Cardiac Myxoma Excision

Myxomas are the most common benign tumors that start in the heart. Most grow from the interatrial septum near the fossa ovalis and hang into the left atrium on a stalk; about 15 percent are in the right atrium, and they can occur in any chamber. They are soft, jelly-like and crumble easily. A myxoma can block blood flow through the mitral valve like a ball valve and cause shortness of breath, fainting or heart failure, and pieces can break off and travel to the brain or limbs. Because of this embolic risk, the tumor is removed promptly once it is found on echocardiography, whatever its size. What makes this operation different is that the tumor must come out whole and must not be squeezed or shaken before the aorta is clamped. Both venae cavae are cannulated directly (rather than through the right atrium) so cannulas do not dislodge the tumor or clutter the field, the heart is handled as little as possible, and the aorta is clamped before the heart is manipulated. The atria are usually opened together through an oblique incision that starts on the right superior pulmonary vein and crosses the right atrium (or the left atrium is opened through Sondergaard's groove), and the tumor is cut out with a 5 to 8 mm rim of normal septum or atrial wall. The hole in the septum is closed with a patch of the patient's pericardium (or bovine pericardium). Afterward the chambers are irrigated and searched for any loose fragment, and the tumor goes to pathology. Myxomas can be familial and can recur, and the surgeon inspects all the chambers. The scrub person's main jobs are gentle, complete specimen handling, accounting for every fragment, and having the pericardial patch ready.