HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

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 Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ravikumar, E. Articles by Thomas, S. Search for Related Content PubMed PubMed Citation Articles by Ravikumar, E. Articles by Thomas, S.

Ann Thorac Surg 2000;70:1077-1079
© 2000 The Society of Thoracic Surgeons

---

Supplement: cardiothoracic techniques & technologies

Minimal access approach for surgical management of cardiac tumors

^a Department of Thoracic and Cardiovascular Surgery, Christian Medical College Hospital, Vellore, India
^b Department of Anaesthesiology, Christian Medical College Hospital, Vellore, India

Address reprint requests to Dr Ravikumar, Department of Thoracic and Cardiovascular Surgery, Christian Medical College Hospital, Vellore 632 004, India
e-mail: eravikumar{at}hotmail.com

Presented at the Sixth Annual Cardiothoracic Techniques and Technologies Meeting 2000, Ft Lauderdale, FL, Jan 27–29, 2000.

	Abstract

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Background. Following our experience with minimally invasive valve replacement operation, we utilized this technique for surgical management of cardiac tumors.

Methods. Between April 1997 and September 1999, 5 consecutive patients with cardiac tumors underwent minimally invasive excision of the tumors. The patients were 4 women and 1 man with an age range of 32 to 50 years. The tumor was located in the left atrium in 4 patients and the right atrium in 1 patient. The common presenting symptoms were dyspnea on exertion (100%), chest pain (60%), palpitation (60%), and transient ischemic attack (20%). Diagnosis was established preoperatively by echocardiography only.

Results. In 2 patients the approach was right parasternal and the subsequent 3 patients had direct-access partial sternotomy. The myxoma was resected transseptally in all patients. There was no hospital mortality. One patient had postoperative embolic episode leading to left hemiparesis. Follow-up did not reveal any complication related to this technique and all were in New York Heart Association (NYHA) functional class I.

Conclusions. Minimal access partial sternotomy is an effective approach that adheres to all the identified surgical principles in successful removal of these tumors. The smaller incision does not compromise the efficacy or safety of the operation, reduces hospital stay, and has a good cosmetic result.

	Introduction

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Minimally invasive cardiac operation is a rapidly developing field in cardiac surgery. It has all the safety and efficacy of a standard cardiac operation with the added advantage of better patient compliance due to significantly less pain and shorter hospital stays, thus leading to reduced cost and more socially acceptable cosmetic results.

Following our experience with the minimal invasive approach for valve replacement, we utilized this technique for surgical management of cardiac tumor [1]. From April 1997 to September 1999, 5 patients with cardiac tumor (4 with left atrial myxoma and 1 with right atrial secondary chondrosarcoma) underwent cardiac operation utilizing minimal access. Two patients underwent operation through the right parasternal approach [2, 3], and the other 3 patients underwent operation through direct-access partial sternotomy.

	Material and methods

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Patients
Between April 1997 to September 1999, there were 5 patients (4 women, 1 man) who underwent resection of left atrial or right atrial tumor utilizing direct-access minimally invasive operation at Christian Medical College Hospital, Vellore, India. Their ages ranged between 32 and 50 years. The tumor was located in the left atrium in 4 patients and the right atrium in 1 patient.

Four patients were symptomatic, and had symptoms related to myxoma (mean duration 12.6 months). The most common symptoms were dyspnea on exertion (80%), palpitation (80%), and chest pain (60%). Transient ischemic attacks were reported in 1 patient (20%).

One patient was asymptomatic. This patient was detected to have a right atrial mass at screening prior to chemotherapy. He had had an operation for seminoma of the testis in 1989, total hip replacement for chondrosarcoma of the right hip in 1997, and an operation for recurrence of the tumor in 1999.

One patient was in New York Heart Association (NYHA) class IV, 3 patients were in NYHA functional class III, and another in class I. One patient had hypothyroidism and hypertension and another patient had diabetes mellitus.

Laboratory analysis revealed mildly elevated leukocyte counts and increased erythrocyte sedimentation rates. Electrocardiograph findings included nonspecific ST-T wave changes and all were in normal sinus rhythm. The diagnosis of atrial myxoma was made by echocardiography in all patients. One patient also had severe tricuspid regurgitation.

Operative technique
The operative procedure entailed administration of general anesthesia with endotracheal intubation in supine position. The first 2 patients underwent operation through the right parasternal approach after bisecting the third and the fourth costal cartilages as described by Cosgrove and colleagues [2, 3]. The right femoral artery and vein were exposed through a right groin incision and after systemic heparinization, they were cannulated using a 15F (18 cm) and 23F (50 cm), straight-tipped Biomedicus cannulas (Medtronic, Grand Rapids, MI). The superior vena cava was cannulated using a DLP 26F wire-reinforced cannula (Medtronic). The superior vena cava was taped and total cardiopulmonary bypass was established by snugging the superior vena cava and clamping the inferior vena cava at the cavoatrial junction using a DeBakey right-angled clamp. The aorta was cross-clamped with a DeBakey angled clamp and antegrade cardioplegia administered. In the other 3 patients direct-access J-shaped partial sternotomy was utilized. Direct cannulation of aorta and both cavas were accomplished in 2 patients, whereas percutaneous cannulation using a Biomedicus cannula was performed in another 2 patients. For the last 3 patients underwent vacuum-assisted venous drainage. A right atriotomy was performed 2 cm from and parallel to Waterson’s groove. The right atrial cavity was exposed by taking stay sutures to the atrial wall.

The surgical approach to the left atrial myxoma was transseptal [4] in all patients. An incision was made in the atrial septum in the region of fossa ovalis; the tumor was excised with a 1.5-cm cuff of full-thickness interatrial septum. All left atrial myxomas were pedunculated. The mitral and tricuspid valves were examined in all cases and were competent except for 1 patient who had preoperative tricuspid regurgitation.

The right atrial mass was a sessile tumor measuring 3.1 x 2.7 cm. The tumor was excised with a 1.5-cm cuff of atrial septum to achieve good clearance.

The defect in the atrial septum was closed with a Dacron double velour fabric patch using running 4-0 Prolene sutures (Ethicon, Edinburgh, Scotland). In 1 of the patients who had associated severe tricuspid regurgitation concomitant DeVega’s tricuspid annuloplasty was performed using 2-0 Ethibond suture (Ethicon).

	Results

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
All patients were electively ventilated for 4 to 8 hours. The postoperative course was uneventful in 4 patients and they were all discharged from the hospital on the seventh postoperative day. One patient suffered postoperative embolic stroke and was discharged on the 11th postoperative day after full recovery. At follow-up all patients were found to be in NYHA functional class I. Two-dimensional echocardiography revealed no intracardiac mass, no residual atrial septal defects, and competent mitral and tricuspid valves (see Table 1).

	Comment

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

The right parasternal approach gave adequate surgical exposure and access to the right and left atrias. As our experience increased with direct-access partial sternotomy in valve replacement surgery, we utilized this as our technique of choice. The partial sternotomy direct access gave us good exposure and allowed direct cannulation of the aorta and both the superior and inferior vena cavas. Exposure of the tumor was excellent in all 5 cases. Margins were confirmed histologically to be tumor free.

In conclusion, minimal access partial sternotomy is effective and affords excellent exposure, and adheres to all the identified surgical principles in successful removal of these tumors. The smaller incision does not compromise the efficacy of the operation, reduces hospital stay, and has good cosmetic results.

	Acknowledgments

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
We thank Ms Johncy Chellam for her help in computing the data and Mr Jayaprakash Chandrashekhar for his secretarial help in processing the manuscript.

	References

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 

1. Ravikumar E., Kumar R., Birudugadda R.B., Thomas S., Chandy S.T. Minimally invasive approach for left atrial myxoma. Asian Cardiovasc Thorac Ann 1998;6:313-315.[Abstract/Free Full Text]
2. Navia J.L., Cosgrove D.M., III Minimally invasive mitral valve operations. Ann Thorac Surg 1996;62:1542-1544.[Abstract/Free Full Text]
3. Cosgrove D.M., III, Sabik J.F. Minimally invasive approach for aortic valve operations. Ann Thorac Surg 1996;62:596-597.[Abstract/Free Full Text]
4. Sellke F.W., Lemmer J.H., Jr, Vandenberg V.F., Ehrenhaft J.L. Surgical treatment of cardiac myxoma. Ann Thorac Surg 1990;50:557-561.[Abstract]
5. Mack M.J., Aronoff R.J., Acuff T.E., Douthit M.B., Bowman R.T., Ryan W.H. The present role of thoracoscopy in the diagnosis and treatment of diseases of the chest. Ann Thorac Surg 1992;54:403-409.[Abstract]
6. Hearn C.J., Kraenzler E.J., Wallace L.K., Starr N.J., Sabik J.F., Cosgrove D.M. Minimally invasive aortic valve surgery. Anaesth Analg 1996;83:1342-1344.[Medline]

This article has been cited by other articles:

				J.-C. M. Walkes, W. R. Smythe, and M. J. Reardon Cardiac Neoplasms Card. Surg. Adult, January 1, 2008; 3(2008): 1479 - 1510. [Full Text]

				R. P. Deshpande, F. Casselman, I. Bakir, G. Cammu, F. Wellens, R. De Geest, I. Degrieck, F. Van Praet, Y. Vermeulen, and H. Vanermen Endoscopic Cardiac Tumor Resection Ann. Thorac. Surg., June 1, 2007; 83(6): 2142 - 2146. [Abstract] [Full Text] [PDF]

				M. J. Reardon and W. R. Smythe Cardiac Neoplasms Card. Surg. Adult, January 1, 2003; 2(2003): 1373 - 1400. [Full Text]

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 Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ravikumar, E. Articles by Thomas, S. Search for Related Content PubMed PubMed Citation Articles by Ravikumar, E. Articles by Thomas, S.