Introduction: While secondary cardiac tumors are more frequent, primary cardiac tumors are considered rare entities, with low prevalence. These tumors tend to affect females more frequently and are located mostly in the left atrium. Hemodynamic derangements, systemic embolization and constitutional symptoms are the common presentations and surgical treatment provides good results.

Materials & methods: Data from 30 consecutive patients with cardiac myxomas who underwent surgery in our institution over a period of 10 years (June 2010 to June 2019) was collected from patient records and analyzed retrospectively. The pre-operative patient characteristics, intra-operative and postoperative data were collected to study the presentation, symptomatology, operative approaches, complications, and outcomes in these patients.

Results: Out of the 30 cases that were included in this study all patients were evaluated pre-operatively with trans-thoracic echocardiography. Left sided masses were approached through the left atrium while right sided ones were dealt with via the right atrium. All patients had cardiac myxoma as confirmed by histopathological diagnosis. Patients were followed up for 60 months and two patients demonstrated tumor recurrence.

Conclusion: Clinical outcomes of myxoma resection are acceptable. With proper surgical technique, good resection margin and timely excision, recovery from symptoms is good and recurrence rates can be lower than 5%.

Myxoma; Heart Neoplasms; Surgery

Tewarson V, Kumar S, Hakim MZ, Kumar S, Singh SK (2020) A 10 year Surgical Experience with Cardiac Myxoma. J Cardiol Clin Res 8(1): 1152

LA: Left Atrium; RA: Right Atrium; TTE: Trans-Thoracic Echocardiography; RV: Right Ventricle; ICU: Intensive Care Unit; CPB: Cardiopulmonary Bypass; NYHA: New York Heart Association; BMI: Body Mass Index

Cardiac tumors represent a heterogeneous group, potentially involving any of the heart structures and secondary tumors (metastatic) are the most frequent, with a 20 to 40 times higher incidence than primary tumors. Primary cardiac tumors have an incidence of 0.02% in autopsy series and around seventy to seventy five percent of them being benign [1]. Of these, the cardiac myxomas are the most common primary cardiac tumor [2,3]. These tumors involve almost all age groups, with females affected 2 to 3 times more frequently than males. About 75% myxomas are said to arise in the left atrium (LA), attached to the limbus of the fossa ovalis or the mitral annulus. Twenty percent originate in the right atrium (RA), while the rest may involve the atria and ventricles simultaneously [4,5]. Cardiac myxomas can present with signs and symptoms that can be attributed to the site and size of the tumors. Thus they can cause hemodynamic compromise, features of valvular dysfunction such as dyspnea and orthopnea and constitutional symptoms such as fever and weight loss [4,6]. If systemic embolization occurs, it can lead to disastrous consequences and warrants emergency surgical resection. We conducted this retrospective study to describe and review our experience and outcomes with surgical resection of these tumors in our center.

Consecutive data from 30 patients with cardiac myxomas who underwent surgery in our institution over a period of 10 years from June 2010 to June 2019 was collected from patient records and analyzed retrospectively. Preoperative patient assessment was done with trans-thoracic echocardiography (TTE). Full informed consent was taken from all patients. All our patients were operated by the same surgical team. After routine prepping and draping, the patients were operated through standard midline sternotomy. Routine cannulation procedures and ante - grade cold blood cardioplegia with moderate hypothermia was employed in all cases.

Surgical approach for left sided masses was through the left atrium (LA), while right atrium (RA), and right ventricle (RV), tumors were removed via right atriotomy (Figure 1).

Figure 1: Intra-operative photograph of a case of Right Atrial Myxoma (white arrow).

Excision was performed in toto with inclusion of the tumor stalk with clear margins and any defect thus created was closed with an autologous pericardial patch. De-airing and weaning from bypass were done in standard manner. After insertion of epicardial pacing leads and ensuring hemostasis, sternotomy closure was done over drains. The patients were shifted un-reversed from anesthesia to the intensive care unit (ICU). Specimens were sent for histopathology analysis as well as tissue culture.

Weaning off from inotropic and ventilator supports was done according to protocols. Drains were removed appropriately. We reviewed and noted the histopathology reports and called the patients for follow up at 1, 6 and 12 months and then annually for 5 years for assessment with clinical presentation, X-ray chest and Trans thoracic echocardiography (TTE).

After retrieving data of patient clinical profile, performance, and operative details along with post-operative changes in performance and clinical parameters along with the histopathology reports, statistical analysis was done using statistical software SPSS for windows (Statistical Product and Service Solutions) Version 19.0.

A total of 30 cases were identified and included in the study (Table 1).

Table 1: Clinical Profile of Patients with Cardiac Tumours (N=30).

Majority of the patients belonged between the ages of 21 and 60 years. Around 63.34% had a fair performance status. There was near equal male and female distribution (14 vs. 16 patients respectively). Twenty percent patients were smokers while 26.67% had type II diabetes mellitus and 10% had hypertension. Chronic renal disease and hepatic dysfunction were seen in 3.33% cases each. Dyspnea was the commonest symptom on presentation (53.33%), while chest pain, palpitations, and constitutional symptoms (fever and weight loss) were seen less frequently. History of past neurological events was present in 4 (13.33 %) cases.

All myxomas were diagnosed by transthoracic echocardiography performed pre-operatively (Table 2).

Table 2: Preoperative 2D ECHO Findings.

Ejection fraction was preserved in all cases with a mean of 59.57 ± 4.92 %. Mean pulmonary artery pressure was 26.67 ± 11.84 mm Hg. Most common tumor site in 73.33% cases was the left atrium (LA), followed by right atrium (RA) in 20%. There was one case of left ventricular tumor and one case involving the right ventricle. Mean tumor dimensions were 4.95 ± 1.42 cm length and 3.34 ± 1.16cm width. While tricuspid regurgitation was commonly seen right ventricular outflow tract obstruction was present in one case and functional mitral stenosis in another.

Perioperative details including cardiopulmonary bypass (CPB), time, aortic cross clamp time and other post-operative data are illustrated in Table 3.

Table 3: Perioperative Details (N=30).

The mean cardiopulmonary bypass (CPB), time was 57.47 ± 11.96 minutes while mean aortic cross clamp time was 34.07 ± 1.25 minutes. Majority of the patients required less than 6 hours of ventilation and inotropic support. While most patients had within 200-400 milliliters (ml), of blood loss, 3 patients (10%) bled >400 ml post operatively. Packed red cell transfusion was done in nine patients out of which three patients needed more than 4 units of packed red cell transfusion. One patient (3.33%), developed acute kidney injury and two had neurological complications in this period (6.67%). Mortality occurred in 1 case (3.33%). Post-operative histopathology in all cases confirmed benign cardiac myxoma.

Patients were followed up routinely at intervals of 1, 6 and12months and then annually up to a period of 5 years. During this period, patients were presenting regularly for follow-up with significant improvement in the functional status. At the three year follow up period, two patients presented with a history of progressive dyspnea. On evaluation of clinical symptoms and echocardiography a recurrence of the tumor was found. These patients were subjected to re-excision of the tumor recurrence.

While cardiac tumors represent a heterogeneous group, potentially involving any of the heart structures and secondary tumors (metastatic) are the most frequent (with a 20 – 40 times higher incidence than primary tumors), primary cardiac tumors have an incidence of 0.02% in autopsy series and around seventy to seventy five percent of them are benign [1]. Myxomas are the most common primary cardiac tumors (50-70%), and are benign. Second in frequency are angiosarcomas (30%), which are most malignant, followed by rhabdomyosarcoma (20%) [7,8]. Myxomas frequently affect the middle age women [3,9]. In our series of cases, the mean age of patients was 35.90 ± 13.5 years at the time of surgery and 53% patients were females signifying a relatively young population with little difference between the genders.

Myxomas vary in size, but the growth rate is difficult to document because they are usually removed after diagnosis [10- 12]. High growth rates in the absence of surgical resection have been documented in patients which usually present late and have high incidence of embolic complications as was seen in our series where 13.33% patients had presented with previous history of cerebrovascular accidents.

In our study, the tumour was mostly located in the left and the right atrium with a frequency of 73.33% and 20 % respectively and this was consistent with the findings in other studies where occurrences in the left atria accounts for 65% to 90% and that in the right atria for 5 to 15 % respectively [13,14].

Regarding the surgical approach, the classical left atrial approach provides sufficient access to left sided tumors, similarly right atriotomy suffices for access to right sided tumors [15,16]. In our series, most cases of LA myxoma were operated successfully using a left atrial approach and RA masses were removed through a right atriotomy incision. The ventricular tumors were removed by access through their respective atria.

Recurrence rate after excision as shown in our study too, has been reported to be less than 5%. This has largely been attributed to seeding from tumor handling and incomplete resections [14,16]. This is considered particularly important in case of young age patients, those with a family history or multiple myxomas or with Carney complex. In all our cases we ensured a wide and complete resection margin as advocated, since it prevents increased incidence of recurrence in these cases [17- 21].

Operative mortality in excision of myxoma has been less than 5% in most studies and mortality is greater in case of ventricular location of the tumor [18,19,22]. Our study had a mortality of (3.33%), in a patient due to prolonged ventilatory complications following neurological event.

Regular follow-up in cardiac myxomas ensures that recurrence if any can be picked up early and excision can be carried out in case of recurrences [23]. All our patients were on regular follow up for 5 years. At the three year follow up period, two patients developed symptoms of progressive dyspnea and on evaluation of clinical symptoms and on echocardiography, a recurrence of the tumor was diagnosed. These patients underwent re-excision. All the rest of the patients were asymptomatic and had significantly improved clinically.

Our study confirms the feasibility of surgery and its timely applications in cases of cardiac myxomas. Besides its immediate impact of early symptomatic relief, this also prevents further complications and deterioration in functional status of patients undergoing resection of cardiac tumors. The follow-up data in our series like others show a successful recovery from surgery with little recurrence and confirms that clinical outcomes of myxoma resection are acceptable in the short and long term.

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