Surgical experience with left atrial myxomas

Between 1974 and 1982, 16 patients (four men, twelve women, mean age 50.5 years) underwent surgery for left atrial myxoma at the Hannover Medical School. Clinical features encompassed cardiac murmurs (100%) and findings compatible with mitral stenosis (87%), chest pain (37%), arrhythmias (37%), syncope (18%) and malaise (37%). Arterial tumor embolism (to the right leg) occurred in one case. The sedimentation rate was consistently elevated. Sinus rhythm was present in 14 and atrial flutter in two patients. In all but one case, the diagnosis was documented through cardiac catheterization. In recent years, however, noninvasive methods such as echocardiography and computer tomography have proved to be accurate and reliable diagnostic methods such that cardiac catheterization would now appear indicated primarily for patients with additional heart disease and for those over the age of 40 years to rule out the presence of asymptomatic coronary artery disease. Surgery was performed with cardiopulmonary bypass and all patients survived the procedure. In 13 cases the tumor was removed through a right atrial approach with septal incision, in two through the left atrium and in one case both approaches were used. Complete removal of the tumor was achieved in all patients. The tumors were found to arise from the atrial septum in 15 and from the inferior wall of the left atrium in one patient. The size of the tumors ranged from 30 mm in diameter up to 100 mm X 60 mm X 40 mm with weights between 4.8 and 125 grams. Although no residual tumors have been seen during an average observation period of 29.2 months (range nine to 56 months), long-term follow-up, readily accomplished with noninvasive methods, is warranted for such patients.     

心脏黏液瘤的外科治疗

目的:总结36例心脏黏液瘤的外科治疗经验。方法:回顾性分析我院自2009年1月至2015年1月间,36例心脏黏液瘤病例手术资料,男性16例,女性20例;平均年龄:(34±4.6)岁,病程1~96个月。诊断为左心房黏液瘤34例,右心房黏液瘤2例,均在体外循环下行黏液瘤摘除术。结果:所有患者手术顺利,无手术死亡。平均ICU入住时间:(1.3±0.2)天,平均住院时间:(12±1.5)天,均无严重并发症。32例患者定期随访1~3年,总随访512个月,平均随访37个月,总的随访率88.9%。所有随访患者心功能I级(NYHA),未见复发和晚期死亡病例。结论:心脏黏液瘤的手术效果确切,手术安全,复发率低。     

心脏黏液瘤的外科治疗

目的探讨心脏黏液瘤的诊断与手术治疗方法。方法体外循环下行心脏黏液瘤摘除29例,经右房-房间隔切口,切除黏液瘤及蒂周围0.5～1.0cm的房间隔组织,房间隔缺损小的直接缝合,大的补片修补。结果29例手术病人均无死亡。门诊随防2个月直4年,心脏功能良好。无黏液瘤复发及再生。结论体外循环下行黏液瘤切除方法可靠确实,治疗彻底。     

Over 14 years of experience with cardiac myxomas

Atrial myxomas are the most commonly encountered tumours of the heart and can present at different ages with different clinical symptoms.They are one of the curable tumours of the heart. Appropriate surgical treatment and surgery must be performed with great precautions in order to prevent fatal systemic embolizations. In this retrospective study we will present our experience of 14 years, between 1990 and 2004, in 27 patients who had been operated for cardiac myxomas. Diagnosis of the myxomas were made by echocardiography in all cases. Surgical approach to the tumour was biatrial in nine, left atrial in II, and transseptal in seven patients. Associated procedures included coronary artery bypass grafting in one, mitral valve repair with tricuspid annuloplasty in two patients, mitral valve replacement in one and bilateral femoral embolectomy in one patient. One hospital mortality occurred as a result of multiorgan failure in a patient with peripheral embolization. None of the patients required recurrent operation, however, mitral valve insufficiency was surgically corrected in one patient.     

Surgical management of cardiac myxomas.

Cardiac myxomas are rare cardiac lesions, though they are the commonest tumours of the heart. Seventeen cases of cardiac myxomas have been operated during the last one decade. Exertional dyspnoea, palpitation and chest pain were the main presenting symptoms. Echocardiographic assessment was the only definitive diagnostic investigation required prior to surgery. Early surgical excision was planned in all the cases. Irrespective of the exposure techniques, removal of the tumour with wide excision of its base was practised. There was one early death due to low cardiac output in a patient brought in a shock like state. Follow up study has revealed 14 patients in NYHA class I and two patients are having class II symptoms. Periodic echocardiographic follow up study has not revealed any recurrence till date. It is concluded that an early diagnosis and surgery gives excellent long term results in these cases.     

右心房黏液瘤的外科治疗

目的总结右心房黏液瘤的治疗经验。方法回顾性分析2006年8月至2011年8月9例右心房黏液瘤病例。术前均经超声心动图确诊,均在体外循环下行黏液瘤切除术。同期行三尖瓣成形术5例、三尖瓣机械瓣置换术1例、冠状动脉旁路移植术1例。结果无死亡病例。随访9例,时间3个月至5年,心功能Ⅰ级6例、Ⅱ级3例,无复发病例,效果良好。结论右心房黏液瘤一经确诊应尽早手术,手术效果满意,复发率低。     

Initial experience with a steerable intracardiac echocardiographic catheter

INTRODUCTION: Intracardiac echocardiography (ICE) has been used to guide radiofrequency catheter ablation procedures and transseptal punctures. The ability to position current ICE catheters is limited. In this study, we report on the initial experience with a steerable ICE catheter in a canine model and in man. METHODS: In a canine model, we compared the image quality and maneuverability of a 9 French (Fr), 9 MHz ICE catheter and a custom 9 Fr, 9 MHz steerable ICE catheter. Imaging was attempted at 7 intracardiac sites. Non-steerable catheter positioning was attempted with the catheter alone or with the curved, long 10 Fr vascular sheath. Steerable catheter positioning was attempted with the catheter alone after the vascular sheath was withdrawn into the inferior vena cava. The steerable ICE catheter was also used to help guide catheter ablation in a patient with right ventricular outflow tract (RVOT) tachycardia. RESULTS: The steerable ICE catheter was easily positioned at all 7 predetermined sites without the need for a long vascular sheath. In contrast, the non-steerable catheter was much more difficult to position. Image quality was similar for both catheters; depths of imaging were 4-8 cm, depending on catheter location. Multiple image planes could be achieved at a single site with tip deflection of the steerable catheter. In man, the steerable catheter was easily positioned to the RVOT. ICE imaging was helpful in positioning the ablation catheter below the pulmonic valve and ensuring good electrode-tissue contact during energy delivery. CONCLUSION: Steerability improved maneuverability and added multiple image planes compared to a non-steerable ICE catheter. Steerability may enhance the utility of ICE in guiding catheter ablation procedures.     

Cardiac myxomas: results of 14 years' experience

From January 1968 to July 1983, 38 patients with an intracardiac myxoma underwent surgical excision of the tumor at our Institution. There were 15 males and 23 females, ranging in age from 17 to 68 years (mean 47.7). In all but 2 patients, the presence of an intracardiac myxoma was documented preoperatively by angiographic and/or echocardiographic study. The first 2 patients of this series were referred with the diagnosis of mitral stenosis, and the myxoma was an unexpected surgical finding. In 32 cases (84.2%) the myxoma was located in the left atrium, in 4 (10.5%) in the right atrium and in 2 (5.3%) in the right ventricle. Surgery was performed on an emergency basis in 36 patients. Two patients (5.2%) both with a left atrial myxoma, died after surgery: one died intraoperatively of hemorrhage and the other after one month of bowel infarction. Follow-up of the 36 survivors ranges from 3 months to 14.5 years (average 5.2 yr); all were controlled by means of clinical and echocardiographic investigations, and no evidence of tumor recurrence was detected. Surgery for intracardiac myxoma, which should be undertaken on an emergency basis, carries a low operative risk; excision of the tumor appears to be curative with no recurrences at long-term follow-up; non-invasive tools are of the utmost importance in both the preoperative assessment and follow-up of these patients.     

Bilateral atrial myxomas. Surgical correction after echocardiographic diagnosis

A case is reported of bilateral atrial myxomas diagnosed noninvasivelyby echocardiography and successfully removed. The excised tumormass consisted of a mobile right atrial myxoma prolapsing intothe right ventricle and a less mobile, not prolapsing myxomain the left atrium. The operation was performed entirely onthe basis of echocardiographic findings, which correlated wellwith the operative results. Further investigation by computertomography verified the diagnosis, but added no extra informationof importance for therapy. Diagnostic aspects of the combinedapplication of M-mode and cross-sectional echocardiography withDoppler echocardiography are emphasized. Postoperative follow-upechocardiography showed the complete removal of the myxomasand improvement of cardiac function.     

Bilateral atrial myxomas. Surgical correction after echocardiographic diagnosis

A case is reported of bilateral atrial myxomas diagnosed noninvasivelyby echocardiography and successfully removed. The excised tumormass consisted of a mobile right atrial myxoma prolapsing intothe right ventricle and a less mobile, not prolapsing myxomain the left atrium. The operation was performed entirely onthe basis of echocardiographic findings, which correlated wellwith the operative results. Further investigation by computertomography verified the diagnosis, but added no extra informationof importance for therapy. Diagnostic aspects of the combinedapplication of M-mode and cross-sectional echocardiography withDoppler echocardiography are emphasized. Postoperative follow-upechocardiography showed the complete removal of the myxomasand improvement of cardiac function.     

Clinicopathologic analysis of cardiac myxomas: Seven years' experience with 61 patients

Objective

Cardiac myxomas are the most common primary neoplasms of heart. The present study was performed on the 61 cases of patients with cardiac myxoma, in order to investigate the tumors’ clinical and pathological features, and to identify the relationship between the pathological characteristics and clinical behaviors.

Methods

A total of 61 cardiac myxoma cases were analyzed and reviewed retrospectively, including the clinical presentations, physical examinations, and echocardiography, electrocardiography, and pathology documents.

Results

The total patient cohort was made up of 37 women and 24 men. The average age at diagnosis was 48.8 years in males and 51.9 years in females. The most common complaint was dyspnea (37 cases, 60.7%) and the most common sign was systolic murmur (30 cases, 49.2%). Two surface structures and three tumor cell arrangement patterns were observed, and statistical analysis revealed the surface structure was related to the cell arrangement pattern. However, neither the cell arrangement pattern nor the tumor surface structure showed a significant correlation with the clinical presentation.

Conclusions

The present study showed the pathological profiles of cardiac myxomas were not related to the clinical presentations. The results of our study indicate morphologic classifications of cardiac myxomas may not be significant for clinical practice.Key Words: Cardiac neoplasms, myxoma, immunohistochemistry, pathology, surgical, neoplasm recurrence, local     

Surgical treatment of major intracardiac lesions associated with discordant atrioventricular connexion

Thirteen patients with a discordant atrioventricular connexion underwent repair of major associated intracardiac defects. Of the patients, 10 had a discordant ventriculoarterial connexion while 3 had double outlet from the morphologically right ventricle. A ventricular septal defect was the most frequently encountered lesion, present alone or in combination with other lesions in all patients. The other major lesions were pulmonary stenosis in 8, Ebstein's malformation of the left atrioventricular valve in 2, and calcific aortic valve disease in one. The operations performed were closure of the ventricular septal defect in 4 patients, closure of the ventricular septal defect with pulmonary valvotomy in 3 patients (one of whom subsequently underwent replacement of the left atrioventricular valve). Modified Fontan's procedure was performed in 6 patients, one of whom also had replacement of the aortic valve. There was no operative death, although there was one early death on the 40th postoperative day due to septicemia. There has been no late death after an average follow-up of 1.2 years. There was one case of surgically induced complete heart block. All other patients are in normal sinus rhythm in New York Heart Association functional class I or II. Elective repair of major intracardiac anomalies in association with a discordant atrioventricular connexion can now be accomplished safely. The modified Fontan's procedure is a viable alternative in certain cases to the placement of an external valved conduit for relief of pulmonary outflow tract obstruction.     

Multiple cutaneous myxomas coinciding with repeated cardiac myxomas. A syndrome

We report on a 31-year-old woman who underwent surgery for two metachronous cardiac myxomas - 7 and 9 years after excision of several cutaneous myxomas. Our observation is a further case of a syndrome-like complex of cardiac and cutaneous myxoma(s), pigmentation anomalies and endocrine disorders described only recently. As modern investigative methods and the development of cardiovascular surgery have brought about an essential improvement in diagnostics and prognosis of cardiac myxomas, the knowledge of this syndrome-like complex is of great therapeutic importance. Therefore, in our opinion, echocardiographic investigations are strongly recommended even in asymptomatic patients, once several cutaneous myxomas are diagnosed histologically.     

Surgical experience with cardiac echinococcosis

Cardiac echinococcosis is a rare affliction of the heart encountered in areas where the tapeworm Echinococcus is endemic. During the 15 years to September 2005, 19 consecutive patients (11 female; mean age, 25.6 +/- 12.8 years) with cardiac echinococcosis were operated on at Damascus University. Diagnosis was mainly established by 2D-echocardiography. Twelve patients also had extracardiac hydatidosis. All patients were operated on using cardiopulmonary bypass and cardioplegia. Intact cysts were generally enucleated, ruptured cysts were exteriorized, and interventricular septal cysts were managed by controlled puncture and aspiration. There was no operative mortality. All patients were placed on mebendazole postoperatively for periods appropriate to the extent of their hydatidosis. There were 4 known late deaths due to systemic extension of the disease. Cardiac echinococcus is a serious disease that should be managed surgically without delay. Enucleation of intact cysts under cardiopulmonary bypass and cardiac arrest is our preferred method of excision. Anthelmintic medical treatment is a valuable and necessary adjunct to surgical management.     

Transvascular intracardiac applications of a miniaturized phased-array ultrasonic endoscope. Initial experience with intracardiac imaging in piglets

BACKGROUND. Recent advances in miniaturization of phased-array and mechanical ultrasound devices have resulted in exploration of alternative approaches to cardiac and vascular imaging in the form of transesophageal or intravascular imaging. Preliminary efforts in adapting phased-array endoscopes designed for transesophageal use to a transvascular approach have used full-sized phased-array devices introduced directly into the right atrium in open-chested animals. The purpose of this study was to assess the feasibility of using a custom-made, very small phased-array endoscope for intracardiac imaging introduced intravascularly through a jugular venous approach in young piglets. METHODS AND RESULTS. Experimental atrial septal defects created in four piglets (3-4 weeks old) had been closed with a buttoned atrial septal defect closure device consisting of an occluder in the left atrium and a counteroccluder in the right atrium. Five to 15 days after atrial septal defect closure, the piglets were returned to the experimental laboratory, where a 6.3-mm, 17-element, 5-MHz phased-array probe mounted on a 4-mm endoscope was introduced through a cutdown incision of the external jugular vein and advanced to the right atrium. From the right atrium all four cardiac chambers, their inflows and outflows, and all four valves were well imaged with minimal superior and inferior rotation. High-resolution imaging of the atrial septum defined with anatomical accuracy, later verified by autopsy, the exact placement of both the occluder and counteroccluder in the left and right sides of the atrial septal defects and the absence of any shunting across the atrial septum in any of the four animals. CONCLUSIONS. Our efforts indicate that transvascular passage of small phased-array probes can be easily accomplished and is a promising technique for detailed visualization of cardiac structures. This approach may provide an alternative to transesophageal echocardiography, particularly for guiding interventional procedures such as placement of transcatheter closure devices in pediatric patients.     

Surgical treatment of atrial myxomas: a report of 20 cases

Twenty atrial myxomas were resected in 20 patients with the use of cardiopulmonary bypass, from the beginning of July 1966 through the end of June 1985, at Severance Hospital, Seoul, Korea. Nineteen patients had left atrial myxomas; 1 had a right atrial myxoma. Left atrial myxomas arose from the intra-atrial septum in 17 patients and from the left atrial appendage in 2 patients. The right atrial myxoma arose from the fossa ovalis. The 13 female and 7 male patients ranged in age from 14 to 63 years. Symptoms most often reported on presentation were those associated with mitral valve obstruction; other symptoms were associated with systemic embolization. The 1st 4 patients were tested with angiocardiography alone, and 3 of these were misdiagnosed. The last 16 were tested by angiocardiography, M-mode echocardiography, and 2-dimensional echocardiography, alone or in various combinations, and there were no further misdiagnoses. In our experience, 2-dimensional echocardiography was the most accurate method of diagnosing cardiac tumors. In 19 patients, surgical approach was through a median sternotomy; in the 20th patient, approach was through a left thoracotomy, due to a preoperative misdiagnosis of mitral stenosis. No intraoperative embolizations or deaths occurred. On follow-up of 17 patients during periods ranging from 6 months to 6 years, we had no late deaths, and only 2 patients suffered late complications: 1 had sudden right hemiparesis caused by an embolus 4 months after surgery (this improved upon conservative treatment); and 1 had a recurrence of tumor 3 years after surgery (the new myxoma was successfully resected). We conclude that patients who have undergone complete excision of benign myxomas now have an excellent prognosis, with minimal risk of intraoperative embolization and late recurrence. We conclude also that 2-dimensional echocardiography is an extremely accurate tool both in early diagnosis of intracardiac myxomas and in late follow-up after resection.     

Echocardiographic characteristics of intravenous leiomyomatosis with intracardiac extension: a single-institution experience

Background: Intravenous leiomyomatosis (IVL) is a rare smooth‐muscle proliferation arising from a uterine myoma and occasionally extending into cardiac chambers. Methods and Results: A series of 10 consecutive patients with histologically and surgically proven intracardiac IVL between 2000 and 2010 in our hospital were reviewed. The echocardiographic features of 10 cases with IVL and extensive spread into the right‐sided cardiac chambers were described for the first time. All patients were female and the mean age was 42 ± 7 years old. The first symptoms of six patients (60%) were exertional dyspnea and palpitation of cardiac origin. Echocardiography showed that all the tumors originated from the inferior vena cava (IVC) and located in cardiac right chambers (70% in right atrium alone, 30% in right ventricle and atrium). Eight masses (80%) were oval, whereas the others (20%) were serpentine, all with well‐demarcated borders and most (70%) with heteroechogenic texture. Five tumors (50%) intermittently prolapsed into right ventricle through the tricuspid valve. Two patients with nodules adhering to the top of the tumors had pulmonary tumorous thromboembolism. Conclusion: Echocardiography is a simple and important technique to diagnose IVL with intracardiac extension. This disease should be considered in a female patient presenting with an extensive mass from IVC with well‐demarcated border in the right‐sided cardiac chambers. (Echocardiography 2011;28:934‐940)