultation was conducted on November 18, 2023. After full communication with her family, she decided to undergo an emergency laparoscopic resection of the left adrenal pheochromocytoma. On the same day, the patient was taken to the operating room with the support of EMCO. When entering the room, the EMCO speed was 3300 rpm, the flow rate was 3.0 L/min, the inhalation oxygen concentration was 100%, the norepinephrine dose rate was 0.4 µg/kg/min, the epinephrine dose rate was 0.05 µg/kg/min, the invasive blood pressure was 76/45 mmHg, and the heart rate was 113 beats/min. The patient’s blood pressure, heart rate, pulse oxygen saturation, body temperature, and exhaled fraction of carbon dioxide were routinely monitored; her cardiac displacement, central venous pressure, and cerebral oxygen saturation were continuously monitored via the radial artery; and her cardiac function and volume status were monitored in real time by transesophageal cardiac ultrasound. After anesthesia induction, the blood pressure in the moving position increased to 162/87 mmHg, and the patient received 0.5% sevoflurane as an inhalant, as well as 120 mg/h propofol and 400 µg/h remifentanil using micropumps, to maintain anesthesia. The operation lasted for 4 hours, the cumulative blood loss was 1000 ml, and a total of 800 ml of red blood cell suspension and 910 ml of fresh frozen plasma were transfused. In the operating room, her blood pressure was 115/78 mmHg, and her heart rate was 89 beats/min. She was transferred to the ICU for further treatment. Pathology confirmed that the patient had a pheochromocytoma, and the postoperative circulation of the patient tended to be stable. The ECMO tube was removed on the second day after surgery, and the patient received two bedside alveolar lavages. After anti-infective treatment, the tracheal catheter was removed on the tenth day after surgery, and she was transferred to a general ward.(Figure 2 , Fig. 3 ). Discussion Pheochromocytoma and paraganglium tumors (PPGLs) are rare endocrine tumors characterized by the secretion of catecholamines. PPGLs store a large amount of catecholamines, and some patients have a tumor content of more than 3 million pg/g of catecholamines. When catecholamines are released into the blood, the plasma catecholamine concentration increases by approximately 1000 times. Almost 80% of pheochromocytomas originate from the adrenal medulla, while only 10%-15% of tumors originate from outside adrenal tissues [ 1 , 2 ]. The paragangliomas originating from outside the adrenal glands are mostly nonfunctional parasympathetic ganglia and functional catecholamine-secreting sympathetic ganglia [ 3 ]. Pheochromocytomas can be divided into three main molecular clusters, among which Krebs cycle/VHL/EPAS1-related tumors are characterized by mainly norepinephrine-secreting phenotypes and are more prone to metastasis and recurrence; therefore, they require close follow-up. The tumors associated with kinase signaling are mainly tumors with adrenaline-secreting phenotypes, which are usually not serious. At present, a few phenotypes related to Wnt signaling have been detected in clinical studies, and further studies are needed to investigate their correlation [ 4 ]. The typical clinical manifestations of pheochromocytoma are headache, increases in blood pressure caused by peripheral vascular contraction due to the binding of catecholamines with vascular α receptors, a rapid heart rate, and sweating caused by stimulation of β adrenergic receptors. Among these manifestations, seizures, hypertension, palpitations, syncope, anxiety and hyperglycemia are more common in pheochromocytoma patients who have tumors that secrete adrenaline. Headache, sweating, and persistent hypertension are more commonly associated with norepinephrine-secreting PPGLs[ 5 ]. However, there are also several extreme clinical manifestations, such as cardiogenic shock, catecholamine cardiomyopathy, and acute coronary syndrome, that can manifest in patients with PPGLs. These extreme cases are often related to the neglect of the condition by doctors and patients [ 6 ]. The manifestations of the case in this report were also due to the failure of doctors and the patient to pay enough attention to the findings during the first visit, resulting in the delay of the condition and the optimal treatment opportunity to be missed. PPGL hypercatecholamine-induced cardiomyopathy is very rare (8%-11%) and can be fatal when it occurs. It is the leading cause of preoperative death in patients with PPGLs and is most commonly observed in patients with adrenal pheochromocytoma (approximately 90%). Excessive catecholamines can directly irritate and eventually damage the heart (causing cardiac diseases such as myocarditis) and the vascular system (causing vascular diseases such as coronary artery vasoconstriction leading to myocardial infarction), regardless of the severity of hypertension [ 2 ]. This patient had no previous history of hypertension, and her life-threatening acute cardiomyopathy was caused by the massive secretion of catecholamines by the pheochromocytoma, consistent with the case descriptions in the literature. Pheochromocytoma cardiomyopathy can be acute or chronic. The most common type of acute PPGL cardiomyopathy is Takotsubo syndrome, which is characterized by arterial vasoconstriction causing severe left ventricular dysfunction [ 5 ], while patients with chronic disease mainly exhibit dilated or hypertrophic cardiomyopathy [ 7 ]. Patients with acute stress cardiomyopathy (Takotsubo type) may have a normal ECG (11%), ST/T wave changes (39%), ST segment elevations (39%), a transient left bundle branch block (4%), or arrhythmias (atrial tachycardia, heart block, and ventricular arrhythmia) (7%) [ 8 ]. Upon admission, the electrocardiogram of the patient of this case indicated sinus tachycardia, frequent atrial premature beats, lambda waves, indoor block, and ST-T changes. Color Doppler ultrasound indicated left ventricular enlargement and reduced left cardiac function. The LVEF being 20%; the clinical manifestations of acute left heart failure, which have many similarities with Takotsubo cardiomyopathy, and the absence of significant coronary artery abnormalities indicated by coronary angiography further confirmed that the patient had acute PPGL cardiomyopathy. The rapid and massive secretion of catecholamines by a pheochromocytoma leads to paroxysmal or persistent hypertension, which can damage the whole body's organ functions. In this case, the electrocardiogram and myocardial enzyme spectrum of the patient were abnormal. However, coronary angiography showed no obvious abnormalities, the myocardial enzyme levels significantly decreased after surgery, and the previous increase in the patient’s myocardial enzyme levels before surgery may have been caused by the coronary artery constriction induced by catecholamines. Acute PPGL cardiomyopathy is caused by temporary myocardial ischemia [ 9 ] and must be distinguished from organic coronary atherosclerotic heart disease. In a retrospective study, increased platelet count and a cosecretion pattern were found to be independent risk factors for cardiovascular complications in PPGL patients. Most PPGL patients mainly secrete norepinephrine, but cosecretion occurs mainly in patients with coexisting cardiovascular complications. In addition to intravascular volume depletion, other sequelae that can occur in PPGL patients are sudden cessation of catecholamine secretion due to tumor necrosis, adrenal receptor desensitization, and hypocalcemia because these tumors normally secrete adrenaline, and these may also lead to hypotension and shock [ 10 ]. According to a multivariate regression model based on 200 studies, nausea or vomiting are not typical clinical manifestations of pheochromocytoma but are associated with increased mortality, but there has been no significant difference in mortality between severe hypertension patients and those without severe hypertension [ 11 ]. In this case, nausea and vomiting at the early stage of the disease also indicate a poor prognosis and a high risk of death. Therefore, the author hopes to share the details regarding the successful treatment of this patient via this case report. The author believes that the successful treatment and good prognosis of this patient are closely related to the support of ECMO technology. The use of extracorporeal membrane oxygenation (ECMO) is increasing worldwide, with 48% of these patients requiring noncardiac surgery, which creates new challenges for both surgeons and anesthesiologists. Adequate preoperative preparation and evaluation are the keys to ensuring the smooth operation of anesthesia. The ECMO parameters should be accurately recorded to evaluate the patient's coagulation function and to determine whether there are complications. In this case, the induction of anesthesia may only require a small amount of anesthetic drugs, and intravenous anesthesia should be the first choice for anesthesia maintenance. Monitoring of the intraoperative anesthetic depth and echocardiographic monitoring are also necessary. For patients receiving ECMO support, a negative fluid balance should usually be maintained. Volumetric therapy may be considered unless massive acute blood loss is accompanied by a decrease in the pulse oxygen saturation. In this case, volume management itself is difficult. Considering the characteristics of pheochromocytomas, preoperative dilatation is needed in these patients. If the volume is insufficient, the patient’s circulation may be difficult to maintain after tumor removal. However, in this case, the patient's cardiac function was significantly reduced, her LVEF was 20%, and the diagnosis of PPGL cardiomyopathy was clear. An excessive volume load can burden the heart and further aggravate myocardial damage. Therefore, under real-time transesophageal echocardiography monitoring, we chose to supplement the appropriate volume and administer the positive inotropic drug epinephrine to regulate the patient’s blood pressure and maintain satisfactory perfusion. It has also been suggested that in ECMO-supported patients, the use of "ultra-protective ventilation" to set VT to a predicted body weight of less than 4 ml/kg and a P Plat of less than 25 cmH2O can reduce pulmonary edema, the inflammatory marker levels and VILI. Due to the absence of anticoagulation therapy in patients receiving perioperative ECMO, the amount of membrane clot formation by the oxygenator will increase, and the membrane function will decrease. Therefore, oxygenator replacement should be considered before surgery [ 12 ]. The successful treatment of this patient confirms the importance of ECMO in the clinical management of a pheochromocytoma crisis and provides a new idea for the future treatment of pheochromocytoma crises. At present, surgical resection of the tumor is the main treatment method for PPGLs. In this case, the respiratory circulation of the patient tended to be stable after tumor resection, all indicators returned to normal, and the patient had a steep decrease in her catecholamine levels after tumor resection (Fig. 4). Studies have shown that 15%-25% of patients still have a poor prognosis due to postoperative metastasis. At present, there are many methods for predicting the metastasis and recurrence of pheochromocytoma, but they are not consistent. Currently, experts and scholars agree that the proliferation of cells expressing Ki 67 (> 3%-5%) and mutations of the succinate dehydrogenase gene (SDHB) are strongly correlated with the metastasis and recurrence of pheochromocytoma [ 13 ]. The pathological outcome of this patient was Ki-67 (5%+), and genetic testing was of great significance for this patient. However, this patient refused to undergo genetic testing, and close follow-up of this patient is necessary to prevent recurrence. Conclusion We report an extremely rare case of a pheochromocytoma crisis complicated by catecholamine cardiomyopathy. This patient was admitted to the hospital with a cardiogenic shock LVEF of 20%, difficulty in maintaining oxygenation, the need for ECOM to maintain life, and a large increase in her plasma levels of norepinephrine and epinephrine, and she received intubation with ventilator-assisted ventilation. After the primary lesion was removed under ECOM maintenance, the patient's vital signs were stable, and her cardiac function returned to normal. Her postoperative LVEF was 57%. However, this type of tumor has a risk of metastasis and recurrence, and based on the pathological classification of the patient's tumor, it is recommended that the patient undergo genetic testing and have close long-term follow-up. Shortcomings There are two deficiencies in the handling of this case. First, this patient’s hormone levels, cardiac function, genetic factors, and imaging findings should have been carefully evaluated before she underwent elective pheochromocytoma resection. Adequate preoperative preparation is necessary, as catecholamines may be released in large amounts during anesthesia induction, endoscopic pneumoperitoneum establishment, and tumor resection, and patients may develop severe hypertension and cardiovascular complications during the perioperative period [ 14 ]. Alpha-adrenergic blockers should be used for at least 7 14 days (when alpha-blockers cannot effectively control the patient’s blood pressure). In addition to the use of calcium channel blockers, the treatment should also consist of the inhibition of clinical symptoms caused by a functional PPGL, restoration of the patient’s intravascular blood volume loss after alpha-adrenergic receptor blockade through a high-salt diet and fluid intake (1000–2000 ml/day), and strict control of the patient's blood pressure and heart rate. Also, the patient’s blood pressure should be stable and below 140/90 mmHg before surgery. The optimal heart rate is 60–70 beats/min when sitting and 70–80 beats/min when standing [ 11 , 15 , 16 ]. Because beta-blockers tend to cause catecholamine overdose thus leading to hypertensive crises, beta-blockers should not be used as first-line therapy and should only be used for the treatment of tachycardia in PPGL patients [ 16 ]. However, due to the urgent change in this patient's condition, there were only 9 days from hospitalization to surgery, and no formal preoperative preparation was carried out. Therefore, the perioperative management of this patient was highly limited, and the patient’s circulation fluctuated sharply, which may have caused potential harm to the patient. Second, the choice of treatment, especially whether to surgically resect the tumor or intervene with the use of subtumor embolization, is worthy of further discussion. This hospital is a prefecture city hospital that lacks experience in interventional tumor embolization, so laparoscopic tumor resection was the only option in this case. However, laparoscopic surgery requires changing the body position, injecting a certain amount of carbon dioxide to maintain a pneumoperitoneum, and inducing hypercapnia after carbon dioxide absorption to further stimulate the release of hormones from the tumor mass. These can all bring further challenges for the perioperative management of these patients. Table 1 Blood gas analysis values of the patient at different time points Glucose(mmol/L) Ph PaCO 2 (mmHg) PaO 2 (mmHg) PaO 2 /FiO 2 (mmHg) BE(mmol/L) Lac(mmol/L) FiO 2 (%) At admission 24.9 7.27 32 65 65 -11.3 10.5 100 Before the operation 6.7 7.46 37 149 373 1.8 0.9 40 During the operation 9.5 7.382 40.7 291.6 296 -1.4 1.66 100 15 days after surgery 5.4 7.42 42 146 355 1.8 0.7 40 Declarations Acknowledgements We thank AJE (www.aje.cn) for its linguistic assistance during the preparation of this manuscript. Availability of data and materials Data archiving is not mandated but data will be made available upon reasonable request. Authors’ contributions All authors contributed to the writing of the manuscript and read and approved the final manuscript. Funding None. Ethics approval and consent to participate The research was prospectively reviewed and approved by Zhejiang Taizhou Hospital , China. . This study was approved by Ethics Committee of Zhejiang Taizhou Hospital [No.KL20240110], and all participants provided written informed consent Consent for publication Not applicable. Competing interests All authors declare no conflict of interest. Author details 1 Zhejiang Taizhou Hospital , China 1 Zhejiang Taizhou Hospital , China 2 Zhejiang Taizhou Hospital , China 3 Zhejiang Taizhou Hospital , China 4 Zhejiang Taizhou Hospital , China References Tarling JA, Kumar R, Ward LJ, Boot C, Wassif WS. Phaeochromocytoma and paraganglioma. J Clin Pathol. Published online March 7, 2024. 2023-209234 Nazari M A, Hasan R, Haigney M, Maghsoudi A, Lenders J W M, Carey R M,Pacak K. Catecholamine-induced hypertensive crises: current insights and management. The Lancet Diabetes & Endocrinology. 2023; 11(12):942-954. Tănăsescu M-D, Popescu Ș, Mincă A, Isac T, Suliman E, Grigorie M M, Suliman E, Stăniloaie D, Timofte D,Ionescu D. Paragangliomas and Anemia: Literature Review and Case Report. Medicina. 2023; 59(11). Nölting S, Bechmann N, Taieb D, et al. Personalized Management of Pheochromocytoma and Paraganglioma [published correction appears in Endocr Rev. 2021 Dec 14;:] [published correction appears in Endocr Rev. 2021 Dec 14;:]. Endocr Rev. 2022;43(2):199-239. Sharma S,Fishbein L. Diagnosis and Management of Pheochromocytomas and Paragangliomas: A Guide for the Clinician. Endocrine Practice. 2023. Anyfanti P, Mastrogiannis Κ, Lazaridis Α, Tasios Κ, Vasilakou D, Kyriazidou Α, Aroutsidis F, Pavlidou O, Papoutsopoulou Ε, Tiritidou A, Kotsis V, Triantafyllou Α, Zarifis Ι, Douma S,Gkaliagkousi Ε. Clinical presentation and diagnostic evaluation of pheochromocytoma: case series and literature review. Clinical and Experimental Hypertension. 2022; 45(1). Szatko A, Glinicki P,Gietka-Czernel M. Pheochromocytoma/paraganglioma-associated cardiomyopathy. Frontiers in Endocrinology. 2023; 14. Dawson D K. Acute stress-induced (takotsubo) cardiomyopathy. Heart. 2018; 104(2):96-102. Ma X, Chen Z, Xia P, Zhang C, Yan K, Fan Y, Wang Y, Ti Y,Bu P. Giant Paraganglioma Complicated With Catecholamine Crisis and Catecholamine Cardiomyopathy: A Case Report and Review of the Literature. Frontiers in Endocrinology. 2022; 12. Zhao L, Meng X, Mei Q, Fan H, Liu Y, Zhou X, Zhu H,Zhang S. Risk Factors for Cardiac Complications in Patients With Pheochromocytoma and Paraganglioma: A Retrospective Single-Center Study. Frontiers in Endocrinology. 2022; 13. Ando Y, Ono Y, Sano A, Fujita N, Ono S,Tanaka Y. Clinical characteristics and outcomes of pheochromocytoma crisis: a literature review of 200 cases. Journal of Endocrinological Investigation. 2022; 45(12):2313-2328. Fierro MA, Daneshmand MA, Bartz RR. Perioperative Management of the Adult Patient on Venovenous Extracorporeal Membrane Oxygenation Requiring Noncardiac Surgery. Anesthesiology. 2018;128(1):181-201. Wang Y, Li M, Deng H, Pang Y, Liu L, Guan X. The systems of metastatic potential prediction in pheochromocytoma and paraganglioma. Am J Cancer Res. 2020;10(3):769-780. De Filpo G, Parenti G, Sparano C, Rastrelli G, Rapizzi E, Martinelli S, Amore F, Badii B, Paolo P, Ercolino T, Mannelli M, Maggi M,Canu L. Hemodynamic parameters in patients undergoing surgery for pheochromocytoma/paraganglioma: a retrospective study. World Journal of Surgical Oncology. 2023; 21(1). Chen J, Jin G, Zhu Y, Hu W, He H, Wang C,Cai X. The importance of perioperative and complication management in the treatment of pheochromocytoma crisis with venoarterial extracorporeal membrane oxygenation (V-A ECMO): a case report and review of the literature. Perfusion. 2021; 38(2):228-235. Utsumi T, Iijima S, Sugizaki Y, Mori T, Somoto T, Kato S, Oka R, Endo T, Kamiya N,Suzuki H. Laparoscopic adrenalectomy for adrenal tumors with endocrine activity: Perioperative management pathways for reduced complications and improved outcomes. International Journal of Urology. 2023; 30(10):818-826. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 20 Dec, 2024 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted Editorial decision: Revision requested 15 Sep, 2024 Reviews received at journal 03 Sep, 2024 Reviews received at journal 01 Sep, 2024 Reviews received at journal 01 Sep, 2024 Reviews received at journal 30 Aug, 2024 Reviewers agreed at journal 28 Aug, 2024 Reviewers agreed at journal 28 Aug, 2024 Reviews received at journal 27 Aug, 2024 Reviews received at journal 26 Aug, 2024 Reviewers agreed at journal 25 Aug, 2024 Reviewers agreed at journal 25 Aug, 2024 Reviewers agreed at journal 23 Aug, 2024 Reviewers agreed at journal 23 Aug, 2024 Reviewers agreed at journal 23 Aug, 2024 Reviewers agreed at journal 23 Aug, 2024 Reviewers agreed at journal 23 Aug, 2024 Reviewers invited by journal 23 Aug, 2024 Editor assigned by journal 01 Aug, 2024 Submission checks completed at journal 01 Aug, 2024 First submitted to journal 31 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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11:32:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4835108/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4835108/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13019-024-03177-w","type":"published","date":"2024-12-20T15:58:04+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":64009083,"identity":"daaafb1e-731a-4b22-97f0-4bed3d3841cb","added_by":"auto","created_at":"2024-09-04 23:11:41","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":793992,"visible":true,"origin":"","legend":"\u003cp\u003eAn 18-lead electrocardiogram of the patient upon admission\u003c/p\u003e","description":"","filename":"FigureI.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4835108/v1/8c149bc8d572ede9ec2fa3b2.jpg"},{"id":64009084,"identity":"4decb35c-db24-4d42-b6b7-955543df25ed","added_by":"auto","created_at":"2024-09-04 23:11:41","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":495768,"visible":true,"origin":"","legend":"\u003cp\u003eH\u0026amp;E staining and immunohistochemistry of the tumors\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4835108/v1/7332d62e8e4dd284aa04d039.jpg"},{"id":64009085,"identity":"814afacf-7e44-4704-a218-87a6e4adf7d9","added_by":"auto","created_at":"2024-09-04 23:11:41","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":162099,"visible":true,"origin":"","legend":"\u003cp\u003ea Preoperative abdominal CT image and b postoperative abdominal CT image\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4835108/v1/0d99704652c94a091e6b41c5.jpg"},{"id":64009086,"identity":"ebaea88c-702e-41c8-9a0d-2b704d753d92","added_by":"auto","created_at":"2024-09-04 23:11:42","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":378596,"visible":true,"origin":"","legend":"\u003cp\u003eChanges in the catecholamine hormone test results at different time points\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4835108/v1/0fdf551d7277469826187ef1.jpg"},{"id":72201938,"identity":"38522d74-0ec4-4011-a52e-bbd06e3ae40b","added_by":"auto","created_at":"2024-12-23 16:12:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2192989,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4835108/v1/bc7fc2bb-edeb-4183-b7df-788629b36b9e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Surgical anesthesia in a patient with a pheochromocytoma crisis supported by ECMO：A Case Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePheochromocytoma is a rare endocrine tumor in which the adrenal medulla or paraganglia pheochromocytoma cells secrete large amounts of catecholamines, and the typical clinical manifestations are persistent or flareup hypertension, severe headache, palpitations and excessive hormone-induced sweating. However, in clinical practice, the symptoms of pheochromocytoma are easily confused with those of other diseases, leading to a misdiagnosis or a missed diagnosis by clinicians, and the risk of death is very high once the optimal treatment time is missed.\u003c/p\u003e"},{"header":"Clinical data","content":"\u003cp\u003eThe patient was a 64-year-old female. The patient was healthy and had no previous history of heart disease, hypertension, diabetes, etc. She was admitted to the hospital at 16:50 on November 9, 2023, complaining of \"palpitations accompanied by nausea and vomiting for 1 day and dyspnea for 20 hours\". One day prior, the patient suddenly experienced heart palpitations with radiating pain in both lower limbs without obvious inducement and was treated in a local hospital. Enhanced abdominal CT revealed that \"the left adrenal area is occupied by a rich blood supply, in which a pheochromocytoma should be considered\", and no special treatment was given. At 17:00 on the same day, the patient suddenly experienced nausea and vomiting, chest tightness and obvious shortness of breath, headache and dizziness, and the staff of the local hospital considered the diagnosis of a \"myocardial injury\". Routine blood tests revealed the following: troponin-I (24.998 ng/ml), BNP (1806 ng/ml), and lactic acid (9.0 mmol/L). Lung CT indicated the presence of \u0026ldquo;diffuse exudative changes in both lungs,\u0026rdquo; indicating diffuse pulmonary edema in both lungs. Acute left heart failure was diagnosed, and no significant improvement was observed after 40 mg of furosemide was given as an intravenous diuretic medication and 5 mg of morphine was given as an intravenous pain medication. The patient gradually became confused, her oxygenation was difficult to maintain, and assisted ventilation with a tracheal intubation ventilator was performed. CT examination of the head and chest indicated the following: \"Ischemic changes in both lateral ventricles and the hemi-oval center. Diffuse exudative changes in both lungs indicating pulmonary edema in both lungs\u0026rdquo;. It was difficult to maintain the stability of the patient\u0026rsquo;s circulatory system after administering large doses of vasoactive drugs, so the patient was transferred to our hospital for further treatment. The patient was admitted to the ICU of our hospital through the outpatient department with the following characteristics: 1. pheochromocytoma, 2. shock, 3. acute heart failure, and 4. acute respiratory failure.\u003c/p\u003e \u003cp\u003eAfter admission, the patient's body temperature was 38.7\u0026deg;C, her heart rate was 148 breaths/min, her respiration rate was 20 breaths/min, and her blood pressure was 108/68 mmHg (epinephrine at 1.5 \u0026micro;g/kg/min and norepinephrine at 1.2 \u0026micro;g/kg/min were continuously pumped). With ventilator support treatment, her blood oxygen saturation was 93% (the oxygen concentration was 100%), and her consciousness was not clear. The pupils on both sides were abnormally large, with a diameter of approximately 2.5 mm on the left side and 2 mm on the right side. The pupillary light reflexes on both sides had disappeared, she had decreased breathing sounds in both lungs, and wet rales were heard in both lungs. Blood gas analysis and blood tests revealed the following: pH, 7.27; plasma lactate, 10.5 mmol/L; bicarbonate concentration, 14.4 mmol/L; oxygen partial pressure, 65 mmHg; oxygenation index, 65 mmHg; white blood cell count, 26.51\u0026times;109/L; neutrophil count, 91.4%; NT proBNP, 14079 pg/ml; glucose, 26.02 mmol/L; creatinine, 233 \u0026micro;mol/L; alanine aminotransferase, 751 U/L; aspartate aminotransferase, 951 U/L; free methoxynorepinephrine, 15511.60 ng/L; free methoxyepinephrine, 4205.70 ng/L; and free metoxyadrenaline substance, 18717.30 ng/L. A bedside color Doppler ultrasound indicated \"left ventricular enlargement; reduced left cardiac function, and an LVEF, of 20%\u0026rdquo;. The diagnoses based on the findings of the electrocardiogram were as follows: \"1; sinus tachycardia (heart rate, 145 beats/min), 2; frequent atrial premature beats, 3; lambda waves, 4, indoor block, 5; and ST-T changes\". The admission diagnoses were as follows: \"1, cardiogenic shock 2, acute respiratory failure 3, acute coronary syndrome 4, pheochromocytoma 5, sepsis 6, acute liver insufficiency, and 7, acute renal insufficiency\".\u003c/p\u003e \u003cp\u003eAt 19:45 on November 9, due to severe cardiogenic shock, the patient underwent EMCO catheter insertion through the right femoral vein-left femoral artery route. The EMCO rotation speed was 3300 rpm, the flow rate was 3.0 L/min, the inhaled oxygen concentration was 100%, and the respirator inhaled oxygen concentration was 50%. A protective lung ventilation strategy was implemented, which included the setting of a small tidal volume of 6 ml/kg. When PEEP was set with optimal oxygen therapy, the patient\u0026rsquo;s percutaneous oxygen saturation increased to 98%. Coronary angiography at 23:20 showed that the LM, LAD, LCX and RCA were normal.\u003c/p\u003e \u003cp\u003eThe patient\u0026rsquo;s vital signs were maintained with the support of ECMO, but the patient still needed a constant rate infusion of 0.25 \u0026micro;g/kg/min norepinephrine to maintain circulation after symptomatic treatment, such as stomach protection, kidney protection, anti-shock therapy and anti-infection therapy. Considering that surgical resection of the tumor or subtumor embolization was the best means of treatment at this stage, a multidisciplinary consultation was conducted on November 18, 2023. After full communication with her family, she decided to undergo an emergency laparoscopic resection of the left adrenal pheochromocytoma. On the same day, the patient was taken to the operating room with the support of EMCO. When entering the room, the EMCO speed was 3300 rpm, the flow rate was 3.0 L/min, the inhalation oxygen concentration was 100%, the norepinephrine dose rate was 0.4 \u0026micro;g/kg/min, the epinephrine dose rate was 0.05 \u0026micro;g/kg/min, the invasive blood pressure was 76/45 mmHg, and the heart rate was 113 beats/min. The patient\u0026rsquo;s blood pressure, heart rate, pulse oxygen saturation, body temperature, and exhaled fraction of carbon dioxide were routinely monitored; her cardiac displacement, central venous pressure, and cerebral oxygen saturation were continuously monitored via the radial artery; and her cardiac function and volume status were monitored in real time by transesophageal cardiac ultrasound. After anesthesia induction, the blood pressure in the moving position increased to 162/87 mmHg, and the patient received 0.5% sevoflurane as an inhalant, as well as 120 mg/h propofol and 400 \u0026micro;g/h remifentanil using micropumps, to maintain anesthesia. The operation lasted for 4 hours, the cumulative blood loss was 1000 ml, and a total of 800 ml of red blood cell suspension and 910 ml of fresh frozen plasma were transfused. In the operating room, her blood pressure was 115/78 mmHg, and her heart rate was 89 beats/min. She was transferred to the ICU for further treatment. Pathology confirmed that the patient had a pheochromocytoma, and the postoperative circulation of the patient tended to be stable. The ECMO tube was removed on the second day after surgery, and the patient received two bedside alveolar lavages. After anti-infective treatment, the tracheal catheter was removed on the tenth day after surgery, and she was transferred to a general ward.(Figure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePheochromocytoma and paraganglium tumors (PPGLs) are rare endocrine tumors characterized by the secretion of catecholamines. PPGLs store a large amount of catecholamines, and some patients have a tumor content of more than 3\u0026nbsp;million pg/g of catecholamines. When catecholamines are released into the blood, the plasma catecholamine concentration increases by approximately 1000 times. Almost 80% of pheochromocytomas originate from the adrenal medulla, while only 10%-15% of tumors originate from outside adrenal tissues [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The paragangliomas originating from outside the adrenal glands are mostly nonfunctional parasympathetic ganglia and functional catecholamine-secreting sympathetic ganglia [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Pheochromocytomas can be divided into three main molecular clusters, among which Krebs cycle/VHL/EPAS1-related tumors are characterized by mainly norepinephrine-secreting phenotypes and are more prone to metastasis and recurrence; therefore, they require close follow-up. The tumors associated with kinase signaling are mainly tumors with adrenaline-secreting phenotypes, which are usually not serious. At present, a few phenotypes related to Wnt signaling have been detected in clinical studies, and further studies are needed to investigate their correlation [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe typical clinical manifestations of pheochromocytoma are headache, increases in blood pressure caused by peripheral vascular contraction due to the binding of catecholamines with vascular α receptors, a rapid heart rate, and sweating caused by stimulation of β adrenergic receptors. Among these manifestations, seizures, hypertension, palpitations, syncope, anxiety and hyperglycemia are more common in pheochromocytoma patients who have tumors that secrete adrenaline. Headache, sweating, and persistent hypertension are more commonly associated with norepinephrine-secreting PPGLs[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, there are also several extreme clinical manifestations, such as cardiogenic shock, catecholamine cardiomyopathy, and acute coronary syndrome, that can manifest in patients with PPGLs. These extreme cases are often related to the neglect of the condition by doctors and patients [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The manifestations of the case in this report were also due to the failure of doctors and the patient to pay enough attention to the findings during the first visit, resulting in the delay of the condition and the optimal treatment opportunity to be missed. PPGL hypercatecholamine-induced cardiomyopathy is very rare (8%-11%) and can be fatal when it occurs. It is the leading cause of preoperative death in patients with PPGLs and is most commonly observed in patients with adrenal pheochromocytoma (approximately 90%). Excessive catecholamines can directly irritate and eventually damage the heart (causing cardiac diseases such as myocarditis) and the vascular system (causing vascular diseases such as coronary artery vasoconstriction leading to myocardial infarction), regardless of the severity of hypertension [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This patient had no previous history of hypertension, and her life-threatening acute cardiomyopathy was caused by the massive secretion of catecholamines by the pheochromocytoma, consistent with the case descriptions in the literature. Pheochromocytoma cardiomyopathy can be acute or chronic. The most common type of acute PPGL cardiomyopathy is Takotsubo syndrome, which is characterized by arterial vasoconstriction causing severe left ventricular dysfunction [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], while patients with chronic disease mainly exhibit dilated or hypertrophic cardiomyopathy [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Patients with acute stress cardiomyopathy (Takotsubo type) may have a normal ECG (11%), ST/T wave changes (39%), ST segment elevations (39%), a transient left bundle branch block (4%), or arrhythmias (atrial tachycardia, heart block, and ventricular arrhythmia) (7%) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Upon admission, the electrocardiogram of the patient of this case indicated sinus tachycardia, frequent atrial premature beats, lambda waves, indoor block, and ST-T changes. Color Doppler ultrasound indicated left ventricular enlargement and reduced left cardiac function. The LVEF being 20%; the clinical manifestations of acute left heart failure, which have many similarities with Takotsubo cardiomyopathy, and the absence of significant coronary artery abnormalities indicated by coronary angiography further confirmed that the patient had acute PPGL cardiomyopathy. The rapid and massive secretion of catecholamines by a pheochromocytoma leads to paroxysmal or persistent hypertension, which can damage the whole body's organ functions. In this case, the electrocardiogram and myocardial enzyme spectrum of the patient were abnormal. However, coronary angiography showed no obvious abnormalities, the myocardial enzyme levels significantly decreased after surgery, and the previous increase in the patient\u0026rsquo;s myocardial enzyme levels before surgery may have been caused by the coronary artery constriction induced by catecholamines. Acute PPGL cardiomyopathy is caused by temporary myocardial ischemia [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] and must be distinguished from organic coronary atherosclerotic heart disease. In a retrospective study, increased platelet count and a cosecretion pattern were found to be independent risk factors for cardiovascular complications in PPGL patients. Most PPGL patients mainly secrete norepinephrine, but cosecretion occurs mainly in patients with coexisting cardiovascular complications. In addition to intravascular volume depletion, other sequelae that can occur in PPGL patients are sudden cessation of catecholamine secretion due to tumor necrosis, adrenal receptor desensitization, and hypocalcemia because these tumors normally secrete adrenaline, and these may also lead to hypotension and shock [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. According to a multivariate regression model based on 200 studies, nausea or vomiting are not typical clinical manifestations of pheochromocytoma but are associated with increased mortality, but there has been no significant difference in mortality between severe hypertension patients and those without severe hypertension [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In this case, nausea and vomiting at the early stage of the disease also indicate a poor prognosis and a high risk of death. Therefore, the author hopes to share the details regarding the successful treatment of this patient via this case report.\u003c/p\u003e \u003cp\u003eThe author believes that the successful treatment and good prognosis of this patient are closely related to the support of ECMO technology. The use of extracorporeal membrane oxygenation (ECMO) is increasing worldwide, with 48% of these patients requiring noncardiac surgery, which creates new challenges for both surgeons and anesthesiologists. Adequate preoperative preparation and evaluation are the keys to ensuring the smooth operation of anesthesia. The ECMO parameters should be accurately recorded to evaluate the patient's coagulation function and to determine whether there are complications. In this case, the induction of anesthesia may only require a small amount of anesthetic drugs, and intravenous anesthesia should be the first choice for anesthesia maintenance. Monitoring of the intraoperative anesthetic depth and echocardiographic monitoring are also necessary. For patients receiving ECMO support, a negative fluid balance should usually be maintained. Volumetric therapy may be considered unless massive acute blood loss is accompanied by a decrease in the pulse oxygen saturation. In this case, volume management itself is difficult. Considering the characteristics of pheochromocytomas, preoperative dilatation is needed in these patients. If the volume is insufficient, the patient\u0026rsquo;s circulation may be difficult to maintain after tumor removal. However, in this case, the patient's cardiac function was significantly reduced, her LVEF was 20%, and the diagnosis of PPGL cardiomyopathy was clear. An excessive volume load can burden the heart and further aggravate myocardial damage. Therefore, under real-time transesophageal echocardiography monitoring, we chose to supplement the appropriate volume and administer the positive inotropic drug epinephrine to regulate the patient\u0026rsquo;s blood pressure and maintain satisfactory perfusion. It has also been suggested that in ECMO-supported patients, the use of \"ultra-protective ventilation\" to set VT to a predicted body weight of less than 4 ml/kg and a P Plat of less than 25 cmH2O can reduce pulmonary edema, the inflammatory marker levels and VILI. Due to the absence of anticoagulation therapy in patients receiving perioperative ECMO, the amount of membrane clot formation by the oxygenator will increase, and the membrane function will decrease. Therefore, oxygenator replacement should be considered before surgery [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The successful treatment of this patient confirms the importance of ECMO in the clinical management of a pheochromocytoma crisis and provides a new idea for the future treatment of pheochromocytoma crises.\u003c/p\u003e \u003cp\u003eAt present, surgical resection of the tumor is the main treatment method for PPGLs. In this case, the respiratory circulation of the patient tended to be stable after tumor resection, all indicators returned to normal, and the patient had a steep decrease in her catecholamine levels after tumor resection (Fig.\u0026nbsp;4). Studies have shown that 15%-25% of patients still have a poor prognosis due to postoperative metastasis. At present, there are many methods for predicting the metastasis and recurrence of pheochromocytoma, but they are not consistent. Currently, experts and scholars agree that the proliferation of cells expressing Ki 67 (\u0026gt;\u0026thinsp;3%-5%) and mutations of the succinate dehydrogenase gene (SDHB) are strongly correlated with the metastasis and recurrence of pheochromocytoma [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The pathological outcome of this patient was Ki-67 (5%+), and genetic testing was of great significance for this patient. However, this patient refused to undergo genetic testing, and close follow-up of this patient is necessary to prevent recurrence.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe report an extremely rare case of a pheochromocytoma crisis complicated by catecholamine cardiomyopathy. This patient was admitted to the hospital with a cardiogenic shock LVEF of 20%, difficulty in maintaining oxygenation, the need for ECOM to maintain life, and a large increase in her plasma levels of norepinephrine and epinephrine, and she received intubation with ventilator-assisted ventilation. After the primary lesion was removed under ECOM maintenance, the patient's vital signs were stable, and her cardiac function returned to normal. Her postoperative LVEF was 57%. However, this type of tumor has a risk of metastasis and recurrence, and based on the pathological classification of the patient's tumor, it is recommended that the patient undergo genetic testing and have close long-term follow-up.\u003c/p\u003e"},{"header":"Shortcomings","content":"\u003cp\u003eThere are two deficiencies in the handling of this case. First, this patient\u0026rsquo;s hormone levels, cardiac function, genetic factors, and imaging findings should have been carefully evaluated before she underwent elective pheochromocytoma resection. Adequate preoperative preparation is necessary, as catecholamines may be released in large amounts during anesthesia induction, endoscopic pneumoperitoneum establishment, and tumor resection, and patients may develop severe hypertension and cardiovascular complications during the perioperative period [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Alpha-adrenergic blockers should be used for at least 7 14 days (when alpha-blockers cannot effectively control the patient\u0026rsquo;s blood pressure). In addition to the use of calcium channel blockers, the treatment should also consist of the inhibition of clinical symptoms caused by a functional PPGL, restoration of the patient\u0026rsquo;s intravascular blood volume loss after alpha-adrenergic receptor blockade through a high-salt diet and fluid intake (1000\u0026ndash;2000 ml/day), and strict control of the patient's blood pressure and heart rate. Also, the patient\u0026rsquo;s blood pressure should be stable and below 140/90 mmHg before surgery. The optimal heart rate is 60\u0026ndash;70 beats/min when sitting and 70\u0026ndash;80 beats/min when standing [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Because beta-blockers tend to cause catecholamine overdose thus leading to hypertensive crises, beta-blockers should not be used as first-line therapy and should only be used for the treatment of tachycardia in PPGL patients [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, due to the urgent change in this patient's condition, there were only 9 days from hospitalization to surgery, and no formal preoperative preparation was carried out. Therefore, the perioperative management of this patient was highly limited, and the patient\u0026rsquo;s circulation fluctuated sharply, which may have caused potential harm to the patient. Second, the choice of treatment, especially whether to surgically resect the tumor or intervene with the use of subtumor embolization, is worthy of further discussion. This hospital is a prefecture city hospital that lacks experience in interventional tumor embolization, so laparoscopic tumor resection was the only option in this case. However, laparoscopic surgery requires changing the body position, injecting a certain amount of carbon dioxide to maintain a pneumoperitoneum, and inducing hypercapnia after carbon dioxide absorption to further stimulate the release of hormones from the tumor mass. These can all bring further challenges for the perioperative management of these patients.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBlood gas analysis values of the patient at different time points\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGlucose(mmol/L)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePh\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePaCO\u003csub\u003e2\u003c/sub\u003e(mmHg)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePaO\u003csub\u003e2\u003c/sub\u003e(mmHg)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePaO\u003csub\u003e2\u003c/sub\u003e/FiO\u003csub\u003e2\u003c/sub\u003e(mmHg)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBE(mmol/L)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eLac(mmol/L)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFiO\u003csub\u003e2\u003c/sub\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAt admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-11.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e10.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBefore the operation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e373\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuring the operation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.382\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e291.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e296\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15 days after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e146\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e355\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank AJE (www.aje.cn) for its linguistic assistance during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData archiving is not mandated but data will be made available upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the writing of the manuscript and read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research was prospectively reviewed and approved by \u003cstrong\u003eZhejiang Taizhou Hospital\u003c/strong\u003e\u003cstrong\u003e,\u0026nbsp;\u003c/strong\u003eChina. . This study was approved by Ethics Committee of Zhejiang Taizhou Hospital [No.KL20240110], and all participants provided written informed consent\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e\u003cstrong\u003eZhejiang Taizhou Hospital\u003c/strong\u003e, China\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e \u003cstrong\u003eZhejiang Taizhou Hospital\u003c/strong\u003e, China\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003e \u003cstrong\u003eZhejiang Taizhou Hospital\u003c/strong\u003e, China\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003e \u003cstrong\u003eZhejiang Taizhou Hospital\u003c/strong\u003e, China\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e4\u003c/sup\u003e\u003cstrong\u003eZhejiang Taizhou Hospital\u003c/strong\u003e, China\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTarling JA, Kumar R, Ward LJ, Boot C, Wassif WS. Phaeochromocytoma and paraganglioma. J Clin Pathol. Published online March 7, 2024. 2023-209234\u003c/li\u003e\n\u003cli\u003eNazari M A, Hasan R, Haigney M, Maghsoudi A, Lenders J W M, Carey R M,Pacak K. Catecholamine-induced hypertensive crises: current insights and management. The Lancet Diabetes \u0026amp; Endocrinology. 2023; 11(12):942-954.\u003c/li\u003e\n\u003cli\u003eTănăsescu M-D, Popescu Ș, Mincă A, Isac T, Suliman E, Grigorie M M, Suliman E, Stăniloaie D, Timofte D,Ionescu D. Paragangliomas and Anemia: Literature Review and Case Report. Medicina. 2023; 59(11).\u003c/li\u003e\n\u003cli\u003eN\u0026ouml;lting S, Bechmann N, Taieb D, et al. Personalized Management of Pheochromocytoma and Paraganglioma [published correction appears in Endocr Rev. 2021 Dec 14;:] [published correction appears in Endocr Rev. 2021 Dec 14;:]. Endocr Rev. 2022;43(2):199-239.\u003c/li\u003e\n\u003cli\u003eSharma S,Fishbein L. Diagnosis and Management of Pheochromocytomas and Paragangliomas: A Guide for the Clinician. Endocrine Practice. 2023.\u003c/li\u003e\n\u003cli\u003eAnyfanti P, Mastrogiannis \u0026Kappa;, Lazaridis \u0026Alpha;, Tasios \u0026Kappa;, Vasilakou D, Kyriazidou \u0026Alpha;, Aroutsidis F, Pavlidou O, Papoutsopoulou \u0026Epsilon;, Tiritidou A, Kotsis V, Triantafyllou \u0026Alpha;, Zarifis \u0026Iota;, Douma S,Gkaliagkousi \u0026Epsilon;. Clinical presentation and diagnostic evaluation of pheochromocytoma: case series and literature review. Clinical and Experimental Hypertension. 2022; 45(1).\u003c/li\u003e\n\u003cli\u003eSzatko A, Glinicki P,Gietka-Czernel M. Pheochromocytoma/paraganglioma-associated cardiomyopathy. Frontiers in Endocrinology. 2023; 14.\u003c/li\u003e\n\u003cli\u003eDawson D K. Acute stress-induced (takotsubo) cardiomyopathy. Heart. 2018; 104(2):96-102.\u003c/li\u003e\n\u003cli\u003eMa X, Chen Z, Xia P, Zhang C, Yan K, Fan Y, Wang Y, Ti Y,Bu P. Giant Paraganglioma Complicated With Catecholamine Crisis and Catecholamine Cardiomyopathy: A Case Report and Review of the Literature. Frontiers in Endocrinology. 2022; 12.\u003c/li\u003e\n\u003cli\u003eZhao L, Meng X, Mei Q, Fan H, Liu Y, Zhou X, Zhu H,Zhang S. Risk Factors for Cardiac Complications in Patients With Pheochromocytoma and Paraganglioma: A Retrospective Single-Center Study. Frontiers in Endocrinology. 2022; 13.\u003c/li\u003e\n\u003cli\u003eAndo Y, Ono Y, Sano A, Fujita N, Ono S,Tanaka Y. Clinical characteristics and outcomes of pheochromocytoma crisis: a literature review of 200 cases. Journal of Endocrinological Investigation. 2022; 45(12):2313-2328.\u003c/li\u003e\n\u003cli\u003eFierro MA, Daneshmand MA, Bartz RR. Perioperative Management of the Adult Patient on Venovenous Extracorporeal Membrane Oxygenation Requiring Noncardiac Surgery. Anesthesiology. 2018;128(1):181-201.\u003c/li\u003e\n\u003cli\u003eWang Y, Li M, Deng H, Pang Y, Liu L, Guan X. The systems of metastatic potential prediction in pheochromocytoma and paraganglioma. Am J Cancer Res. 2020;10(3):769-780.\u003c/li\u003e\n\u003cli\u003eDe Filpo G, Parenti G, Sparano C, Rastrelli G, Rapizzi E, Martinelli S, Amore F, Badii B, Paolo P, Ercolino T, Mannelli M, Maggi M,Canu L. Hemodynamic parameters in patients undergoing surgery for pheochromocytoma/paraganglioma: a retrospective study. World Journal of Surgical Oncology. 2023; 21(1).\u003c/li\u003e\n\u003cli\u003eChen J, Jin G, Zhu Y, Hu W, He H, Wang C,Cai X. The importance of perioperative and complication management in the treatment of pheochromocytoma crisis with venoarterial extracorporeal membrane oxygenation (V-A ECMO): a case report and review of the literature. Perfusion. 2021; 38(2):228-235.\u003c/li\u003e\n\u003cli\u003eUtsumi T, Iijima S, Sugizaki Y, Mori T, Somoto T, Kato S, Oka R, Endo T, Kamiya N,Suzuki H. Laparoscopic adrenalectomy for adrenal tumors with endocrine activity: Perioperative management pathways for reduced complications and improved outcomes. International Journal of Urology. 2023; 30(10):818-826.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4835108/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4835108/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePheochromocytoma is rare in the clinic, and patients with pheochromocytomas mainly present with headache, high blood pressure and sweating. Patients who develop a pheochromocytoma crisis are particularly rare. This report describes the case of a patient in a pheochromocytoma crisis who presented with severe cardiogenic shock, acute respiratory failure, and acute coronary syndrome, who ultimately underwent surgery under general anesthesia with the support of ECMO, and who was discharged healthy.\u003c/p\u003e","manuscriptTitle":"Surgical anesthesia in a patient with a pheochromocytoma crisis supported by ECMO：A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-04 23:11:37","doi":"10.21203/rs.3.rs-4835108/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-15T18:01:14+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-03T12:14:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-01T16:02:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-01T12:20:34+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-30T11:05:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"338794173230356191203999403169208101252","date":"2024-08-29T02:12:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"145716835246510400960879321907067559073","date":"2024-08-28T14:43:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-27T10:43:03+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-26T19:32:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"46123756047879820946215758875401286592","date":"2024-08-25T17:07:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"133802800983717744159996186928482190135","date":"2024-08-25T12:35:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"138375105538132585052972765192783391361","date":"2024-08-23T22:00:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"67397369123514181377675925768474204848","date":"2024-08-23T19:38:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"128951662249013384379318318895555705194","date":"2024-08-23T13:44:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"213093515222614252841388641855267328931","date":"2024-08-23T12:47:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"106432387961395500214927767709279389880","date":"2024-08-23T12:33:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-23T12:30:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-01T09:10:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-01T09:10:31+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2024-07-31T11:30:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"61ba89d2-0cea-457a-b257-026e2fb95259","owner":[],"postedDate":"September 4th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-23T16:04:16+00:00","versionOfRecord":{"articleIdentity":"rs-4835108","link":"https://doi.org/10.1186/s13019-024-03177-w","journal":{"identity":"journal-of-cardiothoracic-surgery","isVorOnly":false,"title":"Journal of Cardiothoracic Surgery"},"publishedOn":"2024-12-20 15:58:04","publishedOnDateReadable":"December 20th, 2024"},"versionCreatedAt":"2024-09-04 23:11:37","video":"","vorDoi":"10.1186/s13019-024-03177-w","vorDoiUrl":"https://doi.org/10.1186/s13019-024-03177-w","workflowStages":[]},"version":"v1","identity":"rs-4835108","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4835108","identity":"rs-4835108","version":["v1"]},"buildId":"uwybb5PU2iWlRI8EIam5Y","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}