Asian Cardiovasc Thorac Ann 1998;6:313-315
© 1998 Asia Publishing EXchange Pte Ltd
Minimally Invasive Approach for Left Atrial Myxoma
Edwin Ravikumar, MCh,
Rajiv Kumar, MCh,
Raju Babu Birudugadda, MCh,
Sara Thomas, MD1,
Sunil Thomas Chandy, DM2
Department of Thoracic & Cardiovascular Surgery
1 Department of Anaesthesiology
2 Department of Cardiology Christian Medical College & Hospital Vellore, India
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For reprint information contact: Edwin Ravikumar, MCh Department of Thoracic & Cardiovascular Surgery Christian Medical College & Hospital Vellore 632004, India Tel: 91 416 22 102 Ext. 2029 Fax: 91 416 32 035 Email: root{at}ceu.cmc.ernet.in
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ABSTRACT
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A 32-year-old female with left atrial myxoma who was in New York Heart Association functional class IV, underwent a minimally invasive excision of the tumor through a right parasternal approach. Early follow-up demonstrated that this technique was effective and had the benefits of low cost, rapid recovery, decreased hospital stay, and a good cosmetic result.
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INTRODUCTION
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The major breakthrough of minimally invasive surgery for a variety of cardiac operations is a direct result of technology and techniques that provide all the advantages of standard cardiopulmonary bypass and cardioplegic arrest in open-heart surgery. The experience we gained by using the minimally invasive techniques of Cosgrove and colleagues1,2 for replacement of mitral and aortic valves prompted us to employ this approach for excision of a left atrial myxoma through a right parasternal incision.
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CASE REPORT
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A 32-year-old female was admitted to Christian Medical College Hospital in Vellore with a history of breathless-ness on exertion and pedal edema of 2 years duration. She was in New York Heart Association functional class IV and had no other complaints pertaining to the cardiovascular or other systems. She had been taking digoxin and furosemide regularly for 6 months prior to admission. The patient was of moderate build and nutritional status. She was anemic and there was no cyanosis or clubbing. All the peripheral pulses were normal. Systemic blood pressure was 110/70 mm Hg but jugular venous pressure was elevated. There was a tapping apex beat in the 5th left intercostal space on the anterior axillary line and left parasternal heave. The first heart sound was loud and an accentuated component of the second heart sound was heard. A tumor plop was noted at the apex. A pansystolic murmur, loudest in the 4th intercostal space in the parasternal region, was also heard. Respiratory system examination revealed bilateral basal crepitations. Her hemogram showed a hemoglobin level of 97 g·L–1 and an erythrocyte sedimentation rate of 65 mm per hour. A chest radiograph showed cardiothoracic ratio of 60% with biatrial enlargement and pulmonary congestion.
Her electrocardiogram revealed normal sinus rhythm with biatrial enlargement and right ventricular hypertrophy. Two-dimensional echocardiography indicated a 6 x 4 cm myxoma attached to the base of the interatrial septum close to the anterolateral commissure of the mitral annulus.
The operative procedure entailed administration of general anesthesia with endotracheal intubation in the supine position. The right side of the chest was elevated 30 degrees. The chest was prepared and draped to enable sternotomy should this become necessary. An 8-cm incision was made, extending from the inferior border of the right 2nd costal cartilage to the superior edge of the 5th costal cartilage, 3 cm lateral to the sternum as described by Cosgrove and colleagues.1,2 The right common femoral artery and vein were exposed through a right groin incision and after systemic heparinization, they were cannulated using a 15 F (18-cm) and 23 F (50-cm) straight-tipped Bio-Medicus cannulae (Medtronic, Inc., Grand Rapids, MI, USA) respectively. The superior vena cava was cannulated separately using a Bard 26 F wire-reinforced cannula. The superior vena cava was taped and total cardiopulmonary bypass was instituted by snagging the superior vena cava and then clamping the inferior vena cava at the cavo-atrial junction using a DeBakey right-angled clamp. The patient was cooled to 28°C. The aorta was cross-clamped with a DeBakey right-angled clamp and antegrade cardioplegia administered.
A right atriotomy was performed 2 cm from, and parallel to, the Waterston groove. The right atrial cavity was exposed by taking stay sutures to the atrial wall. The tumor, measuring 6 x 4 cm, was excised with a 1.5-cm cuff of full-thickness interatrial septum (Figures 1 and 2
). The mitral valve was examined and found to be competent but the tricuspid valve was incompetent due to annular dilatation. The defect in the atrial septum was closed with a Dacron double-velour fabric patch using running 4/0 Proline suture (Ethicon Ltd, Edinburgh, Scotland, UK) and concomitant DeVega's tricuspid annuloplasty was performed using 2/0 Ethibond suture (Ethicon Ltd, Edinburgh, Scotland, UK). The patient was weaned off cardiopulmonary bypass and the femoral vessels were decannulated and repaired.
The patient was electively ventilated for 8 hours. The postoperative course was uneventful and she was discharged from the hospital on the 7th postoperative day. Follow-up after 3 months showed the patient to be in New York Heart Association functional class I. Two-dimensional echocardiography revealed no intracardiac mass and normal mitral and tricuspid leaflets.
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DISCUSSION
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The minimally invasive approach for various surgical procedures has gained momentum and its development stems from experience gained from thoracoscopic surgery, particularly aortic and mitral valve replacements through the right parasternal approach and minimally invasive coronary artery bypass surgery.1–5 The anesthetic technique chosen reflects a goal of rapid tracheal extubation with provision of amnesia and postoperative analgesia. This requires titration of intravenous anesthetics and increased use of inhalation techniques compared to traditional opioid-based anesthesia. Initially, air-way management consisted of insertion of a double-lumen endobronchial tube for one-lung ventilation to facilitate surgical exposure.6 However, as surgical experience has increased, the use of a double-lumen endobronchial tube has decreased. We have always used an endotracheal tube only.
The right parasternal approach simplifies the technique and after the initial learning curve, the surgeon becomes adept at achieving good surgical exposure and access to the right atrium, left atrium, and aortic root. We found that the right parasternal approach provided adequate exposure in this case. The advantages of this technique include a smaller incision without compromising the efficacy of the operation, reduced hospital stay, and a good cosmetic result.
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Acknowledgments
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We would like to thank Charles Sathyaseelan and Seethapathy for their assistance in photography. The word processing of the manuscript has been ably conducted by Jayaprakash Chandrasekaran.
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[Abstract]
[Full Text]
[PDF]
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ABSTRACT
INTRODUCTION
