Surgical Correction of a Giant Left Atrial Myxoma Producing Critical Mitral Stenosis

Slide 1
This video illustrates a case of surgical correction of a giant left atrial myxoma that produced critical mitral stenosis in our patient.

Slide 2
Primary tumors of the heart are extremely rare with their incidence as low as zero point 19%. Three quarters of all cardiac tumors are benign in origin. Myxomas are benign neoplasms, they are the most common type of intracardiac tumors. 75% of myxomas originate from the left atrium, approximately 15-20% from the right atrium, and a very small percentage from the ventricles.

Slide 3
Surgical treatment is recommended as soon as the presence of a myxoma is identified in a patient due to high risk of valvular obstruction and embolization. Over the years three main surgical approaches have been identified – the biatrial approach, the right atrial transseptal approach, and the left atrial approach.

Slide 4
At our institution we favor the right transseptal approach over the other techniques and believe that it provides additional advantages.

Slide 5
The criteria for appropriate surgical intervention for atrial myxoma were defined by Jones and colleagues in 1995 and state that the surgical approach should allow minimal manipulation of the tumor, provide adequate exposure for complete resection of the neoplasm, minimize the risk of recurrence, and be safe and effective.

Slide 6
Our patient is a 66-year-old male who presented to our institution with four months of worsening cough with blood-tinged sputum. The patient developed progressive dyspnea on exertion and remarkably lost 40 lb. of weight over a short period of time. Cardiac evaluation through echocardiography incidentally revealed a myxoma that was producing mitral stenosis and causing the symptoms.

Slide 7
The patients past medical history is significant for severe coronary artery disease and hypertension. Notably the patient was a very heavy smoker, smoking as much as 2 packs per day for over 40 years. Understandably the cough at first presentation was thought to have been caused by smoking.

Slide 8
Pre-operative echocardiography revealed an ejection fraction of 51%, the size of the myxoma was approximated at 7.7 x 4.7 cm, leaving an area of just point 45 square centimeters for the mitral valve.

Slide 9
On these preoperative echo images we can appreciate the size of the myxoma and how it prolapses into the left ventricle through the mitral valve and leaves very little area for the blood to cross the valve.

Slide 10
Computed tomography also showed dramatic images of the myxoma. In this set of axial images we can see a large lobulated low density mass within the left atrium with a broad based attachment in the region of the intra-atrial septum.

Slide 11
Coronal CT images that you can see here also show this large mass in relation to the mitral valve and the left ventricle.

Slide 12
In this image we illustrate in a schematic fashion the approach that we favor for left atrial myxomas, which will be illustrated in the video. The left atrium is approached through an incision of the right atrium and then the septum in the fossa ovalis region.
The myxoma is then removed in one piece with the stalk.

Here we present the video of the surgical procedure.

Slide 13
The chest is opened via median sternotomy, the heart is exposed.

Slide 14
Cardiopulmonary bypass is established by cannulating the ascending aorta and separate cannulation of the superior and inferior vena cava.

Slide 15
The aorta is cross-clamped, antegrade crystalloid cardioplegia is given.

Slide 16
An incision is made on the right atrium, it is extended and opened widely.

Slide 17
An incision is made in the septum and continued around the circumference of the fossa ovalis. The huge mass was attached to the caudal rim of the fossa ovalis.

Slide 18
Once the septal incision is complete an Alice clamp is applied to the part of the atrial septum that is attached to the tumor. Then the giant myxoma is removed in one piece using the “no-touch” technique. The left atrium if then carefully inspected for any residual masses.

Slide 19
After the myxoma was removed we checked the mitral valve, it appeared unaffected. The septum was then re-created using an autologous pericardial patch. The coronary sinus was carefully preserved. The patient also underwent a coronary artery bypass grafting for 3 vessel disease on the same day.

Slide 20 + 21
Pathology Examination revealed scattered stellate cells within a myxoid stroma and multilayered rings of myxoma cells around blood vessels that are infiltrated by lymphocytes.

Slide 22
The patient recovered uneventfully from the surgical procedure and was discharged from the hospital on the fifth postoperative day. At present, 6 years after the resection of this intracardiac tumor the patient is doing well, his symptoms resolved completely, and he has gained back his normal weight.

References

1. Reynen K. Cardiac myxomas. The New England journal of medicine. 1995;333(24):1610-7.
2. Jones DR, Warden HE, Murray GF, Hill RC, Graeber GM, Cruzzavala JL, et al. Biatrial approach to cardiac myxomas: a 30-year clinical experience. The Annals of thoracic surgery. 1995;59(4):851-5; discussion 5-6.
3. Pinede L, Duhaut P, Loire R. Clinical presentation of left atrial cardiac myxoma. A series of 112 consecutive cases. Medicine. 2001;80(3):159-72.
4. Miralles A, Bracamonte L, Rabago G, Pavie A, Bors V, Gandjbakhch I, et al. [Intracardiac myxoma: surgical treatment with trans-septal approach]. Helvetica chirurgica acta. 1990;57(2):203-7.

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