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Ann Thorac Surg 1999;67:1793-1795
© 1999 The Society of Thoracic Surgeons

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Case Reports

Cardiac autotransplant for surgical treatment of a malignant neoplasm

^a Division of Cardiothoracic Surgery, Department of Surgery, Baylor College of Medicine, The Methodist Hospital, Houston, Texas, USA
^b Department of Medicine, Baylor College of Medicine, The Methodist Hospital, Houston, Texas, USA
^c Department of Anesthesiology, Baylor College of Medicine, The Methodist Hospital, Houston, Texas, USA

Accepted for publication November 11, 1998.

Address reprint requests to Dr Reardon, 6550 Fannin, Suite 1619, Houston, TX 77030
e-mail: reardonm{at}bcm.tmc.edu

	Abstract

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Because of their anatomic location, cardiac sarcomas often interfere with cardiac function. Excision is considered to palliate the cardiac defect, but complete excision is often difficult owing to access, particularly in left atrial tumors. Incomplete resection results in tumor recurrence. To achieve complete resection of a large left atrial sarcoma, we used the technique of cardiac explantation, extracorporeal resection of the tumor with cardiac reconstruction, and cardiac autotransplantation.

	Introduction

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Primary cardiac neoplasms are rare entities. Approximately 75% are benign, and of the primary malignant tumors, 75% are sarcomas. For primary cardiac sarcomas, there has been no consistent protocol for treatment, and the benefits of chemotherapy and radiotherapy are uncertain. Most cardiac sarcomas interfere with cardiac function because of their anatomic location; excision is an attractive option for palliation of the functional cardiac defect, and complete resection can result in cure. The overriding problem with resection has been extensive involvement precluding resection or anatomic location hindering access for complete resection and reconstruction. We present the case of a patient with a malignant fibrous histiocytoma (MFH) of the left atrium in whom successful complete resection and cardiac reconstruction were aided by the technique of cardiac explantation, extracorporeal resection of the tumor with cardiac reconstruction, and cardiac autotransplantation.

A 20-year-old man underwent complete excision of an MFH in the left shoulder in June 1997. Because recovery was slow, a transesophageal echocardiogram was performed 2 months later and revealed a left atrial mass occupying a large part of the atrium. Operative exploration was carried out through the interatrial groove with a preoperative diagnosis of the left atrial myxoma. The tumor was thought to be unresectable because of the large amount of atrium involved, the tumor was debulked and the tissue sent for diagnosis. Pathologic study revealed a diagnosis of MFH. The postoperative course was complicated by a cerebrovascular accident from which the patient subsequently recovered.

The patient was referred to The Methodist Hospital and Baylor College of Medicine for evaluation and consideration of radical surgical removal of the tumor. Magnetic resonance imaging and transesophageal echocardiography revealed a large tumor located in the superior left atrium at the base of the left atrial appendage involving the anterior mitral leaflet. In addition, the tumor mass moved into the mitral orifice during diastole, thus causing obstruction with symptoms of dyspnea on mild exertion. Bone scan and liver scan were negative for metastatic disease. After the diagnosis and the treatment options were discussed with the patient and his family, attempted complete resection of the tumor was undertaken on April 27, 1998.

The previous median sternotomy was entered with aortic and right atrial adhesions dissected free. The distal ascending aorta was cannulated for arterial return, and the superior vena cava and the inferior vena cava at the right atrial junction were cannulated for venous inflow. Tapes were placed around the venae cavae. Cardiopulmonary bypass was instituted, and systemic hypothermia of 28°C was achieved. The ascending aorta was cross-clamped, and cold blood-potassium cardioplegia was given in antegrade fashion. After cross-clamping, the rest of the adhesions were taken down, and the interatrial groove was entered.

The left atrium was opened widely, but adequate visualization of the tumor could not be achieved. Therefore, the inferior vena cava–right atrial junction was divided to allow the heart to be elevated. This again did not lead to adequate visualization. The superior vena cava–right atrial junction was divided. Again, there was inadequate visualization of the tumor. Both great vessels were divided in their midportion, and under direct vision, the rest of the left atrium was divided, and the tumor with the heart was removed with a cuff of posterior left atrial wall and pulmonary veins left in place (Fig 1). The heart was placed in a bucket of iced saline solution and inverted to place the left atrium anteriorly. This allowed excellent exposure of the pathologic process, and the tumor was excised along with approximately one third of the left atrial wall, the anterior mitral leaflet, and a corresponding portion of the annulus. The tumor was also removed under direct vision from the coronary arteries.

View larger version (63K): [in this window] [in a new window]   Fig 1. Explantation of heart.

View larger version (63K): [in this window] [in a new window]   Fig 2. Reconstruction of heart.

	Comment

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Primary cardiac neoplasms are rare entities with an autopsy incidence of 0.001% to 0.03% [1]. Large clinical series from Stanford [2] and The Texas Heart Institute [3] comprised 42 and 114 patients, respectively, having operation for primary cardiac neoplasm. Approximately 75% of these tumors are benign and are usually cured by complete resection. Of the 25% of primary cardiac neoplasms that are malignant, 75% are sarcomas. Primary cardiac sarcomas usually cause symptoms of congestive heart failure as a result of the anatomic obstruction of blood flow, and resection is necessary to relieve these symptoms and prevent early death [4]. However, as the occurrence of primary cardiac sarcoma is unusual, the experience of any single surgeon or group of surgeons tends to be limited, and treatment protocols and surgical approaches are not standardized or clear. Chemotherapy and radiotherapy have been used but do not relieve symptoms as well as surgical intervention does and have not led to appreciable increase in survival [2, 3, 5, 6].

Surgical resection has been the mainstay of therapy to allow palliation of symptoms and attempt complete removal for cure. However, most studies note local recurrence of tumor 4 to 10 months after the procedure [2–5, 7]. Several reports [4, 7] detail multiple surgical resections to relieve symptoms caused by local tumor growth with patients dying of local disease recurrence without evidence of metastases. These experiences led us to believe that inadequate surgical resection was a major obstacle in the successful treatment of primary cardiac MFH.

Although standard orthotopic transplantation for cardiac tumor allows complete excision and has been previously described [8] and successfully accomplished, we thought the approach was limited by the number of donor organs available and the high likelihood that our patient would die of local tumor invasion prior to the availability of a donor. The morbidity and mortality associated with the necessary immunosuppression and the unknown effect it might have on metastatic disease were also of concern. Complete resection with maintenance of the native heart is the optimal solution. To achieve this, complete accessibility of the posteriorly located left atrium is necessary. Therefore, cardiac explantation for extracorporeal tumor resection and cardiac reconstruction was considered. Cooley and colleagues [9] reported the initial attempt at this approach for a cardiac tumor. A successful case of autotransplantation for extensive myxoma of the left atrium has been reported from Germany [10], and one case of successful autotransplantation for cardiac MFH from Yugoslavia was mentioned in a European text on cardiac surgery [11].

We successfully used the technique of cardiac excision and extracorporeal complete tumor excision and cardiac reconstruction with subsequent cardiac autotransplantation. Although the initial postoperative course was uneventful, bone marrow metastasis developed, and the patient died 2 months postoperatively; he refused chemotherapy. Prior to death there was no evidence of local recurrence, and cardiac function was noted to be good. Indications for cardiac excision and "bench" surgery could include complex tumor resections, as in the current case, and other conditions requiring complex cardiac reconstruction, such as a mitral valve reconstructive procedure in the patient with a small left atrium.

In conclusion, primary cardiac MFH should be resected to relieve symptoms caused by local tumor growth, provide control of primary tumor, and allow the potential for cure or long-term survival with effective adjuvant therapy. Paramount in achieving these goals is complete local excision, which is greatly aided by the technique of cardiac excision, bench removal of the tumor with cardiac reconstruction, and autotransplantation.

	References

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1. Straus R., Merliss R. Primary tumor of the heart. Arch Pathol 1945;39:74.
2. Dein J.R., Frist W.H., Stinson E.B., et al. Primary cardiac neoplasms. Early and late results of surgical treatment of 42 patients. J Thorac Cardiovasc Surg 1987;93:502-511.[Abstract]
3. Murphy M.C., Sweeney M.S., Putnam J.B., Jr, et al. Surgical treatment of cardiac tumors: a 25-year experience. Ann Thorac Surg 1990;49:612-618.[Abstract]
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5. Putnam J.B., Jr, Sweeney M.S., Colon R., Lanza L.A., Frazier O.H., Cooley D.A. Primary cardiac sarcomas. Ann Thorac Surg 1991;51:906-910.[Abstract]
6. Samoudos G., Reed G.E. Primary cardiac sarcoma. J Thorac Cardiovasc Surg 1972;63:482-485.[Medline]
7. Gabelman C., Al-Sadir J., Lamberti J., et al. Surgical treatment of recurrent primary malignant tumor of the left atrium. J Thorac Cardiovasc Surg 1979;77:914-921.[Abstract]
8. Jamieson S.T., Gaudiani V.A., Reitz B.A., Oyer P.E., Stinson E.B., Shumway N.E. Operative treatment of an unresectable tumor of the left ventricle. J Thorac Cardiovasc Surg 1981;81:797-799.[Abstract]
9. Cooley D.A., Reardon M.J., Frazier O.H., Angelini P. Human cardiac explantation and autotransplantation: application in a patient with a large cardiac pheochromocytoma. Tex Heart Inst J 1985;12:171-176.
10. Scheld H.H., Nestle H.W., Kling D., Stermann W.A., Langebartels H., Hehrlein F.W. Resection of a heart tumor using autotransplantation. Thorac Cardiovasc Surg 1988;36:40-43.[Medline]
11. Kosak M., Gabrijelcic T., Brecelj A., et al. The first successful explantation and autotransplantation of the heart for a recidivant cardiac tumor. In: D’Alessandro L.C., ed. Heart surgery. Ljubljana: Casa Editrice Scientifica Internationale, 1987:345-354.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Michael J. Reardon John C. Baldwin Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Reardon, M. J. Articles by Baldwin, J. C. Search for Related Content PubMed PubMed Citation Articles by Reardon, M. J. Articles by Baldwin, J. C.