Asian Cardiovasc Thorac Ann 1998;6:316-317
© 1998 Asia Publishing EXchange Pte Ltd
Minimally Invasive Excision of Left Atrial Appendage Hemangioma via Hemisternotomy
Robert Tam Kien Wing, FRACS,
Christopher Smith, FRACS,
Guy Wright-Smith, MBBS,
Aubrey A Almeida, MBBS,
Malcolm Davidson, FRACP
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Department of Cardiac Surgery The Prince Charles Hospital Brisbane, Australia
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For reprint information contact: Robert Tam Kien Wing, FRACS Department of Cardiac Surgery The Prince Charles Hospital Rode Road Chermside, Brisbane 4032, Australia Tel: 61 7 3350 8904 Fax: 61 7 3350 8426
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ABSTRACT
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We describe a minimally invasive excision of left atrial appendage hemangioma. This was performed via a hemisternotomy under cardiopulmonary bypass and cardioplegic arrest. The surgical excision was complete and the patient made a normal postoperative recovery.
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INTRODUCTION
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Traditionally, cardiac surgery has been performed with a complete sternotomy. In an effort to minimize the trauma inherent to this practice, current surgical techniques employing limited incisions are evolving. The upper hemisternotomy provides safe performance of a variety of cardiac surgical procedures and it has numerous advantages over the more traditional approach.1–3
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CASE REPORT
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A 40-year-old female presented with an episode of right arm weakness. Carotid duplex and a computed tomography head scan were normal. A chest radiograph showed left hilar lesion confirmed by a computed tomography scan of the chest. Transesophageal echocardiography revealed an extracardiac solid tumor within the pericardium adjacent to the left atrial appendage. There was no pericardial effusion (Figure 1
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Figure 1. Transesophageal echocardiogram demonstrating the mass attached to the left atrial appendage (LAA). Also identified are left ventricle (LV), left atrium (LA), and mitral valve (MV).
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The patient had video-assisted thoracoscopy and an exploratory left anterior minithoracotomy. A solid tumor with a broad base was noted to arise from the left atrial appendage. There was no local invasion. The origin of the tumor made local excision unsafe without cardiopulmonary bypass. A hemisternotomy was performed from the sternal notch to the 4th costal cartilage without horizontally transecting the distal end. The ascending aorta was exposed from the innominate vein to the right atrial appendage. Cardiopulmonary bypass was established by aortic and right atrial cannulation. Crystalloid cardioplegia was infused through the aortic root. The tumor was mobile and it was excised with a 3-mm margin (Figure 2). The left atrial appendage was repaired with running 5/0 polypropylene suture, taking care not to occlude the left pulmonary veins and the circumflex coronary artery. The heart was de-aired through the aortic root vent and the untied suture of the left atrial appendage repair. Cardiopulmonary bypass was discontinued and the sternum was closed with 3 wires. A single chest drain was inserted through the right 5th intercostal space. The patient was extubated 2 hours postoperatively and made an unremarkable recovery (Figure 3). The histology showed benign hemangioma.
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Figure 2. Operative photograph demonstrating the resected tumor (T), aortic cannula (A), and right atrial cannula (V).
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Figure 3. Postoperative photograph demonstrating sutured incisions, hemisternotomy (A), and minithoracotomy (B).
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DISCUSSION
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Primary cardiac tumors are rare. Myxomas are the most common, usually arising from the atrial septum and growing into the cardiac cavity causing symptoms. Malignant cardiac tumors usually have local invasion by the time of diagnosis and carry a poor prognosis. Hemangiomas arising from the left atrial appendage are extremely rare.4
There is current enthusiasm for minimally invasive cardiac surgery with a variety of incisions evolving in an attempt to reduce surgical trauma. We described the use of an upper hemisternotomy to successfully excise a left atrial appendage hemangioma. As in our aortic valve and mitral surgery, we have found the exposure excellent without transecting ("T-ing") the distal end of the hemisternotomy.
There are several advantages in the minimally invasive approach. There is less surgical trauma and postoperative blood loss is reduced. The sternum is stable and without risk of complete sternal wound dehiscence. The risk of right ventricular injury is reduced should the patient require future cardiac surgery. The small incision (Figure 3
) with less wound morbidity, is more acceptable to the patients. This also has the potential benefits of shorter intensive care and hospital stay. With further refinement of equipment, minimally invasive surgery will have applications in more complex cardiac procedures.
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REFERENCES
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Tam RKW, Garlick RB, Almeida AA. Minimally invasive redo aortic valve replacement J Thorac Cardiovasc Surg
1997;114:682–3.[Free Full Text]
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Tam RKW, Ho C, Almeida AA. Minimally invasive mitral valve surgery J Thorac Cardiovasc Surg
1998;115:246–7.[Free Full Text]
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Tam RKW, Almeida AA. Minimally invasive aortic valve replacement via partial sternotomy Ann Thorac Surg
1998;65:275–6.[Abstract/Free Full Text]
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Brizard C, Latremouille C, Jebara VA, Acar C, Fabiani JN, Deloche A, et al. Cardiac hemangiomas Ann Thorac Surg
1993;56:390–4.[Abstract]
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ABSTRACT
INTRODUCTION
