Excision Of Left Atrial Myxoma Research Articles

6564 A Case of Severe Hypercalcemia in Carney's Complex

Abstract Disclosure: J. Chippior: None. M. Rayan: None. L. Wright: None. L.S. Kirschner: Grant Recipient; Self; Medpace, Sparrow, Corcept Therapeutics, Corcept, Spruce, CinCor, Crinetics, Adrenas. S.W. Ing: Grant Recipient; Self; Alexion Pharmaceuticals, Inc., Amgen Inc, Radius Health, Inc, Takeda, Ultragenyx, Amolyt, Bridge Bio. Carney complex is a rare syndrome with fewer than 750 reported cases, characterized by lentigniosis, myxomas, and the occurrence of both endocrine and non-endocrine tumors. An inactivating mutation PRKAR1A, which encodes for the type 1A regulatory subunit of Protein kinase A, is responsible for over 70% of familial cases and 37% of sporadic cases. A 31-year-old female with a history of Carney complex, Cushing syndrome due to primary pigmented nodular adrenocortical disease (PPNAD), facial lentigines, spinal Schwannomas, and recent ischemic stroke secondary to embolization of a cardiac atrial myxoma, was transferred to our medical center for hyperemesis and severe hypercalcemia. Albumin-corrected serum calcium measured 15.4 mg/dL (8.6-10.5 mg/dL), ionized calcium 7.8 mg/dL (4.6-5.3 mg/dL) associated with suppressed PTH, normal PTH-related protein, and elevated bone turnover markers, C-telopeptide 4,273 pg/ml (150-635) and Procollagen Type 1 N-terminal Propeptide 222 mcg/L (19-83). Evaluation for etiology of hypercalcemia revealed elevated 1,25 dihydroxy vitamin D at 107.0 pg/ml (20-79) and elevated interleukin-6 at 11 pg/ml (<6.4). IL-6 is expressed by cardiac myxomas. Serum angiotensin-converting enzyme level was 50 U/L (16-85) and infectious workup was negative for potential granulomatous causes of elevated calcitriol (including testing for tuberculosis, histoplasma, blastomyces, bartonella, and coccidioides). CT angiogram of the abdomen and pelvis (completed in preparation of atrial myxoma resection) revealed ground-glass opacities in bilateral posterior lung fields and multiple pulmonary nodules, with the largest measuring 8 mm. After treatment with aggressive intravenous fluid resuscitation, intramuscular calcitonin, and intravenous zoledronic acid, corrected calcium normalized to 9.4 mg/dL at discharge. Urinary cortisol was 6.2 mcg per 24-hr (3.5-45), for which she started hydrocortisone 20 mg daily to treat suspected adrenal insufficiency as excess cortisol secretion in PPNAD may be episodic. Thus remission of hypercortisolism may have unmasked an underlying hypercalcemia, and adrenal insufficiency itself may have contributed to this finding. She had excision of left atrial myxoma and has continued to exhibit normal calcium levels on steroid replacement therapy. Repeat chest CT to further characterize these pulmonary findings is planned. This case illustrates a unique constellation of endocrine features associated with severe hypercalcemia in Carney complex. Presentation: 6/1/2024

6564 A Case Of Severe Hypercalcemia In Carney's Complex

Abstract Disclosure: J. Chippior: None. M. Rayan: None. L. Wright: None. L.S. Kirschner: Grant Recipient; Self; Medpace, Sparrow, Corcept Therapeutics, Corcept, Spruce, CinCor, Crinetics, Adrenas. S.W. Ing: Grant Recipient; Self; Alexion Pharmaceuticals, Inc., Amgen Inc, Radius Health, Inc, Takeda, Ultragenyx, Amolyt, Bridge Bio. Carney complex is a rare syndrome with fewer than 750 reported cases, characterized by lentigniosis, myxomas, and the occurrence of both endocrine and non-endocrine tumors. An inactivating mutation PRKAR1A, which encodes for the type 1A regulatory subunit of Protein kinase A, is responsible for over 70% of familial cases and 37% of sporadic cases. A 31-year-old female with a history of Carney complex, Cushing syndrome due to primary pigmented nodular adrenocortical disease (PPNAD), facial lentigines, spinal Schwannomas, and recent ischemic stroke secondary to embolization of a cardiac atrial myxoma, was transferred to our medical center for hyperemesis and severe hypercalcemia. Albumin-corrected serum calcium measured 15.4 mg/dL (8.6-10.5 mg/dL), ionized calcium 7.8 mg/dL (4.6-5.3 mg/dL) associated with suppressed PTH, normal PTH-related protein, and elevated bone turnover markers, C-telopeptide 4,273 pg/ml (150-635) and Procollagen Type 1 N-terminal Propeptide 222 mcg/L (19-83). Evaluation for etiology of hypercalcemia revealed elevated 1,25 dihydroxy vitamin D at 107.0 pg/ml (20-79) and elevated interleukin-6 at 11 pg/ml (<6.4). IL-6 is expressed by cardiac myxomas. Serum angiotensin-converting enzyme level was 50 U/L (16-85) and infectious workup was negative for potential granulomatous causes of elevated calcitriol (including testing for tuberculosis, histoplasma, blastomyces, bartonella, and coccidioides). CT angiogram of the abdomen and pelvis (completed in preparation of atrial myxoma resection) revealed ground-glass opacities in bilateral posterior lung fields and multiple pulmonary nodules, with the largest measuring 8 mm. After treatment with aggressive intravenous fluid resuscitation, intramuscular calcitonin, and intravenous zoledronic acid, corrected calcium normalized to 9.4 mg/dL at discharge. Urinary cortisol was 6.2 mcg per 24-hr (3.5-45), for which she started hydrocortisone 20 mg daily to treat suspected adrenal insufficiency as excess cortisol secretion in PPNAD may be episodic. Thus remission of hypercortisolism may have unmasked an underlying hypercalcemia, and adrenal insufficiency itself may have contributed to this finding. She had excision of left atrial myxoma and has continued to exhibit normal calcium levels on steroid replacement therapy. Repeat chest CT to further characterize these pulmonary findings is planned. This case illustrates a unique constellation of endocrine features associated with severe hypercalcemia in Carney complex. Presentation: 6/1/2024

Comparing Short-Term Outcomes of Right Mini-Thoracotomy and Median Sternotomy for Isolated Left Atrial Myxoma Excision

Comparing Short-Term Outcomes of Right Mini-Thoracotomy and Median Sternotomy for Isolated Left Atrial Myxoma Excision

Excision of left atrial myxoma under perfused ventricular fibrillation with hypothermia after coronary artery bypass grafting

BackgroundRedo heart surgery has become increasingly common but involves additional high surgical risk, especially redo surgery after coronary artery bypass grafting (CABG).Case presentationIn this study, we report the case of a 57-year-old Chinese male with left atrium myxoma who had previously undergone CABG. Common surgical methods usually include aortic cross-clamping, administering cold cardioplegia perfusion to protect the myocardium, opening the heart, and then removing the tumor. However, for patients with previous CABG, redo thoracotomy and ascending aortic cross-clamping present a greater risk of damage to the grafted vessels. In this study, we chose a right lateral mini-thoracotomy incision and hypothermia-induced ventricular fibrillation to minimize damage and avoid any adverse effects on the bridge vasculature. The patient recovered uneventfully and was discharged seven days after surgery.ConclusionsFor patients with previous CABG, minimally invasive right thoracotomy under perfused ventricular fibrillation with hypothermia is safe and reliable and can prevent potential damage to the ascending aorta and graft.

A Case of Intramural Hematoma in the Right Atrium after Excision of Left Atrial Myxoma

A Case of Intramural Hematoma in the Right Atrium after Excision of Left Atrial Myxoma

Robotic Aortic Valve Replacement: First 50 Cases

BackgroundExisting management challenges in selecting transcatheter vs surgical aortic valve replacement (SAVR) include bicuspid stenosis, low clinical risk, horizontal valve position, aortic insufficiency (AI), and need for concomitant procedures or mechanical valves. To address these gaps, we present our early experience with fully robotic-assisted aortic valve replacement (RAVR). MethodsBetween January 2020 and February 2021, 50 consecutive RAVR operations were performed using a 3- to 4-cm lateral mini-thoracotomy 3-port technique with transthoracic aortic clamping, similar to our robotic mitral platform. Conventional SAVR prostheses were implanted with interrupted braided sutures in all cases. ResultsThe 50 patients were a median age of 67.5 years, body mass index was 29 kg/m2, calcified bicuspid disease was present in 28 (56%), and severe AI in 8 (16%). Ejection fraction was 0.55 ± 0.08 (mean ± SD), and The Society of Thoracic Surgeons predicted risk of mortality was 1.54% ± 0.7%. Mechanical prostheses were used in 16 of 50 (32%), and 7 required concomitant procedures, including Cox maze in 3, aortic root enlargement in 2, and left atrial appendage clipping, mitral repair, and left atrial myxoma excision in 1 each. Median times (minutes) were 166 for cardiopulmonary bypass, 117 for cross-clamp, 4 for valvectomy, 20 for annular sutures, and 31 for aortotomy closure. All times plateaued after the initial 5 cases. Extubation occurred in 42 of 50 patients (84%) in the operating room, and within 4 hours in the remaining 8 (16%). There was no 30-day operative mortality or stroke. All had 30-day echocardiography demonstrating no valvular or perivalvular abnormalities. ConclusionsRAVR appears to have procedural safety and short-term outcomes to rival alternatives. Incremental experience may facilitate the safe performance of concomitant procedures as deemed necessary.

Efficacy and safety of catheter ablation in patients with new-onset atrial arrhythmia after surgical excision of left atrial myxoma

Objective: To evaluate the safety and efficacy of catheter ablation in patients with new-onset atrial arrhythmia after surgical excision of left atrial myxoma. Methods: Nine patients with new onset atrial arrhythmia and a prior history of left atrial myxoma, who received surgical myxoma excision and catheter ablation between September 2014 and November 2019, were included in the present study. Baseline characteristics, procedural parameters during catheter ablation, severe perioperative adverse events, recurrence rate of arrhythmia and clinical prognosis were analyzed. Kaplan Meier survival analysis was used to define the maintenance rate of sinus rhythm after catheter ablation in this patient cohort. Results: Nine patients were included. The average age was (55.8 ± 9.1) years old (3 male), there were 3 patients (3/9) with paroxysmal atrial fibrillation (PAF) and 6 patients (6/9) with atrial flutter or atrial tachycardia (AFL or AT). Ablation was successful in all patients, there were no perioperative complications such as stroke, pericardial effusion, cardiac tamponade, vascular complications or massive hemorrhage. During a mean follow-up time of 40.0 (27.5, 55.5) months, sinus rhythm was maintained in six patients (6/9) after the initial catheter ablation. The overall sinus rhythm maintenance rate was 2/3. In addition, 1 out of the 3 AF patients (1/3) developed recurrence of AF at 3 month after ablation, and 2 out of the 6 AFL or AT patients (2/6) developed late recurrence of AF or AFL (19 months and 29 months after ablation), two out of three patients with recurrent AFs or AFL received repeated catheter ablation and one patient remained sinus rhythm post repeat ablation. Meanwhile, there was no recurrence of atrial myxoma, no death, stroke, acute myocardial infarction and other events during the entire follow-up period. Conclusions: Catheter ablation is a safe and feasible therapeutic option for patients with new-onset atrial arrhythmia after surgical excision of left atrial myxoma.

Left Atrial Dissection and Rupture Following Excision of Left Atrial Myxoma: Role of Transesophageal Echocardiography

Left atrial mass after excision of a left atrial myxoma may occur due to residual or additional masses, such as biatrial or multicentric myxomas and inverted left atrial appendage. In this E-challenge, the authors present a case where intraoperative transesophageal echocardiography allowed visualization of a left atrial mass after excision of a left atrial myxoma. Detailed examination demonstrated that the mass was due to left atrial dissection that progressed to rupture, allowing its early detection and repair. A high index of suspicion, as well as coordination between the surgeon and the perioperative echocardiographer, played a crucial role in the detection and management of this complication.

Decompensated Aortic Stenosis in a Young Patient with Multiple Comorbidities - A Case Report

Abstract Aortic valve replacement is a safe therapy that can reverse cardiac remodeling and increase cardiac contractility, improve symptoms and quality of life. We presented a case of a 35-year-old male patient admitted to the Emergency Institute for Cardiovascular Disease and Transplantation of Târgu Mureș, Romania, due to severe aortic stenosis with severely depressed ejection fraction, left atrial myxome and a history of deep vein thrombosis and pulmonary thromboembolism. He underwent excision of the aortic valve and replacement with a mechanical prosthesis, excision of left atrial myxoma and tricuspid annuloplasty. The postoperative evolution was favourable with a significant recovery of the left ventricular systolic function and regression of cardiac symptomatology. This case was particular due to the rapid progression of the aortic pathology with the reduction of cardiac (systolic) function in a relatively short time as well as the occurrence of the thromboembolic event unrelated to the left atrial myxoma and rather associated with the background of cardiac failure with low cardiac output.

Comparison of two Approach – Right atrial Trans-septal versus Left atrial for Left atrial myxoma

Myxomas are the most common primary benign tumors of the heart and different surgical approaches are being used for Left atrial myxoma excision. Biatrial approach has been classic surgical technique for Left atrial myxoma excision . Some surgeon prefers one atrial incision. In this study two surgical approaches for left atrial myxoma was compared in 54 patient from August 2006 to may 2015,Patient were divided in to two groups according to surgical approach left atriotomy ( n=27 ) and right atrial trans- septal approach ,n= 27 ) criteria studied were pre- and post-operative functional capacity, left ventricular ejection fraction, pulmonary artery pressure, cardiac rhythm, cardiopulmonary bypass time and aortic cross clamp time,hospital stay and blood transfusion. Only Aortic cross clamp time was significantly higher in group 2, otherwise no significant difference was seen.in any other criteria between two groups.

Carney Complex with Right Ventricular Myxoma following Second Excision of Left Atrial Myxoma

We report a case of Carney complex with massive right ventricular myxoma after two-time excision of a left atrial myxoma. The patient was a 45-year-old woman with pyrexia. She temporarily lost consciousness during examination, and echocardiography and computed tomography (CT) showed a massive tumor in the right ventricle. Loss of consciousness was determined to be caused by intracardiac obstruction of blood flow due to the tumor, and corrective surgery was performed. Pathological findings indicated myxoma with no malignancy. Myxomas are benign, but there is frequent recurrence of tumors associated with Carney complex. Because her myxomas were accompanied by unusual skin pigmentation, she was diagnosed with Carney complex. Carney complex has a high rate of myxoma recurrence, and often runs in families. In all cases, it is necessary to observe the patient's course closely.

Open heart surgery in Nigeria; a work in progress

BackgroundThere has been limited success in establishing Open Heart Surgery programmes in Nigeria despite the high prevalence of structural heart disease and the large number of Nigerian patients that travel abroad for Open Heart Surgery. The challenges and constraints to the development of Open Heart Surgery in Nigeria need to be identified and overcome. The aim of this study is to review the experience with Open Heart Surgery at the Lagos State University Teaching Hospital and highlight the challenges encountered in developing this programme.MethodsThis is a retrospective study of patients that underwent Open Heart Surgery in our institution. The source of data was a prospectively maintained database. Extracted data included patient demographics, indication for surgery, euroscore, cardiopulmonary bypass time, cross clamp time, complications and patient outcome.Results51 Open Heart Surgery procedures were done between August 2004 and December 2011. There were 21 males and 30 females. Mean age was 29 ± 15.6 years. The mean euroscore was 3.8 ± 2.1. The procedures done were Mitral Valve Replacement in 15 patients (29.4%), Atrial Septal Defect Repair in 14 patients (27.5%), Ventricular Septal Defect Repair in 8 patients (15.7%), Aortic Valve Replacement in 5 patients (9.8%), excision of Left Atrial Myxoma in 2 patients (3.9%), Coronary Artery Bypass Grafting in 2 patients (3.9%), Bidirectional Glenn Shunts in 2 patients (3.9%), Tetralogy of Fallot repair in 2 patients (3.9%) and Mitral Valve Repair in 1 patient (2%). There were 9 mortalities (17.6%) in this series. Challenges encountered included the low volume of cases done, an unstable working environment, limited number of trained staff, difficulty in obtaining laboratory support, limited financial support and difficulty in moving away from the Cardiac Mission Model.ConclusionsThe Open Heart Surgery program in our institution is still being developed but the identified challenges need to be overcome if this program is to be sustained. Similar challenges will need to be overcome by other cardiac stakeholders if other OHS programs are to be developed and sustained in Nigeria.

Emergency Excision of Cardiac Myxoma and Endovascular Coiling of Intracranial Aneurysm after Cerebral Infarction

Cardiac myxoma is the most common primary tumor of the heart, located mainly in the left atrium. Cerebral embolization or intracranial aneurysm formation as a consequence of left atrial myxomas has been well documented, whereas myxoma embolization causing the combination of cerebral infarction and intracranial myxomatous aneurysm is rare. We report herein, a 67-year-old female with a cardiac myxoma who experienced a left hemispheric embolic ischemic stroke and in addition was found to have right internal carotid artery aneurysm. The patient underwent emergency surgical excision of left atrial myxoma 2 hours after the stroke onset and endovascular coiling of the aneurysm a week later. Although the timing of cardiac surgery is controversial in patients who have had recent ischemic stroke, we recommend immediate resection of cardiac myxoma, if feasible, and early endovascular treatment of associated intracranial myxomatous aneurysms.

Contrasting effect of different cardiothoracic operations on echocardiographic right ventricular long axis velocities, and implications for interpretation of post-operative values

BackgroundPatients undergoing coronary artery bypass grafting (CABG) experience a reduction in right ventricular long axis velocities post surgery. ObjectivesWe tested whether the phenomenon of right ventricular (RV) long axis velocity decline depends on the chest being opened fully by mid-line sternotomy, pericardial incision, or on the type of operation performed. MethodBy intraoperative transoesophageal echocardiography (TEE) we recorded serial right ventricular (RV) systolic pulse-wave tissue Doppler velocities during 6 types of elective procedure: 53 CABG surgery, 15 robotic-assisted minimally-invasive CABG (RCABG), 28 aortic valve replacement (AVR), 8 minimally-invasive aortic valve replacement (mini-AVR), 5 mediastinal mass excision, and 1 left atrial myxoma excision. Pre and post operative transthoracic echocardiography (TTE) were also conducted. ResultsSurgery without substantial opening of the pericardium did not significantly reduce RV systolic velocities (RCABG 13±1.8 versus 12.4±2.7cm/s post; mini-AVR 11.9±2.3 versus 11.1±2.3cm/s; mediastinal mass excision 13.9±3.1 versus 13.8±4cm/s). In contrast, within 5min of pericardial incision those whose surgery involved full opening of the pericardium had large reductions in RV velocities: 54±11% decline with CABG (11.3±1.9 to 5.1±1.6cm/s, p<0.0001), 54±5% with AVR (12.6±1.4 to 5.7±0.6cm/s, p<0.001) and 49% with left atrial myxoma excision (11.3 to 15.8cm/s). This persisted immediately after pericardial opening to the end of surgery (61±11%, p<0.0001; 58±7%, p<0.0001; 59% respectively). ConclusionsIt is full opening of the pericardium, and not cardiac surgery in general, which causes RV long axis decline following cardiac surgery. The impact is immediate (within 5min) and persistent.

Atrial myxoma presenting with orthostatic hypotension in an 84-year-old Hispanic man: a case report

IntroductionLeft atrial myxomas remain the most common benign primary cardiac tumors, and these cardiac growths can masquerade as mitral stenosis, infective endocarditis and collagen vascular disease. Atrial myxomas are found in approximately 14-20% of the population and can lead to embolization, intercardiac obstructions, conduction disturbances and lethal valve obstructions.Case presentationAn 84-year-old Hispanic man presented with complaints of dizziness upon standing, and with no prior history of heart murmurs, syncope, shortness of breath, or chest pain. Physical examination revealed evidence of orthostatic hypotension and a soft grade 1/6 systolic murmur at the left sternal border. A transthoracic echocardiogram revealed a large atrial myxoma occupying the majority of the left atrium, with the posterior border of the large atrial mass defined by eccentric mitral regurgitation identified during cardiac catheterization. Left atrial myxoma excision was performed, revealing a 7 × 6.5 × 4.5 cm atrial tumor attached to a 4 × 3 × 2 cm stalk of atrial septal tissue.ConclusionThis patient didn't present with the common symptoms associated with an atrial myxoma, which may include chest pain, dyspnea, orthopnea, peripheral embolism or syncope. Two-dimensional echocardiography provides substantial advantages in detecting intracardiac tumors. We recommend a two-dimensional echocardiogram in the workup of orthostatic hypotension of unknown etiology after the common causes such as autonomic disorders, dehydration, and vasodilative dysfunctions have been ruled out. By illustrating this correlation between orthostasis and an atrial myxoma, we hope to facilitate earlier identification of these intracardiac growths.

Study To Compare The Effect Of Supine Lying Position Along With Mobilization Over Half Lying Position Head Up 45 Degree In Patients Following Open Heart Surgery

Effect of body positioning on lung volumes and capacities have been well established over past three decades with supine lying being the least physiological and standing the most physiological position. This study with same subject cross over design aims to compare the effect of supine lying position along with mobilization over half lying position in subjects following open heart surgery in relation to heart rate, blood pressure, partial pressure of oxygen and carbon dioxide. 30 subjects who underwent open heart surgery between 15 January 2005 to 30 January 2006 were studied.12 patient out of 30 patients studied underwent mitral valve replacement,7 patients underwent coronary artery bypass grafting ,3 patients underwent aortic valve replacement ,2 patients have undergone left atrial myxoma excision ,3 patients have undergone ventricular septal closure and 1 each have undergone atrial septal defect closure,left atrial clot excision and repair of tetralogy of fallot .Significant changes were observed between HLrr with Serr (p < .005) while non significant changes were observed in other compared variables. The overall result of this study indicate that the half lying position (Hi) is equally effective as supine lying with mobilization. Thus the null hypothesis is accepted.

Less Invasive Intracardiac Surgery Performed Without Aortic Clamping

Aortic clamping and cardioplegia delivery add complexity to performing intracardiac procedures through a right minithoracotomy. Recent publications have shown excellent patient outcomes after mitral valve (MV) procedures undertaken through thoracotomy on the fibrillating heart. We reviewed our experience with this approach. From March 2000 to September 2006, 100 patients underwent MV repair (n = 42), MV annuloplasty (n = 28), MV replacement (n = 18), atrial septal defect closure (n = 10), tricuspid valve repair (n = 1), and left atrial myxoma excision (n = 1). A modified maze procedure (n = 4) or left minimally invasive direct coronary bypass grafting (MIDCABG) (n = 2) was combined in six cases. The mean age was 57 +/- 11 years (range, 22 to 89); 27 patients were in New York Heart Association (NYHA) class III or IV; 24 cases were first or second time reoperations; 20 patients had a left ventricular ejection fraction of less than 0.3. All the operations were carried out on the fibrillating heart without cross-clamping the aorta through a right minithoracotomy using peripheral cannulation. Mean fibrillation time was 73 +/- 31 minutes (range, 10 to 198 minutes). There was no conversion to sternotomy. Postoperative inotropic support was needed in 20 cases. One patient who underwent a third time reoperation died within 30 days of mesenteric ischemia (hospital mortality = 1%). Complications were the following: four reoperations for bleeding (4%); two strokes (2%). Postoperative median hospital length of stay was five days (range, 2 to 58 days). None of the patients has required MV reoperation after hospital discharge. Follow-up was complete. All survivors were in NYHA class I or II. Ventricular fibrillation simplifies less invasive intracardiac procedures and carries lower complication rates and perioperative mortality compared with conventional surgery.

Ockham's razor or Hickam's dictum: a right atrial mass following excision of left atrial myxoma

We report a case of a 54-year-old man presenting with a right atrial mass 7 months after undergoing a left atrial myxoma excision surgery. The differential diagnosis included recurrent myxoma or thrombus. The patient underwent repeat open sternotomy on cardiopulmonary bypass. Histopathological evaluation of the mass revealed an organizing thrombus. This report is, to our knowledge, the first that demonstrates right atrial thrombus shortly following excision of left atrial myxoma.

Iatrogenic Tako-Tsubo cardiomyopathy

We report a rare case of Tako-Tsubo cardiomyopathy developed after excision of left atrial myxoma and adrenaline infusion given for blood pressure augmentation in a 56-year-old lady. Although the risk for developing Tako-Tsubo cardiomyopathy associated with adrenaline use has not been established, caution is still warranted.

Robot-assisted endoscopic excision of left atrial myxomas

Recent advances in robotic instrumentation have facilitated endoscopic intracardiac procedures.1,2 We report our initial experience with endoscopic left atrial myxoma excision with the da Vinci Surgical System (Intuitive Surgical, Inc, Sunnyvale, Calif).