Minimally Invasive Left Atrial Myxoma Resection Using 3D Technology

The atrial myxoma is the most frequent cardiac tumor, located in the left atrium in 75 percent of the time (1). The most dangerous presentation is the papillary, which indicates is the surgical removal with the aim to avoid embolic complications (2-5).

The minimally invasive approach (MICS) has shown to be a feasible technique. The MICS approach has shown relevance recently based on benefits such as less trauma, bleeding, postoperative pain, and faster rehabilitation (6, 7).

Resection through a MICS-3D HD has some advantages because it allows faster and better visualization with a deep understanding of the pathology. Some groups have shown improvements in the learning curve when using 3D technology compared with classic 2D (8, 9).

There are plenty of controversies regarding the MICS-3D approach such as pleural adhesions, ascending aorta calcification, severe femoral artery calcification, aortic regurgitation ≥2+, or thoracic wall deformities. Therefore, the indication and the patient-selection criteria must be chosen thoroughly.

This video presents a case of a left atrial myxoma resection through a MICS-3D video-assisted approach, a technique not often described in the literature, and demonstrates how it can be performed effectively.

The Patient

A sixty-seven-year-old man with a history of hypertension and NYHA I presented with hemiparesis on the right side of the body. A cerebral magnetic resonance image (MRI) was performed, and an ischemic lesion was observed at the left parietal lobe. The catheter lab showed no coronary lesions. In the transesophageal echocardiography (TEE) a 7.9 cm mass located in the left atrium and implanted at the fossa ovale bulging to the left ventricle was observed, and then confirmed with cardiac MRI (Fig. 2 B, C). Based on this information, the team decided on surgical resection.

The Surgery

First, a right minithoracotomy was performed between the fourth and fifth intercostal space (ICS). Two 5 mm accessory ports were used to insert the Chitwood aortic clamp in the right third ICS at the midaxillary line and a 3D video camera at the right fourth ICS. Surgeons used 3D glasses during most of the procedure. A Mohr atrial retractor, long-shafted instruments for minimally invasive surgery, and long-shafted knotters were used. A Storz video camera with a mechanical arm was also used. Long arterial and venous cannulas for CPB management were inserted through a minimal 3-4 mm incision in the femoral artery, femoral, and jugular vein. These are considered bicaval cannulations in MICS when approaching through right atrium. In all cases, their position was guided and controlled by transesophageal echocardiography (TEE).

An aortic clamp was placed and a single dose of 2,000 mL Bretschneider antegrade cardioplegia was given. After the right atrium opening, an incision was made at the fossa ovale in order to reach the left atrium. Then the myxoma was identified and removed gently. 

The surgeon and all the assistants used special glasses for the 3D video camera and 3D technology. This allowed for a better understanding of the depth, better perspective, and improved image quality. When the whole mass was removed, the team started to close the atrial septal defect with a pericardial patch with a running suture of polypropylene. The final TEE showed no left atrium mass or shunt through the septum.

De-airing was achieved with a third suction instrument once the left atriotomy was closed, together with an aortic venting needle (VN). Cardiopulmonary bypass was continued, reducing perfusion until the CPB pump was stopped with the VN in place. Once the absence of air bubbles in the heart was confirmed by TEE, CPB was briefly reinitiated to withdraw the VN and perform an extra hemostatic suture.

Both cross-clamp time and cardiopulmonary bypass time were 99 and 190 minutes, respectively. Weaning from mechanical ventilation was accomplished three hours later and the patient was discharged on the fifth day. At the one-year follow up there was no evidence of a tumor.

References

1. De Loma, J. G., Marcos, J. F. V., Tejedor, J. M. M., & González, S. G. (2009). Left Atrial Myxoma. Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery, 4(6), 351–353. doi:10.1097/imi.0b013e181c48b92
2. Gaisendrees, C., Mader, N., Sabashnikov, A., et al (2019). Minimally invasive resection of a giant left atrial myxoma: a case report. Perfusion, 026765911986512. doi:10.1177/0267659119865125
3. Montero-Cruces, L., Pérez-Camargo, D., Carnero-Alcázar, M., et al. 15 años de experiencia en el tratamiento quirúrgico del mixoma cardiaco. Cirugía Cardiovascular. doi:10.1016/j.circv.2019.11.003
4. Adrián Yebra López,* Carlos Laertes Cruz Enríquez,‡ Teresa Gutiérrez Reza, et al. Resection of intracardiac giant mixoma with reconstruction of the interatrial septum: Case report and review of literature, 73 (2).170-174
5. Ernesto Chaljub-Bravo, Gustavo J. Bermúdez-Yera, Yolepsis F., et al.Presentación clínica y tratamiento quirúrgico de mixomas cardiacos en la tercera edad. Reporte de 2 casos,Cirugía Cardiovascular,Volume 26, Issue 6,2019,Pages 296-301.
6. José M. Melero, Gemma Sánchez-Espín, Arantxa Guzón, et al. Minitoracotomía anterior derecha: un abordaje consolidado,Cirugía Cardiovascular,Volume 27, Issue 1,2020,Pages 3-8,ISSN 1134-0096,https://doi.org/10.1016/j.circv.2019.10.003
7. Santana, O., Larrauri, M. C., Escolar, E., et al. (2014). La cirugía valvular mínimamente invasiva. Revista Colombiana de Cardiología, 21(3), 188–194. doi:10.1016/s0120-5633(14)70278-5
8. Marin Cuartas, M., Javadikasgari, H., Pfannmueller, B., et al. Mitral valve repair: Robotic and other minimally invasive approaches. Progress in Cardiovascular Diseases, 60(3), 394–404. doi:10.1016/j.pcad.2017.11.002
9. Romero-Loera, S., Cárdenas-Lailson, L. E., de la Concha-Bermejillo, F., Crisanto-Campos, et al. Comparación de destrezas en simulador de laparoscopia: imagen en 2D vs. 3D. Cirugía y Cirujanos, 84(1), 37–44. doi:10.1016/j.circir.2015.06.032

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