Ann Thorac Surg 1997;64:274-275
© 1997 The Society of Thoracic Surgeons
How To Do It
Modified Biatrial Approach for the Surgical Excision of Left Atrial Myxomas
Kyriakos St. Rammos, MD
Department of Cardiothoracic Surgery, Aristotle University Medical School, AHEPA General Hospital, Thessaloniki, Greece
Accepted for publication January 28, 1997.
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Abstract
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The biatrial approach generally has been accepted as the method for excision of atrial myxoma, having the advantages of identifying the site of attachment, inspection of the four cardiac chambers, and adequate irrigation. A technique that uses this approach, adding safety and completeness of removal of left atrial myxomas attached to the septum, is described.
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Introduction
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A simplified technique for surgical excision of left atrial myxoma attached to the atrial septum, using the biatrial approach, was used in 3 young female patients. The diagnosis was established with two-dimensional echocardiography. The technique takes the advantages of the biatrial approach [1] and adds further safety and completeness of removal of the tumor, to lessen the possibility of future recurrence, and by the precise limited excision of the attachment possibly lessens the incidence of postoperative arrhythmias.
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Technique
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Crdiopulmonary bypass is instituted with ascending aortic and bicaval cannulation, keeping manipulation of the heart at a minimum. Under moderate hypothermia, St. Thomas' I cardioplegic solution is infused in an antegrade fashion with simultaneous surface saline-slush cooling. An incision is made in the left atrial wall posterior to the interatrial groove, and the tumor and its attachment are identified without any mobilization of it. An oblique right atriotomy is made, the right chambers are explored, and then the superior rim of the left atriotomy is retracted. Four 4-0 Ticron sutures (Davis + Geck, Danbury, CT) are passed about 5 mm away from the attachment of the tumor in an quadrant fashion and exiting from the atriotomy (Fig 1
). Retracting the superior rim of the right atriotomy, the surgeon makes a circular incision while holding the sutures in the left hand, carefully avoiding injury of the Koch triangle (Fig 2). Because the perimeter of the attachment is usually smaller than the bulk of the tumor, a medium-size gauze is placed in the left atrium and around the tumor before retrieval of the tumor via the atrial septal defect. The atrial septal defect is repaired with a Dacron patch (Fig 3). The left and right atrial incisions are closed and air is properly vented before release of the aortic cross-clamp.
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Fig 1. . Four 4-0 Ticron sutures are passed about 5 mm away from the attachment of the tumor in a quadrant fashion and exiting from the right atriotomy.
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Fig 2. . Retracting the superior rim of the right atriotomy, the surgeon makes a circular incision while holding the sutures in the left hand, carefully avoiding injury of the Koch triangle.
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Fig 3. . A medium-size gauze is placed in the left atrium and around the tumor before retrieval of the tumor via the atrial septal defect, which is repaired with a Dacron patch.
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Comment
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Myxomas of the heart, usually located in the left atrium, are benign tumors that can metastasize, embolize, and cause hemodynamic obstruction and death [2]. Surgical excision under cardiopulmonary bypass was first carried out successfully by Crafoord [3] and has been established as the only treatment for these tumors [4]. Kabbani and Cooley [1] described the technique of biatrial approach for these tumors in 1973 and recently reemphasized the advantages of this approach [5]. The advantages are the identification of the site of attachment, inspection of the four cardiac chambers, the adequate irrigation, and the prevention of fragmentation and intraoperative embolization. The final objective of the surgeon is to lessen the possibility of recurrence and to some extent the incidence of postoperative arrhythmias.
Using the above-described technique, precise excision of the tumor is applied, keeping the septal excision at its minimum, thus avoiding increased incidence of supraventricular arrhythmias even when the defect is closed with a patch. The retrieval of the tumor through the septal defect, while protected with a gauze, avoids the risk of fragmentation and embolization. It is a reproducible technique that is easily taught to residents and has excellent long-term results, as our 3 female patients have no evidence of recurrence 8 to 10 years later.
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Footnotes
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Address reprint requests to Dr St. Rammos, Karolou Diehl 29, Thessaloniki 546 23, Greece.
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References
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- Kabbani SS, Cooley DA. Atrial myxoma: surgical considerations. J Thorac Cardiovasc Surg 1973;65:731–7.[Medline]
- McAllister HA Jr. Cardiac tumors. In: Cooley DA, ed. How I do it: techniques for treating cardiovascular disease. State of the art reviews. Cardiac surgery. Philadelphia: Hanley and Belfus, 1990:437–64.
- Crafoord C. Discussion on mitral stenosis and mitral insufficiency. In: Lam CR, ed. Proceedings of the International Symposium on Cardiovascular Surgery. Philadelphia: Saunders 1995:202.
- Castañeda AR, Varco RL. Tumors of the heart: surgical considerations. Am J Cardiol 1968;21:357–62.[Medline]
- Kabbani SS, Jokhadar M, Meada R, et al. Atrial myxoma: report of 24 operations using the biatrial approach. Ann Thorac Surg 1994;58:483–8.[Abstract/Free Full Text]
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Abstract
Introduction
