Thyroidectomy on VA-ECMO for Thyroid Storm: A Case Report
2Otolaryngology, Head and Neck Surgery, Hadassah Hebrew University Medical Center
3Cardiothoracic Surgery, Hadassah Hebrew University Medical Center
4Hematology, Hadassah Hebrew University Medical Center
Introduction:
Thyroid-storm with heart-failure is a rare, life threatening complication of hyperthyroidism. In refractory cases, urgent thyroidectomy is required for definitive control of thyrotoxicosis. Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) is a supportive measure for cardiorespiratory failure requiring continuous anticoagulation to prevent clotting. Here, we present a case of thyrotoxic cardiac-failure, successfully treated with thyroidectomy while on VA-ECMO. To our knowledge, only one such case has previously been reported.
Case:
A 48-year-old women with a known history of poorly controlled Graves` disease and resulting heart-failure with reduced ejection-fraction, was admitted for vomiting and rapid atrial-fibrillation. Initial treatment for suspected thyroid-storm included propranolol, propylthiouracil, Lugol`s solution and hydrocortisone. Soon-after, the patient suffered cardiorespiratory collapse with refractory cardiogenic shock requiring implantation of an Intra-aortic balloon-pump and VA-ECMO for circulatory support. Laboratory thyrotoxicosis was confirmed and daily plasmapheresis was added, though multi-organ failure ensued. Urgent thyroidectomy was deemed necessary to definitively control thyrotoxicosis but weaning from ECMO seemed impossible. In a joint multidisciplinary decision including endocrinology, cardiology, cardiothoracic-surgery, ENT, hematology, MICU and anesthesiology, anticoagulation was withheld for 24-hours to allow for surgery on ECMO. Total thyroidectomy with meticulous hemostasis was uneventful with preservation of recurrent nerves and parathyroids. Penrose drains were placed to secure gradual resumption of anticoagulation. Thyrotoxicosis resolved and ECMO was explanted with normalization of cardiac function. Due to severe ICU myopathy patient was eventually discharged to a rehabilitation facility.
Conclusion:
Urgent thyroidectomy for treatment of thyroid-storm is a viable option even on VA-ECMO. A multidisciplinary team-based approach is critical for success.
