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Residual Left Atrial Mass After Myxoma Resection
Residual Left Atrial Mass After Myxoma Resection Pritul R. Patel, MD, Gregory W. Fischer, MD, and Himani V. Bhatt, DO, MPA
A
68-YEAR-OLD WOMAN was admitted to the authors’ institution complaining of shortness of breath and chest pain. Her workup demonstrated a large (5 cm 5 cm) atrial mass by transthoracic echocardiography. She subsequently was scheduled for resection. On the day of surgery, transesophageal echocardiography confirmed the presence of this large, pedunculated left atrial mass, which originated from the interatrial septum just proximal to the orifice of the right superior pulmonary vein. Its visual appearance resembled that of a myxoma. The rest of the transesophageal echocardiography (TEE) examination was unremarkable (Fig 1 and Video 1). The atrial mass was resected completely, including a 1.5 cm 2 cm segment of the interatrial septum, consistent with the attachment site of the tumor. This defect in the interatrial septum was reconstructed with a pericardial patch. The atrium was closed and the patient successfully weaned off cardiopulmonary bypass. Immediately after cardiopulmonary bypass, repeat TEE found a small mass in the left atrium (Fig 2 and 3; Video 2 and 3). What is the diagnosis?
Fig 1. Midesophageal four-chamber view showing the large left atrial myxoma.
Fig 2. Midesophageal bicaval view showing a “residual mass” in the left atrium.
Fig 3. A three-dimensional view showing the atriotomy suture line and a residual mass.
From the Department of Anesthesiology, Division of Cardiothoracic Anesthesiology, Mount Sinai Medical Center, New York, NY. Pritul R. Patel, MD, Mount Sinai Medical Center, One Gustave L. Levy Place, KCC 8th Floor Box 1010, New York, NY 10029. E-mail: [email protected] © 2014 Elsevier Inc. All rights reserved. 1053-0770/2602-0033$36.00/0 http://dx.doi.org/10.1053/j.jvca.2014.04.025 Key words: atrial myxoma, Sondergaard's groove, interatrial groove Journal of Cardiothoracic and Vascular Anesthesia, Vol 28, No 6 (December), 2014: pp 1707–1708
1707
1708
PATEL ET AL
DIAGNOSIS: REMNANT ATRIAL TISSUE SECONDARY TO ATRIOTOMY SUTURE LINE
The TEE examination revealed a small mass originating from the wall of the left atrium in close proximity to the original myxoma insertion site (Fig 2 and 3; Video 2 and 3). Initially, the mass appeared to be residual tumor; however, further analysis utilizing the bicaval view found a small mass inferior to the original insertion site. The differential diagnosis at the time included the possibility of a second mass, which might not have been appreciated initially because of the presence of the primary atrial myxoma, or redundant tissue related to the atriotomy suture line. After discussion with the surgical team, the decision was made to reinstitute cardiopulmonary bypass and re-explore the left atrium. The original suture line was reopened, and the “residual” mass was determined to be redundant atrial tissue secondary to a remnant of the atriotomy suture line. The redundant atrial tissue was excised, the left atrium was closed, and the patient was weaned off cardiopulmonary bypass without difficulty. The repeat TEE exam showed no remaining lesion. The remaining postoperative course was uneventful. Myxomas found in the left atrium can be approached surgically either transeptally or through the interatrial plane.1 In the present case, the left atrium was opened via an incision
near the interatrial plane (Sondergaard’s groove). This technique involves dissection of the tissue between the right superior pulmonary vein and the venous sinus of the atrium. These two walls join to form the septum secundum segment of the atrial septum. This technique allows exposure of the most medial and anterior aspects of the left atrium, just adjacent to the interatrial septum. During closure of the atriotomy incision, residual tissue along the suture line remained, mimicking a mass at the end of the suture line in close proximity to the interatrial septum. There are some case reports in the literature describing reoperation secondary to a suspicious mass after an initial procedure. Sheik et al described a right atrial thrombus 3 years after atrial septal defect repair, which they attributed to the thrombogenic potential from the suture line.2 Babu and colleagues presented the formation of a myxoma in a patient who had surgery for ventricular septal defect and pulmonary stenosis. They attributed the myxoma formation to proinflammatory changes secondary to surgical trauma to the atrial wall.3 Both of these cases resulted in a reoperative sternotomy and mass excision. In contrast, cardiopulmonary bypass was reinstituted immediately and the suture line was repaired in the current case. In the current case, the patient had an adequate myxoma excision, but it was a suture line “artifact” that caused reinstitution of cardiopulmonary bypass.
REFERENCES 1. Jones DR, Warden HE, Murray GF, et al: Biatrial approach to cardiac myxomas: A 30-year clinical experience. Ann Thorac Surg 59: 851-856, 1995 2. Sheik AY, Schrepfer S, Stein W, et al: Right atrial mass after primary repair of an atrial septal defect: Thrombus masquerading as a myxoma. Ann Thorac Surg 84:1742-1744, 2007
3. Kale SB, Badkhal A, Kumar NM, et al: Right atrial mass after open heart surgery: Tumour or thrombus? Heart Lung Circ 21: 287-288, 2012
A
68-YEAR-OLD WOMAN was admitted to the authors’ institution complaining of shortness of breath and chest pain. Her workup demonstrated a large (5 cm 5 cm) atrial mass by transthoracic echocardiography. She subsequently was scheduled for resection. On the day of surgery, transesophageal echocardiography confirmed the presence of this large, pedunculated left atrial mass, which originated from the interatrial septum just proximal to the orifice of the right superior pulmonary vein. Its visual appearance resembled that of a myxoma. The rest of the transesophageal echocardiography (TEE) examination was unremarkable (Fig 1 and Video 1). The atrial mass was resected completely, including a 1.5 cm 2 cm segment of the interatrial septum, consistent with the attachment site of the tumor. This defect in the interatrial septum was reconstructed with a pericardial patch. The atrium was closed and the patient successfully weaned off cardiopulmonary bypass. Immediately after cardiopulmonary bypass, repeat TEE found a small mass in the left atrium (Fig 2 and 3; Video 2 and 3). What is the diagnosis?
Fig 1. Midesophageal four-chamber view showing the large left atrial myxoma.
Fig 2. Midesophageal bicaval view showing a “residual mass” in the left atrium.
Fig 3. A three-dimensional view showing the atriotomy suture line and a residual mass.
From the Department of Anesthesiology, Division of Cardiothoracic Anesthesiology, Mount Sinai Medical Center, New York, NY. Pritul R. Patel, MD, Mount Sinai Medical Center, One Gustave L. Levy Place, KCC 8th Floor Box 1010, New York, NY 10029. E-mail: [email protected] © 2014 Elsevier Inc. All rights reserved. 1053-0770/2602-0033$36.00/0 http://dx.doi.org/10.1053/j.jvca.2014.04.025 Key words: atrial myxoma, Sondergaard's groove, interatrial groove Journal of Cardiothoracic and Vascular Anesthesia, Vol 28, No 6 (December), 2014: pp 1707–1708
1707
1708
PATEL ET AL
DIAGNOSIS: REMNANT ATRIAL TISSUE SECONDARY TO ATRIOTOMY SUTURE LINE
The TEE examination revealed a small mass originating from the wall of the left atrium in close proximity to the original myxoma insertion site (Fig 2 and 3; Video 2 and 3). Initially, the mass appeared to be residual tumor; however, further analysis utilizing the bicaval view found a small mass inferior to the original insertion site. The differential diagnosis at the time included the possibility of a second mass, which might not have been appreciated initially because of the presence of the primary atrial myxoma, or redundant tissue related to the atriotomy suture line. After discussion with the surgical team, the decision was made to reinstitute cardiopulmonary bypass and re-explore the left atrium. The original suture line was reopened, and the “residual” mass was determined to be redundant atrial tissue secondary to a remnant of the atriotomy suture line. The redundant atrial tissue was excised, the left atrium was closed, and the patient was weaned off cardiopulmonary bypass without difficulty. The repeat TEE exam showed no remaining lesion. The remaining postoperative course was uneventful. Myxomas found in the left atrium can be approached surgically either transeptally or through the interatrial plane.1 In the present case, the left atrium was opened via an incision
near the interatrial plane (Sondergaard’s groove). This technique involves dissection of the tissue between the right superior pulmonary vein and the venous sinus of the atrium. These two walls join to form the septum secundum segment of the atrial septum. This technique allows exposure of the most medial and anterior aspects of the left atrium, just adjacent to the interatrial septum. During closure of the atriotomy incision, residual tissue along the suture line remained, mimicking a mass at the end of the suture line in close proximity to the interatrial septum. There are some case reports in the literature describing reoperation secondary to a suspicious mass after an initial procedure. Sheik et al described a right atrial thrombus 3 years after atrial septal defect repair, which they attributed to the thrombogenic potential from the suture line.2 Babu and colleagues presented the formation of a myxoma in a patient who had surgery for ventricular septal defect and pulmonary stenosis. They attributed the myxoma formation to proinflammatory changes secondary to surgical trauma to the atrial wall.3 Both of these cases resulted in a reoperative sternotomy and mass excision. In contrast, cardiopulmonary bypass was reinstituted immediately and the suture line was repaired in the current case. In the current case, the patient had an adequate myxoma excision, but it was a suture line “artifact” that caused reinstitution of cardiopulmonary bypass.
REFERENCES 1. Jones DR, Warden HE, Murray GF, et al: Biatrial approach to cardiac myxomas: A 30-year clinical experience. Ann Thorac Surg 59: 851-856, 1995 2. Sheik AY, Schrepfer S, Stein W, et al: Right atrial mass after primary repair of an atrial septal defect: Thrombus masquerading as a myxoma. Ann Thorac Surg 84:1742-1744, 2007
3. Kale SB, Badkhal A, Kumar NM, et al: Right atrial mass after open heart surgery: Tumour or thrombus? Heart Lung Circ 21: 287-288, 2012