The Next Best Approach For Left Atrial Myxomas After Right Minithoracotomy: Video-assisted Biatrial Inversion Exposure
Joseph M. Arcidi1, Rubina A. Mirza2, Wendell H. Elliott3, Paul Samm4, Hanumanth K. Reddy2.
1Michigan Center for Heart Valve Surgery, Flint, MI, USA, 2Cardiovascular Institute of Southern Missouri, Poplar Bluff, MO, USA, 3Kneibert Clinic, Poplar Bluff, MO, USA, 4Poplar Bluff Regional Medical Center, Poplar Bluff, MO, USA.
OBJECTIVE: Right lateral thoracotomy with video assistance provides excellent exposure of the interatrial septum, the attachment site for 70% of left atrial myxomas. Most, however, are still approached from a full or abbreviated sternotomy due to tumor fragility. Alternatives to Sondergaard’s groove atriotomy, including superior septal and biatrial approaches with a right transseptal incision, have been utilized for large tumors, but we recently performed a biatrial approach with video-assisted inversion to nearly replicate right minithoracotomy exposure.
METHODS: This 69yo male presented with dyspnea during mild exertion, orthostasis, and incidental detection of a left atrial mass on contrast CT obtained for prostate cancer treatment surveillance. Echocardiography demonstrated a solitary 4.1x3.2cm mobile mass attached to the septum prolapsing across the mitral valve. Coronary angiography showed mild disease. The patient preferred sternotomy. At operation, utilizing bicaval cannulation, left atriotomy with handheld retraction exposed the mass but not its attachment. A 4cm right atriotomy paralleling the crista teminalis was performed. With handheld retraction on the lip of the left atriotomy, simultaneous pulsion with a Kittner on the interatrial septum from the right inverted the septum (image sequence) and exposed the sessile attachment, with a 10mm-30° telescope providing illumination and circumferential attachment point exposure. Septal attachment resection proceeded entirely from the left atrial aspect without tumor contact or traction on the septal margin, with part of the resection defect being full-thickness. The defect was closed with an autologous pericardium patch against the left atrial septum, confirming patch security from right septal exposure and postbypass echocardiography.
RESULTS: The patient awoke neurologically intact and was discharged home on day 8 after a course complicated only by supraventricular tachycardia.
CONCLUSIONS: Existing transsternal biatrial exposure techniques have not afforded the excellent single chamber exposure of the septal myxoma attachment as a right lateral thoracotomy. Our approach, however, using a parallel right atriotomy for targeted pulsion combined with video assistance produces septal inversion and provides visualization comparable to lateral thoractomy for surgeons transitioning from sternotomy.
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