Redo Endoscopic Left Ventricular Mass Removal

The authors present the case of an 81-year-old man who, after an inferior myocardial infarction in 1990, underwent heart surgery involving three coronary artery bypasses. The right internal thoracic artery was used for the left anterior descending artery, the left internal mammary artery for the obtuse marginal, and a saphenous vein graft for the right coronary artery. Prior to that, he had undergone surgery to remove a myxoid sarcoma from the left quadriceps femoris and a left carotid endarterectomy. During a routine cardiologic check-up, an encapsulated left ventricular mass measuring 26 x 32 mm was found by chance, with a pedicle arising from the posteromedial papillary muscle. The patient was admitted to the cardiac surgery unit and underwent an MRI, which confirmed the presence of a formation in the left ventricle constituted by a capsule with semisolid content. 

The patient was then scheduled for surgery. Preoperatively, the patient was evaluated by a cardio CT scan with the purpose of identifying the course of the grafts as well as the most favorable approach. This exam revealed a chronically occluded vein graft, calcification of the distal ascending aorta, and the right mammary artery crossing the aorta on its mid-portion. 

The operation was performed through a right mini-thoracotomy approach in the fourth intercostal space with single left lung ventilation. Cardiopulmonary bypass was instituted by right subclavian artery and right femoral vein cannulation due to peripheral arteriopathy. After dissecting adherences and identifying the right internal thoracic artery, a vent in the ascending aorta was placed.  

On a beating heart and mild hypothermia, the left atrium was opened. The use of a Superflex soft tissue retractor through the mitral valve annulus allowed the exposure of the left ventricular mass, which was easily removed from the posteromedial papillary muscle. The mass appeared as a thick, capsulated mass of duroelastic consistency, containing myxomatous tissue. The histologic examination confirmed it to be a metastatic myxoid liposarcoma with a condroid capsule and dystrophic calcifications.  

The patient was easily weaned from cardiopulmonary bypass, and the operation completed as usual. Transesophageal echocardiography showed no residual mitral regurgitation. The patient was weaned from mechanical ventilation after a few hours and had an uneventful postoperative course. On the eighth postoperative day, the patient was discharged home. 

References

1. Kai Xu, Zengshan Ma, Bowen Li, Zhenhua Wang, Han Song, Xiao Bai, Xiangbin Meng, Kai Liu, Xin Zhao. Totally thoracoscopic surgical resection of left ventricular benign tumor. JTCVS Techniques, Volume 20, 2023. Pages 116-122, ISSN 2666-2507. https://doi.org/10.1016/j.xjtc.2023.04.018.
2. Langenaeken T, Basoglu A, Kaya A, Yilmaz A. Total endoscopic left ventricle lipoma removal. J Cardiothorac Surg. 2021 Aug 4;16(1):218. doi: 10.1186/s13019-021-01602-y. PMID: 34348760; PMCID: PMC8335990.
3. Mohamed Rahouma, Mohammed J. Arisha, Adham Elmously, Magdy M. El-Sayed Ahmed, Cristiano Spadaccio, Kritika Mehta, Massimo Baudo, Mohamed Kamel, Esraa Mansor, Yongle Ruan, Mahmoud Morsi, Shon Shmushkevich, Ihab Eldessouki, Mostafa Rahouma, Abdelrahamn Mohamed, Ivancarmine Gambardella, Leonard Girardi, Mario Gaudino. Cardiac tumors prevalence and mortality: A systematic review and meta-analysis. International Journal of Surgery. Volume 76, 2020. Pages 178-189. ISSN 1743-9191. https://doi.org/10.1016/j.ijsu.2020.02.039.

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