Ann Thorac Surg 2006;82:1514-1517
© 2006 The Society of Thoracic Surgeons
Case Reports
Left Atrial Sarcoma: Resection and Repair by Cardiac Autotransplant and In Situ Pericardial Patch
Donald B. Doty, MDa,*,
John R. Doty, MDa,
Bruce B. Reid, MDa,
Jeffrey L. Anderson, MDb
a Division of Cardiovascular and Thoracic Surgery, Salt Lake City, Utah
b Division of Cardiology, LDS Hospital, Salt Lake City, Utah
Accepted for publication November 28, 2005.
* Address correspondence to Dr Doty, 324 Tenth Avenue, 184, Salt Lake City, UT 84010 (Email: donald.doty{at}ihc.com).
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Abstract
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This report demonstrates the method of resection of a left atrial tumor involving the right superior pulmonary vein. The unique features are use of adjacent pericardium as an in situ patch to reconstruct the left atrium when there is no margin of left atrium remaining on the pulmonary veins and cardiac autotransplantation.
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Introduction
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Patients with malignant tumors in the left atrium are usually incapacitated by obstruction of egress of blood flow from the pulmonary veins. Presence of the tumor in the blood stream predisposes early metastasis. Resection of the tumor in the left atrium is a technical challenge. The tumor is within and behind the left atrium and covered by the cardiac mass making access difficult. Furthermore, in order for the atrial wall resection to encompass the tumor necessitates reconstruction of the left atrium to provide sufficient reservoir capacity. Operative treatment of malignant tumor of the left atrium has been successfully accomplished by cardiac explant to gain access. This case report details the method of resection of a left atrial sarcoma involving the right superior pulmonary vein and reconstruction of the left atrium to allow autotransplantation.
A 46-year-old woman presented with anxiety attacks consisting of extreme shortness of breath and painful inhalation at rest. Transesophageal echocardiography revealed tumor in the left atrium. A positron-emission tomographic scan showed the tumor in the mediastinum without evidence of metastasis. Magnetic resonance imaging of the heart showed an extensive tumor attachment involving the right superior pulmonary vein, the entire dome of the left atrium, and the posterior wall between the right and left superior pulmonary veins (Fig 1). The superior vena cava and right pulmonary artery were displaced anteriorly by the tumor (Fig 2). Operation was indicated to relieve pulmonary venous obstruction and to establish tumor diagnosis.
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Fig 1. Cardiac magnetic resonance image shows large mass in the left atrium involving the right superior pulmonary vein, entire dome of the left atrium, and posteriorly between the right and left pulmonary veins.
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Fig 2. (A) Artist's concept of the extent of the tumor (shaded area) with the heart removed from the pericardial sac. The tumor extended into the superior vena cava and the right superior pulmonary vein. It also involved the pericardial sac posterior to the heart coming close to the other pulmonary veins. (B) Shows the posterior and superior aspects of the heart with the shaded area indicating the extent of tumor involvement of the heart. The right pulmonary artery, right superior pulmonary veins and the left atrium between the origins of the pulmonary veins were involved with tumor.
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The operation was performed on cardiopulmonary bypass with cold crystalloid cardioplegic arrest of the heart. The superior vena cava was divided above the tumor mass. The ascending aorta was divided. The pulmonary artery was divided at the bifurcation. The inferior vena cava was divided on the right atrium. The left atrium was opened just above the atrioventricular groove, and the incision extended in front of the inferior pulmonary vein on the right side coming to a bulky tumor in the right superior pulmonary vein. The atrial incision was extended to the left. The tumor was very close, but not into the orifices of the left pulmonary veins. The veins were divided individually, leaving no atrium attached. The left atrial incision was extended superiorly around the left atrial appendage and the aorta, leaving a small cuff of atrium attached to the aorta. The superior vena cava, right pulmonary vein, and atrial septum were firmly attached to the tumor. A portion of the right atrium and the septum were left attached to the tumor as the incision was extended. The right pulmonary artery was divided near the bifurcation and at the hilum, leaving the major part of the artery attached to the tumor. The heart was then separated from the patient and placed in an ice and saline bath for cold preservation. The right upper and middle lobes were resected en bloc with the tumor, preserving the right phrenic nerve. The tumor with the attached pericardium was removed posteriorly, leaving the orifices of the left pulmonary veins and the right inferior pulmonary vein cut flush with the pericardial sac. Gross margins of the resection were clean, and all margins were negative on final pathologic examination.
Reconstruction of the left atrium was accomplished by attaching the orifices of the pulmonary veins securely to the remaining posterior pericardium (Fig 3A). The cut edge of the pericardium posteriorly between the pulmonary veins was attached to a free patch of autogenous pericardium (Fig 3B) obtained anteriorly and fixed in glutaraldehyde solution. The heart was reimplanted. The remaining left atrial cuff on the heart was attached to the pericardial sac, forming a ridge of the in situ pericardium below and around the pulmonary veins (Fig 4A). Superiorly, the free pericardial patch was shortened to form the dome of the reconstructed left atrium (Fig 4B). The inferior vena cava was reanastomosed. The right pulmonary artery was reconstructed using an 8-mm externally reinforced polytetrafluoroethylene graft to bridge from the bifurcation to the right pulmonary artery at the hilum (Fig 5A). The tip of the right atrial appendage was excised. The large opening into the right atrium as a consequence of resection was extended to allow rotation of the appendage superiorly for anastomosis to the superior vena cava (Fig 5B). The operation was completed by anastomosis of the aorta.
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Fig 3. (A) Reconstruction of the pulmonary vein to the left atrium continuity. Pulmonary veins are attached to the adjacent pericardial sac. Shaded area represents the posterior pericardium resected with the tumor. (B) Reconstruction of the posterior and superior aspects of the left atrium. The free pericardial patch is attached to the superior aspect of the pulmonary veins and pericardial edge between the inferior pulmonary veins.
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Fig 4. (A) Cardiac autotransplantation to the in situ pericardium. The left atrium is attached to the in situ pericardium at the appropriate position below the pulmonary veins. (B) Reconstruction of the dome of the left atrium. The pericardial patch is attached to the anterior left atrium. Inset demonstrates completed left atrial reconstruction.
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Fig 5. (A) The right pulmonary artery is reconstructed using an 8-mm externally reinforced polytetrafluoroethylene graft to bridge from the bifurcation to the right pulmonary artery at the hilum. The main pulmonary artery is reanastomosed. The inset shows reanastomosis of main pulmonary artery. (B) The inferior vena cava is reanastomosed. The tip of the right atrial appendage is excised. The large opening into the right atrium is extended to allow rotation of the appendage superiorly for anastomosis to the superior vena cava (inset).
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The patient remained in the hospital for 2 weeks while recovering from operation. She did well, returning home and enjoying a routine convalescence. Two months later she had severe headaches develop. Computerized axial tomography of the brain showed a large mass, presumably metastatic. Brain stem compression and death followed promptly.
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Comment
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Resection of cardiac neoplasm occurring in the left atrium is technically challenging. Preoperative assessment of tumor extent and invasion is enhanced by the use of cardiac magnetic resonance imaging [1]. Cardiac magnetic resonance imaging is particularly useful in delineating extension into pulmonary or systemic veins and can also provide accurate assessment of ventricular and valvular function, which cannot be determined on computerized axial tomography.
Access to the lesion is the problem, because the cardiac mass covers the area of interest. Removing the heart to get it out of the way is the method of solving the access problem. Cooley and colleagues [2] explanted the heart to resect a pheochromocytoma located in the left atrium. The heart was then autotransplanted. Scheld and colleagues [3] reported removal of an extensive myxoma of the left atrium using autotransplantation. Kosak and colleagues [4], quoted by Reardon and colleagues [5], described use of autotransplantation for treatment of a cardiac tumor. Reardon and colleagues [5], who was co-author on the Cooley and colleagues' [2] report, described resection of malignant fibrous histiocytoma of the left atrium using the autotransplantation technique. There was adequate left atrial tissue remaining on the pulmonary veins to allow direct anastomosis of the left atrium after reconstruction with bovine pericardium.
Use of adjacent pericardium as an in situ patch has been described by Cartmill [6], although he seldom receives the credit. This was later described by Corno and colleagues [7] for enlargement of the left atrium between the pulmonary veins on the right side in patients having obstructed pulmonary veins after Mustard's operation for transposition of the great arteries. We used in situ pericardial patches for reconstruction and re-routing of the vena cavae during cardiac transplantation associated with situs inversus [8].
This report draws on the prior experience of using autotransplantation of the heart combined with reconstruction of the left atrium using in situ pericardium when there is no margin of the left atrium remaining on the pulmonary veins after resection of the left atrial tumor. Using the adjacent pericardial sac provides the correct anatomic shape and greatly simplifies reconstruction of the left atrium. In situ pericardial techniques may also apply to reconstruction of other cardiac chambers or vascular structures.
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References
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- Restrepo CS, Largoza A, Lemos DF, et al. CT and MR imaging findings of malignant cardiac tumors Curr Probl Diagn Radiol 2005;34:1-11.[Medline]
- Cooley DA, Reardon MJ, Frazier OH, Angelini P. Human cardiac explantation and autotransplantation: application in a patient with a large cardiac pheochromocytoma Tex Heart Inst J 1985;12:171-176.[Medline]
- Scheld HH, Nestle HW, Kling D, Stermann WA, Langebartels H, Hehrlein FW. Resection of a heart tumor using autotransplantation Thorac Cardiovasc Surg 1988;36:40-43.[Medline]
- Kosak M, Gagrijelcic T, Brecelj A, et al. The first successful explantation and autotransplantation of the heart for a recidivant cardiac tumorIn: D'Alessandro LC, editor. Heart surgery. Ljubljana: Casa Editrice Scientirica Internationale; 1987. pp. 345-354.
- Reardon MJ, DeFelice CA, Sheinbaum R, Baldwin JC. Cardiac autotransplant for surgical treatment of a malignant neoplasm Ann Thorac Surg 1999;67:1793-1795.[Abstract/Free Full Text]
- Cartmill T. In-situ pericardial patch. 1972; personal communication. Referenced in Doty DB. Cardiac surgery: a looseleaf workbook and update service. Chicago IL: Yearbook Medical Publishers; 1987TGA A27.
- Corno AF, Laks H, George B, Williams RG. Use of in situ pericardium for surgical relief of pulmonary venous obstruction following Mustard's operation Ann Thorac Surg 1987;43:443-444.[Abstract/Free Full Text]
- Doty DB, Renlund DG, Caputo GR, Burton NA, Jones KW. Cardiac transplantion in situs inversus J Thorac Cardiovasc Surg 1990;99:493-499.[Abstract]
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Abstract
Introduction
