Ann Thorac Surg 1997;63:833-835
© 1997 The Society of Thoracic Surgeons
Case Reports
Video-Assisted Removal of Left Ventricular Mass
Ignacio G. Duarte, MD,
Kathleen N. Fenton, MD,
W. Morris Brown, III, MD
Division of Cardiothoracic Surgery, Department of Surgery, Crawford Long Hospital, Emory University School of Medicine, Atlanta, Georgia
Accepted for publication October 23, 1996.
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Abstract
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The use of endoscopic technology, widely accepted in general surgery and general thoracic surgery, has recently gained popularity in cardiac surgery, as witnessed by the development of minimally invasive cardiac surgery. Intracardiac employment of this technology, however, has largely been limited to enhanced fiberoptic visualization in anecdotal cases. We present a case employing thoracoscopic instruments in the removal of a benign intracavitary lesion using cardiopulmonary bypass.
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Introduction
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Endoscopic surgery is gaining popularity in both general surgery and general thoracic surgery, but has not yet emerged into the mainstream of cardiac surgery. Despite the emerging use of thoracoscopic instruments in minimally invasive coronary revascularizations, the use of endoscopic technology in cardiac surgery has predominantly been one of intracardiac fiberoptic visualization [1–5]. We present a case involving the use of a standard thoracoscope and thoracoscopic dissecting forceps for visualization and excision of an intraventricular mass in a patient during cardiopulmonary bypass.
The patient is a 58-year-old man with a past medical history significant for coronary artery disease, hypertension, and gout. In August 1995 he suffered an anterior myocardial infarction and emergent cardiac catheterization revealed a 95% lesion of the proximal left anterior descending artery and an 80% stenosis of the ramus intermedius, with a hypokinetic anterior wall and akinesis of the left ventricular (LV) apex (ejection fraction = 0.45). Thrombolytic therapy (tissue plasminogen activator) was instituted and percutaneous transluminal angioplasties of both lesions were performed. After obtaining informed consent as part of a study approved by the Human Investigations Committee, we gave him Tirofiban, an antiplatelet drug. Tirofiban was administered concurrently with the tissue plasminogen activator and during the percutaneous transluminal angioplasty, and its administration was discontinued after 36 hours of intravenous administration. His hospital course was uncomplicated and he was discharged on a regimen of metoprolol, aspirin, simvastatin, allopurinol, and lisinopril.
Six months after the percutaneous transluminal angioplasty, he returned for a follow-up cardiac catheterization as part of the Tirofiban study protocol. He had been asymptomatic throughout this period. Left heart catheterization revealed mild apical-septal hypokinesis (ejection fraction = 0.60), 40% ramus stenosis, mild luminal irregularity of the proximal left anterior descending coronary artery and 40% stenosis of the proximal and mid right coronary artery. Ventriculography showed an elliptic, mobile mass at the LV apex (Fig 1
). No evidence of the mass was detected on review of the previous catheterization, and the mass was thought to be a thrombus. Given the 60% risk of cardioarterial embolization with a freely mobile, pedunculated mass within the LV, emergent removal was advised, and after consent was obtained the patient was prepared for operation [6].
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Fig 1. . Preoperative cardiac catheterization ventriculogram revealing mass in the left ventricular cavity.
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Intraoperative transesophageal echocardiography confirmed the presence of a left ventricular mobile apical mass (Fig 2). After median sternotomy, the aorta and right atrium were cannulated, and cardiopulmonary bypass was begun using a "no-touch" technique for the heart. The aorta was cross-clamped and the heart arrested with antegrade, oxygenated, cold crystalloid cardioplegia. The aorta was opened in a transverse fashion, and the LV cavity was inspected through the aortic valve. The mass, however, was not readily visualized. A video thoracoscope (10 mm; Karl-Storz, Germany) was then inserted into the proximal aorta, through the aortic valve, and advanced into the left ventricle under endoscopic visualization. The ventricular cavity was kept free of blood by aspiration through the aortic valve using cardiotomy suction. A mobile, 2 x 2.5-cm mass was clearly visible at the left ventricular apex (Figs 3, 4). Thoracoscopic alligator dissecting forceps (4 mm; Karl-Storz) were advanced alongside the thoracoscope, and the mass was grasped and removed. Two separate fragments of organized thrombus were removed. The wall of the LV then was inspected and showed no evidence of residual thrombus. The area was irrigated with iced saline solution and suctioned to remove any particulate debris. The heart was allowed to refill with blood, and the aortotomy was closed. The cross-clamp time was 31 minutes and the cardiopulmonary bypass time was 45 minutes. Cardiopulmonary bypass was easily weaned, and the patient was transferred to the cardiac surgical intensive care unit in stable condition.
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Fig 2. . Intraoperative transesophageal echocardiogram demonstrating oval mass at the left ventricular apex.
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Fig 3. . Intracavitary mass at the left ventricular apex as seen through a video thoracoscope advanced through the aortic valve under cardiopulmonary bypass.
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On postoperative day 1 he continued to do well, was extubated, and was transferred to the regular floor. A transthoracic echocardiogram was performed on postoperative day 2, which revealed septal-apical and apical akinesis, apical-lateral moderate hypokinesis, an overall ejection fraction of 0.45, a 3.3-cm aortic diameter, and no evidence of an LV mass. The patient was anticoagulated orally with warfarin to prevent recurrence and was discharged on postoperative day 4, stable and asymptomatic.
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Comment
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This report describes use of endoscopic instruments in an intracardiac procedure under conditions of extracorporeal circulation. The presumed benign nature of the LV mass and the patient's otherwise healthy condition and anatomy (the aortic valve free of disease and the aortic root large enough to accomodate a thoracoscope) permitted the successful conduct of this procedure. Such a procedure would clearly not be applicable for the excision of a malignant cardiac tumor, for example. As advances in endoscopic surgical technology continue to occur, its role in cardiac surgery can only be expected to expand.
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Footnotes
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Address reprint requests to Dr Brown, Department of Cardiothoracic Surgery, Crawford Long Hospital, 550 Peachtree St NE, Atlanta, GA 30365-2225.
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References
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- Cutler EC, Levine SA, Beck CS. The surgical treatment of mitral stenosis: experimental and clinical studies. AMA Arch Surg 1924;9:689–821.[Abstract/Free Full Text]
- Tanabe T, Yokota A, Sugie S. Cardiovascular fiberoptic endoscopy: development and clinical application. Surgery 1980;87:375–9.[Medline]
- Legget ME, Shaw DP. Fiberoptic cardioscopy under cardiopulmonary bypass: potential for cardioscopic surgery. Ann Thorac Surg 1994;58:222–5.[Abstract/Free Full Text]
- Fujimura O, Lawton MA, Koch CA. Direct in vivo visualization of right cardiac anatomy by fiberoptic endoscopy: observation of radiofrequency-induced acute lesions around the ostium of the coronary sinus. Eur Heart J 1994;15:534–40.[Abstract/Free Full Text]
- Burke RP, Michielon G, Wernovsky G. Video-assisted cardioscopy in congenital heart operations. Ann Thorac Surg 1994;58:864–8.[Abstract/Free Full Text]
- Meltzer RS, Visser CA, Fuster V. Intracardiac thrombi and systemic embolization [Review]. Ann Intern Med 1986;104:689–98.[Abstract/Free Full Text]
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Abstract
Introduction
