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Asian Cardiovasc Thorac Ann 2000;8:167-168
© 2000 Asia Publishing EXchange Pte Ltd

CASE STUDY

Biatrial Approach for Bicameral Myxoma With Mitral Regurgitation

Pankaj Goel, MCh, Nainar Madhu Sankar, MS, PhD, Sethurathinam Rajan, MCh, Kotturathu Mammen Cherian, FRACS

Institute of Cardiovascular Diseases
Madras Medical Mission
Chennai, Tamil Nadu, India
For reprint information contact: Kotturathu Mammen Cherian, FRACS Tel: 91 44 625 9801 Fax: 91 44 625 9919 or 625 9920 email: mmmbits{at}giasmd01.vsnl.net.in Institute of Cardiovascular Diseases, Madras Medical Mission, 4A Dr. J Jayalalitha Nagar, Mogappair East, Chennai 600050, Tamil Nadu, India.

   Abstract
TOP
 Abstract
Introduction
 Case Report
 Discussion
 References
 
A 16-year-old girl presented with an episode of syncope. Two-dimensional echocardiography revealed masses in the left atrium and left ventricle with severe mitral regurgitation. She underwent removal of myxomas and mitral valve replacement using an extended biatrial approach.


   Introduction
TOP
 Abstract
 Introduction
Case Report
 Discussion
 References
 
Cardiac tumors are rare and myxomas are the most common benign tumors of the heart. Myxomas can occur in any of the cardiac chambers but have a predilection for the left atrium.1 Left ventricular myxomas are uncommon and represent only 2.5% to 4% of reported cases of myxoma.2 This report describes a patient with one myxoma arising from the left atrium and another from the left ventricle.


   Case Report
TOP
 Abstract
 Introduction
 Case Report
Discussion
 References
 
A 16-year-old girl, who previously had been in good health, was admitted for evaluation after a single episode of syncope. On physical examination, the positive findings were the presence of systolic plop and a grade II/VI middiastolic murmur at the apex. Electrocardiography showed normal sinus rhythm and a normal heart axis. Transthoracic echocardiography in apical 4-chamber view revealed a large pedunculated mass attached to the interatrial septum, measuring 42 x 47 mm (Figure 1Go). The posterior mitral leaflet was myxomatous with an additional mass attached to its ventricular surface. Severe mitral regurgitation was seen when the atrial mass protruded into the mitral valve with a posterolateral eccentric jet. There was grade II tricuspid regurgitation with a right ventricular systolic pressure of 100 mm Hg and moderate pulmonary arterial hypertension.



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  		Figure 1. Transthoracic 2-dimensional echocardiogram showing masses in the left atrium and left ventricle. AoV = aortic valve, LA = left atrium, LV = left ventricle, PML = posterior mitral leaflet, RV = right ventricle.

 
The patient underwent excision of the myxoma and mitral valve replacement using cardiopulmonary bypass with moderate hypothermia and antegrade cold blood cardioplegia for myocardial protection. Aortic, high superior vena caval, and inferior vena caval cannulation were used to establish cardiopulmonary bypass. The superior vena cava was transected and the left atrium was opened using the standard incision that was extended to the roof of the left atrium. This incision provided excellent exposure of the left heart structures. The right atrium was opened parallel to the atrioventricular groove. The left atrial myxoma with its stalk and part of the interatrial septum were excised. The left ventricular myxoma was found to be tethered to the posterior mitral leaflet chordae. Since it was not possible to excise the tumor completely without sacrificing the posterior mitral leaflet, the valve was excised and replaced with 27-mm St. Jude Medical valve (St. Jude Medical, Inc., St. Paul, MN, USA) using continuous polypropylene suture. The atrial septum was repaired through the right atrium using a pericardial patch. The patient made an uneventful postoperative recovery and maintained normal sinus rhythm. The postoperative transthoracic echocardiogram did not detect any residual tumor. The diagnosis of myxoma was confirmed on histopathological examination.


   Discussion
TOP
 Abstract
 Introduction
 Case Report
 Discussion
References
 
Myxomas usually occur in the left atrium and arise from the interatrial septum. Hemodynamically, left-sided myxomas may either cause obstruction of the mitral valve orifice or impair valve closure by obstruction or leaflet damage leading to regurgitation.3 This case was unusual as the mechanism of regurgitation was impairment of valve closure by the tumor and tethering of the tumor to the posterior mitral leaflet chordae, leading to chordal shortening and impaired posterior mitral leaflet movement.

The preferred treatment for myxomas is complete surgical removal with total excision of the root of the pedicle. In 1955, Crafoord4 reported the first successful excision of left atrial myxoma using temporary cardiopulmonary bypass. Although various approaches have been described to achieve adequate exposure of left atrial myxomas, the biatrial approach has become the gold standard.5,6 In this case, the presence of an additional left ventricular mass and involvement of the mitral valve called for impeccable exposure of left heart structures. It was therefore decided to use a modified extended biatrial approach. This technique includes extension of the left atriotomy to the roof of the left atrium after superior vena caval transection; the right atrium is opened by an oblique atriotomy. In 1993, Luisi and colleagues7 reported the use of the extended biatrial approach for removal of myxoma. More recently, Zeebregts and colleagues8 reported modifications of the extended biatrial approach for removal of left atrial myxomas. In both of these approaches, the superior vena cava is not transected. However, it was felt to be necessary in this patient for adequate exposure and complete removal of the ventricular myxoma. Excellent exposure was provided by the extended biatrial approach and we strongly recommend its use for excision of left atrial myxoma, especially in the presence of multiple tumors or in cases where a concomitant mitral valve procedure is contemplated.


   References
TOP
 Abstract
 Introduction
 Case Report
 Discussion
 References
 

  1. McAllister HA, Fenoglio JJ Jr. Tumors of the cardiovascular system. Atlas of tumor pathology. 2nd series. Washington: Armed Forces Institute of Pathology, 1973:111–9.

  2. Meller J, Teichholz LE, Pickard AD, Matta R, Litwak R, Herman MV, et al. Left ventricular myxoma: echocardiographic diagnosis and review of literature. Am J Med 1977;63:816–23.[Medline]

  3. Penny JL, Gregory JJ, Ayres SM, Giannelli S Jr, Rossi P. Calcified left atrial myxoma simulating mitral insufficiency: hemodynamic and phonocardiographic effects of tumor movement. Circulation 1967;36:417–21.[Abstract/Free Full Text]

  4. Crafoord C. Discussion on mitral stenosis and mitral insufficiency. In: Lam CR, editor. Proceedings of the Henry Ford Hospital International Symposium on Cardiovascular Surgery. Philadelphia: Saunders, 1955:202–11.

  5. Jones DR, Warden HE, Murray GF, Hill RC, Graeber GM, Cruzzavala JL, et al. Biatrial approach to cardiac myxomas: a 30-year clinical experience. Ann Thorac Surg 1995; 59:851–6.[Abstract/Free Full Text]

  6. Kabbani SS, Jokhadar M, Meada R, Jamil H, Abdun F, Sandouk A, et al. Atrial myxoma: report of 24 operations using the biatrial approach. Ann Thorac Surg 1994;58: 483–8.[Abstract]

  7. Luisi VS, Caparrotti S, Guiraudon GM. Extended vertical transatrial septal approach for the removal of left atrial myxoma. Ann Thorac Surg 1993;56:1216.

  8. Zeebregts CJ, Schepens MA, Knaepen PJ. Extended vertical transatrial septal approach for the removal of left atrial myxoma. Eur J Cardio-thorac Surg 1998;13:90–3.[Abstract/Free Full Text]





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