Christopher King, DO
Dr.
Palmetto General Hospital, United States
Disclosure information not submitted.
Title: Thyrotoxicosis Induced Biventricular Cardiogenic Shock
Case Report Body:
Introduction: Cardiomyopathy as an initial presentation of thyrotoxicosis is rare, occurring in less than 6% of patients with less than 1% of patients presenting with severe LV dysfunction. We present a case of a patient who presented with thyrotoxicosis and biventricular cardiogenic shock.
Description: A 33-year-old male with a history of hyperthyroidism, diabetes, and noncompliance presented with symptoms of palpitations, shortness of breath, and generalized weakness. The initial presenting rhythm was atrial-fibrillation. Laboratory findings were significant for an undetectable TSH with an elevated Free T3/T4. Treatment for thyrotoxicosis was started with propranolol and methimazole. The patient’s symptom of shortness of breath became worse after initiation of treatment and was attributed to persistent atrial-fibrillation with rapid ventricular response. Propranolol was switched to an esmolol drip. Shortly after initiation of esmolol drip, the patient became hemodynamically unstable and suffered a PEA cardiac arrest. The patient was able to achieve ROSC with resuscitation. Echocardiogram done after cardiac arrest showed a left ventricular ejection fraction of less than 15%. Right and left cardiac catheterization was done revealing biventricular heart failure. Right and left impella support devices were placed. Hospital course was complicated by multiorgan failure including renal failure, respiratory failure and liver failure. Patient was subsequently transferred to an outside hospital for initiation of VA ECMO. While receiving ECMO, the patient's cardiac and respiratory function recovered. Shortly after decannulation liver and renal function recovered as well.
Discussion: Although rare, thyrotoxicosis associated cardiomyopathy can be fatal if not recognized early. Due to the association with cardiogenic shock, the mortality rate is close to 30%. Management differs from traditional treatment of thyrotoxicosis, specifically, beta-blockers are not used as they can cause hemodynamic instability. Our patient presented with an unrecognized cardiomyopathy and subsequently had a cardiac arrest leading to multiorgan failure necessitating VA ECMO as a life-saving intervention. Fortunately, our patient was able to recover all organ function.