UCSF

A 59 year old female with past medical history of metastatic neuroendocrine tumor without cardiac involvement was admitted for transarterial catheter embolization (TACE) procedure of liver lesions. During the TACE procedure, she developed hypertensive urgency treated with intravenous beta blocker therapy and continuous octreotide for carcinoid reaction. The following day she developed acute pulmonary edema and labile blood pressures requiring low dose norepinephrine. Octreotide infusion was up-titrated to 500 mcg/hour with concern for carcinoid crisis. On physical exam, she was tachycardic and regular without notable murmurs or extra cardiac sounds, no elevated jugular venous distension, and no lower extremity edema. She had bilateral crackles on pulmonary exam and was diaphoretic and delirious. There were sub-millimeter lateral ST- segment elevations on her electrocardiogram but her troponin levels were elevated to 14 ng/dL. Point of care cardiac ultrasound demonstrated severely impaired left ventricular systolic function without regional wall motion abnormalities. Coronary angiogram revealed diffuse coronary vasospasm and elevated left ventricular end-diastolic pressure. On right heart catheterization, she had elevated filling pressures, pulmonary arterial oxygen saturation of 25%, and cardiac index of 1.42 L/min/m2. Our patient was diagnosed with cardiogenic shock secondary to octreotide mediated coronary vasospasm causing diffuse myocardial injury. Continued multidisciplinary discussions were needed to determine appropriate vasopressor and inotropic agent use to support cardiac function without triggering further hormonal dysregulation during carcinoid crisis. Her cardiac function eventually improved with left ventricular Impella support and gradual down-titration of octreotide dose. Norepinephrine, epinephrine, and phenylephrine were avoided in favor of vasopressin, and dobutamine was switched to milrinone to prevent further sympathetic activation. She was able to wean off Impella and pressor support and had improvement of her left ventricular function on repeat echocardiography one month later. She has not had recurrence of heart failure symptoms and continues to follow up with oncology via tele-visits.