Ann Thorac Surg 2007;83:2142-2146
© 2007 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Endoscopic Cardiac Tumor Resection
Ranjit P. Deshpande, FRCS(C-Th),
Filip Casselman, MD, PhD*,
Ihsan Bakir, MD,
Guy Cammu, MD,
Francis Wellens, MD,
Raphael De Geest, MD,
Ivan Degrieck, MD,
Frank Van Praet, MD,
Yvette Vermeulen, MS,
Hugo Vanermen, MD
Department of Cardiovascular and Thoracic Surgery, OLV Clinic, Aalst, Belgium
Accepted for publication January 29, 2007.
* Address correspondence to Dr Casselman, Department of Cardiovascular & Thoracic Surgery, OLV Clinic, 164 Moorselbaan, Aalst, 9300 Belgium. (Email: filip.casselman{at}olvz-aalst.be).
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Abstract
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Background: The purpose of this study is to report our 9 years’ experience with endoscopic cardiac tumor resection using the port access approach.
Methods: From March 1997 to December 2005, 27 patients (mean age, 56.2 ± 16.9 years; 70% female) underwent endoscopic cardiac tumor resection using endocardiopulmonary bypass and endoaortic-balloon clamp technique. Nineteen (70%) patients presented in New York Heart Association class I, 4 patients presented with embolic stroke, and 4 patients presented with atrial arrhythmias. All patients underwent echocardiography on admission, intraoperatively, at discharge, and at follow-up evaluation. Eight patients additionally required mitral valve replacement (n = 1), tricuspid valve replacement (n = 1), mitral valve repair (n = 2), mini-maze (n = 1), and closure of patent foramen ovale (n = 3). Mean follow-up was 3.4 ± 2.7 years.
Results: Mean endoaortic-balloon clamp and endocardiopulmonary bypass times were 68.8 ± 30.8 minutes and 112.2 ± 41.5 minutes, respectively. There were no conversions to sternotomy. Tumors resected were classified as left atrial myxoma (n = 20), right atrial myxoma (n = 3), lipoma (n = 1), intravenous leiomyoma involving the inferior vena cava and the tricuspid valve (n = 1), plexiform tumor of the sinoatrial node (n = 1), and papillary fibroelastoma of aortic valve noncoronary cusp (n = 1). There were no hospital deaths. Mean intensive care unit and hospital stays were 1.4 ± 1.1 days and 7.3 ± 3.4 days, respectively. Postoperative complications were evolving stroke (n = 1), re-exploration for bleeding (n = 1), and myocardial ischemia requiring stenting (n = 1). Follow-up failed to demonstrate residual or recurrent tumor. One patient had a small residual atrial septal defect. Ninety-two percent of patients appreciated the cosmetic result and fast recovery.
Conclusions: Endoscopic cardiac tumor resection is feasible and a valid oncologic approach with an attractive cosmetic advantage over median sternotomy.
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Introduction
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Cardiac tumors may be primary or secondary and malignant or benign. Myxomas are the most frequent primary benign atrial tumors, and surgical resection is the therapy of choice [1]. Based on our large experience with endoscopic cardiac surgery [2, 3] we extrapolated this technique to cardiac tumor resection. This study summarizes a single-center experience in 27 consecutive patients undergoing endoscopic cardiac tumor resection through port access approach during a 9-year period.
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Material and Methods
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Patient Characteristics
This is a retrospective study of prospectively collected data. From March 1997 to December 2005, 27 consecutive patients diagnosed with cardiac tumors underwent endoscopic cardiac tumor resection. During this period no median sternotomies were performed for resection of cardiac tumors. Patient characteristics are given in Table 1. Previous embolic events possibly related to tumor were one right retinal artery embolism causing unilateral blindness and three cerebrovascular accidents, two recent and one old. There were no redo cases for recurrence of tumor. No patient had familial inheritance for cardiac tumors. Coronary angiography in patients aged 45 years or more did not reveal obstructive coronary artery disease.
We confirm that the institutional review board approved and waived the requirement for individual patient consent for this retrospective study.
Echocardiography Findings
Preoperative transthoracic echocardiography (TTE) findings are given in Table 2.
Patient Satisfaction
Patient satisfaction survey was based on clinical follow-up and telephone interview.
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Results
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Surgical Technique
Our endoscopic cardiac surgical technique has been described in detail elsewhere [2, 3]. It was modified depending on the site and invasiveness of the cardiac tumors confirmed by intraoperative transesophageal echocardiography (TEE). In brief, all patients were ventilated with a double-lumen endotracheal tube and placed in a supine position, with slight elevation of the right hemithorax. Under TEE guidance, a 14F or 17F DLP cannula (Medtronic DLP, Grand Rapids, MI) was placed percutaneously by the anesthesiologist through the internal jugular vein into the superior vena cava. The right common femoral artery and vein were exposed. An anterolateral working port of 4 to 6 cm was made in the midportion of the right inframammary groove, usually in the fourth intercostal space. A camera port was also made in the same space at the level of the anterior axillary line. After systemic heparinization, the femoral vessels are cannulated by means of the Seldinger technique. Transesophageal echocardiography was used to precisely introduce and position the venous cannula (21F to 25F) into the right atrium at the junction with the inferior vena cava. Similarly the femoral arterial cannula (21F to 23F) was introduced. The endoaortic-balloon clamp (Johnson & Johnson Corp, New Brunswick, NJ) was positioned from the groin in the ascending aorta just above the sinotubular junction. Endocardiopulmonary bypass was established with the aid of kinetic-assisted venous drainage. On opening the pericardium, both cavae were circled in anticipation of patch repair of the interatrial septum. On achieving cardioplegic asystolic arrest using the endoaortic-balloon clamp technique and venting of the left atrium, a patent foramen ovale was closed first in 3 patients. Sixty-three percent of tumors were solid. Tumors larger than 5 cm were extracted using an endobag (Fig 1). Operative details are given in Table 3. The mean endocardiopulmonary bypass and endoaortic-balloon clamp times were 112.2 ± 41.5 minutes and 68.8 ± 30.8 minutes, respectively. There were no intraoperative complications or conversions to sternotomy.
Assessment of Complete Resection
Complete resection of tumor was confirmed by direct vision and intraoperative TEE in all patients before ending endocardiopulmonary bypass. Transesophageal echocardiography also evaluated any structural valvular or atrial septal defects causing significant regurgitation or left to right shunt. On postoperative day 5 all patients underwent TTE. Postoperative histologic evaluation also confirmed completeness of resection. The margins of each excised tumor were examined and found free of disease with special attention to the patients who had localized resection with direct closure of the defect. We did not perfrom any frozen-section examinations.
Immediate Postoperative Course
All patients were managed postoperatively in the intensive care unit. Immediate postoperative course is given in Table 4. One patient required re-exploration through the same working port for excessive bleeding from the intercostal artery, which was controlled easily. Six hours postoperatively 1 patient required stenting for myocardial ischemia not resolving on medication. His preoperative coronary angiogram had shown 40% narrowing in the mid left anterior descending artery. These 2 patients made a complete recovery.
Late Postoperative Events
Early and 30-day mortality was zero. Ninety-two percent of patients were in sinus rhythm. Two patients required amiodarone to treat atrial fibrillation. One reverted to sinus rhythm, and the other was discharged while taking anticoagulants for controlled atrial fibrillation. Sixty-six percent of patients were started on prophylactic anticoagulation, 1 for mechanical mitral prosthesis, 2 for mitral repair with pericardial patch, 1 for bioprosthetic tricuspid valve replacement, and the rest for pericardial patch closure of the resected tumor defect. Transthoracic echocardiography before discharge revealed preserved left ventricular function and no evidence of residual tumor or left to right shunt. There were no wound complications. The total length of hospital stay was between 4 and 17 days with a mean of 7.3 ± 3.4 days. One patient who presented with evolving embolic stroke was transferred postoperatively to a stroke rehabilitation center.
Tumor Histology
Eighty-five percent of resected tumors were atrial myxomas. Others were lipoma (n = 1), intravenous leiomyoma involving the inferior vena cava and the tricuspid valve (n = 1), plexiform tumor of the right ventricle on the sinoatrial node (n = 1), and papillary fibroelastoma of the noncoronary cusp of the aortic valve (n = 1). Histopathologic examination confirmed completeness of tumor resection in all patients with the specimen edges clear of tumor.
Follow-Up
Follow-up was complete in all patients. Mean follow-up was 3.4 ± 2.7 years. All patients were in sinus rhythm. Symptomatic New York Heart Association class distribution was 71.4% and 29.6% in class I and II, respectively. On TTE there was no evidence of recurrence of tumor. One patient had a small left to right shunt without hemodynamic compromise. No patients had significant valvular dysfunction.
Two patients required late interventions. One patient receiving anticoagulants underwent thoracoscopic pericardial fenestration for pericardial collection caused by elevated international normalized ratio 15 days after discharge. At 3 months 1 patient was reoperated on by means of sternotomy at a different center for suspicious recurrence of tumor. Histopathologic examination proved this to be a thrombus over the pericardial patch used for interatrial defect closure. This patient was not taking anticoagulants because of previous gastrointestinal bleeding complications. The patient who was transferred postoperatively to a stroke rehabilitation center died on the 100th postoperative day. Actuarial postoperative survival was 100% at 30 days and 96.3% at 1 year (Fig 2).
Twenty-three of 27 (85%) patients were extremely happy with cosmesis. Eighteen patients (66%) had no discomfort. Forty percent of patients were back to work within 8 weeks.
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Comment
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Regardless of whether a cardiac tumor is benign or malignant, it is important to resect it because of the possibility of embolization or valvular obstruction and to establish accurate histologic diagnosis. The surgical approach for resection of cardiac tumor has to be chosen according to its benefits and drawbacks. Centofanti and colleagues [4] believe that complete resection is best performed through a median sternotomy, under extracorporeal circulation and cardiac arrest. Jones and associates [5] propose resection using a biatrial approach. This assures minimal manipulation of the tumor, provides good exposure for complete resection, and allows inspection of all four cardiac chambers to minimize recurrence. Others consider that the left atriotomy approach is adequate and have demonstrated low recurrence rates and safety of this technique [6]. Minimally invasive approaches are being applied with increasing frequency in all areas of cardiac surgery, and cardiac tumors are no exception. These have included right parasternal or partial sternotomy, and right submammary incision with femoral bypass and cardioplegic arrest or unclamped ventricular fibrillation [7].
As a reference center for endoscopic cardiac surgery since 1997, mitral and tricuspid valve repairs and replacements, atrial septal defect closures, and cardiac tumor resections have been performed with very low morbidity and mortality [2, 3]. We call this technique endoscopic because the resection of cardiac tumors was performed through a keyhole working port in the fourth intercostal space, avoiding rib spreading. Video-assistance and shafted instruments facilitate surgery through a soft-tissue retractor and provide excellent vision. Accurate positioning of arterial and venous cannulas and catheters guided by TEE are essential to this technique. Systemic benefits of endoscopic surgery include surgical actions limited to the thorax owing to a small opening, less blood loss, and no local cooling or possible aspiration of fluids, fat, and bone. We believe that with the advent of intraoperative TEE, visual inspection of all four cardiac chambers is unnecessary. The endoscopic approach reduces manipulation of the heart, preventing tumor dislodgment and embolism. Second, it highlights the appearance, exact size, attachment, and local spread of the tumor, and thus the precise extent of resection can be planned (Fig 3).
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Fig 3. (A) Small myxoma (M) over the anterior mitral leaflet (AML). (B) Myxoma being excised. (C) Defect repaired with pericardial patch (PP).
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Because preoperative histologic diagnosis is difficult to establish, resection should include the base or root of the pedicle and the full thickness of the adjacent interatrial septum or endocardium [8]. We performed full-thickness resection with direct closure of the defect in 45% of patients. These tumors had small pedicles arising either from the free wall of the atria, interatrial septum, pulmonary veins, or sinoatrial node. Pericardial patch repair was used in 55% of patients. These tumors were large with a broad base over the interatrial septum or atrial free wall. Some caused structural damage to a heart valve, requiring valve repair by annuloplasty or replacement with a prosthetic valve. We removed papillary fibroelastoma attached to the noncoronary cusp of the aortic valve through a left atrial incision and repaired the mitral valve with extension of the pericardial patch to the anterior leaflet. In one case of a large intravenous leiomyoma, the tricuspid valve was replaced owing to structural destruction.
Cardiac tumors have an incidence between 0.17% and 0.19%, and the majority are benign [9]. There were no malignant tumors in our series. Most tumors were myxomas (85%), and 55% were arising in the left atrium. There were no tumors arising from the ventricles. Similar to other series we found a higher incidence in women [10]. The clinical features of cardiac tumors may mimic mitral or tricuspid valve stenosis [11]. Only 25% of our patients were symptomatic with dyspnea (New York Heart Association class II), and the rest had mild constitutional symptoms. Most patients are in normal sinus rhythm; in contrast to the findings in mitral valve disease, atrial fibrillation is uncommon. Only 14% (4 of 27 patients) in this series presented with atrial arrhythmias. Nonmyxoma benign tumors may cause symptoms because of proximity to excitable structures in the endocardium. The youngest patient in our series, who was 16 years old, presented with refractory supraventricular tachycardias. He had a plexiform tumor of the right ventricle over the sinoatrial node. Peripheral and central tumor embolism occurs in 30% to 40% [12]. We had an unusually low rate (14%) of embolism. One such patient presented with cerebral stroke and required emergency surgery.
Mugge and coworkers [13] showed comparable detection rates between TTE and TEE, with TTE accuracy approaching 100%. We used TTE for preoperative evaluation and postoperative follow-up. The short-term and long-term prognosis of benign cardiac tumors is excellent. Operative mortality is 0% to 3% [14]. In our series we had 0% in hospital mortality. One patient with preoperative stroke in evolution died on the 100th postoperative day. The overall risk of recurrence is approximately 12% and 22% for familial and complex myxomas, respectively, whereas it is only 1% to 3% for sporadic tumors. Semiannual echocardiography follow-up examinations are indicated in all cases [5]. Our follow-up of 9 years based on clinical visits and echocardiography has revealed no recurrence. Young age, family history, and multifocality are factors known to predispose to recurrence, which were absent in our patient cohort. Analysis of outpatient clinic and telephone questionnaires produced 92% overall patient satisfaction. More than 40% of patients returned to work within less than 4 weeks.
In conclusion, endoscopic resection of cardiac tumors is safe, achieves complete tumor resection, and fulfills the main goals of minimally invasive cardiac surgery: comfort, cosmesis, and a fast track to complete rehabilitation.
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References
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- Casselman FP, Van Slycke S, Wellens F, et al. Mitral valve surgery can now routinely be performed endoscopically Circulation 2003;108(Suppl 1):II-48-II-54.[Medline]
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Abstract
Introduction
) -free survival (n = 27).