Ann Thorac Surg 1998;66:275-276
© 1998 The Society of Thoracic Surgeons
How to Do It
Modified biatrial approach for the extensive resection of left atrial myxomas
Massimo Massetti, MDa,
Gerard Babatasi, MD, PhDa,
Olivier Le Page, MDa,
Satar Bhoyroo, MDa,
Andre Khayat, MDa
a Department of Thoracic and Cardiovascular Surgery, University Hospital, Caen, France
Accepted for publication February 20, 1998.
Address reprint requests to Dr Massetti, Department of Thoracic and Cardiovascular Surgery, CHU "Cote de Nacre," 14033 Caen Cedex, France
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Abstract
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Surgical excision of left atrial myxomas is usually curative. When the root of the pedicle and the full thickness of the adjacent interatrial septum are excised, the repair of the created atrial septal defect requires a pericardial or Dacron patch. The biatrial approach generally has been accepted as the technique having the advantages of well identifying the site of attachment and inspection of the four cardiac chambers. We proposed a modification of this technique that allows the reconstruction of the created septal defect without any foreign patch.
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Introduction
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The majority of cardiac myxomas arise from the atrial septum, usually from the region of the fossa ovalis. Eighty percent to 90% of these tumors are in the left atrium [1]. To avoid incomplete removal and recurrence, complete eradication of the base of implantation is necessary, and the biatrial approach offers an excellent visualization of the left and right cavities allowing easy manipulation of the tumor mass [2]. After the excision, the created atrial septal defect is closed directly or, when too large, with a Dacron patch. Here we describe a simplified technique for surgical excision of a left atrial myxoma attached widely to the septum, using a biatrial approach and employing a rotational flap of free right atrial wall to repair the septum.
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Technique
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In our department, since November 1996, intracardiac procedures have been routinely approached through a less invasive sternotomy. A short (6 to 9 cm) median skin incision followed by a subcomplete sternotomy permits a limited opening of the chest without compromising the surgical exposure. Conventional central cardiopulmonary bypass is instituted with ascending aorta and bicaval cannulation. The venae cavae are cannulated through the atrial wall as close as possible to their origin. Special attention is paid to avoid damage to the sinoatrial region and keep manipulation of the heart at a minimum. After aortic cross-clamping, cardioplegic arrest of the heart is obtained by infusion of cold crystalloid cardioplegic solution into the aortic root and maintained by repeated infusions according to the myocardial temperature as measured by a probe. A first incision is made in the left atrium posterior to the interatrial groove (Fig 1A). Blood is removed and the tumor and its attachment are identified and explored with the index finger without any mobilization of the mass. Assuming that the myxoma is widely attached to the atrial septum, a second incision is made in the free right atrial wall; the line of incision is made in a curved fashion to create an omega-shaped flap (parabolic flap). This flap has to be tailored in the central part of the right atrium; its attachment base must lie in the interatrial groove to allow the atrial flap to rotate freely inside the atrium (Fig 1B). The atriotomy edges are retracted with fine sutures, and the right cavities are inspected in case a second tumor is present. A 4-0 Ti-cron (Davis & Geck, Danbury, CT) suture is passed near the base of the tumor through the left atrial incision, and with gentle traction on the suture, the right atrial septum is then opened with a knife through the right incision (Fig 1C). A full-thickness segment of the interatrial septum, including the fossa ovalis, is excised and the tumor is delivered with minimal manipulation through the left atrial incision (see Fig 1C). The interior of the left atrium is copiously irrigated with saline solution to evacuate any residual tumor fragments. The atrial defect (Fig 1D) is then closed with the free wall of the right atrium trimmed to the appropriate shape of the defect, rotated to the plane of the septum, and sutured with two continuous 5-0 polypropylene sutures (Fig 1E). Finally the right atrium is closed directly with two 4-0 polypropylene continuous sutures: the superior edge of the atriotomy is sutured to the inferior edge, which is constituted (laterally) by the native inferior edge and (in the center) by the bent base of the flap (Fig 1F). Usually dearing techniques are performed before release of the aortic cross-clamp.
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Fig 1. (A) Lines of atrial incision in the modified biatrial approach. (B) Exposure of the atrial septum through the right incision. (C) Tumor excision with the extensive resection of the septal attachment. (D) Free wall flap trimmed to the neo-secundum-type defect. (E) Septal repair using the free wall flap of the right atrium. (F) Final aspect of the closed biatrial approach.
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Comment
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Myxomas are the most frequent primary tumor of the heart [1]. Usually located in the left atrium, they are benign, but rarely metastases have been reported in different areas [1]. Once the diagnosis of such a lesion is made, an operation should be carried out without delay. Surgical excision under cardiopulmonary bypass is the only treatment of these tumors, but a consensus regarding the surgical approach has not been achieved. A simple approach through the left atrium was first carried out successfully by Crafoord in 1954 [3], and this approach, eventually combined with transeptal extirpation, became the most commonly used by the cardiac surgeons. In 1973 Kabbani and Cooley [2] described a technique of biatrial approach for these tumors; among the advantages are the identification of the site of attachment, the inspection of the four cardiac chambers, and the adequate irrigation. In each case, when an extensive resection of the septum is necessary, a Dacron or pericardial patch is used to repair the defect. According to the principle that, whenever it is possible, it is preferable to avoid the use of foreign materials in intracardiac reconstructions, in our modified technique the repair of the septal defect is carried out with an autologous pedicled patch. An essential step, inspired by our technique for the ostium primum defect repair [4], is the rotation of a pedicled flap running from the free wall of the right atrium to the septum. The theoretic advantages consist of a lower risk of thromboembolic complications, a lower risk of endocarditis, and the reduction of the aortic cross-clamping time. Although cardiac myxomas are histologically benign, they may be lethal because of their strategic position. Surgical removal is mandatory when they are diagnosed. Our modified biatrial approach offers an excellent exposure and permits reconstruction of the interatrial septum without any foreign materials.
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Acknowledgments
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We acknowledge Mr Gerard Lecornu for his technical contribution to the illustrations.
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References
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- Reynen K. Cardiac myxomas. N Engl J Med 1995;333:1610-1617.[Free Full Text]
- Kabbani S.S., Cooley D.A. Atrial myxoma: surgical considerations. J Thorac Cardiovasc Surg 1973;65:731-737.[Medline]
- Crafoord C. Discussion on mitral stenosis and mitral insufficiency. In: Lam C.R., ed. Proceedings of the International Symposium on Cardiovascular Surgery, Henry Ford Hospital, Detroit, Michigan, March 1955. Philadelphia: Saunders, 1995:202.
- Massetti M., Babatasi G., Neri E., Khayat A. Alternative technique for the ostium primum defect repair: a free wall flap of right atrium. Ann Thorac Surg 1997;63:1803-1804.[Abstract/Free Full Text]
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