Year : 2010 | Volume
: 13 | Issue : 3 | Page : 257--259
Congenital hypopituitarism: Monitoring after coronary artery bypass grafting
Stavros Siminelakis1, Angeliki Kotsanti1, Nikolaos G Baikoussis1, Maria Andrikoula2, Eleni Bairaktari3, George Papadopoulos4,
1 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Ioannina, Greece
2 Department of Endocrinology, University of Ioannina, School of Medicine, Ioannina, Greece
3 Department of Biochemistry, University of Ioannina, School of Medicine, Ioannina, Greece
4 Department of Clinical Anesthesiology and Intensive Postoperative Care Unit, University of Ioannina, School of Medicine, Ioannina, Greece
Nikolaos G Baikoussis
Cardiac Surgeon. Kolokotroni 4, Messatida 26500, Patras
Cardiovascular disease in patients with congenital hypopituitarism is not rare; however, there is a lack of reports referring to cardiac interventions in such patients. We present a 76-year-old man with complete pituitary hormone deficiency, who presented with recurrent events of unstable angina. He had a significant stenosis of the left anterior descending artery and he underwent off-pump coronary artery bypass. Our aim is to present the successful management of this patient with congenital hypopituitarism who underwent cardiac surgery and to review the relevant literature.
|How to cite this article:|
Siminelakis S, Kotsanti A, Baikoussis NG, Andrikoula M, Bairaktari E, Papadopoulos G. Congenital hypopituitarism: Monitoring after coronary artery bypass grafting.Ann Card Anaesth 2010;13:257-259
|How to cite this URL:|
Siminelakis S, Kotsanti A, Baikoussis NG, Andrikoula M, Bairaktari E, Papadopoulos G. Congenital hypopituitarism: Monitoring after coronary artery bypass grafting. Ann Card Anaesth [serial online] 2010 [cited 2020 Sep 26 ];13:257-259
Available from: http://www.annals.in/text.asp?2010/13/3/257/69051
Hypopituitarism is a disorder characterized by partial or complete deficiency of pituitary hormone secretion, such as growth or somatotroph hormone (GH), thyroid-stimulating hormone or thyrotropin (TSH), follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin (PRL) and adrenocorticotropic hormone (ACTH) deficiency and may be derived either from pituitary or hypothalamic disease.  Congenital hypopituitarism (CHP), due to birth trauma/asphyxia or a genetic mutation, is a rare cause of hypopituitarism compared to other causes such as pituitary adenomas, parasellar diseases, pituitary surgery, head and neck radiation or head injury. Its incidence is estimated to be between 1:3,000 and 1:4,000 births.  Clinical presentation is variable, depending on the type and severity of hormone deficiencies and the patient's age at diagnosis. The symptoms may be non-specific in the early neonatal period, becoming obvious with time. If CHP is left untreated, the main symptoms that develop include delayed puberty, amenorrhea, short stature and cognitive alterations. Occasionally, the condition may be life-threatening, especially in patients with ACTH deficiency, and an early diagnosis is mandatory. Cardiovascular disease in patients with hypopituitarism is not rare; however, on searching the literature, we have found only four relevant articles describing coronary artery bypass grafting (CABG) in such patients. Two of these articles refer to patients with hypopituitarism, either idiopathic or due to transsphenoidal microsurgery, for a pituitary adenoma , and the other two refer to patients with Sheehan's syndrome. , Therefore, the aim of our paper is to present the successful management of a patient with CHP who underwent CABG without the use of the extracorporeal circulation and to review the relevant literature emphasizing the need for close monitoring of serum pituitary hormone levels pre- and post-operatively in such patients.
Our patient is a 76-year-old man, weighing 40 kg and with a height of 135 cm, receiving daily treatment with oral levothyroxine sodium (0.1 mg Χ 1) and methylprednisolone (8 mg Χ 1) for CHP. He presented with recurrent events of unstable angina. His medical history included a previous hospital admission for treatment of myocardial infraction a month prior to his current admission.He had yet another for treatment of scrotal hernia 2 months prior. Coronary angiography revealed a significant stenosis (90%) of the proximal left anterior descending artery (LAD), while transthoracic echocardiography revealed normal cardiac function (ejection fraction = 65%). The logistic EuroSCORE of our patient was 2,69%, enlisting him in the low-risk group. His hormonal data on admission were: insulin-like growth factor-I (IGF-I or somatomedin C), 50.5 ng/ml (reference range, 120-310 ng/ml); insulin-like growth factor binding protein-3 (IGFBP-3), 1.9 ng/ml (1.5-4.6 ng/ml); cortisol, 7.4 μg/dl (5-23 μg/dl); tyriiodothyronine (T3), 0.46 ng/ml (0.5-1.4 ng/ml); thyroxine (FT4), 1.43 ng/dl (0.7-1.85 ng/dl); FSH, 12.2 IU/l (2-10 IU/l); LH, 6.7 IU/l (<9 IU/l); TSH, 0.94 μIU/ml (0.5-4.8 μIU/ ml); PRL, 11.7 ng/ml (3.5-19.4 ng/ml); testosterone, 3.11 ng/ml (2.6-11 ng/ml); sex hormone binding globulin (SHBG), 57.3 nmol/l (13-71 nmol/l).
An off-pump coronary artery bypass was performed using the left internal mammary artery to the LAD using the off- pump coronary artery bypass grafting (OPCAB) technique. The operative monitoring included Swan Ganz catheter, SVO 2, TEEcho and cerebelar oxymetry with Somanetics Corporation, 1653 East Maple Road, Troy, MI, USA, 48083-4208. In addition, the patient received hydrocortisone 300 mg IV intraoperatively and an infusion of hydrocortisone 300 mg/ day IV for 48 h post-operatively. After 48 h, the patient returned to his previous regular dose of hydrocortisone. The early postoperative of the patient was completely uneventful.
T3 decreased below normal on the third post-operative day and remained unchanged (0.25 ng/ml) thereafter, while the concentrations of T4 and FT4 stayed within the normal range. Cortisol levels were found to be increased (50 μg/dl) on the second post-operative day and returned to the normal range a week later. In general, the post-operative course was uneventful and the patient was discharged in excellent condition 2 weeks later to better manage his hormone profile.
Hypopituitarism in adults has been linked to increased cerebrovascular and cardiovascular morbidity and mortality. The presence of risk factors for cardiovascular disease, such as central adiposity, dyslipidemia, a prothrombotic state with reduced fibrinolytic activity, a higher prevalence of hypertension, increased peripheral insulin resistance, increased incidence of impaired glucose tolerance, abnormal cardiac structure and impaired cardiac performance has consistently been reported in adults with hypopituitarism.  On the other hand, it is known that hormones influencing the perioperative course of any patient include glucocorticoids and thyroid hormones. Cortisol is a major stress response hormone that has metabolic, catabolic, anti-inflammatory and vasoactive properties on the cardiac muscle and the peripheral vasculature. It also has inotropic effects and modulates free water distribution within the vascular compartment. During periods of stress or serious illness, patients with normal hypothalamic-pituitary-adrenal axis function are found to have consistently elevated serum cortisol levels by 2-10-times the upper limit of normal lacking the physiological diurnal variation.  However, the increased serum cortisol levels post-operatively in our patient resulted from the intravenous dose of glucocorticoids he received in order to improve his response to the stress of the operation. It is well known that adrenal insufficiency not successfully managed post-operatively leads to adrenal crisis, which may manifest with hypotension, sepsis, fever, vomiting and toxic psychosis.  It must be noted that in hypopituitarism, glucocorticoid replacement should precede thyroid hormone replacement to reduce the risk of adrenal insufficiency that may result from increased demands of enhanced metabolism caused by thyroid hormones. Our patient was receiving both thyroxine and glucocorticoid replacement as he had been scheduled long ago to undergo the operation. In patients with hypopituitarism, the advisable treatment for preventing adrenal insufficiency post-operatively is by supplementary administration of glucocorticoids. It was decided, therefore, to supplement intravenous dose of hydrocortisone as the mandatory perioperative treatment in our patient. In order to reduce the stress response, OPCAB was carried out in order to avoid cardiopulmonary bypass. On the other hand, thyroid hormone deficiency usually causes derangement of cardiovascular, pulmonary, renal and central nervous system function and alters drug metabolism in ways that could predispose to surgical complications. A profound deficiency of thyroid hormone can cause cardiovascular disease and aggravate many pre-existing conditions. Our patient was clinically euthyroid and, in collaboration with endocrinologists, we monitored closely his serum concentrations of T3 and FT4 without altering the dose of levothyroxine. Nevertheless, the total T3 decreased on the third post-operative day and remained unchanged (0.25 ng/ml) till his discharge from hospital. The concentrations of FT4 remained within the normal range throughout admission. In conclusion, hypopituitarism, either congenital or acquired, has been associated with higher cerebrovascular and cardiovascular morbidity and mortality. The perioperative management of these patients includes maintenance of serum thyroxine and cortisol levels in the normal range in order to prevent likely adverse outcome due to surgical stress. In conclusion, CABG surgery may be successfully undertaken in such patients.
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