Minimally Invasive Excision of Pulmonary Valve Mass via Left Anterior Thoracotomy

The Patient

A fifty-six-year-old woman with HIV had been undergoing workup at an outside institution for progressive shortness of breath when a CT scan was obtained to evaluate for pulmonary embolism. A 1.5 cm lesion was found in the main pulmonary artery adjacent to the pulmonary valve. The clinical picture was not consistent with endocarditis or pulmonary embolism. Despite treatment with anticoagulation and antibiotics, there was no resolution or improvement in the patient’s symptoms. She was transferred for further care.

Review of the imaging showed a 1.5 cm mass adherent to the pulmonary valve cusps. There was concern for cardiac tumor, most likely a papillary fibroelastoma. Transesophageal echocardiography clearly showed a large mobile mass on the pulmonary valve. There was no obvious leaflet damage and the pulmonary valve functioned well. In order to better characterize the mass and to prevent pulmonary thromboembolism, the decision was made to excise the mass surgically.

The Surgery

A 5 cm left mini anterior thoracotomy was made in the second intercostal space. The left internal thoracic artery was divided between two clips, the left pleural space was entered, and mediastinal fat was dissected away from the pericardium. The pericardial space was then entered. Stay sutures were used to optimize visualization of the right ventricular outflow pulmonary, pulmonary valve, and the main pulmonary artery. The femoral vessels were exposed and controlled with vessel loops for cardiopulmonary bypass. A multistage venous cannula was advanced over a wire using echocardiographic guidance into the superior vena cava for optimal drainage. To improve visualization, the left second rib was shingled at its insertion into the sternal joint. A wound protector and mini thoracotomy retractor were placed and additional stay sutures were placed in the pericardium to optimize exposure. A plegeted Prolene suture was used to retract the right ventricular outflow tract caudally to better visualize the base of the pulmonary artery.

Once on cardiopulmonary bypass, the pulmonary artery was opened distal to the pulmonary valve with beating heart. A small caliber basket sucker was placed through the incision to siphon blood away from the working area. Stay sutures were placed on the wall of the pulmonary artery for better exposure. A gelatinous mass was seen adherent to the cusps of the pulmonary valve. It was gently grasped and pulled into view. The base of the mass was incised with a scalpel with care not to damage the pulmonary valve. The pulmonary artery was irrigated and then closed in a single layer using 5-0 Prolene, and the retraction sutures were cut. Hemostasis was achieved, and the patient was easily weaned off cardiopulmonary bypass. The femoral artery was then directly repaired prior to giving protamine. A chest tube was placed in the left pleural space and the second rib was approximated to the sternum using a plate. The incision was closed in layers and the patient transferred to the ICU.

The patient did well and was discharged home on postoperative day three. Final pathology showed a papillary fibroelastoma.

References

1. Tyebally S, Chen D, Bhattacharyya S, Mughrabi A, Hussain Z, Manisty C, Westwood M, Ghosh AK, Guha A. Cardiac Tumors: JACC CardioOncology State-of-the-Art Review. JACC CardioOncol. 2020 Jun 16;2(2):293-311. Doi: 10.1016/j.jaccao.2020.05.009. PMID: 34396236; PMCID: PMC8352246.

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