Totally Endoscopic Resection of Left Atrial Myxoma and Mitral Valve Repair

The video presents a totally endoscopic port access technique using a three-dimensional endoscopic system for resection of the left atrial myxoma and mitral valve repair without robotic assistance.

A 57-year-old male was admitted to the hospital because of fatigue three weeks prior. At the admission, he presented with NYHA II symptoms. Clinical examination showed arrhythmia, and a systolic murmur grade 3/6.

- Blood tests showed: increases in CRP and procalcitonin

- ECG showed: atrial fibrillation

- Transthoracic echocardiography revealed a neoplasm in the left atrium. The mass measuring 40 x 50 mm had a stalk attached to the interatrial septum. The tumor looked fragile and was moving deeply into the left ventricle during diastole causing significant obstruction (max gradient 22mmHg), and a high risk of embolism. The mitral valve had a lesion of ruptured chordae, P2 prolapse, and severe regurgitation. Endocarditis was suspected.

- MSCT: revealed prolapsing across the atrioventricular valves. Metastatic workup was negative.

The patient underwent an urgent operation. We used the technique of totally endoscopic port access. He was placed in supine position under general anesthetic, with double-lumen endotracheal intubation. The right side of the chest was slightly elevated at 300, two arms along the body. External defibrillator pads were attached under omoplates.

A 2 cm tranverse incision was made in the left groin and arterial cannula were done indirectly via a Dacron graft (8mm in diameter), anastomosed end-to-side to the right common femoral artery. Venous drainage with bicaval cannulation were percutaneously inserted via the right femoral vein and right internal jugular vein, using the Seldinger technique.

Three trocars were placed in the right chest of the patient: A 10 mm trocar in the 5th intercostal space (ICS) at the midaxillary line for the 3D camera, a 12 mm trocar in the 5th ICS between the anterior axillary line and the midclavicular line for main surgical instruments (electrosurgical knife, needle holder, scissors, etc.), and a 5 mm trocar in the 3th ICS at the anterior line for secondary instruments.

CPB was initiated, and CO2 inflowed into the chest cavity. After lung deflation, the pericardium was opened 2 cm anterior to the phrenic nerve and pericardium traction sutures were made. The superior vena cava was snared using a perlon suture thread size 2, passed out through the 5 mm trocar; the IVC was left free.

The aorta was clamped by the transthoracic Chitwood clamp (at 4th ICS, midaxillary line). Cardiac arrest were done with single dose of Custodiol cardioplegia solution injected antegrade into the root of the aorta via needle(Medtronic MiARTM cannulae) placed through the hole for the 12 mm trocar (outside the trocar).

We used right atrial transseptal approach. Right atriotomy was performed and 4-0 prolene atrial wall stay sutures were made for interatrial septum exposure.

The surgical manipulations were done through 3 trocars <1.2cm, under 3D video screen.

A nylon bag was put into the thoracic cavity via the 12mm trocar, in preparation for the tumor harvest.

Two 4-0 prolene traction sutures were placed: one at the lower rim of the septum secondum (lifting the septal at the orifice of the inferior caval vein for preventing blood and tumor immigration into the IVC left free), the other at the ridge of fossa ovalis (the attachment of the tumor). Interatrial septostomy was done. Exposure revealed a a large tumor (maximum size 7 cm), which macroscopically resembled a myxoma, attached via a stalk to the interatrial septum at the ridge of the fossa ovalis and muscular rim.

The tumor was removed completely with extensive resection of the myxoma attached to interatrial septum in one piece by no touch technique and delivered into the nylon bag.

The heart chambers were carefully inspected with the 3D endoscope to ensure complete tumor removal without any debriment residues. The mitral valve was inspected and examined revealing: the posterior leaflet (P2 scallop) prolapse due to a torn chorda and suspected infective endocarditis lesions. The mitral valve was repaired with triangular leaflet resection and partial posterior band annuloplasty.

The interatrial septostomy and the right atriotomy were closed using double-layer continuous 4/0 prolene running sutures. The patients was weaned from bypass. The tumor-containing nylon bag was pulled out through the 12 mm trocar hole. The pericardium was closed with continuous Ti-Cron 2-0 stitches, CPB finnished, and an 18Fr drain was placed in pericardial cavity. The 28 Fr pleural cavity drain was inserted through the 10 mm trocar position.

The bypass time and aortic cross-clamp time were 217 and 136 mins, respectively. The total operative time was 300 minutes. Postoperative mechanical ventilation: 22 hours; ICU time: 4 days.

Pathologic examination confirmed the diagnosis of cardiac myxoma.

The postoperative course was uneventful, the patient was discharged with mild mitral regurgitation after four weeks (with antibiotic treatment for infective endocarditis).

The operation was performed at Cardiovascular Centre – E Hosptial – Ha Noi – Viet Nam. We hope that this video will be useful to you. Do not hesitate to contact us if you have any questions about this video. Thank you!

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