Refractory Hypotension post Coronary Artery Bypass Graft Unmasking Hypoaldosteronism: Case Report and Literature Review
International Journal of Cardiovascular and Thoracic Surgery
Volume 5, Issue 2, March 2019, Pages: 47-50
Received: Mar. 27, 2019;
Accepted: May 17, 2019;
Published: Jun. 12, 2019
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Carla Sawan, Department of Endocrinology, Saint George Hospital University Medical Center, University of Balamand, Beirut, Lebanon
Nadine Kawkabani, Department of Cardiac Anesthesia, Saint George Hospital University Medical Center, University of Balamand, Beirut, Lebanon
Youmna Francis, Department of Endocrinology, Saint George Hospital University Medical Center, University of Balamand, Beirut, Lebanon
Omar Boustros, Department of Cardiothoracic Surgery, Saint George Hospital University Medical Center, University of Balamand, Beirut, Lebanon
Simon Bejjani, Department of Cardiothoracic Surgery, Saint George Hospital University Medical Center, University of Balamand, Beirut, Lebanon
Fadi Abou Jaoudeh, Department of Cardiology, Saint George Hospital University Medical Center, University of Balamand, Beirut, Lebanon
Rola Darwiche, Department of Cardiac Anesthesia, Saint George Hospital University Medical Center, University of Balamand, Beirut, Lebanon
Bassam Abou Khalil, Department of Cardiothoracic Surgery, Saint George Hospital University Medical Center, University of Balamand, Beirut, Lebanon
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The sympathetic nervous system and the renin-angiotensin-aldosterone system (RAAS) are the cornerstones of cardiovascular adaptation. The simultaneous presence of disorders involving both is not uncommon, especially in patients with coronary artery disease undergoing coronary artery bypass surgery (CABG). This is the case of a patient with both hyporeninemic hypoaldosteronism and autonomic dysfunction. This article describes his clinical course before and after CABG surgery, along with a literature review of those interrelated entities. Our patient is a 63-year-old male with a history of hypertension and hyperlipidemia presenting for CABG for triple vessel disease. On the day of admission, the patient had sudden unprovoked loss of consciousness along with hypotension and bradycardia. He reported having had similar episodes in the past at times of emotional stress. After stabilization, the patient underwent CABG surgery the next day and it was uneventful. Four hours later, he developed another episode of hypotension with bradycardia which resolved upon administration of fluids. On postoperative day 2, while removing the jugular line, he had loss of consciousness with 5 seconds pause recorded on his bedside monitor. A carotid massage confirmed carotid sinus hypersensitivity, which necessitated the insertion of a pacemaker. However, patient continued to have similar episodes despite a functioning device. Workup revealed hyporeninemic hypoaldosteronism with an undetectable aldosterone level, although patient was not diabetic, had normal cortisol level, and had no other risk factors for those findings. Patient was started on fludrocortisone 0.1 mg daily; his hemodynamics improved markedly, and his symptoms resolved permanently. Our patient has hyporeninemic hypoaldosteronism caused most likely by his autonomic dysfunction, rather than having of two separate entities. A review of the literature showed that primary autonomic insufficiency with reduced circulating norepinephrine levels prevent renin activation and subsequently aldosterone release, leading to hyporeninemic hypoaldosteronism. Coronary artery disease is a known cause of autonomic dysfunction and CABG surgery unmasks this entity, which explains the exacerbation of our patient’s symptoms during this phase.
RAAS, Hyporeninemic Hypoaldosteronism, CAD, CABG
To cite this article
Fadi Abou Jaoudeh,
Bassam Abou Khalil,
Refractory Hypotension post Coronary Artery Bypass Graft Unmasking Hypoaldosteronism: Case Report and Literature Review, International Journal of Cardiovascular and Thoracic Surgery.
Vol. 5, No. 2,
2019, pp. 47-50.
Copyright © 2019 Authors retain the copyright of this article.
This article is an open access article distributed under the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/
) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Huikuri HV1, Stein PK. Heart rate variability in risk stratification of cardiac patients. Prog Cardiovasc Dis. 2013 Sep-Oct; 56 (2): 153-9.
Arnold AC, Ng J, Lei L, Raj SR. Autonomic Dysfunction in Cardiology: Pathophysiology, Investigation, and Management. Can J Cardiol. 2017; 33 (12): 1524–1534.
White PC. Aldosterone synthase deficiency and related disorders. Mol Cell Endocrinol. 2004 Mar 31; 217 (1-2): 81-7.
New MI, Lekarev O, Parsa A, et al. Genetic Steroid Disorders. In: Academic Press. 1st ed; 2013; Chapter 3D page 78
Sousa AG, Cabral JV, El-Feghaly WB, de Sousa LS, Nunes AB. Hyporeninemic hypoaldosteronism and diabetes mellitus: Pathophysiology assumptions, clinical aspects and implications for management. World J Diabetes. 2016; 7 (5): 101–111.
Szylman P, Better OS, Chaimowitz C, et al. Role of hyperkalemia in the metabolic acidosis of isolated hypoaldosteronism. N Engl J Med. 1976; 294: 361-365.
DeLeiva A, Christlieb AR, Melby JC, et al. Big renin and biosynthetic defect of aldosterone in diabetes mellitus. N Engl J Med. 1976 Sep 16; 295 (12): 639-43.
Chen Y, Yu Y, Zou W, Zhang M, Wang Y, Gu Y. Association between cardiac autonomic nervous dysfunction and the severity of coronary lesions in patients with stable coronary artery disease. J Int Med Res. 2018; 46 (9): 3729–3740.
Lakusic N, Mahovic D, Kruzliak P, et al. Changes in Heart Rate Variability after Coronary Artery Bypass Grafting and Clinical Importance of These Findings. Biomed Res Int. 2015: 680515.
Wilczynski C, Shah L, Emanuele MA, Emanuele N, Mazhari A. Selective Hypoaldosteronism: A review. Endocr Pract. 2015 Aug; 21 (8): 957-65.
Tuck ML, Sambhi MP, Levin L. Hyporeninemic hypoaldosteronism in diabetes mellitus. Studies of the autonomic nervous system's control of renin release. Diabetes. 1979; 28: 237-241.
Data JL, Gerber JG, CrupWJ, et al. The prostaglandin system-A role in canine baroreceptor control of renin release. Circ Res. 1978 Apr; 42 (4): 454-8.
Ballermann BJ, Zeidel ML, Gunning ME, et al. Vasoactive peptides and the kidney. In: Brenner BM, Rector FC Jr (Eds). The Kidney. 4th ed. Philadelphia, Pa, WB Saunders; 1991; pp 515-17.
Polsky FI, Roque D, Hill PE. Hyporeninemic hypoaldosteronism complicating primary autonomic insufficiency. West J Med. 1993; 159 (2): 185–187.
Love DR, Brown JJ, Chinn RH, et al. Plasma renin in idiopathic orthostatic hypotension: Differential response in subjects with probable afferent and efferent autonomic failure. Clin Sci. 1971; 41: 289-99.
Rose BD, Post TW. Clinical Physiology of Acid-Base and Electrolyte Disorders. 5th ed. New York, NY: McGrawHill; 2001.