Scandinavian Journal of Thoracic and Cardiovascular

Surgery

ISSN: 0036-5580 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/icdv19

Urgent indications for surgery in primary or

secondary cardiac neoplasm

Ulrich Hake, Stein Iversen, Franz-X. Schmid, Rainer Erbel & Hellmut Oelert

To cite this article: Ulrich Hake, Stein Iversen, Franz-X. Schmid, Rainer Erbel & Hellmut
Oelert (1989) Urgent indications for surgery in primary or secondary cardiac neoplasm,
Scandinavian Journal of Thoracic and Cardiovascular Surgery, 23:2, 111-114, DOI:
10.3109/14017438909105978

To link to this article: http://dx.doi.org/10.3109/14017438909105978

Published online: 12 Jul 2009.

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 Scand J Thor Cardiovasc Surg 23: 111-114, 1989

URGENT INDICATIONS FOR SURGERY IN PRIMARY OR SECONDARY

CARDIAC NEOPLASM

Ulrich Hake, Stein Iversen, Franz-X. Schmid, Rainer Erbel and Hellmut Oelert

From the Division of Cardiothoracic and Vascular Surgery and the Medical Department II,
University Clinics of Mainz, FRG

(Accepted for publication May 5, 1988)

Downloaded by [Flinders University of South Australia] at 13:13 16 March 2016

Abstract. Ten patients underwent resection of primary or
secondary cardiac tumor. Two-dimensional transthoracic
echocardiography per se accurately located the endolumi-
nal cardiac mass in nine patients, and transesophageal
echocardiography demonstrated a right atrial tumor in the
tenth case. The indications for urgent surgery included
prior embolic events (3 cases), syncopal attacks (2) or
echocardiographic evidence of a multilobulated mass (2
cases). The operative strategy was standardized for atrial
tumors, but for malignant myocardial neoplasm both the
anatomic site and the extent of tumor growth determined
the surgical procedure. Histologic examination showed
myxoma in seven cases, fibroma in one and metastases of
malignant melanoma in two cases. The course after resec-
tion of endoluminal benign tumor was uneventful apart
from transient atrial fibrillation in four cases. Follow-up
echocardiography (after 4-28 months) showed no recurrent
growth. In both cases of intracardiac metastases there was
recurrence within 6 to 8 months after resection of the
growth.
Key words: intracardiac tumors, echocardiographic diag-
nosis, urgent cardiac surgery.
Early diagnosis of primary or secondary myocardial
tumor requires much skilI. The reason is not lack of
sensitive diagnostic techniques, but the frequently
uncharacteristic or obscure clinical features of car-
diac neoplasms, and also relative inexperience of
these rare tumors, A review of the literature showed
that in many cases the diagnosis was established only
after the appearance of serious complications (2, 5 ,
10).
We now report our diagnostic approach and surgi-
cal experience of primary or secondary cardiac
tumors, with emphasis on the importance of prompt
surgical intervention after diagnosis.
PATIENTS AND METHODS
Resection of endoluminal or intramyocardial primary or
secondary cardiac neoplasm was performed on ten patients
during the period April 1985-July 1987. Table I summar-
izes the relevant preoperative clinical data.
Standard two-dimensional transthoracic and trans-
esophageal echocardiography (Fig. 1) were performed in
all cases. The echocardiographic configuration and location
of endoluminal masses are summarized in Table 11. Protru-
sion of a left atrial tumor across the mitral orifice was dem-
onstrated by transthoracic echocardiography in one case.
In a patient with severe constitutional symptoms and pul-
monary hypertension, the transesophageal echocardio-
graphy detected a pedunculated polypoid mass in the right
atrium after several negative two-dimensional transthoracic
echocardiographies. Two patients with left atrial tumor
and, respectively, coronary artery disease and constrictive
pericarditis, were studied also with cardiac catheterization
andlor coronary angiography.
The mean time from diagnosis of an endoluminal tumor
to operation was 1.9 (range 1-4) days. Seven operations
were performed within one day of diagnosis, the reasons
being a history of syncopal attacks (2 cases) or systemic em-
bolization (2), or echocardiographic evidence of a left at-
rial multivillose mass (2 cases). The seventh patient, with
acute right ventricular obstruction, was taken to the operat-
ing room under resuscitation.
The operations were performed with cardiopulmonary
bypass, moderate hypothermia, aortic cross-clamping and
cold cardioplegic arrest. All atrial tumors were approached
through a right atriotomy. Lavage and inspection of all car-
diac chambers to exclude possible additional neoplasm or
debris were routinely performed. The atrial defect created
by septal excision was regularly repaired with a dacron
patch. Follow-up was complete and included annual trans-
thoracic and transesophageal echocardiography.
RESULTS
Benign tumors. At operation the echocardiographic
appearance of either a smooth-surfaced ovoid or a
multilobulated mass (Fig. 2) was confirmed in each
of these eight cases.
In five patients with suspected left atrial tumor
and echocardiographic evidence of septal attach-
ment, a disc of atrial septum around the stalk was

Scand J Thor Cardiovasc 23

 112 U. Hake et al.
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Fig. 1. Two-dimensional echocardiogram indicating a round um, RA = right atrium, A 0 = aorta, IAS = interatrial sep-
atrial mass partially occluding the atrium. LA = left atri- tum.

primarily excised. In one case the stalk was attached
to the roof of the left atrium and removal was ac-
complished by deep endocardia1 resection. Routine
intraoperative testing of the tricuspid or mitral valve
after removal of tumor yielded no sign of incompe-
tence. Histologic examination of the excised tumors
revealed seven myxomas and one fibroma.
The post-resection course was uneventful in the
patients with benign tumor, except for transient at-
rial fibrillation (4 cases), which was rapidly con-
verted to sinus rhythm. Follow-up with transthoracic
and transesophageal echocardiography showed no
recurrent growth during a mean period of 15.2
(range 4-28) months.
Malignant tumors. In the two patients with intra-
operative histologic evidence of metastatic mela-
noma the operative procedure was modified. One of
them had been treated for melanoma for several
Table I. Preoperative clinical data
years, and a multilobulated bluish mass was found
occluding the lumen of the superior vena cava and
extending into the right atrium. The tumor was at-
tached to the roof of the right atrium and was easily
removed with partial resection of the endocardium.
The second patient was referred to our department
with a diagnosis of acute right ventricular obstruc-
tion and cardiogenic shock. Two-dimensional echo-
cardiography indicated a large, smooth-surfaced
mass extending from the right atrium into the right
ventricle. At operation a bluish tumor filled the right
ventricular cavity and right atrium, obstructing the
tricuspid valve (Fig. 3). Invasive growth of tumor
into the tricuspid annulus and the right anterior ven-
tricular wall necessitated extensive resection of the
ventricular wall followed by dacron patch reconstruc-
tion and tricuspid valve replacement. Histologic ex-
amination confirmed the intraoperative diagnosis of
malignant melanoma in both cases.
Recurrent growth with obstruction of the superior
vena cava was found in the first patient 6 months

No. of patients 10
Age range (years) 26-12 Table 11. Preoperative echocardiographic findings
Malelfemale 311
Symptoms No. of patients Tumor configuration
Exertional dyspnea 4
Transient ischemic attacks 1 Tumor location Ovoid Multilobulated
Stroke 2
Syncope 2 Right atrium 1 2
Arthritis 1 Right ventricle 1
Fever 1 Left atrium 4 2
~~

Scand I Thor Cardiovasc 23


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after operation. The second patient died 8 months
postoperatively, due to diffuse metastatic pulmonary
and systemic spread of melanoma without post-
mortem evidence of local recurrence. The site of the
primary tumor remained unknown in this case.
DISCUSSION
The benign histologic structure of atrial myxomas
strongly contrasts with their clinical malignancy (7,
8). Thus, in addition to embolic events usually in-
volving the central nervous system, or syncopal at-
tacks, severe constitutional symptoms have been as-
sociated with these tumors (6).
Transthoracic two-dimensional echocardiography
8-898242
Urgent surgery f o r cardiac neoplasms 113
Fig.2. Macroscopic appearance of a
multilobulated myxoma removed
from the left atrium.
as first-choice diagnostic technique can reliably de-
pict the size and mobility of an endocardia1 tumor
(5). The limitations imposed by the anatomy of the
chest wall on conventional echocardiography (3) can
be easily overcome by the transesophageal ap-
proach, which accurately located a right atrial myx-
oma in one of our patients following several false-
negative transthoracic echocardiographies. Cardiac
catheterization, which involves the nondeterminable
risk of tumor embolization, should be restricted to
patients with suspected associated cardiac disease
(9).
Although no exact data are available concerning
incidence of serious tumor-associated complications
between diagnosis and operation, the unpredictable
Fig.3. Right atrial view demcmstrat-
ing a bluish right ventricular mass
extending into the right atriutm .
Scand J Thor Cardiovasc 23
 114 U. Hake et al.
clinical course of atrial myxoma calls for prompt
surgical intervention after diagnosis. Recently an-
tecedent embolic events or transient ischemic at-
tacks, as in three of our patients, frequently indicate
a friable and villose myxoma with impending disrup-
tion of further fragments. Echocardiographic dem-
onstration of a multilobulated left atrial mass, or of
tumor movement across the atrioventricular orifice,
were indications for urgent operation in three of our
ten patients.
Surgery of atrial neoplasms has been standardized
(11). To avoid local recurrence, excision of a cuff of
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normal atrial tissue around the tumor stalk, or at
least a partial wall-thickness resection has been re-
commended (12).
The dismal prognosis in primary or secondary
malignant cardiac neoplasm is associated either with
local nonresectability or with widespread metastases
at the time of diagnosis (1,4).As in one of our cases
with right ventricular inflow obstruction, a malig-
nant cardiac neoplasm may be unexpectedly encoun-
tered at operation, and a palliative procedure is all
that can be done to avert an emergency situation.
In summary, endoluminal cardiac neoplasms can
be accurately located with different echocardio-
graphic techniques. Because of the high incidence of
serious complications of atrial tumors, delay to op-
eration should be minimized. Radical resection of at-
rial myxoma with careful avoidance of tumor frag-
mentation involves minimal perioperative risk. Post-
operatively annual echocardiography is advisable in
order to detect rare recurrence of myxoma. Surgi-
cal treatment of primary or secondary malignant car-
diac neoplasm is feasible only in a minority of cases
and is usually intended to improve the quality of life.
Scand J Thor Cardiovasc 23
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