Hyperthyroid Induced Cardiac Failure Requiring Intra-Aortic Balloon Pump during Thyroidectomy

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38 https://jes-online.org

ABSTRACT

Hyperthyroid states can negatively impact cardiac function and exacerbate cardiac failure.

In cases refractory to medical management, thyroidectomy may be indicated. However, the myocardial depressive effects of inhaled anesthetics in addition to hemodynamic lability of induction, complicate operative planning. While other institutions have published their experience utilizing local anesthesia and sedation during thyroidectomy, this requires agreement with the patient to employ that strategy. We report a case of a patient with refractory hyperthyroidism and exacerbated cardiac failure who underwent thyroidectomy after intra-aortic balloon pump placement given his reluctance to proceed utilizing local anesthesia and monitored anesthesia care.

Keywords: Hyperthyroidism; Heart failure

INTRODUCTION

Hyperthyroidism is deleterious to cardiac function and can contribute to worsening failure in acute episodes of decompensation. Thyroidectomy offers definitive treatment however among patients with advanced heart failure or those presenting with acute decompensation, careful consideration of anesthetic technique while augmenting myocardial function is critical to achieving positive outcomes. We present a case of a patient with heart failure who presented with hyperthyroidism and acute decompensation who required intra-aortic balloon placement to undergo thyroidectomy during hospitalization.

CASE REPORT

A 68 year-old man with a history of dilated non-ischemic cardiomyopathy (New York Heart Association Class IV) and paroxysmal atrial fibrillation who had undergone mechanical mitral valve replacement in 2002 and automatic implantable cardioverter defibrillator (AICD) placement in 2003 developed fatigue and other symptoms concerning for thyroid dysfunction. Of note, he had also been on long term amiodarone per his cardiologist.

He was seen by his primary care provider in February and started on thyroid replacement therapy for presumed primary hypothyroidism. He presented to the hospital in May with J Endocr Surg. 2021 Mar;21(1):38-40

https://doi.org/10.16956/jes.2021.21.1.38 pISSN 2508-8149·eISSN 2508-8459

Short Communication

Received: Dec 19, 2020 Revised: Mar 10, 2021 Accepted: Mar 14, 2021 Correspondence to Elliot Toy

General Surgery Residency Program, AdventHealth Orlando, 2501 N. Orange Avenue Suite 235, Orlando, FL 32804, USA.

E-mail: [email protected] Copyright © 2021. Korean Association of Thyroid and Endocrine Surgeons; KATES This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://

creativecommons.org/licenses/by-nc/4.0/).

ORCID iDs Elliot Toy

https://orcid.org/0000-0002-8829-6023 Alberto Monreal

https://orcid.org/0000-0002-6991-7672 Joseph Reza

https://orcid.org/0000-0002-0697-2420 Joseph D. Portoghese

https://orcid.org/0000-0002-3754-1922 Conflict of Interest

No potential conflict of interest relevant to this article was reported.

Author Contributions

Conceptualization: Alberto Monreal, Joseph Reza; Investigation: Elliot Toy, Alberto Monreal, Joseph Reza; Methodology: Elliot Toy, Alberto Monreal, Joseph Reza; Resources: Elliot Toy, Alberto Monreal; Supervision: Joseph D. Portoghese; Validation: Alberto Monreal, Joseph Reza; Writing - original draft: Elliot Toy, Alberto Monreal, Joseph Reza; Writing - review & editing: Elliot Toy, Alberto Monreal, Joseph Reza.

Elliot Toy , Alberto Monreal , Joseph Reza , Joseph D. Portoghese

General Surgery Residency Program, AdventHealth Orlando, Orlando, FL, USA

Hyperthyroid Induced Cardiac Failure

Requiring Intra-Aortic Balloon Pump

during Thyroidectomy

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worsening decompensated heart failure with trans-thoracic echocardiogram demonstrating and ejection fraction of 12%. He was evaluated by the heart failure service and started on inotropic support. Further investigation demonstrated a thyroid stimulating hormone 0.005 u/mL and a free T4 level of >7.7 ng/dL prompting ultrasonographic evaluation and antibody testing. This demonstrated bilateral lobar enlargement with multiple sub-centimeter nodules. Subsequent thyroid scan did not demonstrate uptake suspicious for sub-acute or autoimmune thyroiditis and serologic antibody testing was negative, including for thyrotropin antibodies. He was seen by the endocrinology service and was diagnosed to have amiodarone induced thyrotoxicosis type II and started on methimazole and hydrocortisone.

He remained on this regimen for 2 weeks while and his medical therapy was optimized. After 2 weeks of medical therapy, he continued to require inotropic support with biochemical evidence of persistent hyperthyroidism. He was then evaluated for durable mechanic circulatory support and possibly transplant. The committee's decision was that he would require thyroidectomy to establish candidacy for left ventricular device placement or cardiac transplant. During screening colonoscopy, he developed unstable ventricular tachycardia.

Once he recovered from this episode he was evaluated for thyroidectomy. Given his cardiac function, he was offered thyroidectomy with local anesthesia under monitored anesthesia care (MAC). We discussed with the patient the increased risk of hemodynamic instability with general anesthesia compared to local anesthesia, but he was adamantly against local anesthesia. After discussion with the heart failure service, it was decided that given the hemodynamic collapse experienced during colonoscopy, an intra-aortic balloon pump (IABP) would be placed prior to thyroidectomy. He was taken for thyroidectomy under general anesthesia with IABP in place. During the case, there was no evidence of hemodynamic instability or collapse. After successful thyroidectomy, he required inotropic support briefly and the IABP was successfully removed on the fourth post-operative day. He then underwent conversion to bi-ventricular AICD placement. He was ultimately discharged home 2 weeks after thyroidectomy.

DISCUSSION

The effect of thyroid hormone on cardiomyocyte function has been previously described.

Thyroid hormone modulation of structural and regulatory genes including the myosin heavy chain gene and both the sarcoplasmic reticulum Ca²⁺-ATPase and its inhibitor phospholamban, regulate contractility and diastolic relaxation during the cardiac cycle (which encode the contractile proteins of thick filaments in the cardiac myocyte) (1). The physiologic effects observed on the cardiovascular system include decrease in systemic vascular resistance (SVR), increases in both chronotropy and inotropy and blood volume.

The decrease in SVR via T3 mediated effects on ionic channels and nitric oxide synthase results in activation of the renin-angiotensin aldosterone system, ultimately resulting in increased sodium retention and increased plasma volume. In the sinoatrial node, thyroid hormone affects action potential duration and repolarization via genomic and non-genomic mechanisms. Beta adrenergic stimulation increases intracellular second messenger cAMP which then accelerated depolarization ultimately resulting in elevation of the heart rate.

These cellular level changes manifest the intricate physiologic balance struck between cardiac function and thyroid hormone.

Clinically, this relationship has been observed in patients with heart failure. Pantos et al. (2) showed a correlation between plasma concentration of T3 and cardiac oxygen consumption 39 https://jes-online.org https://doi.org/10.16956/jes.2021.21.1.38

Hyperthyroid Cardiac Failure Requiring Intra-aortic Balloon Pump Thyroidectomy

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and performance in patients with heart failure. Surgical correction of hyperthyroid states has also been shown to improve cardiac function postoperatively (3). Surgical cure in patient with severely depressed cardiac function, while the definitive option, is challenged by the patients' ability to tolerate general anesthesia. And in patients requiring mechanical augmentation of cardiac function, this presents an additional tactical challenge.

Hemodynamic lability and the myocardial depressive effects of inhaled anesthetics make this option for anesthetic planning less desirable. To address this issue several institutions have reported their experience utilizing local anesthesia and completing the thyroidectomy under MAC (4-6). This approach is a valuable tool among patients with advanced heart failure who require mechanical augmentation of their cardiac function. As such, there are case reports of utilizing local anesthesia under MAC during total thyroidectomy among patients with left ventricular assist device (7). In our case, the patient was offered thyroidectomy under local anesthesia with MAC however he was adamant that he would not proceed with surgery with this anesthetic strategy. After discussion with our heart failure team, we elected to place an IABP to augment his cardiac function and proceed with general anesthesia for this case without complication.

In parallel with previous reports describing recovery of cardiac function after thyroidectomy, we observed recovery of cardiac function to the degree that the patient did not require inotropic infusion, left ventricular assist device placement or cardiac transplant. To our knowledge, this is the first published report of employing IABP to supplement cardiac function among patients with decompensated heart failure who otherwise are not amenable to local anesthesia and require thyroidectomy.

REFERENCES

1. Klein I, Danzi S. Thyroid disease and the heart. Curr Probl Cardiol 2016;41:65-92.

PUBMED | CROSSREF

2. Pantos C, Dritsas A, Mourouzis I, Dimopoulos A, Karatasakis G, Athanassopoulos G, et al. Thyroid hormone is a critical determinant of myocardial performance in patients with heart failure: potential therapeutic implications. Eur J Endocrinol 2007;157:515-20.

3. Muthukumar S, Sadacharan D, Ravikumar K, Mohanapriya G, Hussain Z, Suresh RV. A prospective study on cardiovascular dysfunction in patients with hyperthyroidism and its reversal after surgical cure. World J Surg 2016;40:622-8.

4. Kim SE, Kim E. Local anesthesia with monitored anesthesia care for patients undergoing thyroidectomy:

a case series. Korean J Anesthesiol 2016;69:635-9.

5. Kim MS, Kim BH, Han YE, Nam DW, Hah JH. Clinical outcomes after local anesthesia with monitored anesthesia care during thyroidectomy and selective neck dissection: a randomized study. Eur Arch Otorhinolaryngol 2017;274:3789-94.

6. Snyder SK, Roberson CR, Cummings CC, Rajab MH. Local anesthesia with monitored anesthesia care vs general anesthesia in thyroidectomy: a randomized study. Arch Surg 2006;141:167-73.

7. Sharma A, Trigo-Blanco P, Oprea AD. Perioperative considerations for a patient with a left ventricular assist device undergoing thyroidectomy. Cureus 2020;12:e7132.

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Hyperthyroid Cardiac Failure Requiring Intra-aortic Balloon Pump Thyroidectomy