Left atrial myxomas: clinical characteristics, evaluation and considerations in classifying tumors]

Eleven patients underwent surgical excision for left atrial myxomas. Clinical symptoms, coronary angiographic findings and operative procedures were evaluated. Myxomas were classified into two types based on macroscopical findings, and clinical characteristics of these two types were analyzed. Seven cases (64%) classified as "lobular-type myxomas" were seen as lobulated, gelatinous and fragile. Four cases (36%) were classified as "round-type myxomas" were round and elastic soft. Primary symptoms included dyspnea on exertion in five cases (45%) and neurological disturbances in six cases (55%). Brain emboli were found in four patients by CT scan, and were classified as lobular-type myxomas. These eleven myxomas successfully removed in all cases. Four of these myxomas, which were pedunculated with fine fibrous stalks, were shaved along the base at the atrial septum or free wall. Others were excised completely along with a portion of the adjacent septum. Microscopic examination of the operative specimens revealed that two lobular-type myxomas with broad-based attachment to left atrial septum had invaded the atrial septum. All patients are doing well and have had no signs of myxoma recurrence at postoperative periods ranging from 10 months to 12 years (mean follow-up 5.3 years). Seven patients underwent selective coronary angiography due to a diagnosis of a coronary artery disease. All coronary angiograms were normal in all cases. In five (71%) of these seven, abnormally dilated atrial branches were seen as supplying the tumor. In two cases with round-type myxomas, neovascularity was evident and was made up of clusters of tortuous vessels with tumor blush.(ABSTRACT TRUNCATED AT 250 WORDS)     

Approach in the management of atrial myxoma with long-term follow-up

Between 1972 and 1982, 9 patients underwent successful excision of atrial myxomas at the Upstate Medical Center. Eight patients had a left atrial myxoma and 1 a biatrial myxoma. There were 5 female and 4 male patients ranging from 16 to 63 years of age. Preoperative findings consisted of cerebral or peripheral emboli, congestive heart failure, and nonspecific symptoms. Diagnosis was confirmed by echocardiography and angiography in all but 1 patient. A biatrial operative approach was utilized in all patients except 1. Complete excision of the tumor with a cuff of normal tissue was performed. All heart chambers were carefully explored for presence of multicentric myxomas or tumor debris. There were no operative deaths or intraoperative embolizations. Follow-up has been 1 1/2 to 11 years. There has been 1 late noncardiac death. All patients underwent echocardiography postoperatively with no recurrence. The risk of intraoperative embolization and late recurrence is minimal with the biatriotomy technique. Two-dimensional echocardiography is extremely accurate in early diagnosis of myxomas and in the late follow-up of patients.     

房顶及房间隔联合切口置换二尖瓣

目的报告１９９７年３～１２月用房顶及房间隔联合切口为１４例患者行二尖瓣置换术及术后心律随访结果。方法常规体外循环及心肌保护。首先做右心房斜切口，继而行房间隔切口，两切口汇于隔顶后向前切开左房顶３～４ｃｍ。带扣线置于左房顶切口下缘及房间隔作牵引，行二尖瓣置换。随访时复查心电图。结果无左房顶切口出血的病例，除１例术后死于急性肾功能衰竭和呼吸衰竭外，１３例患者恢复出院。随访结果：术前为窦性心律的３例患者术后仍为窦性心律，而术前为心房纤颤的１０例患者中除１例术后恢复窦性心律外，余９例仍为心房纤颤。结论在常规左心房直切口或经房间隔切口显露困难时，房顶及房间隔联合切口是一种较好的选择     

Evaluation of superior transseptal approach for the removal of left atrial myxoma

We compared the operative outcomes among 14 patients who underwent the removal of left atrial myxoma with four different approaches; right lateral (n = 2), transseptal bi-atrial (Dubost, n = 4), conventional transseptal (n = 4) and superior transseptal approach (STA, n = 4). Concomitant operations were performed in 4 cases (CABG, two; aortic valvuloplasty, one; mitral valve replacement, one), and two out of 4 cases were in the STA group. The mean operation, cardiopulmonary bypass and aortic cross-clamp times were shorter in the STA group compared to the other three group. The total amount of postoperative drain discharge and the peak value of creatine kinase were also lower in the STA group compared to the other three groups. Among the patients in sinus rhythm before operation, the use of STA was associated with a greater incidence (100%) of postoperative atrial fibrillation or junctional rhythm. These rhythm disturbances were temporary, and all returned to sinus rhythms during hospital stay. We conclude that STA is an excellent approach with a nice surgical view to expose and remove the left atrial myxoma.     

左房顶-房隔径路二尖瓣手术与心律失常

目的：验证左房顶－房隔径路二关瓣手术的安全性。方法：１９９３年１０月至１９９７年１２月,采用此径路行二尖瓣手术５１例,其中二尖瓣替换术（ＭＶＲ）１８例,二尖瓣成形术（ＭＶＰ）１例,二尖瓣及主动脉瓣替换术（ＤＶＲ）３２例。     

Diagnosis and treatment of 52 cases of cardiac myxoma

43 patients with cardiac myxoma had undergone surgical removal of the tumors under CPB 38 tumors were located in the left atrium, 5 in right atrium, and 1 in right ventricle respectively. The sites of attachment of the tumor stalk observed during operation were as follows: 34 left atrial myxomas were attached to the interatrial septum and 4 left atrial myxomas to the atrial wall. 5 right atrial myxomas were attached to the interatrial septum and 1 right ventricular myxoma to the ventricular wall. 1 patient with a right ventricular myxoma which had been removed one year ago appeared new one in the left atrium and the tumor was cut too. The diagnosis of cardiac myxoma was confirmed by 2D-echo-cardiography in all of our cases. Mitral valve replacement was done in 1 patient in this series. There was one death postoperatively. Besides these 43 cases, there were 9 patients who had not been operated upon, because of refusal of operation in 5, sudden death from cardiac arrest before operation in 2, coma from cerebral thrombosis in 1, and serious pulmonary tuberculosis in another one respectively.     

右心粘液瘤的诊治

目的　探讨右心粘液瘤的诊治及疗效。方法　自 1984年 8月至 1999年 6月 ,16例右心粘液瘤病人接受外科治疗 ,术前超声心动图明确右房粘液瘤 11例 ,右室粘液瘤 5例 ,4例右房粘液瘤同时合并左房粘液瘤。均在体外循环下行粘液瘤摘除术 ,1例同时行三尖瓣置换术。结果　无围术期死亡 ,1例术后出现左心功能衰竭 ,运用左心辅助装置治疗后好转。随访 1个月到 15年 ,平均 4 8年。 1例术后13年粘液瘤原位复发再次手术治疗 ,复发率 6 .2 5 %。结论　右心粘液瘤一经确诊应立即手术 ,且效果好、安全。超声心动图对右心粘液瘤的诊断具有极其重要的作用。     

Cardiac Myxoma

Ten patients with cardiac myxoma were reviewed. They ranged from 23 months to 60 years old. Echocardiography was the most helpful noninvasive diagnostic technique. The tumor was demonstrated by angiocardiography, left atrial myxomas frequently migrating to the left ventricle in diastole. Hemodynamically, left atrial myxomas were associated with moderately severe pulmonary hypertension and simulated mitral stenosis or insufficiency and right atrial myxomas, with right atrial hypertension. There were 7 myxomas in the left atrium, 2 in the right atrium, and 1 in the right ventricle.Eight patients underwent open-heart operation with removal of the myxoma, 1 had concomitant tricuspid valve replacement, and 1 had biopsy of the right ventricle only. The other patient was a Jehovah's Witness and refused operation. One patient died of cardiac arrest intraoperatively, and another died of a bilateral cerebral infarct. One patient had recurrence requiring reoperation. Postoperative hemodynamic and clinical improvement was more striking in patients with a left atrial myxoma presumably due to a normal mitral valve in contradistinction to the tricuspid valve.     

A rare pathology on the anterior mitral valve leaflet

Cardiac myxomas are most common tumors encountered in the left atrium and the transesophageal echo (TEE) appearance of myxomas may mimic a thrombus. Left atrial thrombi are more common than myxomas especially in patients with ventricular dysfunction, atrial fibrillation, mitral valve disease and they are classically found in the left atrial appendage. The incidence of left atrial thrombi in the presence of sinus rhythm is detected in only 0.1 % patients, in more than 20,000 TEE exams conducted over an 11-year period. In this encounter, patient had multiple pedunculated thrombi arising from an isolated point source on the A2 segment of the mitral valve leaflet. There was no prior history of any organic heart disease. In addition, there was no evidence of stasis in the left atrium.     

The surgical treatment of atrial myxomas. Clinical experience and late results in 33 patients

Thirty-three patients (28 female and five male) from 17 to 70 years of age (mean age 48 years) underwent excision of left atrial myxomas between 1957 and 1981 at The Cleveland Clinic Foundation. Twenty-four patients presented with congestive heart failure, three with tachyarrhythmias, two with syncope, and one each with angina, peripheral embolization, hemoptysis, and recurrent pleural effusions. Symptoms were present from 1 to 72 months before operation (mean 11.2 months). Thirty-one tumors originated from the atrial septum and two from the mitral valve anulus. Twenty-nine tumors were pedunculated, and four were sessile; they weighed from 20 to 112 gm (mean 57 gm). No right atrial or ventricular tumors were identified. The myxomas were successfully removed in all patients, either by shaving them from the atrial septum (n = 17) or by excising a portion of normal atrial septum with the tumor (n = 16). One death (3.0%) occurred 8 days after operation as a result of multiple tumor emboli to the coronary circulation. Follow-up is current and complete in all cases (range 1 to 25 years, mean 6.7 years). Twenty-eight patients are in New York Heart Association Class I, and the remaining four patients are in Class II. No recurrent myxomas have been identified clinically or by echocardiography in any patient. Altogether, 24 patients have been studied by two-dimensional echocardiography up to 20 years after operation (mean 4.0 years). In this series, excellent results were obtained by simple excision of the tumor, with or without a margin of normal atrial septum. Long-term clinical and echocardiographic follow-up is recommended since late recurrence, although rare, has been reported.     

Surgical treatment of 22 cardiac myxomas: A review.

Twenty-two cases of cardiac myxomas were reviewed. The patients were 8 men and 14 women ranging in age from 12 to 73 (mean: 50.8 +/- 16. 6) at operation. They suffered from dyspnea, palpitation, and cough, similar to mitral disease symptoms, and cerebral emboli in 6 patients (30%) with left atrial myxomas. Echocardiography, especially transesophageal, was useful in diagnosing cardiac tumors and location. In 20 cases, tumors were at the left atrium and at the right in 2. Left atrial myxomas were approached through a septal incision in 17 cases; a large circular incision of the biatrium was used in 3 patients with large tumors or mitral regurgitation. Left atrial myxomas were attached to the atrial septum in 17 cases, the posterior wall of the left atrium in 2, and near the posterior commissure of the mitral valve in 1. Right atrial myxomas were attached to the atrial septum in 1 and posterior wall beside the inferior vena cava in 1. Resected myxomas weighed from 10 to 90 (mean: 39.1 +/- 19.1) g. No correlation was seen between features such as neurologic symptoms, feeding artery on coronary angiography, or functional status and tumor weight. No recurrence was seen.     

Totally robotic resection of myxoma and atrial septal defect repair

Resection of left atrial myxoma and large atrial septal defect repair were performed in 55 patients using the da Vinci S surgical system to evaluate device safety and efficacy. Fifty-five patients underwent resection of left atrial myxomas (n=10) or secundum-type ASD (n=45) repairs with three cases of concomitant tricuspid valve repairs, using the da Vinci S surgical system. Mean age of the patients was 38+/-12.2 years (range 12-61 years). Cardiopulmonary bypass was achieved peripherally, aortic occlusion was performed with Chitwood cross-clamp, and antegrade cardioplegia was administered via anterior chest. Via four port incisions in the right chest and a 2-2.5-cm working port, all the procedures were completed with the da Vinci robot. All patients had successful resection or repairs. The mean CPB times and aortic cross-clamp times were 108.6+/-12.5 min and 45+/-11.5 min, respectively. There were no operative deaths, strokes, or device-related complications. One patient was reexplored for bleeding. There were no incisional conversions. All the patients were discharged. da Vinci S surgical system has no limitations to safe resection of left atrial myxomas and of ASD repairs, surgical results are excellent, and this technology is of reproducible value with excellent cosmetic results.     

Frequency of Left Atrial Myxoma with Concomitant Coronary Artery Disease

Purpose: Simultaneous coronary artery bypass grafting with a resection of left atrial myxoma has been rarely reported. The ages and the symptoms of patients who have left atrial myxomas and coronary artery disease are similar. In this report, we present our cases of left atrial myxoma with concomitant coronary artery disease who were all treated surgically. Methods: Between September 1998 and January 2001, 11 patients were surgically treated after being diagnosed to have left atrial myxoma. Routine coronary angiography was performed on all patients preoperatively. In four patients concomitant coronary artery disease was identified. At surgery we performed coronary artery bypass grafting after a resection of left atrial myxoma in three patients. Results: All patients were weaned from cardiopulmonary bypass without any difficulty. The postoperative course was uneventful. The follow-up period was 17 ± 10 months (range 3–32 months). All patients were symptom-free and no recurrence of myxoma was detected. Conclusion: Based on our experience, cardiovascular surgeons should be aware of the concomitance of these diseases. It is therefore recommended that coronary angiography should be performed on all patients who present with left atrial myxomas. Received: November 5, 2001 / Accepted: September 3, 2002 Reprint requests to: N. Erdil This paper was presented at the World Society of Cardio-thoracic Surgeons 11th World Congress in Sao Paulo, Brazil (August 12–15, 2001)     

机器人系统行心房黏液瘤切除术40例

目的 总结机器人二尖瓣置换术的临床应用,以评估其安全性及有效性.方法 2008年6月至2011年4月,20例患者接受机器人二尖瓣置换术,男7例,女13例;年龄32～65岁,平均(44.7±9.8)岁.术前心功能Ⅰ～Ⅱ级16例,Ⅲ级4例.15例合并房颤.股动、静脉及右侧颈内静脉插管建立体外循环.右侧胸壁打直径为0.8cm的器械臂孔3个,直径为1.5～2.5cm工作孔1个,术者于三维成像系统下遥控微创器械完成二尖瓣置换.术中食管超声引导建立体外循环并评估手术效果.术后常规进行随访.结果 无手术死亡及术中术式转化.机器人二尖瓣置换平均体外循环(137.1±21.9)min,主动脉阻断(99.3±17.4)min.随访(12.1±6.6)个月,未见瓣周漏等并发症.结论 机器人系统可安全、有效地完成二尖瓣置换,术后近期效果良好.

Abstract：

Objective To determine the safety and efficacy of robotic mitral valvereplacement using da Vinci S system.Methods From August 2008 to April 2011, over 400 cases of robotic cardiac surgery have been completed in Chinese PLA general hospital, in which 20 patients with isolated mitral valve stenosis underwent robotic mitral replacement, including 7 male and 13 female patients with a mean age of (44.7 ±9.8) years (ranging from 32 to 65 years). 16 patients had a NYHA class Ⅰ～Ⅱ heart function and 4 patients were NYHA class Ⅲ. Fifteen patients were concomitant with atiral fibrillation. Surgery approach was achieved through 4 right chest ports with femoral perfusion and Chitwood aortic occlusion. Antegrade cold blood cardioplegia was administered directly via chest for myocardial protection. The transesophageal echocardiography was used intraoperatively to estimate the surgical results. Results All patients had successful valve replacement including mechanical and tissue valve replacement. There was no conversion to a median sternotomy. The mean cardiopulmonary bypass and arrested heart time were(137.1 ±21.9) minutes and (99.3 ±17.4) minutes. Echocardiographic follow-up in all patients revealed no complications. Conclusion Robotic mitral valve replacement is safe and efficacious in the patients with isolated mitral valve disease.     

Superior septal approach for mitral valve surgery: a word of caution

Objective: Superior septal approach provides excellent exposure of the mitral valve and the subvalvular structures. The unavoidable section of the sinus node artery is in relationship with this technique. We have studied the electrical changes associated after using this approach. Material and Methods: We studied 247 cases of mitral valve surgery from 1996 to 2003. The patient population was divided into two comparative groups: group I (128 cases) was represented by the superior septal approach and group II (119 cases) composed the conventional right lateral approach through the left atrium. Preoperatively, 48 patients (37.5%) in group I and 46 (38.6%) in group II were in a normal sinus rhythm. Mean follow-up was 30.7 months in group I and 33.5 months in group II. Results: There was no mortality in group I and eight cases (6.7%) in group II. A high incidence of changes as junctional rhythm was observed in group I, especially after weaning of cardiopulmonary bypass and on the first day after surgery (P>0.001). Postoperative P–R interval of the patients in sinus rhythm was 100±30 ms in group I and 148±24 ms in group II (P>0.05). P–R interval in group I was shorter than normal. P-wave morphology changed becoming inverted in leads II, III and aVF after surgery in these cases in group I. A full recuperation in P–R interval and the P-wave axis was seen in 52 cases (87.5%) in patients in group I after the third postoperative month. A definitive pacemaker implantation was need in two cases (1.5%) in group I and in six (5%) in group II (P>0.05). Conclusions: A superior septal approach is directly related with the loss of normal sinus rhythm because of the section of the sinus node artery. After a brief period of transient electrical changes, a new low atrial or coronary sinus rhythm slower than normal sinus rhythm appears. In consequence, a word of caution must be strongly considered in patients critically dependent on normal sinus rhythm, despite the low incidence of definitive electrical changes. Normal sinus rhythm appears again after the third postoperative month.     

Contralateral recurrent myxoma of the heart.

Nineteen recurrences of a left atrial myxoma have been reported in 16 patients. This paper deals with the removal of a right ventricular myxoma three and one-half years following excision of a left atrial tumor. Because of the possibility of recurrence, postoperative follow-up of all patients with intracardiac myxomas is mandatory.     

Primary cardiac tumors: early and late results of surgical treatment in 91 patients.

BACKGROUND: Between March 1980 and September 1997, 91 patients underwent evaluation and treatment for primary cardiac neoplasms. METHODS: Tumors were grouped into three categories: atrial myxomas, benign nonmyxomas, and malignant tumors. Survivors were contacted; no one was lost to follow-up. The mean follow-up for this series is 7 +/- 5 years. RESULTS: Eighty-three patients were diagnosed with atrial myxomas (Male/Female: 29/54), average age 55 +/- 13 years. The hospital mortality was 3.6% (3/83), the late mortality was 6.5% (5/80). No recurrent myxomas have been identified clinically or by echocardiography in any patient. Three patients were diagnosed with benign nonmyxoma tumors. (Male/Female: 2/1), average age 64 +/- 8 years. There were no perioperative deaths and 1 patient died 4 years postoperatively from fibroma, with no linked causes. No recurrent tumors have been identified. Five patients were diagnosed with malignant tumors. (M/F: 1/4), average age 53 +/- 16 years. The hospital mortality was 20% (1/5); in 3 patients a redo-operation was necessary after 8, 11, and 12 months because of tumor recurrence. All patients died within 3 years of the first operation (mean 13 +/- 14 months). CONCLUSIONS: Surgical resection, when possible, is the treatment of choice for all primary cardiac tumors. Patients with benign tumors are probably cured by resection and in our experience there was no known tumor recurrence. Effective palliation is possible with resection of malignant tumors, but more effective adjuvant therapy will be necessary to improve long-term prognosis.     

Current Management of Atrial Myxoma with Emphasis on a New Diagnostic Technique

Sixteen patients aged 22-64 years have undergone removal of atrial myxoma at the Johns Hopkins Hospital. The first two patients had myxomas removed by closed surgical approach, and both died. Fourteen consecutive patients have undergone operation with the aid of cardiopulmonary bypass, and all survived. There has been one late death unrelated to myxoma. Current surgical approach is excision of the tumor and its stalk or base and resection of the portion of intra-atrial septum to ensure complete removal. Recently a new diagnostic technique of two-dimensional phased array real time echocardiography has been used in four patients, including a pregnant woman, to confirm the clinical diagnosis of atrial myxoma. This technique provides a two-dimensional view of both atria and ventricles in cross section or sagittal view. This noninvasive method is painless, is independent of cardiac function and carries no risk or radiation hazard. The two-dimensional echocardiogram is superior to the standard one-dimensional or M-mode echocardiogram for diagnosis of myxoma in that it can evaluate simultaneously both right and left atria, can detect smaller space-occupying lesions because of better resolution and can more readily determine the size of the lesion and its stalk, can evaluate the mobility of the tumor and can determine more accurately the extent of tumor obstruction. Because of these qualities, we have relied on two-dimensional echocardiography as the definitive diagnostic procedure for detection of atrial myxoma. Currently operation for atrial myxoma is performed without cardiac catheterization or angiocardiography.     

心房纤维颤动的外科治疗

３例采用改良迷宫术探索进行心房纤颤外科治疗获成功。病人术前均为风湿性心脏病，心功能Ⅲ－Ⅳ级，心房纤颤病史３－１０年，左房直径５２－５８ｍｍ，心胸比率０．６４－０．７０。在进行改良迷宫术的同时，２例行二尖瓣替换，１例行双瓣替换及三尖瓣环缩。术后２例自动复跳，１例电击除颤复跳。３例术后早期均为窦性心律。２例术后３年恢复良好，正常心律，心功能Ｉ级；１例术后３个月死于脑血管意外。文中重点介绍了手术方法，提     

Second recurrence of cardiac myxoma 7 years after the initial operation

We report a rare case of a 23-year-old woman in who recurrent multiple cardiac myxomas were resected first time 4 years after the initial operation and second time three years after the second operation. In February 2000, she was diagnosed with right ventricular myxoma. The initial cardiac tumor was successfully resected through a right atrium approach and the tricuspid valve was changed with a biological prosthesis; the patient has been followed-up by ultrasound echocardiography every 6-month after discharge. Four years after, the echocardiography revealed one masse in the left atrium, which was resected using a trans-septal approach. Due to malfunction of the tricuspid prosthesis, this was changed with a biological one. After another three years, the echocardiography revealed once again two masses, this time in the right atrium and left ventricle. The third surgery was performed and all 2 myxomas were successfully resected through a combined right atrial and left ventricle approach. One year after the third operation, she has been doing well without any sign of recurrence of myxoma. A long-term follow-up is mandatory in patients after the resection of a cardiac myxoma.