PSAT123 Pheochromocytoma Resection and Coronary Artery Bypass Surgery: Chicken or the Egg??? - A Case Report

INTRODUCTION: Pheochromocytoma (PCC) is a rare catecholamine-secreting neuroendocrine tumor with an incidence of 8 per million person-years. Advanced Coronary artery disease (CAD) and PCC may coexist secondary to chronic sympathetic activation, resulting in irreversible vascular wall growth and accelerated vascular atherosclerosis. The hemodynamic management of this association often represents a challenging dilemma due to the dramatic consequences of the hypertensive crisis caused by excessive catecholamine release. here we present a case of concomitant triple vessel disease and PCC to shed a light on our sequence of management to help guide providers as currently due to the rarity of the disease and the association, the available data regarding the sequence of management is controversial and is decided on a case by case basis. CASE PRESENTATION: a 55-year-old male with a history of uncontrolled hypertension, Chronic headaches, and kidney disease presented due to abrupt onset of crushing chest pain and was admitted for further evaluation of hypertensive emergency and NSTEMI with a blood pressure of 260/170 and Troponin of 3.8 ng/L. Coronary Angiography showed significant triple-vessel disease. Due to persistent hypertension and high suspicion of PCC, Serum metanephrine and normetanephrine, and fractioned catecholamines were ordered and showed significant elevation. CT of the abdomen and pelvis showed a 1.5 cm heterogeneous left adrenal mass. Nuclear medicine scan showed increased uptake of radiotracer in the left adrenal gland suggestive of PCC. DISCUSSION: PCC presents a high risk of morbidity and mortality, especially during surgical procedures if left untreated. The management of concomitant advanced CAD and PCC poses a unique challenge in terms of appropriate sequence and time interval between the two procedures. After a multidisciplinary team discussion including cardiology, cardiothoracic surgery, and endocrinology we decided to perform CABG first with preoperative preparation including Alpha-adrenoreceptor blockage for 1 week prior to surgery, followed by PCC resection at a later stage. The patient underwent coronary revascularization with grafting of three vessels. The perioperative course was uneventful. After three weeks the patient underwent successful PCC resection, with successful gradual down titration of alpha locate therapy. CONCLUSION: A two-stage approach of CABG was PCC the section at a later stage under optimal preoperative preparation appears to be a safe and feasible modality in patients with advanced CAD and PCC. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.