Resection Of Myxoma Research Articles

76. Cardiac myxoma, surgical experience and results of 35 cases

Cardiac myxoma, the most common primary heart tumor, is located mainly in the left atrium. Approximately 80% of primary heart tumors are benign, and 50% of these are myxomas. We review our data from January 2004 to January 2014, 35 cases of cardiac myxoma resection done in Althawra general Hospital – Cardiac center and mean follow up 60 months. Total number was 35 cases, mean age 44.2 years (age range 22–65 years ) and female predominant accounting for 21 compared to 14 male, 3 were hypertensive, 5 smokers and one with positive hepatitis B virus, 48% of our patients were O+ve blood group and 28.5% were A+ve. The presenting symptoms were shortness of breath in 48.5%, palpitation in 22.5%, strock in 17%, syncope in 8.5%, and accidental finding in 6%. Resection of the myxoma done under total CBP and worm blood cardioplegic arrest, through the right atrial approach, and the resected mass sent for histopathological examination. In all cases Histopathological examinations confirm the diagnosis of Myxoma. Operative Mortality rate were 2.8% (one patient) and we have one patient with recurrent myxoma after 2 years interval representing 2.8%. No late death recorded during the followup period. Surgical resection of cardiac myxoma is the only cure and it is safe with low recurrent rate.

Corticosteroid prophylaxis for fetal immaturity in a pregnant patient with atrial myxoma

We report a case of a woman at 32nd gestational week, admitted for resting dyspnea, showing left atrial (LA) myxoma.Cardiac myxomas are the most common primary benign tumors of the heart. The incidence of cardiac myxomas diagnosed in pregnancy is extremely low.In the present case, cesarean delivery and concomitant surgical resection of LA myxoma were both delayed after corticosteroid prophylaxis in order to reduce neonatal cerebral, intestinal, and pulmonary complications.<Learning objective: The rarity of these cases makes the management more related to anecdotal experiences. In our case, the gestational age was lower than 34th week, but the fetus was sufficiently large to be delivered before heart surgery with low risk of prematurity complications after an adequate corticosteroid prophylaxis. A waiting approach with several days of corticosteroid prophylaxis was successfully adopted. When the pregnant hemodynamics are stable with low risk of complications, heart surgery should be delayed after corticosteroid prophylaxis.>

Outcomes of multiple myxoma resections with carney complex

Introduction: Carney Complex is a rare multiple endocrine neoplasia with cardiac myxomas being the most common cause of death among affected patients. One must consider how many heart surgeries a patient may acquire before the treatment itself becomes a significant risk factor. The use of an intra-aortic filter during cardiac surgeries is recommended, and heart transplantation treatment for Carney Complex patients is proposed. Presentation of case: A 24-year-old female presented with lightheadedness and was found to have a cardiac myxoma on the left atrium. The patient underwent myxoma resections on four separate occasions. The patient underwent a fifth cardiac myxoma resection. However, three days post-operatively, the patient experienced right-sided hemiplegia and imaging showed 99% left carotid artery occlusion. The patient was deemed unqualified for neurosurgical intervention and the patient died 5 days post-operatively. Discussion: Cardiac surgery can become detrimental with multiple surgical resections. With increased number of cardiac surgeries and increased risk for morbidities postoperatively, Carney Complex patients should have an intra-aortic filter to lower the risk of stroke. Conclusions: Intra-aortic filter usage is recommended during surgical resection of cardiac tumors to capture emboli before they travel into the systemic circulation. Heart transplant may prove beneficial to Carney complex cases, however neither the optimal number of cardiac operations nor the timing of heart transplantation in the disease are documented in literature, limiting evidence for solid therapeutic guidelines.

Postoperative atrial fibrillation in patients with left atrial myxoma: cardiovascular topic

SummaryIntroductionThe aim of this study was to determine the factors associated with postoperative atrial fibrillation (AF) in patients with left atrial (LA) myxoma.MethodsThirty-six consecutive patients with LA myxoma (10 men, mean age: 49.3 ± 15.7 years), who were operated on between March 2010 and July 2012, were included in this retrospective study. Pre-operative electrocardiograms and echocardiographic examinations of each patient were reviewed.ResultsPostoperative AF developed in 10 patients, whereas there was no evidence of paroxysmal AF after resection of the LA myxoma in the remaining 26 patients. The patients who developed AF postoperatively were significantly older than those who did not develop AF (median: 61.5 vs 46 years; p = 0.009). Among the electrocardiographic parameters, only P-wave dispersion differed significantly between postoperative AF and non-AF patients (median: 57.6 vs 39.8 ms, p = 0.004). Logistic regression analysis revealed P-wave dispersion (OR: 1.11, 95% CI: 1.003–1.224, p = 0.043) and age (OR: 1.13, 95% CI: 1.001–1.278, p = 0.048) as independent predictors of postoperative AF in our cohort of patients.ConclusionsP-wave dispersion is a simple and useful parameter for the prediction of postoperative AF in patients with LA myxoma.

Cardiac Myxomas: A 50-Year Experience With Resection and Analysis of Risk Factors for Recurrence

Myxomas are the most common cardiac tumors, but there are insufficient data regarding long-term survival and recurrence rates. Our objective was to examine late results and attempt to determine a strategy for recurrence monitoring, as there are no recommended guidelines at present. We performed a retrospective analysis of 194 patients (mean age 57.2 ± 15.6 years; 62.4% female) undergoing resection of cardiac myxoma from June 1955 to June 2011. The left atrium (n= 155, 80%) was the most common location, and the mean tumor size was 4.3 ± 2.1 cm by 3.2 ± 1.6 cm by 2.1 ± 1.3 cm. Dyspnea (n= 68) and palpitations (n= 57) were the most common complaints, and 28 patients (14.4%) were asymptomatic. The tumor was exposed through the respective atria in the majority of patients (n= 187). Bypass and cross-clamp times were 59.1 ± 33.4 minutes and 35.2 ± 21.7 minutes, respectively. Two thirds of the tumors were excised with an endocardial button, and the rest were resected at the base of the stalk. Operative mortality was 0.5%. Ten, 20 and 30-year survival was 77%, 52% and 34%, respectively, which was comparable to an age-matched general population (p= 0.191). Older age at operation was the only significant predictor of subsequent mortality (p < 0.001). There was no significant difference in survival when patients were stratified by sex (p= 0.784), location of tumor (p= 0.087), the largest tumor dimension (p= 0.257) or surgical technique (endocardial button versus base of the stalk, p= 0.502). Tumors recurred in 11 patients; freedom from tumor recurrence was 92%, 91%, and 86% at 10, 20, and 30 years, respectively. Younger age at surgery (hazard ratio 0.94, p= 0.002), smaller tumor dimension (hazard ratio 0.58, p= 0.011), and tumor localized to the ventricles (hazard ratio 7.29, p= 0.013) were predictors of recurrence. Cardiac myxomas can be resected with low early mortality and excellent late survival. Tumor recurrence is more likely to occur in the first 10 postoperative years, especially in younger patients, patients with a smaller tumor mass, or tumor location in the ventricle. Patients with these findings require closer imaging surveillance in the first decade after resection.

Long-term survival after extended resection of primary atrial myxosarcoma

The vast majority of adult primary cardiac tumours (75%) are benign. The differentiation between malignant and benign lesions based on imaging is often difficult. Furthermore, it is challenging to distinguish between a cardiac myxoma and a myxosarcoma histologically. We report the case of a 48-year-old female who underwent resection of myxoma. Fourteen months postoperatively, she developed dyspnoea and evidence of local recurrence was observed. An open biopsy was performed and compared with the initially resected specimen. A primary cardiac myxosarcoma was diagnosed. Extended resection of the tumour including a part of the left atrium and the left lung was performed. Follow-up at 4 years shows no radiological evidence of any further recurrence and the patient is satisfied with a good quality of life. Despite the infrequent nature and particularly in view of the poor prognosis of cardiac myxosarcoma with a median overall survival of ∼12–17 months, we were able to demonstrate in our case that, with an extensive medical and surgical therapy and an interdisciplinary approach, a long-term disease-free survival can be achieved.

Stroke of a cardiac myxoma origin.

ObjectiveThe clinical features of cardiac myxoma stroke have not been sufficiently described. Debates remain concerning the options and timing of treatment and the clinical outcomes are unknown. This article aims to highlight the pertinent aspects of this rare condition.MethodsData source of the present study came from a comprehensive literature collection of cardiac myxoma stroke in PubMed, Google search engine and Highwire Press for the year range 2000-2014.ResultsYoung adults, female predominance, single cerebral vessel (mostly the middle cerebral artery), multiple territory involvements and solitary left atrial myxoma constituted the outstanding characteristics of this patient setting. The most common affected cerebral vessel (the middle cerebral artery) and areas (the basal ganglion, cerebellum and parietal and temporal regions) corresponded well to the common manifestations of this patient setting, such as conscious alteration, ataxia, hemiparesis and hemiplegia, aphasia and dysarthria. Initial computed tomography scan carried a higher false negative rate for the diagnosis of cerebral infarction than magnetic resonance imaging did. A delayed surgical resection of cardiac myxoma was associated with an increased risk of potential consequences in particular otherwise arterial embolism. The mortality rate of this patient population was 15.3%.ConclusionCardiac myxoma stroke is rare. Often does it affect young females. For an improved diagnostic accuracy, magnetic resonance imaging of the brain and echocardiography are imperative for young stroke patients in identifying the cerebral infarct and determining the stroke of a cardiac origin. Immediate thrombolytic therapy may completely resolve the cerebral stroke and improve the neurologic function of the patients. An early surgical resection of cardiac myxoma is recommended in patients with not large territory cerebral infarct.

出血性脳梗塞発症急性期に左房粘液腫摘出術を行った1例

症例は82歳女性．意識障害（JCS II-10），右片麻痺，失語を認め当院に救急搬送された．頭部MRI検査で左中大脳動脈領域に急性期脳梗塞を認め，発症3時間以内であったためt-PA療法を施行された．同日施行した心エコー検査で左房内に径55×23 mmの可動性のある腫瘤を認めた．緊急での腫瘤摘出も検討したが梗塞巣が左大脳半球の広範囲に及んでいたため，数日間経過観察する方針とした．発症4日目の頭部CT検査で同部位に出血性梗塞，頭部MRI検査で左大脳半球に新規梗塞巣を認めた．意識レベルや失語は改善傾向であったため，手術当日に頭部CT検査で出血巣の拡大がないことを確認し，発症5日目に腫瘤摘出術を体外循環下に施行し，術後脳合併症の併発なく退院した．左房粘液腫は心原性脳梗塞をきたすため発見早期に外科的切除を行う必要があるが，脳梗塞発症急性期には人工心肺使用による出血性梗塞の危険があるため，手術を行う時期を決定するのに難渋する．本症例では広範囲脳梗塞発症後に出血性梗塞をきたしていたものの，①神経学的所見の悪化を認めなかったこと，②発症4日目の頭部MRI検査で新たに梗塞巣を認め，致死的な梗塞を再度きたす可能性があったこと，③手術当日に再度頭部CT検査を行い，出血巣の拡大を認めなかったことから脳梗塞発症急性期の開心術に踏み切り良好な結果を得たため，文献的考察を加えて報告する．

Cardiac myxoma in pregnancy: a comprehensive review.

ObjectiveCardiac myxoma in pregnancy is rare and the clinical characteristics of this entity have been insufficiently elucidated. This article aims to describe the treatment options and the risk factors responsible for the maternal and feto-neonatal prognoses.MethodsA comprehensive search of the literature of cardiac myxoma in pregnancy was conducted and 44 articles with 51 patients were included in the present review.ResultsTransthoracic echocardiography was the most common diagnostic tool for the diagnosis of cardiac myxoma during pregnancy. Cardiac myxoma resection was performed in 95.9% (47/49); while no surgical resection was performed in 4.1% (2/49) patients (P=0.000). More patients had an isolated cardiac myxoma resection in comparison to those with a concurrent or staged additional cardiac operation [87.2% (41/47) vs. 12.8% (6/47), P=0.000]. A voluntary termination of the pregnancy was done in 7 (13.7%) cases. In the remaining 31 (60.8%) pregnant patients, cesarean section was the most common delivery mode representing 61.3% and vaginal delivery was more common accounting for 19.4%. Cardiac surgery was performed in the first, second and third trimester in 5 (13.9%), 14 (38.9%) and 17 (47.2%) patients, respectively. No patients died. In the delivery group, 20 (76.9%) neonates were event-free survivals, 4 (15.4%) were complicated and 2 (7.7%) died. Neonatal prognoses did not differ between the delivery modes, treatment options, timing of cardiac surgery and sequence of cardiac myxoma resection in relation to delivery.ConclusionThe diagnosis of cardiac myxoma in pregnancy is important. Surgical treatment of cardiac myxoma in the pregnant patients has brought about favorable maternal and feto-neonatal outcomes in the delivery group, which might be attributable to the shorter operation duration and non-emergency nature of the surgical intervention. Proper timing of cardiac surgery and improved cardiopulmonary bypass conditions may result in even better maternal and feto-neonatal survivals.

Open Heart Surgery in Dialysis-Dependent Chronic Kidney Failure Patients: Clinical Experience

Objective: We aimed to present patients with dialysis-dependent chronic kidney failure who underwent open heart surgery. Materials and Methods: Sixteen patients with dialysis-dependent end-stage chronic kidney failure (7 males, 9 females; mean age 62±11; range 30-75) were involved in the study. Coronary artery bypass surgery was performed for 12 patients, 2 patients underwent both coronary artery bypass surgery and aortic valve replacement, 1 underwent both ascending aorta and aortic valve replacement, and right atrial myxoma resection was performed for 1 patient. The preoperative, intraoperative, and postopera- tive data were analyzed retrospectively. Results: Fourteen patients underwent coronary artery bypass surgery, and the mean distal bypass was found to be 3.07±0.9. The mean cross-clamp time was 50±27 minutes, and the total cardiovascular bypass duration was 87±40 minutes. None of the patients needed revision. The mean drainage volume was 500±150 milliliters. Atrial fibrillation occurred in 4 patients (25%), and all of them converted to sinus rhythm through medical treatment. One patient died on the second postoperative day because of fatal arrhythmia that occurred after dialysis, and 1 patient died because of low cardiac output during the intensive care follow-up. The mortality rate was 12.5%. The mean intensive care unit hospitalization time was 52±4 hours, and the total hospitalization time was 7±2 days. Conclusion: Open heart surgery can be performed with acceptable mortality and morbidity rates for patients having dialysis- dependent chronic kidney failure.

Glandular cardiac myxoma: case report with literature review

Glandular cardiac myxoma is rare, representing only 5% of cardiac myxomas. A 51-year-old female developed embolic events caused by left atrial myxoma. She underwent myxoma resection and had an uneventful postoperative course. Histology of the resected myxoma revealed a glandular cardiac myxoma. In this article, the peculiar case was presented and the origin of cardiac myxoma was discussed.

Outcomes of video-assisted minimally invasive approach through right mini-thoracotomy for resection of benign cardiac masses; compared with median sternotomy.

We performed a retrospective study of patients who underwent a video-assisted minimally invasive right mini-thoracotomy approach for cardiac benign tumor resection compared with median sternotomy. Of 23 patients who underwent isolated benign cardiac mass resection at the Japanese Red Cross Nagoya Daiichi Hospital from 2001 to 2014, 16 patients were treated through median sternotomy and seven were operated through right mini-thoracotomy. No hospital deaths occurred. The duration of operation, cardiopulmonary bypass time, and aortic clamp time showed no significant differences. Although the postoperative intubation time and intensive care unit stay time did not differ significantly between the groups, the duration of hospital stay was significantly shorter in the minimally invasive group (17.5 ± 5.6 vs. 10.4 ± 1.5 days; p = 0.004). All of the patients except two were followed to the late phase (late follow-up rate, 91.3%), for a mean duration of 4.7 ± 3.7 years. There were two late deaths in the sternotomy group and no recurrences in either group during the follow-up period. We concluded that the clinical outcome of the minimally invasive technique for myxoma resection was acceptable and the technique is feasible.

Cardiac myxomas: a 27-year surgical experience

Amac: Bu calismada merkezimizde yapilan cerrahi kardiyak miksoma rezeksiyonunun sonuclari bildirildi. Ca­lis­ma­pla­ni:­Ocak 1985 Aralik 2012 tarihleri arasinda miksoma tanisiyla ameliyat edilen 99 hasta (67 kadin, 32 erkek, ort. yas 49.8±16 yil; dagilim 5-76 yil) retrospektif olarak incelendi. Ameliyat oncesi tani transtorasik ekokardiyografi ile konuldu. Son takip vizitine kadar gecen ortalama sure 123.4±85.7 ay idi. Bul gu lar: Tum hastalar median sternotomi ile ameliyat edildi. Tumorun kokeni 92 hastada sol atriyum olup, en sik yerlesim yeri 85 hastada interatriyal septumdu. Bir hasta haric tum hastalarda total rezeksiyon yapildi. Kirk bes hastaya (%45.5) papiller miksoma, 54 hastaya (%54.5) solid miksoma tanisi konuldu. Embolik olay riski papiller tip miksomalarda, solid tipe kiyasla, anlamli oranda yuksek bulundu (%44.4’e kiyasla %9.3, p<0.01). Erken mortalite %5 idi. Tek degiskenli analiz sonuclarina gore ileri yas (p=0.04), ameliyat oncesi atriyal fibrilasyon varligi (p=0.02), periferik emboli (p=0.03) ve ameliyat sonrasi inotropik destek ihtiyaci (p=0.008) erken mortalite icin risk faktorleri olarak belirlendi. Bes, 10 ve 20 yillik aktueryal sagkalim oranlari sirasi ile %98, %94 ve %89 idi. Sagkalanlarda nuks orani %1.2 olarak tespit edildi. So­nuc:­Kardiyak miksoma cerrahisi, dusuk ameliyat riski tasimakla birlikte, mukemmel kisa ve uzun donem sonuclar ile iliskilendirilir. Ancak, uzun donemde dusuk nuks riskine ragmen, hastalar yillik ekokardiyografi ile takip edilmelidir. Anah tar soz cuk ler: Kardiyak tumor; miksoma; cerrahi; sagkalim. Background:­ In this study, we reported the outcomes of surgical resection of cardiac myxomas performed in our center. Methods: A retrospective review of 99 patients (67 females, 32 males, mean age 49.8±16 years; range 5 to 76 years) who were operated for myxoma between January 1985 and December 2012 was conducted. Preoperative diagnosis was established by transthoracic echocardiography. The mean time to the last follow-up visit was 123.4±85.7 months. Results:­ All patients were operated through median sternotomy. The site of origin of the tumor was left atrium in 92 patients and the most common implantion site was interatrial septum in 85 patients. A complete resection of the tumor was performed in all patients except one. Forty five patients (45.5%) were diagnosed with a papillary myxoma, while 54 patients (54.5%) were diagnosed with a solid myxoma. The risk of embolic events in papillary type of myxoma was significantly higher than the solid type (44.4% vs. 9.3%, p<0.01). Early mortality was 5%. Univariant analysis showed advanced age (p=0.04), preoperative presence of atrial fibrillation (p=0.02), peripheral embolism (p=0.03), and need for postoperative inotropic support (p=0.008) as the risk factors for early mortality. Actuarial survival rate was 98%, 94% and 89% at five, 10 and 20 years, respectively. The rate of recurrence was 1.2% in survivors. Conclusion:­Surgical treatment of cardiac myxoma carries a low operative risk and is associated with excellent short and long-term results. However, despite low risk of recurrence in the long-term, the patients should be followed with annual echocardiography.

Cerebral Infarction due to Cardiogenic Emboli Originating from Atrial Myxoma: A Case Report

Cardiogenic embolism due to atrial myxoma is a rare cause of cerebral infarction. A 51-year-old woman presented to a hospital elsewhere with sudden onset of vision loss, loss of consciousness and subsequent circulatory collapse. Computed tomography and magnetic resonance imaging of brain revealed a rostral brainstem infarction, cerebral angiography showed evidence of occlusion of the left posterior cerebral artery, and echocardiographic examination revealed the presence of a mass in the left atrium. The patient received palliative care and was discharged. Four months later, she presented with muscle weakness in both legs and was unable to walk. Ultrasonography revealed atherosclerotic plaques in the left and right carotid arteries and multiple segmental emboli in the lower extremities. In addition, physical examination revealed bilateral blepharoptosis, poor pupillary reaction to light, deficient upward and downward eye movements and limited adduction. Anticoagulants and blood-lipid lowering drugs were administered. Auscultation of the precordium revealed systolic murmurs when the patient was in a sitting position. Echocardiographic examination and computed tomography of the chest disclosed a mass in the left atrium. The patient underwent surgical resection of the atrial mass. Histopathological examination of the resected tumor revealed a glandular cardiac myxoma. At four-month follow-up, there was some improvement in neurological symptoms. A cardiac origin of cerebral infarction should be suspected in middleaged patients who present with cardiac myxoma. Early surgical resection of the cardiac myxoma is important to prevent further embolic events.

Robotic technology in cardiovascular medicine

Robotic technology has been used in cardiovascular medicine since the late 1990s. Interventional cardiology, electrophysiology, endovascular surgery, minimally invasive cardiac surgery, and laparoscopic vascular surgery are all fields of application. Robotic devices enable endoscopic reconstructive surgery in narrow spaces and fast, very precise placement of catheters and devices in catheter-based interventions. In all robotic systems, the operator manipulates the robotic arms from a control station or console. In the field of cardiac surgery, mitral valve repair, CABG surgery, atrial septal defect repair, and myxoma resection can be achieved using robotic technology. Furthermore, vascular surgeons can perform a variety of robotically assisted operations to treat aortic, visceral, and peripheral artery disease. In electrophysiology, ablation procedures for atrial fibrillation can be carried out with robotic support. In the past few years, robotically assisted percutaneous coronary intervention and abdominal aortic endovascular surgery techniques have been developed. The basic feasibility and safety of robotic approaches in cardiovascular medicine has been demonstrated, but learning curves and the high costs associated with this technology have limited its widespread use. Nonetheless, increased procedural speed, accuracy, and reduced exposure to radiation and contrast agent in robotically assisted catheter-based interventions, as well as reduced surgical trauma and shortened patient recovery times after robotic cardiovascular surgery are promising achievements in the field.

Multiple cerebral aneurysms detected 20 years after resection of left atrial myxoma in a patient with carney complex

Multiple cerebral aneurysms detected 20 years after resection of left atrial myxoma in a patient with carney complex

人工腱索による三尖弁形成術を要した三尖弁粘液腫の1例

人工腱索による三尖弁形成術を要した三尖弁粘液腫の1例

Infected Cardiac Myxoma: an Updated Review.

OBJECTIVE This study aims to present an updated clinical picture of the infected cardiac myxoma. Revankar & Clark made a systematic review of infected cardiac myxoma based on the literature before 1998. Since then, there has not been any updated information describing its recent changing trends.METHODS A comprehensive literature search of infected cardiac myxoma was conducted on MEDLINE, Highwire Press and Google between 1998 and 2014.RESULTS In comparison with Revankar & Clark's series, the present series disclosed a significantly decreased overall mortality. It is believed that refinement of the prompt diagnosis and timely management (use of sensitive antibiotics and surgical resection of the infected myxoma) have resulted in better outcomes of such patients.CONCLUSION The present series of infected cardiac myxoma illustrated some aggravated clinical manifestations (relative more occasions of high-grade fever, multiple embolic events and the presence of refractory microorganisms), which should draw enough attention to careful diagnosis and treatment. In general, the prognosis of infected cardiac myxoma is relatively benign and the long-term survival is always promising.

Heart Surgery Practice in Sub Saharan Africa: Single Nigerian Institutional Midterm Results and Challenges

Background: The majority of prospective cardiac surgical patients in sub Saharan Africa lack access to open heart surgery. We reviewed our midterm results to identify the obstacles to growth and challenges with sustainability. Methods: Records of patients undergoing heart surgery at LASUTH from December 2004 to March 2006 were retrospectively reviewed for clinical and outcome data. Results: Twenty four patients age 10-50, mean 28.0 +/? 10.49 years and 13 (54.2%) males underwent surgery. 12 (50.0%) patients had mechanical valve replacements, 11 (45.8%) closure of septal defects and 1 (4.2%) left atrial myxoma resection. Logistic euroscore for valve patients was 5.81 +/? 4.74 while observed mortality was 8.3% (1/12). Overall 30 days operative mortality was 8.3% (2/24) and major morbidity 4.2% (1/24). Patients with septal defects closure stopped clinic visits within a year. Valve patients follow up was complete in 90.1% with mean duration of 55.2 +/? 15.3 months. Late events occurred only in females with mitral valve replacements. The 5-year freedom from thromboembolism and bleeding was 74.0% and survival 82.0% in valve patients. Conclusion: Despite limited resources heart surgery can safely be performed with good outcomes by trained local personnel under supervision of visiting foreign teams until they are proficient to operate independently. Patients with less complex congenital defects have excellent postsurgical outcomes, while patients with rheumatic valve replacement are subject to ongoing valve related morbidity and mortality therefore require lifetime follow up. Choice of prosthetic valve for the mostly indigent and poorly educated population remains a challenge. We now prefer stented tissue valve despite its known limitations, in child bearing age females desirous of childbirth and others unlikely to comply with anticoagulation regimen. Barriers to sustainability include poor infrastructures, few skilled manpower, inadequate funding and restricted patient access due to inability to pay without third party insurance or government Medicaid.

Multiple intracranial aneurysms followed left atrial myxoma: case report and literature review.

Cerebral aneurysms follows atrial myxoma is a rare neurological complication. We report a patient with multiple cerebral aneurysms three years after resection of left atrial myxoma and further review the literature. The characteristics of these aneurysms are indefinite and variable. They can occur prior or post the resection of cardiac myxoma. "Metastasize and Infiltrate" theory may be the key mechanism in the formation of these aneurysms. Magnetic resonance imaging (MRI), computed tomography (CT) and angiography are useful in the diagnosis while digital subtraction angiography (DSA) is the best choice. There are no definite guidelines for therapy of these aneurysms. Resection of the cardiac myxomas, chemotherapy, radiotherapy, coil embolization and surgical treatment could be helpful.