Totally Endoscopic Left Atrial Myxoma Resection

In this CTSNet series, Dr. Mario Castillo-Sang presents innovative, totally endoscopic cardiac procedures for a variety of conditions. Stay tuned for more series videos in the coming weeks.       

The authors present the case of a 62-year-old female patient who was incidentally diagnosed with a left atrial myxoma during a routine coronary compute tomography angiography (CTA) study. The patient was completely asymptomatic and had no history of cerebrovascular events. 

The mass was further studied with transesophageal echocardiography (TEE) and cardiac MRI, confirming the myxoma diagnosis, which measured 2.5 cm in diameter. 

The patient was offered an endoscopic approach for myxoma resection. The authors’ endoscopic approach consisted of a working incision that was a 2.5 cm incision in the fourth intercostal space, expanded with an extra-small soft tissue retractor and no rib spreader. The camera port was a 10mm trocar in the third intercostal space. A 5 mm incision was placed in the fourth anterior intercostal space for the atrial lift retractor. Femoral bypass was achieved via cutdown with direct arterial and venous cannulation. 

The heart was arrested using antegrade del Nido solution, and the patient was cooled to 32 degrees Celsius. The left atrium was opened through the interatrial groove, and the left atrial retractor was introduced. Immediately, the mass was visible, located 2 cm above the A3 region of the mitral valve and measured approximately 2 cm in length. 

The surgeons resected the endocardial base/stalk of the mass, and in doing so, entered the right atrium. The mass was removed completely, and then the iatrogenic atrial septal defect was closed with 4-0 polypropylene sutures. A cryoprobe was then used to perform cryoablation of the surrounding tissues at the base. Once this was completed, the left atrium was closed, and the heart was reanimated. The surgeons then opened the right atrium to inspect its structures and ensure there were no unidentified injuries. 

The patient was extubated in the operating room and had a full recovery after a three-day hospital stay. She resumed strenuous physical activity three weeks later. 

Endoscopic resection of left atrial myxomas has been safely and effectively performed for many decades (1, 2). Preoperative imaging is paramount to effectively plan and deliver a safe operation. 

References

1. Deshpande RP, Casselman F, Bakir I, Cammu G, Wellens F, De Geest R, Degrieck I, Van Praet F, Vermeulen Y, Vanermen H. Endoscopic cardiac tumor resection. The Annals of thoracic surgery. 2007 Jun 1;83(6):2142-6.
2. Abdelbar A, Zacharias J. Endoscopic surgery for cardiac tumours. InEndoscopic Cardiac Surgery: Tips, Tricks and Traps 2023 Jun 15 (pp. 237-243). Cham: Springer International Publishing

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