Cardiac Critical Care NP Charlote, North Carolina, United States
Disclosure(s):
Laura Quintana: No financial relationships to disclose
Background:
Introduction: Thyroid storm is a rare, life-threatening condition that can precipitate cardiogenic shock in severe or refractory cases. We present a case of refractory thyroid storm treated with early total thyroidectomy while supported on VA-ECMO, resulting in rather rapid cardiac recover
Methods: 55-year-old Vietnamese woman with no prior medical history presented to the emergency department with two weeks of palpitations and dyspnea. She was found to have rapid atrial fibrillation (heart rate 190 bpm), elevated free T4 (6 ng/dL), undetectable TSH, BNP of 2000 pg/mL, and a Burch-Wartofsky score of 65, confirming thyroid storm. Transthoracic echocardiography revealed severe biventricular dysfunction (LVEF 10%) with severe mitral and tricuspid regurgitation. Despite treatment with methimazole, corticosteroids, and unsuccessful synchronized cardioversion, her end organ function worsened, and shock state progressed to SCAI Stage E on (HD) 1. Right heart catheterization demonstrated elevated filling pressures and a depressed cardiac index, while left heart catheterization showed no evidence of obstructive coronary artery disease. Despite up-titration of vasopressors and aggressive diuresis, she required VA-ECMO and Impella CP cannulation the same day, followed by transfer to a tertiary center. Upon arrival, emergent plasmapheresis was performed. On hospital day (HD) 2 thyroid studies remained elevated (free T4 4.83 ng/dL, free T3 9.28 pg/mL), with persistent atrial fibrillation and tachycardia led to multidisciplinary discussions with endocrinology led to consultation of head and neck surgery. On HD3, an emergent total thyroidectomy was performed without complications
Outcome: By (HD) 4, echocardiography-guided ECMO weaning demonstrated improvement in LVEF to 25%. VA-ECMO and Impella were successfully decannulated on (HD) 5. By (HD) 10, LVEF had recovered to 55%, though the right ventricle remained moderately dilated. Due to persistent weaknesses and failed extubations, tracheostomy was performed on (HD) 17, and the patient was discharged to a long-term acute care facility on (HD) 28.
Conclusion: This case represents one of the earliest reported thyroidectomies performed on VA-ECMO, earlier than the reported median of HD6. Early surgical intervention, facilitated by rapid multidisciplinary coordination, likely contributed to the recovery of LVEF, supporting early thyroidectomy as a viable strategy in refractory thyroid-storm complicated by cardiogenic shock requiring VA-ECMO.
