Endoscopic Septal Tumor Resection With Biatrial Reconstruction

A 44-year-old woman undergoing preoperative evaluation for a uterine myomectomy was incidentally diagnosed with a cardiac mass. She reported a three-month history of mild dyspnea, palpitations, and tachycardia, with no other significant findings on physical examination. Transthoracic echocardiography revealed a homogeneous 5 × 6 cm mass occupying the right atrium. Computed tomography and positron emission tomography were performed to exclude metastatic disease, which demonstrated no metastases or increased metabolic activity within the tumor.

Surgical Approach

The patient underwent a totally endoscopic resection through a right minithoracotomy. She was positioned with slight right-sided elevation, and three ports were placed: a working port in the fourth intercostal space (ICS), a camera port in the fourth ICS, and a stab incision in the sixth ICS for pericardial retraction. Cardiopulmonary bypass was established through surgical cutdown and cannulation of the right femoral vessels. After pericardiotomy and the placement of traction sutures, the superior vena cava was dissected and snared. Because of the tumor size, the inferior vena cava could not be safely dissected and was left on open venous drainage during cardiac arrest. Following aortic cross-clamping and cardioplegic arrest—achieved using an initial dose of 40 ml/kg of del Nido blood cardioplegia and a maintenance dose of 20 ml/kg after the 90-minute mark—a right atriotomy exposed a large mass involving the interatrial septum, part of the inferior vena cava, and the ostium of the right pulmonary veins. Complete tumor excision was achieved. A surgical gauze was temporarily placed at the inferior vena cava outlet to minimize air entrainment. Reconstruction was performed using a two-patch bovine pericardial technique to restore the pulmonary venous confluence, interatrial septum, and the right atrial free wall. The atriotomy was closed, the cross-clamp removed, and the patient was successfully weaned from cardiopulmonary bypass.

The aortic cross-clamp time was 156 minutes, and the cardiopulmonary bypass time was 229 minutes. No perioperative blood transfusions were required. The patient was extubated 13 hours postoperatively, transferred to the surgical ward the following day, and discharged on postoperative day 12. At the two-week follow-up, she reported complete resolution of symptoms. Histopathology confirmed a cavernous hemangioma, and no additional treatment was indicated.

Conclusion

Large benign cardiac tumors can be safely excised using a totally endoscopic approach, even when extensive atrial reconstruction is required. Complex reconstruction of the atrial septum, pulmonary venous inflow, and right atrium is feasible through minimally invasive techniques, which provide excellent clinical outcomes while avoiding a median sternotomy. Given the benign nature of cardiac cavernous hemangiomas, complete surgical resection remains the treatment of choice, and minimally invasive approaches should be considered whenever technically feasible.

References 

1. Samhan, A., Ahmed, S., Lewis, A. A., Cremer, P. C., ElHarake, L., Lomasney, J. W., Johnston, D. R., & Al-Kazaz, M. (2025). Rare presentation of a primary cardiac mass: Insights into multimodal imaging, histopathology, and surgical management. JACC: Case Reports, 30(18), 103931. https://doi.org/10.1016/j.jaccas.2025.103931
2. Shin, C., Ju, M. H., Lee, C. H., Lim, M. H., & Je, H. G. (2023). Surgical Outcomes of Cardiac Myxoma Resection Through Right Mini-Thoracotomy. Journal of chest surgery, 56(1), 42–48. https://doi.org/10.5090/jcs.22.094
3. Mikus, E., Fiorentino, M., Sangiorgi, D., Costantino, A., Calvi, S., Tenti, E., Tremoli, E., Tripodi, A., & Savini, C. (2025). Comparative analysis of surgical outcomes in cardiac myxoma resection: Sternotomy versus right mini-thoracotomy. Cardiovascular Innovations and Applications, 10(1). https://doi.org/10.15212/CVIA.2025.0015
4. Munteanu, I. R., Novaconi, R. C., Merce, A. P., Dima, C. N., Falnita, L. S., Manzur, A. R., Streian, C. G., & Feier, H. B. (2025). Cardiac Hemangiomas: A Five-Year Systematic Review of Diagnosis, Treatment, and Outcomes. Cancers, 17(9), 1532. https://doi.org/10.3390/cancers17091532
5. Qamar, F., Kharsa, C., Letham, P., Aoun, J., Goel, S. S., Kleiman, N. S., Reardon, M. J., & Atkins, M. D. (2025). Cardiac Cavernous Hemangioma. JACC. Case reports, 30(4), 102956. https://doi.org/10.1016/j.jaccas.2024.10295

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.