Totally Endoscopic Right 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 52-year-old male patient who presented with dyspnea on exertion and fatigue. The patient’s workup demonstrated a large 4 cm right atrial mass causing partial right ventricular inflow obstruction as the mass bobbed in and out of the tricuspid valve. Cardiac MRI suggested the mass was a myxoma, and the patient was offered an endoscopic myxoma resection. 

The endoscopic approach consisted of a 2.5 cm working incision in the fourth intercostal space and a 10 mm port in the third intercostal space for a 30-degree angled endoscope. 

The cannulation strategy for cases in which full cardiopulmonary control was needed included femoral arterial cannulation with a bicaval venous strategy, utilizing a direct right internal jugular percutaneous cannulation and femoral cannulation. The pericardiotomy was made 3 cm above the phrenic nerve and was carried along the center portion of the aorta superiorly all the way to the diaphragm inferiorly, where it teed off into the anterior aspect towards the left side. The operation was performed with a beating heart to offer the advantage of monitoring the heart rhythm. The myxoma was resected sharply, and cryoablation was performed at the base of the mass. The area of resection was oversewn with 4-0 polypropylene, and the right atrium was closed. The patient was separated from bypass and extubated in the operating room. He made a full recovery and was discharged home on postoperative day two. 

Atrial myxomas can be safely resected endoscopically (1). Cryoablation of the base can be performed in cases where an aggressive resection of the base would lead to significant morbidity (2). The endoscopic approach lends itself to myxoma resection, offering patients an excellent recovery profile. 

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. Marinakis S, Mircev D, Wauthy P. Cryoablation for a right atrial myxoma arising from the Koch’s triangle: a case report. Journal of Cardiothoracic Surgery. 2013 Dec;8:1-3.

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