Total thyroidectomy for amiodarone-associated thyrotoxicosis in patients with severe cardiac disease

Surgical treatment of amiodarone-associated thyrotoxicosis (AAT) is effective although fewer than 100 cases have been reported world wide.

We reviewed 14 patients treated with total thyroidectomy by a single surgeon from 1998 to 2005.

There were 11 male and 3 female patients who ranged in age from 26 to 82 years (average 50.5). Nine patients refractory to medical management and 5 in whom amiodarone needed to be continued were treated surgically. Ten patients developed thyrotoxicosis while being treated with amiodarone, but 4 became thyrotoxic after ceasing amiodarone 2, 2, 6 and 13 months previously. One patient recently had a cardiac transplant, and 4 were on the active cardiac transplant waiting list. Cardiac ejection fractions ranged from 15% to 50% (average 39%). Four patients had serious complications from medication used to control thyrotoxicosis, including one case of agranulocytosis from carbimazole. Total thyroidectomy was performed under general anaesthesia with no significant intraoperative complications and no deaths. There were no recurrent laryngeal nerve injuries. Two patients required short-term calcium supplementation. All patients had rapid resolution of their symptoms and were euthyroid on thyroxine postoperatively. Two patients had such improvement they were removed from the cardiac transplant list.

Despite severe cardiac disease, total thyroidectomy can be performed successfully under general anaesthesia. Surgery should be considered early in the treatment plan. Surgery is particularly appropriate where it is considered necessary to continue amiodarone, when there are complications from the medications used to treat thyrotoxicosis and to facilitate fitness for or defer the need for cardiac transplantation.