Ann Thorac Surg 2004;78:1470-1472
© 2004 The Society of Thoracic Surgeons
Case report
Combined Radiofrequency Ablation and Myxoma Resection Through a Port Access Approach
Mustafa Guden, MDa,*,
Belhhan Akp
nar, MDa,
Mehmet U. Ergenoglu, MDa,
Ertan Sagbas, MDa,
Ilhan Sanisoglu, MDa,
Ugur Ozbek, MDb
a Department of Cardiovascular Surgery Kadir Has University Medical Faculty, Florence Nightingale Hospital, Istanbul, Turkey,
b Department of Anesthesia, Kadir Has University Medical Faculty, Florence Nightingale Hospital, Istanbul, Turkey
Accepted for publication July 10, 2003.
* Address reprint requests to Dr Guden, Department of Cardiovascular Surgery, Florence Nightingale Hospital, Abide'i Hürriyet Cad, No. 290, 80220 Sisli, Istanbul, Turkey
zmguden{at}ttnet.net.tr
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Abstract
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Myxomas are common cardiac tumors that are traditionally managed by complete excision through a median sternotomy approach with the use of cardiopulmonary bypass. We discuss a patient with left atrial myxoma and chronic atrial fibrillation who underwent surgical excision and combined irrigated radiofrequency ablation for atrial fibrillation through a Port Access approach. Minimally invasive operations constitute an expanding field for the treatment of many cardiac diseases and may be an alternative for the treatment of this pathology because of less surgical trauma and cosmetic superiority. In this case, both excision of the myxoma and radiofrequency ablation were feasible through this minimally invasive approach. The combination of direct and endoscopic views enabled both procedures to be performed safely and efficiently.
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Introduction
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Technologic developments have extended the applications of minimally invasive techniques. Endoscopic systems have enabled cardiac surgeons to perform procedures such as atrioventricular valve replacement or repair, myxoma resection, and surgical radiofrequency ablation safely and efficiently through a small incision.
A 62-year-old man was admitted to the hospital with complaints of chronic cough, exercise dyspnea, and palpitations. He had had chronic atrial fibrillation for 2 years and was in New York Heart Association functional class III. Transthoracic echocardiography revealed a 6.4 x 4.2-cm lobulated mass originating from the interatrial septum in the left atrium. Two-dimensional color flow Doppler echocardiography revealed a pedunculated left atrial mass that prolapsed into the mitral valve orifice in diastole, causing functional mitral valve stenosis and mild mitral regurgitation. Cardiac catheterization confirmed mild mitral regurgitation and normal coronary arteries with a mildly dilated left ventricle, but overall normal left ventricular function. The patient was scheduled for removal of myxoma and radiofrequency ablation through a Port Access (Cardiovations, Somerville, NJ) approach.
The patient underwent a detailed preoperative evaluation that included computed tomography and arterial Doppler examination to detect any contraindications for Port Access operations, such as lung adhesion or iliac artery disease. After such risk factors were ruled out, the patient underwent operation.
After the standard induction of anesthesia, the patient underwent double-lumen intubation for single-lung ventilation. After the administration of heparin 2 mg/kg, a 19F arterial cannula (DLP Inc, Grand Rapids, MI) was introduced through the right internal jugular vein percutaneously to assist venous drainage during cardiopulmonary bypass (CPB). Transesophageal echocardiographic (TEE) examination confirmed the presence of the tumor, which arose from the interatrial septum, was localized next to the fossa ovalis and 1 cm close to the mitral valve annulus, and was moving across the mitral valve into the left ventricle. The patient was placed in the supine position with the right side tilted approximately 30 degrees, and external defibrillation pads were placed. A 4-cm right lateral minithoracotomy in the fourth intercostal space was performed. A soft tissue retractor (Cardiovations, Somerville, NJ) was used for exposure of the surgical field, avoiding the division or traction of any ribs. A 5-mm camera port (Storz; Karl Storz GmBH and Co, Tuttingen, Germany) was introduced through the fourth intercostal space. A second port was introduced through the sixth intercostal space on the midaxillary line for left atrial venting and carbon dioxide insufflation, which began immediately after the right lung was deflated. Simultaneously the right femoral artery and vein were prepared by means of a 2-cm oblique incision in the groin. CPB was established by femoral arterial and venous cannulas. A 19F arterial cannula (DLP Inc) was used for arterial cannulation. Venous drainage was obtained with a 24F to 29F femoral cannula (DLP Inc) and the 19F arterial cannula, which was previously inserted into the right internal jugular vein, thus allowing adequate venous drainage. The pericardium was opened 2 cm above and parallel to the phrenic nerve. The patient was cooled to 28°C. Both vena cavae were encircled with tapes. A transthoracic aortic clamp (Chitwood clamp; Scanlan, St. Paul, MN) was introduced percutaneously from the second intercostal space on the front axillary line. After the cross-clamping of the aorta, blood cardioplegia was administered through a custom-made (DLP Inc) antegrade cardioplegia cannula inserted into the ascending aorta. The right atrium was opened, and the fossa ovalis was located. The interatrial septum was incised longitudinally, and the tumor was excised, leaving a 1-cm margin around its pedicle (Fig 1). Autologous pericardium was used to close the defect in the atrial septum. The excised myxoma was 6.5 x 5.5 cm in size. After excision of the tumor, left atrial radiofrequency ablation (Cardioblate; Medtronic Inc, Minneapolis, MN) was performed (Fig 2). The ablation pattern is shown in Figure 3. The ablation procedure added 9 minutes to the ischemic time. The atrial septum was closed primarily afterward to prevent any possible damage to the suture lines from the radiofrequency energy. The mitral valve was tested with saline and was competent. The durations of CPB and aortic cross-clamp were 160 and 120 minutes, respectively. After weaning from CPB, TEE revealed no mitral valve insufficiency and no gradient on the mitral valve. Sinus rhythm was gained without cardioversion at the end of the procedure. Histopathologic examination of the mass identified myxoma. The patient was extubated 3 hours after the operation and had a rapid and uncomplicated recovery. He was discharged from the hospital on the eighth day in sinus rhythm. Three months later, the patient was in New York Heart Association class I. Holter monitoring revealed a stable sinus rhythm, and transthoracic echocardiography revealed atrial contractility with a prominent A wave.
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Fig 1. After the longitudinal incision of the interatrial septum, the myxoma was excised. (IAS = interatrial septum; T = tumor.)
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Fig 3. Dots indicate endocardial ablation lines inside the left atrium. (a = left atrial appendage; LPVs = left pulmonary veins; MV = mitral valve; RPVs = right pulmonary veins.)
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Comment
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Myxomas are common primary cardiac tumors that are mostly attached to the septum around the fossa ovalis as a polypoid and often pedunculated mass. The curative treatment of choice for myxomas is surgical removal, because the potential embolic complications may be debilitating or lethal. Conventional operation requires a median sternotomy incision and has an operative mortality rate of less than 3%.
Port Access operations have arisen as a viable alternative to conventional methods, especially during mitral valve operation. The safety and efficacy of this approach have been established by many series. Port Access operation can provide minimal discomfort, less postoperative pain, fast postoperative recovery, excellent cosmetic healing, and a shortened hospital stay [1, 2]. In addition, young patients are satisfied with the size of their incisions. Tumor manipulation should be minimal during this kind of operation to prevent intraoperative tumor dislodgment and embolization [3], which is another advantage of Port Access operation, because manipulation of the heart is minimal. Resection of myxomas through a Port Access approach has been reported previously [4, 5]. However, a combined tumor resection and radiofrequency left-sided Maze procedure is a novel approach. Radiofrequency ablation is a well-established less invasive method for the surgical treatment of atrial fibrillation, and the safety and efficacy of the method have been previously published [6]. Although various lesion patterns for ablation have been suggested, we chose a left-sided ablation procedure that replicates the Maze procedure. The aim was to combine 2 less invasive procedures during a single operation. The application of radiofrequency ablation through minimally invasive approaches can broaden its use, especially during such concomitant procedures.
Optimal exposure greatly facilitates left atrial myxoma resection and is mandatory for safe and effective tumor resection. To avoid recurrence, excision must include a wide base of the atrial septum and a part of the atrial septal wall, which must be removed, with the pedicle of the tumor. Biatrial exposure is usually recommended to limit manipulation of the tumor and to allow visualization of all 4 chambers of the heart [7, 8]. After proper localization of the tumor with TEE guidance, my colleagues and I preferred right atriotomy and a transseptal approach. Access was easily provided to the atrial septum, the mitral valve, and the free atrial wall, and the myxoma could be resected with an adequate button of normal interatrial septum. As mentioned previously, adequate exposure is vital during this type of operation, and cosmetic concerns should not compromise surgical results. In this case, the Port Access approach provided an excellent direct and endoscopic view for both procedures and facilitated complete surgical removal of the tumor and radiofrequency ablation without compromising the efficacy or safety of the operation.
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References
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- Glower DD, Landolfo KP, Clements F, et al. Mitral valve operation via port access versus median sternotomy. Eur J Cardiothorac Surg. 1998;14(Suppl 1):143–147
- Grossi EA, Zakow PK, Ribakove G, et al. Comparison of postoperative pain, stress response, and quality of life in port access vs standard sternotomy coronary bypass patients. Eur J Cardiothorac Surg. 1999;16(Suppl 2):39–42
- Van Trigt P III, Sabiston DC Jr. Tumors of the heart. Sabiston DC Jr, Spencer FC. Surgery of the chest. 6th ed. Philadelphia: Saunders; 1995. p. 2069–2088
- Schroeyers P, Vermuelen Y, Wellens F, et al. Video-assisted Port-Access surgery for radical myxoma resection. Acta Chir Belg. 2002;102:131–133[Medline]
- Ko PJ, Chang CH, Lin PJ, et al. Video-assisted minimal access in excision of atrial myxoma. Ann Thorac Surg. 1998;66:1301–1305[Abstract/Free Full Text]
- Güden M, Akpnar B, Sanisoglu
, Sagba
E, Bayndr O. Intraoperative saline-irrigated radiofrequency modified Maze procedure for atrial fibrillation. Ann Thorac Surg. 2002;74:1301–1306
- Bortolotti U, Maraglino G, Rubino M, et al. Surgical excision of intracardiac myxomas: a 20 year follow-up. Ann Thorac Surg. 1990;49:449–453[Abstract]
- Miralles A, Bracamonte L, Soncul H, et al. Cardiac tumors: clinical experience and surgical results in 74 patients. Ann Thorac Surg. 1991;52:886–895[Abstract]
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Abstract
Introduction
