Case Report:
A 28-year old female was admitted to our Hospital with ventricular arrhythmia, hypotension and respiratory failure secondary to pulmonary oedema. Blood pressure was 70 ⁄ 40 mmHg with heart rate being 130 beats / min and significant ST elevation in V1-V3 leads. Despite inotropic and vasoconstrictor support (noradrenaline 0.05 μg/kg/min and dobutamine 10 μg/kg/min), the echocardiogram revealed a poor biventricular function (left ejection fraction [EF] < 25%). Blood test documented elevated troponin-I levels (54,7 ng/mL). Because of the worsening hemodynamic instability and metabolic acidosis, mechanical ventilation was started and a V-A ECMO device was implanted through the surgical cannulation of the right femoral artery (Return, 17 French BIO-MEDICUS TM cannula) and the right femoral vein (Access, 21 French Multi–Stage BIO-MEDICUS cannula). A 9 French reperfusion cannula was distally inserted in the main femoral artery to prevent limb ischemia. Therefore, the unloading of the LV was obtained by inserting an IMPELLA-CP, through the left femoral artery. A trans-aortic 2,5 L/m flow was obtained. Heparin was continuously administrated to maintain activated clotting time between 150 and 200 sec. An emergency coronary angiography detected patent coronary arteries. An endomyocardial biopsy was also performed to exclude acute myocarditis. The urinary catecholamine levels were several times higher than normal; Epinephrine 2980 µg/day (normal range2-14 µg/day); Norepinephrine 3876 µg/day (normal range 230-120 µg/day); Homovanillic acid 75 mg/day (normal renage <15 mg/day); Vanilmandelic acid 85,5 mg/day (normal range<8 mg/day). A subsequent abdominal computed tomography revealed the presence of a 5 cm nodular lesion within the left adrenal gland [Fig. 1], highly suggestive for the diagnosis of pheochromocytoma. A pharmacological therapy comprehensive of alpha- and beta-blockade was therefore started. A very fast recovery was observed and the weaning from ECMO was started after only 24 hours of full support; the patient was discontinued from ECLS on day 4. The IMPELLA-CP was then switched to 1,5 L/m flow, on day 5. On day 6, it was safely removed [Fig 2] and a completely recovery of EF was assessed by echocardiographic evaluation (EF > 60%). The patient underwent adrenalectomy 3 weeks after the initial emergency presentation and the histological examination confirmed the diagnosis of pheochromocytoma. The post-procedural course was uneventful and 10 days later the patient was discharged from our department.