Benjamin Yang, MD and Douglas Johnston, MD
Cleveland Clinic Foundation, Cleveland, OH, USA
This chapter is a revision and update of that included in the previous edition of the TSRA Operative Dictations in
Cardiothoracic Surgery written by Paul A. Perry, MD and J. Nilas Young, MD.
Essential Operative Steps
- Lines and monitoring. If Swan-Ganz catheter is indicated, do not pass through the right atrium if there is a right sided
myxoma. It can be passed directly by the surgeon after finishing the procedure and before closing the right atrium - General endotracheal anesthesia with single lumen endotracheal tube
- Intraoperative transesophageal echocardiogram
- Median sternotomy
- Open pericardium, pericardial well, survey ascending aorta for plaque burden
- Systemic heparinization (400u/kg)
- Arterial cannulation
- Bicaval cannulation with snares; high SVC and low IVC cannulation for extensive masses which require additional
exposure - Antegrade (± retrograde) cardioplegia catheter
- Carbon dioxide diffusion into operative field
- Check ACT (>400 seconds)
- Initiate CPB
- Aortic cross clamp
- Antegrade cardioplegia and topical cooling for cardiac arrest
- Atriotomy
- For left atrial masses usually open right atrium and divide atrial septum at fossa ovalis (most tumors are located in left
atrium along the septum); alternatively, can expose and incise the left atrium or perform bi-atrial incisions to fully
expose the mass and allow for inspection of all cardiac chambers - Traction stays sutures or handheld atrial retractor to expose mass
- Identify base of mass
- Sharply excise mass off atrial wall en-bloc with 5mm margin circumferentially
- Irrigation of atrium/ventricle to remove any debris
- Repair atrium. Patch closure of septum
- Close right atrium with running prolene suture (allow heart to fill with blood prior to completing suture line)
- Remove aortic crossclamp
- Atrial and ventricular pacer wire placement
- Vigorous deairing under TEE guidance
- Wean from CPB
- Check for normal sinus rhythm
- Venous decannulation
- Protamine administration
- Aortic decannulation
- Meticulous hemostasis
- Chest tube placement
- Sternotomy closure
Potential Complications and Pitfalls
- Timing of surgery after known embolic event should be appropriate (eg. >7 days) to minimize risk of intraoperative
embolization and to allow time for brain recovery for CBP - Tumor embolization due to manipulation of the heart before crossclamp
- Phrenic nerve injury during dissection of SVC
- Atrial incision site selection should be specified to the location of the mass, as indicated by preoperative imaging. If
additional exposure is needed for large left atrial masses, can consider additional left atrial incision or extension of
trans-septal incision towards the dome of the left atrium. - In cases where tumor involves SVC, cephalad extension of atriotomy into SVC should be performed laterally to avoid
SA node. IVC involvement can be managed with peripheral venous cannulation and extension caudal into the
intrapericardial IVC - SA node, AV node, or conduction system injury during atrial exposure or mass excision
- Valvular injury during atrial exposure or mass excision
- Goal is to obtain negative margins
- Resected tissue should be sent for pathologic evaluation
Template Dictation
Preoperative Diagnosis: [INDICATION: echocardiographic findings consistent with atrial myxoma with or without
symptoms (embolism, obstruction, arrhythmia, etc.)]
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed: Resection of Left/Right Atrial Mass
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [SEX] with [DURATION] history of atrial mass. Preoperative echocardiogram
reveals [FINDINGS: e.g. 2cm pedunculated left atrial myxoma].
Outcome: TEE demonstrated preserved biventricular function and no ASD.
Description of the Procedure: The patient was taken to the operating room on [DATE]. Identity and planned procedure were
verified, and the patient was placed on the operating room table in the supine position. General anesthesia was obtained. Central
venous and radial arterial lines were inserted. Preoperative transesophageal echocardiogram was performed, and the mass was
identified. The chest, abdomen, groins, and lower extremities were prepped and draped in sterile fashion. A surgical timeout
was performed.
Median sternotomy was created, and a sternal retractor placed. After identification of the innominate vein, the pericardium was
opened, and a pericardial well was created. [UNITS] of systemic heparin were administered. The aortic cannulation sutures
were placed in the ascending aorta below the level of the innominate artery. The aortic cannula was then inserted, secured,
deaired, and confirmed to have pulsatile flow by the perfusionist. Venous cannulation sutures were then placed and the SVC
and IVC cannulas were inserted and secured. The superior and inferior vena cavae were dissected out and encircled with
umbilical tape. After placing a pursestring suture in the proximal ascending aorta, an aortic root vent needle was inserted for
administration of antegrade cardioplegia. Gas diffuser was placed along the wound edge and used to flood the operative field
with carbon dioxide. The aortic crossclamp was placed. Antegrade cardioplegia was administered and there was rapid
myocardial arrest. A total of [BLANK]mL of cardioplegia was given. Ice was applied to the heart. For the duration of the
procedure, [BLANK]mL of cardioplegia was administered at 15–20-minute intervals.
The right atrium was exposed and an atriotomy was made parallel to the atrioventricular groove. The fossa ovalis was identified
and atrial septostomy was performed. The atrial retractor was inserted, and the atrial mass was identified along the [BLANK].
A #15 blade scalpel was then used to excise the mass off the atrial wall, taking care to obtain an approximate 5mm margin of
myocardial tissue circumferentially. The excision site was then oversewn with multiple interrupted 5-0 prolene sutures,
resulting in excellent approximation of endocardium. The left atrium was copiously irrigated with [BLANK]mL of saline. The
atrial septostomy was repaired with a patch of bovine pericardium, and the right atriotomy was then closed primarily with
running 4-0 prolene.
Hot shot cardioplegia was administered and the patient was rewarmed. The aortic crossclamp was removed. Atrial and
ventricular pacing wires were inserted and tested for appropriate capture. Vigorous deairing maneuvers were performed under
TEE guidance and the aortic root vent was removed. The patient was weaned from cardiopulmonary bypass. A normal sinus
rhythm was noted. The venous cannulae were removed. A test dose of protamine was administered, and the patient was
monitored for adverse reaction before the protamine was resumed. The aortic cannula was then removed. A total
of [NUMBER] chest tubes were placed in the [LEFT/RIGHT] pleural space, and [NUMBER] chest tubes were placed in the
mediastinum. Hemostasis was confirmed. The sternum was closed with [NUMBER] stainless steel sternal wires. The wound
was irrigated with saline. The soft tissue was closed in layers and the skin approximated with staples. The wounds were dressed.
All instrument, sponge, and needle counts were confirmed to be correct, twice, at the end of the operation. The patient was
subsequently transferred to the postoperative cardiac surgical intensive care unit with stable hemodynamics
and [BLANK] inotropic support. Dr. [BLANK] was present and scrubbed for [BLANK] elements of the procedure.
Multiple Choice Question(s)
A 48-year-old woman with a 6-week history of shortness of breath and fatigue is referred to you with transthoracic
echocardiogram showing LVEF of 55% and a pedunculated right atrial mass with extension to the superior vena cava
consistent with atrial myxoma. Which of the following cannulation strategies would be best?
A. Central aortic, dual stage right atrial venous cannulation
B. Central aortic, SVC and IVC bi-caval venous cannulation
C. Central aortic, femoral and left IJ venous cannulation
D. Central aortic, femoral and right IJ venous cannulation
E. Femoral arterial, femoral venous cannulation
Answer: C.
Sources
Ramlawi B, Reardon MJ. Cardiac Neoplasms. In: Cohn LH, Adams DH, editors. Cardiac Surgery in the Adult, 5e, New
York, NY: McGraw-Hill Education; 2017.
Centofanti P, Di Rosa E, Deorsola L, Dato GM, Patanè F, La Torre M, et al. Primary cardiac tumors: early and late results of
surgical treatment in 91 patients. Ann Thorac Surg 1999;68:1236–41.
