Left Atrial Tumor Excision With Mitral and Tricuspid Valve Repair and Coronary Revascularization

The authors present a case of left atrial tumor excision combined with mitral and tricuspid valve repair and coronary revascularization, performed through a left anterior minithoracotomy in the fourth intercostal space.

Patient Selection and Evaluation

The patient was a 73-year-old female with persistent atrial fibrillation and a history of multiple cardioembolic strokes. Echocardiography demonstrated a 20 × 20 mm left atrial tumor attached to the posterior mitral leaflet, moderate mitral regurgitation, severe tricuspid regurgitation, and preserved left ventricular function. Coronary angiography revealed multivessel coronary artery disease involving the left anterior descending artery (LAD), obtuse marginal branches, and right coronary artery (RCA).

Contrast-enhanced computed tomography (CT) is mandatory for minimally invasive cardiac surgery (MICS) planning for the authors’ cardiac team. It helps determine the optimal incision site, delineates vessels relevant to cardiopulmonary bypass (CPB) cannulation and left internal mammary artery (LIMA) harvesting, and assesses the depth and location of the mitral valve.

Operative Steps

The procedure included right femoral cannulation; endoscopic harvesting of the left radial artery and right saphenous vein; LIMA harvesting; coronary artery bypass grafting; excision of the left atrial tumor through a right atriotomy and interatrial septal approach; mitral valve repair; and tricuspid valve repair.

Peripheral cannulation was performed under transesophageal echocardiography (TEE) guidance to ensure safe cannula placement and minimize the risk of complications. TEE was also used to assess the result of mitral valve repair.

Preference Card

The following cannula were used during this procedure:

• Bio-Medicus Multi-Stage Femoral Venous Cannula, 25 Fr
• DLP‚ Femoral Arterial Cannula, 17 Fr (for jugular vein cannulation)
• EOPA Arterial Cannula, 18 Fr

Technical Considerations

The key technical aspect of this case was the use of specific exposure maneuvers through the left anterior thoracotomy. For safe performance of exposure maneuvers, including placement of tapes around the ascending aorta, superior and inferior venae cavae, and left pulmonary veins—the authorsapply this principle: “If I can see it, I can safely perform it.” This requires clear identification of the relevant anatomical structures and continuous visualization of the instrument tip before it is passed through the tissues. These maneuvers can be practiced electively during routine procedures performed through a median sternotomy and have been previously described (1, 2). The Babliak Retractor was used for this procedure. Adequate cardiac decompression and release of the pericardial retraction sutures are important for exposure of the coronary anastomotic sites. This step may sometimes be overlooked by the assistant.

Mitral valve exposure was obtained using traction tapes around the superior vena cava, inferior vena cava, ascending aorta, and left pulmonary veins, as previously described (3). These maneuvers are generally sufficient to provide adequate exposure. In this case, Idol mitral hooks were also used.

The tumor was attached to the P2 segment of the posterior mitral leaflet and was excised en bloc with partial resection of P2. The leaflet defect was repaired, the P2–P3 cleft was closed, and a 28 mm mitral annuloplasty ring was implanted. Tricuspid valve repair was performed using the De Vega annuloplasty technique. A Babliak Knot Pusher was used for tying knots at greater depth.

Proximal anastomoses are performed on the beating heart using partial aortic clamping. A curved side-biting clamp is used to bring the ascending aorta closer to the operative field, thereby facilitating exposure.

Conclusion

In this video case, the authors present only the main steps of the procedure; the remaining technical steps have been described in a previous CTSNet publication (4).

The postoperative course was uneventful, and histopathological examination confirmed cardiac papillary fibroelastoma.

This case demonstrates that left anterior minithoracotomy can be a versatile minimally invasive approach for selected patients with complex combined cardiac pathology, allowing coronary revascularization, atrial tumor excision, and mitral and tricuspid valve repair through the same access.

Reference(s)

1. Babliak O, Demianenko V, Marchenko A, Babliak D. Multivessel minimally invasive on-pump direct coronary artery revascularization. Journal of Visualized Surgery. 2023 Jan;9:2–2. Available from: http://dx.doi.org/10.21037/jovs-22-2
2. Babliak O, Demianenko V, Melnyk Y, Revenko K, Babliak D, Stohov O, et al. Multivessel Arterial Revascularization via Left Anterior Thoracotomy. Seminars in Thoracic and Cardiovascular Surgery. Elsevier BV; 2020;32(4):655–62. Available from: http://dx.doi.org/10.1053/j.semtcvs.2020.02.032
3. Babliak O, Lazoryshynets V, Demianenko V, Babliak D, Marchenko A, Revenko K, et al. New approach to the mitral valve through the left anterior minithoracotomy for combined valve and coronary surgical procedures. JTCVS Techniques. 2023 Dec; Available from: http://dx.doi.org/10.1016/j.xjtc.2023.11.015
4. Babliak D, Babliak O. Mitral Valve Replacement and Coronary Revascularization Via the Left Anterior Minithoracotomy. November 2024. https://doi.org/10.25373/ctsnet.27625374

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