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Ann Thorac Surg 1995;59:851-856
© 1995 The Society of Thoracic Surgeons

Biatrial Approach to Cardiac Myxomas: A 30-Year Clinical Experience

David R. Jones, MD, Herbert E. Warden, MD, Gordon F. Murray, MD, Ronald C. Hill, MD, Geoffrey M. Graeber, MD, Jose L. Cruzzavala, MD, Robert A. Gustafson, MD, Alexander Vasilakis, MD

Department of Surgery, West Virginia University, Morgantown, West Virginia


   Abstract
Top
 Footnotes
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Early surgical intervention for atrial myxomas mitigates morbidity and usually offers cure. The operative approach to resect these tumors is controversial. The purpose of this study was to review our experience with the biatrial approach between 1964 and 1994. The location of the myxoma was left atrium in 17 and right atrium in 3. Mean preoperative New York Heart Association functional classification was 2.7. Surgical approach to the tumor was biatrial in all patients. There were no perioperative strokes, myocardial infarctions, or deaths. Mean follow-up was 7.5 years (range, 2 mo to 27 years) with a postoperative New York Heart Association functional classification of 1.4. One late death occurred, which was unrelated to the myoxma. Advantages of biatrial approach include (1) definition of tumor pedicle by direct visualization, (2) minimal manipulation of the tumor, (3) adequate margins of excision, (4) inspection of all heart chambers, and (5) secure closure of the atrial septal defect. Long-term follow-up demonstrates the efficacy of this operative approach to atrial myxomas.


   Introduction
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 Abstract
 Introduction
Material and Methods
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 Comment
 References
 
See also page 855.

The first successful resection of a left atrial myxoma using cardiopulmonary bypass was performed in 1954 by Clarence Craaford [1]. With the advent of echocardiography more of these tumors have been diagnosed and resected even in asymptomatic patients. As experience with atrial myxomas has been obtained, several surgical principles have evolved. In an effort to achieve a safe, efficacious operation that adheres to these principles several operative approaches have been described [2–4]. The approach to atrial myxomas include an isolated left or right atriotomy, right atriotomy with transseptal incision, and biatrial approach.

The operative approach used to resect these tumors should provide excellent exposure and safe excision. The purpose of this study was to review one institution's experience with the biatrial approach to cardiac myxomas over a 30-year period.


   Material and Methods
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 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
Study Population
Between 1964 and 1994 there were 20 patients (13 female, 7 male) who underwent resection of an atrial myxoma using cardiopulmonary bypass at West Virginia University Hospitals. The average patient age was 55 years (range, 18 to 76 years). The tumor was located in the left atrium in 17 patients and in the right atrium in 3 patients.

All patients had symptoms related to their myxoma with a mean duration of symptoms of 12.5 months. The most common symptoms included dyspnea on exertion (61%), generalized malaise (55%), palpitations (33%), syncope (22%), chest pain (17%), and transient ischemic attacks (17%). These symptoms are similar to those in other series [5–9]. Physical examination revealed a murmur in 72% of patients and a pathognomonic ``tumor plop'' in 30% of these patients. One patient with a right atrial myxoma had peripheral edema. Preoperative New York Heart Association functional class assessment was class I, 2; II, 7; III, 7; and IV, 4 [10].

One patient suffered from the complex cardiac myxoma syndrome, which is characterized by cardiac myxomas, lentiginosis, and occasionally pituitary or testicular tumors [5]. This patient had two myxoma recurrences in the right atrium, 2 and 9 years after the initial successful removal of a right atrial myxoma. Both of these recurrences did not involve the interatrial septum and were approached via a right atriotomy. They are not reported in this series. One patient had an associated secundum atrial septal defect and has been reported previously [11].

Laboratory analysis revealed a low-grade leukocytosis in 24% of patients. An increased sedimentation rate and gamma globulinopathy were identified in 19% of patients. Anemia was present in 17% of patients, and no patient had thrombocytopenia.

The diagnosis of atrial myxoma was made by echocardiography in 95% of patients (Fig 1Go). Cardiac catheterization was performed in 95% of patients and revealed mild to severe pulmonary artery hypertension in 52% of patients. Electrocardiographic findings included nonspecific ST-T wave changes and occasional premature atrial complexes. All patients were in normal sinus rhythm except 1 who had a right bundle-branch block. Documentation of an atrial myxoma prompted early operative intervention in each patient. The average time to operation, after diagnosis, was 72 hours (range, 2 hours to 11 days).



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  		Fig 1. . A representative transthoracic echocardiogram showing a large left atrial myxoma prolapsing through the mitral valve. This tumor arose from the base of the right inferior pulmonary vein.

 
Surgical Technique
Exposure of the heart and great vessels was provided by a median sternotomy (17) or right thoracotomy (3). Bicaval cannulation was used for left atrial tumors with care being taken to minimize manipulation of the heart to avoid tumor embolization. Cardiopulmonary bypass was instituted with moderate hypothermia and topical saline-slush cooling. Hyperkalemic crystalloid or blood cardioplegia was delivered concomitantly depending on the surgeon's preference.

A left atriotomy was made posterior to the interatrial groove (Fig 2Go). This incision was usually 3 to 5 cm and was not used to mobilize the tumor. The diagnosis and location of the myxoma were confirmed.



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  		Fig 2. . The biatrial incisions are shown here. The left atrial incision (inferior dotted line) is only large enough to identify the site of origin of the tumor. The right atriotomy (superior dotted line) is larger to excise the septum and myxoma and to remove tumor.

 
A right atriotomy was performed and the right atrium and ventricle were explored for the possibility of tumor extension from the left atrium or for a second myxoma. A right-angle clamp or the operator's finger was introduced under direct visualization through the small left atriotomy and provided a reference point that allowed right atrial excision of the tumor with an adequate rim of interatrial septum (Fig 3Go).



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  		Fig 3. . A right-angle clamp introduced through the left atriotomy provides a reference point for the surgeon to begin excision of tumor and interatrial septum.

 
A full-thickness excision of a portion of the interatrial septum was performed and the tumor removed through the right atriotomy (Fig 4Go). Myxomas not attached to the septum underwent a subendocardial or full wall thickness resection with pericardial patch closure of the defect. The left heart chambers were carefully inspected for tumor fragments or other myxomas. The mitral valve was inspected for valvular damage or annular dilatation secondary to the myxoma.



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  		Fig 4. . The myxoma is resected en bloc through the right atriotomy with an adequate rim of interatrial tissue.

 
The surgically created atrial septal defect was closed primarily or with a pericardial patch (Fig 5Go). The left and right atriotomies were closed and the left ventricle vented before the discontinuation of bypass. Although of theorectical concern only, all shed cardiac blood and irrigant were discarded to avoid return of any myxoma cells to the circulation.



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  		Fig 5. . The atrial septal defect is closed either primarily or with a pericardial patch. Notice the orifice of a pulmonary vein visualized through the atrial septal defect.

 
If the tumor was located in the right atrium, the inferior vena cava usually was cannulated via the transfemoral route and the superior vena cava cannulated directly. An oblique right atriotomy was performed. The left atrium subsequently was opened, the tumor and surrounding septum were excised, all heart chambers explored, and the atriotomies closed.

Follow-up
Patients were followed up between 1964 and 1994 with a range of 0.2 years to 27 years (mean follow-up, 7.5 years). Routine echocardiography was not part of the follow-up. Cumulative duration of follow-up was 152 patient-years, and no patient was lost to follow-up. Survival data were obtained through clinic visits or via telephone from April to May 1994.


   Results
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 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
Surgical Findings
A biatrial approach was employed for resection of all tumors. Seventeen myxomas (85%) were located in the left atrium. Fifteen were attached to the interatrial septum, one to the posterior wall, and one at the base of the right inferior pulmonary vein. Three right atrial myxomas (15%) all were attached to the interatrial septum.

Procedures associated with resection of the myxoma included coronary artery bypass grafting (2), mitral valve repair (2), and closure of a secundum atrial septal defect (1).

Pathologic examination of all tumors showed the average dimension to be 4.3 x 3.3 x 2.6 cm. Fifty percent of the tumors were friable or myxoid and gelatinous. The majority were sessile-based or had a broad stalk or base of attachment. These required wide interatrial septum excision and placement of a pericardial patch. All excisional margins showed no evidence of tumor.

Early Results
There were no perioperative deaths. There was one significant atrial dysrhythmia that required cardioversion. Two patients required reoperation within 24 hours of the primary procedure. In the first, who had a right atrial myxoma resection, a coagulopathy developed necessitating reoperation for bleeding. The second patient was transferred to our institution with a postintubation tracheal laceration and a clinical picture of congestive heart failure. Repair of the tracheal laceration was performed initially. Postoperatively, the cause of the congestive heart failure was found to be secondary to a large, prolapsing left atrial myxoma. After resection of the myxoma, a coagulopathy developed with clinical signs of cardiac tamponade, which necessitated reoperation.

Postoperative cardiac rhythm at the time of hospital discharge was normal sinus in 95% of patients. One patient had a first-degree atrioventricular block, and the patient with repair of the secundum atrial septal defect had a right bundle-branch block.

Late Results
There was one death in the late follow-up period. This patient had a fatal myocardial infarction 2 years after the successful resection of a right atrial myxoma. Preoperative cardiac catheterization had failed to demonstrate significant coronary atherosclerotic disease.

Postoperative New York Heart Association functional classification was determined within 6 months of their operation. All patients were in functional class I or II with an average of 1.4.


   Comment
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
Atrial myxomas are uncommon but with early surgical treatment morbidity is mitigated and cure is usually possible. The surgical approach to atrial myxomas should (1) allow minimal manipulation of the tumor, (2) provide adequate exposure for complete resection of the tumor, (3) allow inspection of all four heart chambers, (4) minimize recurrence, and (5) be safe and efficacious. There is still considerable controversy, however, concerning the most appropriate surgical approach to achieve the above surgical principles. This point is emphasized by reviewing the largest series of operative approaches to left atrial myxomas, including this one, reported within the past six years (Table 1Go). The frequency of the various operative approaches are biatrial, 38%; left atriotomy, 34%; and transseptal, 28%. Clearly, the optimal operative approach to the atrial myxoma lacks uniformity.


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  		Table 1. . Operative Approaches to Left Atrial Myxomas
 
Advocates of the left atriotomy approach [4, 12, 13] consider the exposure to be adequate and have demonstrated low recurrence rates and safety of this technique. Interestingly, 34% to 85% of patients had a subendocardial, not full-thickness, resection of the interatrially based tumor [4, 12]. This approach prevents inspection of all four cardiac chambers. In addition, a left atriotomy alone requires excessive minipulation of tumor and, depending on the size of the tumor, may prevent adequate excisional margins to be obtained [8]. It is for these reasons that an isolated left atriotomy fails to meet required surgical principles of atrial myxoma resection.

The transseptal approach to atrial myxomas is a technique in which the interatrial septum is incised vertically through a right atriotomy. The line of incision in the septum and resection of the tumor may be guided by intraoperative transesophageal echocardiography [14]. Proposed advantages of this technique include only one atrial incision, adequate exposure to evaluate the mitral valve, low recurrence rates, and long-term efficaciousness [5, 14]. Kabbani and colleagues [8] have criticized this approach as being inadequate to identify the site of tumor attachment and for thorough inspection of all cardiac chambers. Alternatively, Chitwood [15] has used transesophageal echocardiography successfully to identify tumor attachment and to inspect cardiac chambers. Removal of large myxomas with this approach may be difficult and may necessitate bisection of the tumor to remove it safely [15]. This degree of tumor manipulation seems unnecessary and potentially dangerous. In addition, Sellke and associates [5] reported a 12% incidence of microscopically positive tumor margins using the transseptal approach. Finally, 15% to 40% of the left atrial tumors are not attached to the interatrial septum [3, 5, 6] and a transseptal approach, even with modification [16], may provide difficult exposure to these tumors.

The biatrial approach to atrial myxomas, popularized by Cooley in 1973 and reported by others [7, 8, 11], involves two incisions. The initial left atriotomy should be only large enough to confirm the diagnosis of myxoma, to identify the tumor pedicle in the case of left atrial myxomas, and to assess the friability and size of the tumor. We do not attempt to mobilize the tumor through this incision, only to localize it under direct visualization. The right atrial incision allows inspection of the right atrium and ventricle for coexistent myxomas. The biatrial incisions then facilitate resection of the myxoma with optimal margins of excision. Finally, the left cardiac chambers can be inspected adequately for mitral valve abnormalities, other tumors, and tumor fragments.

This study supports the biatrial approach to atrial myxomas. Exposure of the myxoma was excellent in all cases. Adequate excisional margins of the tumor were confirmed histologically. There were no significant intraoperative difficulties using this approach even when other procedures were performed. As supported by others [8, 15], we found no significant mitral valve abnormalities that required mitral valve replacement. All cases of mitral incompetence were managed with either commissural sutures or ring annuloplasty.

Perhaps one of the most compelling reasons to employ a biatrial approach is provided by evaluation of the pathologic specimens. The average size of the myxomas was 4.3 x 3.3 x 2.6 cm, which is not insignificant. In addition, the majority of myxomas were friable and sessile, or pedunculated with a broad base. Evaluation of our pathologic data is supported by Burke and Virmani [6], who reported the Armed Forces Institute of Pathology experience with cardiac myxomas. He found 70% of tumors were sessile or had a broad base. In addition, 60% of the tumors were friable or irregularly surfaced, and these were responsible for 94% of embolic symptoms. The difficulty in managing large myxomas, incomplete inspection of all chambers for tumor emboli, and inadequate surgical excisional margins have been criticisms of either the left atrial or transseptal approach or both. The biatrial approach allowed adequate exposure to remove these lesions en bloc, thus avoiding tumor embolization and potential seeding of tumor cells.

Recurrence of cardiac myxomas is 4% to 5% in most larger series [5, 8, 12]. We had one recurrence (5% incidence) in a patient who had a right atrial myxoma and also had the complex myxoma syndrome. This patient's pathologic margins of excision were negative for tumor and most likely this recurrence was secondary to an implant from the first operation.

The biatrial approach has been criticized for being responsible for a high incidence of arrhythmias and conduction disturbances after resection of left atrial myxomas [3, 17]. We had only one significant dysrhythmia and one conduction disturbance postoperatively. This is contrasted with a 12% incidence of complete heart block and a 46% incidence of new onset atrial fibrillation or flutter in the immediate postoperative period as reported by Sellke and associates [5] using the transseptal technique. We have found the biatrial approach affords superb exposure and allows avoidance of the conduction system.

A second criticism of the biatrial approach has been the extra incision, which potentially may be associated with increased bleeding postoperatively. We had no bleeding from either atrial incision suture line, and both reoperations for bleeding were secondary to a coagulopathy as previously discussed.

Long-term follow-up of these 20 patients demonstrates the safety and efficacy of the biatrial approach to atrial myxomas. The postoperative New York Heart Association functional class was class I or II in all patients. There was one death, unrelated to the myxoma, in this series. These long-term findings of the efficacy of the biatrial approach have been supported by others [7, 8].

In conclusion, this study supports the clinical efficacy, safety, and long-term success of the biatrial approach to atrial myxomas. The biatrial approach adheres to all of the identified surgical principles for the successful removal of these tumors.


   Footnotes
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 Footnotes
Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 
Presented at the Forty-first Annual Meeting of the Southern Thoracic Surgical Association, Marcos Island, FL, Nov 10--12, 1994.

Address reprint requests to Dr Jones, Department of Surgery, West Virginia University, PO Box 9238, HSCN, Rm 4066B, Morgantown, WV 26506-9238.


   References
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

  1. Craaford C. Discussion on mitral stenosis and mitral insufficiency. In: Lam CR, ed. Proceedings of the International Symposium on Cardiovascular Surgery. Philadelphia: Saunders, 1955:202--11.
  2. Kabbani SS, Cooley DA. Atrial myxoma. Surgical considerations. J Thorac Cardiovasc Surg 1973;65:731–7.[Medline]
  3. Bortolotti U, Maraglino G, Rubino M, et al. Surgical excision of intracardiac myxoma: a 20-year follow-up. Ann Thorac Surg 1990;49:449–53.[Abstract]
  4. Meyns B, Vanclemmput J, Flameng W, Daenen W. Surgery for cardiac myxoma. A 20-year experience with long-term follow-up. Eur J Cardiothorac Surg 1993;7:437–40.[Abstract]
  5. Sellke FW, Lemmer JH Jr, Vandenberg BF, Ehrenhaft JL. Surgical treatment of cardiac myxomas: long-term results. Ann Thorac Surg 1990;50:557–61.[Abstract]
  6. Burke AP, Virmani R. Cardiac myxoma. A clinicopathologic study. Am J Clin Pathol 1993;100:671–80.[Medline]
  7. Castells E, Ferrans V, Octavio De Toledo MC, et al. Cardiac myxomas: surgical treatment, long-term results, and recurrence. J Cardiovasc Surg 1993;34:49–53.[Medline]
  8. Kabbani SS, Jokhader M, Meada R, et al. Atrial myxoma: report of 24 operations using the biatrial approach. Ann Thorac Surg 1994;58:483–8.[Abstract]
  9. St. John Sutton MG, Mercier LA, Giuliani ER, Lie JT. Atrial myxomas. A review of clinical experience in 40 patients. Mayo Clin Proc 1980;55:371–6.[Medline]
  10. Goldman L, Hashimoto B, Cook EI, Los Calzo A. Comparative reproducibility and validity of systems for assessing cardiovascular functional class: advantages of a new specific activity scale. Circulation 1981;64:1227–34.[Abstract/Free Full Text]
  11. Jones DR, Hill RC, Abbott AE Jr, Gustafson RA, Murray GF. Unusual location of an atrial myxoma complicated by a secundum atrial septal defect. Ann Thorac Surg 1993;55:1252–3.[Abstract]
  12. Actis Dato GM, de Benedictis M, Actis Dato A Jr, Ricci A, Sommariva L, de Paulis R. Long-term follow-up of cardiac myxomas (7--31 years). J Cardiovasc Surg 1993;34:141–3.[Medline]
  13. Larsson S, Lepore V, Kennergren C. Atrial myxomas: results of 25 years' experience and review of the literature. Surgery 1989;105:695–8.[Medline]
  14. Chitwood WR Jr. Cardiac neoplasms: current diagnosis, pathology, and therapy. J Cardiac Surg 1988;3:119–54.[Medline]
  15. Chitwood WR Jr. Invited commentary. Atrial myxoma: report of 24 operations using the biatrial approach. Ann Thorac Surg 1994;58:487–8.
  16. Mazzucco A, Faggian G, Bortolotti U. Simplified excision of a left atrial myxoma. Int Surg 1983;68:181–2.[Medline]
  17. Bateman TM, Gray RJ, Raymond MJ, Chaux A, Czer LSC, Matloff JM. Arrythmias and conduction disturbances following operation for the removal of left atrial myxomas. J Thorac Cardiovasc Surg 1983;86:601–7.[Abstract]

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