EJCTS Click here for details of sales representative
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Yu-Sheng Chang
Pyng Jing Lin
Jaw-Ji Chu
Hui-Ping Liu
Feng-Chun Tsai
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Chang, Y.-S.
Right arrow Articles by Yang, M.-W.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Chang, Y.-S.
Right arrow Articles by Yang, M.-W.

Eur J Cardiothorac Surg 1998;14:S160-S165
© 1998 Elsevier Science NL

Video-assisted cardiac surgery for intracardiac tumors 1

Yu-Sheng Chang, Chau-Hsiung Chang, Pyng Jing Lin*, Jaw-Ji Chu, Hui-Ping Liu, Hung-Chang Hsieh, Feng-Chun Tsai, Min-Wen Yang

Division of Thoracic and Cardiovascular Surgery, Department of Anesthesiology, Chang Gung Memorial Hospital, Chang Gung University, 199, Tun-Hwa North Road, Taipei, Taiwan

* Corresponding author. Tel.: +886 3 328 1200; fax.: +886 3 328 5818.


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 
Objective: To present our experience in surgical excision of intracardiac tumors in three patients using video-assisted cardiac surgical techniques. Methods: Three patients received emergency video-assisted cardiac surgery for excision of right atrial or left atrial tumors. These surgeries were performed through right anterior submammary minithoracotomies and guided by video-assisted endoscopic techniques by projected images on a video monitor while under femoro–femoral cardiopulmonary bypass. The myocardium was protected by continuous coronary perfusion with fibrillatory arrest. Conventional instruments were used. Results: All but one of the tumors were excised completely. The bypass time was 88–148 min. The operation time was 3.5–4.4 h. There were no operative deaths. Pathological examination of the tumors showed left atrial myxoma, metastatic left atrial choriocarcinoma, and right atrial lymphoma. One patient died from non-cardiac origin 5 weeks after discharge. Follow-up was completed with the two survivors. Transthoracic echocardiographic examination showed good ventricular function without any residual tumors. They were both in New York Heart Association functional class I or II. They were satisfied with the cosmetic healing of their incisions. Conclusion: Video-assisted cardiac surgery is technically feasible and can be performed in surgical excision of intracardiac tumors.

Key Words: Video-assisted cardiac surgery • Myxoma • Cardiac


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 References
 
Excision of intracardiac tumors is traditionally carried out with a median sternotomy, cardiopulmonary bypass, and cardioplegic arrest of the heart [7]. However, the unpleasant cosmetic results and possible complications of median sternotomy are occasionally troublesome [6].

The concept of video-assisted cardiac surgery has been introduced recently into the milieu of cardiac surgery [3, 4, 10, 14, 22]. These surgeries have been performed through minithoracotomies with the guidance of a video-assisted endoscope. The minimally invasive nature of these surgeries can potentially lessen incisional pain, minimize incisional length, enhance functional recovery, and shorten hospital stays. In this review, we present our preliminary results with the use of video-assisted cardiac surgical techniques for three patients with intracardiac tumors operated on at the Chang Gung Memorial Hospital.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 References
 
2.1 Patients
From October 1995 to November 1996, three patients (one man and two women) received emergency video-assisted cardiac surgery at the Chang Gung Memorial Hospital, for excision of right atrial (one patient) or left atrial (two patients) tumors (Table 1 ). Their ages ranged from 25 to 80 years. The presenting symptoms were cardiac asthma in patient 1, multiple cerebral hemorrhage with deep coma in patient 2, and ascites and legs edema in patient 3. The diagnoses were established by transthoracic echocardiographic examination. Cardiac catheterization was not performed. Emergency surgery was arranged after the diagnosis was confirmed. All the patients or their family members were informed that a median sternotomy might be necessary and all signed an operative consent form.


View this table:
[in this window]
[in a new window]
  		Table 1. Patient information
 
2.2 Operative techniques
Under general anesthesia with single lumen endotracheal intubation, the patients were put in a left semidecubitus position. Transesophageal echocardiographic monitoring was set up. A right anterior submammary minithoracotomy (4–6 cm in length) through the fourth intercostal space was made without excision of the ribs (Fig. 1 ). A small rib spreader was used in these incisions to facilitate instrumentation. A 10-mm, zero degree endoscope (Stryker Endoscopy, San Jose, CA) was inserted through the manipulation incision or through a separate thoracostomy incision (1–2 cm in length) (Fig. 1). The intracardiac lesions were approached with the endoscope using projected images on the video monitor after the heart was arrested.


Figure 1
View larger version (130K):
[in this window]
[in a new window]
  		Fig. 1. Pictures of an 80-year-old woman (patient 1) taken 1 week after surgery. The arrow head indicates the thoracostomy created in the fourth intercostal space in the anterior axillary line for introduction of the endoscope. The arrow indicates the submammary incision (6 cm).

 
Cardiopulmonary bypass was established through a groin incision (3–4 cm in length) with cannulation of the femoral artery with an aortic cannula (THI aortic perfusion cannula, Argyle, Division, Sherwood Medical, St. Louis, MO) and the femoral vein with a chest tube (Thoracic catheter, Mallinckrodt Laboratories, Athlone, Ireland). The venous cannula was inserted up to the level of the retrohepatic inferior vena cava while the inferior vena cava was snared at the junction with the right atrium. A membranous oxygenator was used. Systemic hypothermia began immediately after the start of extracorporeal circulation with a rectal temperature of 26–36°C (28.1±1.8°C). Cannulation of the superior vena cava through the right atrium was performed in patients 1 and 3. In patients 1 and 2, the aorta was not crossclamped and the heart was protected with continuous coronary perfusion with fibrillatory arrest, without the infusion of cardioplegic solution. Topical cooling of the heart was not performed. In patient 3, the rectal temperature was maintained at 36°C throughout the operation and the heart was kept beating.

In patient 1, with the left atrial myxoma, the endoscope was inserted into the left atrium via a small incision in the right superior pulmonary vein to define the margin of the tumor pedicle on the interatrial septum. The interatrial septum was then incised from the right atrial side with a 1-cm margin along the pedicle of the myxoma (Fig. 2 ). The myxoma (2x3x6 cm) was removed through the right atrium with the full thickness of the interatrial septum (Fig. 3 ). The right ventricle, left atrium, and left ventricle were inspected for any residual tumor using the endoscope. The interatrial defect was then closed directly with a running suture.


Figure 2
View larger version (95K):
[in this window]
[in a new window]
  		Fig. 2. In patient 1, the interatrial septum was incised from the right atrial side with a 1 cm margin along the pedicle of the myxoma. The myxoma was removed through the right atrium with full thickness of the interatrial septum. The arrow head indicates the interatrial septum attached to the pedicle of the myxoma. The arrow indicates part of the myxoma.

 

Figure 3
View larger version (85K):
[in this window]
[in a new window]
  		Fig. 3. The exercised myxoma (2x3x6 cm).

 
In patient 2, with the left atrial metastatic tumor, a 4-cm stab incision was made posterior to the interatrial groove and the left atrium was entered. The endoscope was advanced to enter the left atrium. A 1x1x2-cm tumor located on the posterior wall of the left atrium was removed smoothly using a ringed forceps.

In patient 3, with right atrial and ventricular tumors, a 4-cm stab incision was made on the right atrium which was then entered. The endoscope was advanced to enter the right atrium. The tumors located in the right atrium and right ventricle were removed, as much as possible, piece by piece with a tumor forceps. The left atrium was not explored.

After removal of the tumors, the endoscope was advanced into the all four cardiac chambers in patient 1, into the left atrium and ventricles in patient 2, and right atrium and ventricle in patient 3 for any residual or dislodged tumors. The interatrial septum, left atriotomy, or right atriotomy was closed with running 4-0 prolene sutures (Ethicon, UK).

After completing the intracardiac procedures in patient 1 and 2, first the left ventricle and then the left atrium were filled with blood. The patients were kept in a head-down position. The air in the left atrium was then carefully evacuated by rotating the operating table in all directions before complete closure of the interatrial septum or the left atriotomy while inflating the lungs. There was no obvious air bubble noted on transesophageal echocardiographic examination. A venting needle could be inserted into the right superior pulmonary vein, the highest position of the heart after rotating the operating table, to evacuate the residual air, if any.

Cardioversion, in patients 1 and 2, was easily performed by putting the cardioverter (CodeMaster Hewlett–Packard, McMinnville, OR) pediatric pads on the surface of heart through the manipulation incision.

Cardiopulmonary bypass was terminated after rewarming of the patients. Temporary epicardial pacemaker wires were not set up. Hemostasis and closure of the incisions were easily achieved. The femoral arteriotomy and venotomy were carefully repaired with interrupted non-absorbable sutures.

Conventional non-disposable instruments were used in these surgeries for incision, dissection, grasping, suturing, and hemostasis. We did not use any expensive disposable endoscopic instrument in these surgeries.


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 References
 
All the tumors were excised completely except for those in patient 3. The duration of cardiopulmonary bypass was 88–148 min. The operation time was 3.5–4.4 h. Cardiotonic drugs and intra-aortic balloon pumping were not used. Patients 1 and 3 regained consciousness in the early postoperative period and their endotracheal tubes were removed on the first postoperative day. There were no operative deaths. Pathological examination of the tumors showed left atrial myxoma in patient 1, metastatic left atrial choriocarcinoma in patient 2, and right atrial lymphoma in patient 3. There was no tumor detected in the uterus of patient 2 by ultrasonographic examination. Patient 3 received chemotherapy and radiotherapy. None of the patients experienced wound or lower limb vascular complications. The postoperative length of stay was 9, 6, and 12 days, respectively.

Patient 2 was discharged in deep coma status and died from non-cardiac origin 5 weeks later with stable hemodynamics. Follow-up (14.2 and 6.1 months) was completed with the two survivors. Transthoracic echocardiographic examination showed good ventricular function without any residual or recurrent tumors. They were found to be in New York Heart Association functional class I or II. They were satisfied with the good cosmetic healing of their incision. (Fig. 1).


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
References
 
The rapid recovery from surgery of these critically ill patients indicates that video-assisted cardiac surgery can offer a good chance of survival for persons with intracardiac tumors.

Traditionally, standard cardiac surgery for the excision of an intracardiac tumor has required a long and probably painful median sternotomy incision. The results are generally excellent, however, the unpleasant cosmetic effect and possible complications of median sternotomy are occasionally troublesome [6]. From the experience of laparoscopic and thoracoscopic surgeries, video-assisted endoscopic techniques can be applied to replace the classical standard procedures without compromising the treatment [15]. Video-assisted thoracic surgery offers the promise of expediency, safety, minimal discomfort, less postoperative pain, quick functional recuperation, excellent cosmetic healing, shortened hospital stays, and, therefore, savings in cost [8, 15]. In this preliminary experience, there were no operative deaths, no wound or lower limb vascular complications, and no added neurological deficits. The incision length as well as the postoperative length of stay was short, and the patients were satisfied with the cosmetic healing. These results indicate that video-assisted cardiac surgery is a technically feasible and probably safe procedure with an expectation of the above mentioned benefits of video-assisted endoscopic surgeries.

In cardiac surgery, cardiopulmonary bypass can be performed through cannulation of the femoral artery and vein with favorable reliable results [6, 9]. In video-assisted cardiac surgery, numerous experiences demonstrate that simple femoro–femoral bypass can provide satisfactory perfusion of all vital organs, including the brain [3, 4, 10–14, 22]. In this series, there were no vascular complications noted in the lower limbs during the follow-up period. The small groin incision was cosmetically acceptable by our patients. The bypass time, 88–148 min, was longer than other series approached through median sternotomy [2, 17]. However, with more experience, the bypass time may be significantly shortened.

Infusion of a cardioplegic solution is the standard procedure for providing myocardial protection. However, continuous perfusion of the heart without cross-clamping the ascending aorta, can offer adequate myocardial protection [1, 3, 4, 10–14, 22]. In this series, using video-assisted cardiac surgery with continuous coronary perfusion, there was no low cardiac output postoperatively. Cardiotonic drugs and intraaortic balloon pumping were not used. This indicated that adequate myocardial protection was achieved. However, larger series are required to determine the role of and its limitation of fibrillatory arrest in video-assisted cardiac surgery.

De-airing is an important procedure in cardiac surgery, especially in video-assisted cardiac surgeries in which the aorta is not crossclamped. Using the de-airing procedures described in this report or previous reports, the air in the cardiac chambers could be effectively evacuated [3, 4, 10–14, 22]. Before the heart resumed beating, transesophageal echocardiographic examination was performed to detect any residual air [5, 21]. A venting needle could be inserted into the right superior pulmonary vein, the highest position of the heart after rotating the operating table, to evacuate the residual air, if any. All our patients, except patient 2 who had preoperative cerebral embolization and hemorrhage, woke from the anesthesia promptly after arriving at the intensive care unit. There was no evidence of neurological defect postoperatively, indicating adequate de-airing.

Myxoma is the most common benign tumor of the heart. The results of surgical excision are excellent with low morbidity and mortality rates [2, 17]. To avoid recurrence, the surgical margin of the excision must include a wide base of atrial septum. The biatrial transseptal approach through a right atriotomy has been employed with good results [2, 17]. Approach through both atria using video-assisted cardiac surgical techniques, as was done in one of our patients, can (1) define the margin of the tumor pedicle on the interatrial septum, (2) provide adequate margins of excision on the interatrial septum, and (3) explore all the heart chambers to detect any simultaneous myxoma or debris of the tumors (Table 2 ).


View this table:
[in this window]
[in a new window]
  		Table 2. Surgical information
 
Choriocarcinoma is a common trophoblastic tumor. An important characteristic of this tumor is that its primary manifestation can be from its metastases, the most common being pulmonary, vaginal, pelvic or cerebral. Cerebral metastases occur in 10–20% of patients and are the leading cause of death in those who die from this disease. There are few reports of choriocarcinoma presenting as intracavitary masses in the left atrium [18, 20]. The results of these cases were not satisfactory. The goals of cardiac surgery are to relieve symptoms, enhance the quality of life, and secure a histological diagnosis. In patient 2, the goals of surgery were prevention of further embolization and establishment of the histological diagnosis of the left atrial tumor.

Primary cardiac lymphomas are extremely rare tumors. The majority of these cases are diagnosed post-mortem and with an increasing frequency are seen in immuno-compromised individuals [16, 19]. The role of surgery is yet to be determined. However, establishment of the diagnosis and relief of the obstructive symptoms were indicated for our patient 3. Chemotherapy and radiotherapy were performed postoperatively with good results.

The major advantage of video-assisted cardiac surgery is excellent illumination, good magnification, and visualization of the intracardiac structures without the need for a wide incision, such as median sternotomy. Exploration of cardiac chambers, after removal of the main tumor, for any simultaneous, residual, or dislodged tumors could be easily accomplished by the video-assisted endoscope. The minimally invasive nature of this procedure might reduce the incidence of postoperative mediastinitis and keep wound pain to a minimum. None of our patients experienced wound infection or mediastinitis. The patients were satisfied with the minithoracotomy incision. The postoperative length of stay (mean 9 days), including postoperative chemoradiotherapy for patient 3, seemed short in these critically ill patients. These outcomes demonstrated that video-assisted cardiac surgery for excision of intracardiac tumors is technically feasible and might offer quick functional recovery and good cosmetic healing.


   Footnotes
 
1 Presented at the World Congress on Minimally Invasive Cardiac Surgery, under the auspices of the European Association of Cardiothoracic Surgery, Paris, May 30–31, 1997. Back


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 

  1. Akins CW. Non-cardioplegic myocardial preservation for coronary revascularization. J Thorac Cardiovasc Surg 1984;88:174-181.[Abstract]
  2. Bortolotti U, Maraglino G, Rubino M, Santini F, Mazzucco A, Milano A, Fasoli G, Livi U, Thiene G, Gallucci V. Surgical excision of intracardiac myxomas: a 20-year follow-up. Ann Thorac Surg 1990;49:449-453.[Abstract]
  3. Carpentier A, Loulmet D, Carpentier A, Le Bret E, Haugades B, Dassier P, Guibourt P. First open heart operation (mitral valvuloplasty) under videosurgery through a minithoracotomy. CR Acad Sci Paris 1996;319:219-223.
  4. Chang CH, Lin PJ, Chu JJ, Liu HP, Tsai FC, Lin FC, Chiang CW, Su WC, Yang MW, Tan PPC. Video-assisted cardiac surgery in closure of atrial septal defect. Ann Thorac Surg 1996;62:697-701.[Abstract/Free Full Text]
  5. Furuya H, Suzuki T, Okumura F, Klshi Y, Uefuji T. Detection of air embolism by transesophageal echocardiography. Anesthesiology 1983;58:124-129.[Medline]
  6. Kirklin JW, Barratt-Boyes BG. Cardiac Surgery, second ed. Churchill Livingstone Inc. New York, pp 61–127..
  7. Kirklin JW, Barratt-Boyes BG. Cardiac Surgery, second ed. New York: Churchill Livingstone, 1993:129–165..
  8. Lewis RJ, Caccavale RJ, Sisler GE. Special report: videoendoscopic thoracic surgery. New Engl J Med 1991;88:473-475.
  9. Lin PJ, Chang CH, Tan PPC, Wang CC, Chang JP, Liu DW, Chu JJ, Tsai KT, Kao CL, Hsieh MJ. Protection of the brain by retrograde cerebral perfusion during circulatory arrest. J Thorac Cardiovasc Surg 1994;108:969-974.[Abstract/Free Full Text]
  10. Lin PJ, Chang CH, Chu JJ, Liu HP, Tsai FC, Chu PH, Chiang CW, Yang MW, Shyr MH, Tan PPC. Video-assisted mitral valve surgeries. Ann Thorac Surg 1996;61:1781-1787.[Abstract/Free Full Text]
  11. Lin PJ, Chang CH, Chu JJ, Liu HP, Hsieh HC, Tsai FC, Lin, FC, Chiang CW, Su WJ, Yang MW, Tan PPC. Video-assisted cardiac surgery: preliminary experience in one center. Circulation 1996;94(8)(Suppl):I–174..
  12. Lin PJ, Chang CH, Chu JJ, Chang JP, Tsai KT, Liu HP, Hsieh HC, Tsai FC, Hsieh MJ. Surgical closure of atrial septal defect: Video-assisted cardiac surgery or median sternotomy? Chest 1996;110(4)(Suppl):207S..
  13. Lin PJ, Chang CH, Chu JJ, Liu HP, Tsai FC, Lin FC, Chiang CW, Yang MW, Tan PPC. Video-Assisted coronary artery bypass grafting during hypothermic fibrillatory arrest. Ann Thorac Surg 1997;63:1113-1117.[Abstract/Free Full Text]
  14. Lin PJ, Chang CH, Chu JJ, Liu HP, Tsai FC, Su WC, Yang MW, Tan PPC. Minimally invasive cardiac surgical techniques in the closure of ventricular septal defect: an alternative approach. Ann Thorac Surg 1998;65:165–170..
  15. Liu HP, Chang CH, Lin PJ, Hsieh HC, Chang JP, Hsieh MJ. Video-assisted thoracic surgery – the Chang Gung experience. J Thorac Cardiovasc Surg 1994;108:834-840.[Abstract/Free Full Text]
  16. Margolion DA, Fabian V, Mintz U, Botham M. Primary cardiac lymphoma. Ann Thorac Surg 1996;61:1000-1001.[Abstract/Free Full Text]
  17. Miralles A, Bracamonte L, Soncul H, Diaz del Castillo R, Akhtar R, Bors V, Pavie A, Gandjbackhch I, Cabrol C. Cardiac tumors: clinical experience and surgical results in 74 patients. Ann Thorac Surg 1991;52:886-895.[Abstract]
  18. Ravi Kishore AG, Desai N, Nayak G. Choriocarcinoma presenting as intracavitary tumor in the left atrium. Int J Cardiol 1992;35:405-407.[Medline]
  19. Roller MB, Manoharan A, Lvoff R. Primary cardiac lymphoma. Acta Haematol 1991;85:47-48.[Medline]
  20. Seigle JM, Caputy AJ, Manz HJ, Wheeler C, Fox JL. Multiple oncotic intracranial aneurysms and cardiac metastasis from choriocarcinoma: case report and review of the literature. Neurosurgery 1987;20:39-42.[Medline]
  21. Spotnitz HM, Malm JR. Two-dimensional ultrasound and cardiac operations. J Thorac Cardiovasc Surg 1982;83:43-51.[Abstract]
  22. Tsai FC, Lin PJ, Chang CH, Liu HP, Tan PPC, Lin FC, Chiang CW. Video-assisted cardiac surgery: preliminary experience in reoperative mitral valve surgery. Chest 1996;110:1603-1607.[Abstract/Free Full Text]




This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Yu-Sheng Chang
Pyng Jing Lin
Jaw-Ji Chu
Hui-Ping Liu
Feng-Chun Tsai
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Chang, Y.-S.
Right arrow Articles by Yang, M.-W.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Chang, Y.-S.
Right arrow Articles by Yang, M.-W.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS