Totally endoscopic extensive resection and reconstruction of the left atrial wall for myxoma with unusual origin

Aesthetic surgical scars of the patient at follow-up visit.

Central Message.

Extensive resection of myxoma and adjacent structures lowers recurrence risk but increases procedural complexity. Nonetheless, this approach appears feasible when performed endoscopically.

Myxoma is the most common primary cardiac tumor, with approximately 80% to 85% occurring in the left atrium (LA). When originating from the interatrial septum (IAS) and extending to the lateral and posterior LA walls, complete resection necessitates atrial wall reconstruction—a technically demanding task via endoscopic access. This report presents a case series demonstrating successful endoscopic resection and LA wall reconstruction using small trocars and ports.

Case Presentation

From August 2018 to March 2022, 4 patients with LA myxoma underwent totally endoscopic resection and LA reconstruction. Preoperative demographic and pathophysiological data are summarized in Table E1. All participants provided written informed consent permitting the use of their clinical data, imaging, and surgical videos for publication in scientific research. Institutional review board/ethical approval was not required. Data available upon request.

Surgical Procedures

Trocar and port placement is illustrated in Figure 1. The procedure for establishing peripheral cannulation has been detailed in a previously published study.¹

Figure 1.

Port and trocar installation. Preoperative markings of the midaxillary line and extended submammary fold (dotted lines). The port and trocars included: (1) the 2- to 3-cm main working port (yellow line) was at the fifth intercostal space on the anterior axillary line, (2) a 5-mm trocar for the left-hand instruments and Chitwood clamp (orange circle), (3) a 5-mm trocar for the endoscopic camera and carbon dioxide insufflation (blue circle), and (4) a 5-mm incision for left vent (white circle).

For tumors originating from the IAS and the inferior part of the LA posterior wall, the transseptal approach was used. Complete resection involves excising both the IAS and the affected LA wall, maintaining a 5-mm margin from the tumor base (Figure 2, A). The specimen is enclosed within a retrieval bag and extracted through the primary working port. The LA wall is reconstructed using bovine pericardium and secured with a single-layer running suture (Figure 2, B and C).

Figure 2.

The operative steps of the 2 cases. The first case: tumor originates from the IAS and the inferior part of LA posterior wall. A, Complete resection of myxoma and related structures through the transseptal approach. B, Resulting defect shows pericardial fat. C, Reconstruction using a bovine patch after mitral valve repair. The second case: myxoma widely adhered to the IAS and the LA lateral and posterior walls. D, Complete resection of myxoma and LA wall through left atriotomy. E, LA defect directly communicates to the oblique sinus. F, LA wall was reconstructed using a bovine patch. IAS, Interatrial septum; LA, left atrium; MV, mitral valve; RA, right atrium; Post., posterior; RIPV, right inferior pulmonary vein; SVC, superior vena cava.

For tumors adherent to the IAS and extending toward the right inferior pulmonary vein and the LA posterior wall, resection is accomplished via 2 incisions. The IAS is opened to excise the septal portion, followed by a left atriotomy along the interatrial groove to remove the tumor segments adherent to the lateral and posterior walls (Figure 2, D, and Video 1). Both the affected LA wall and the IAS are excised with a 5-mm safety margin. Reconstruction of the LA walls is achieved using bovine pericardium, secured with a single-layer running suture (Figure 2, E and F, Video 1).

Mitral and tricuspid valve repairs were performed in cases with significant preoperative regurgitation. Closure of the IAS was achieved either by direct suturing or by using a patch, depending on the extent of resection. Surgical details are summarized in Table E2. All patients achieved full recovery, with no recorded complications or tumor recurrence during both the in-hospital and follow-up periods.

Discussion

Myxoma recurrence may result from incomplete tumor resection.^2,3 Incomplete excision often is attributable to challenging or hazardous tumor locations, such as the lateral and posterior walls of the LA, the LA appendage, or the mitral valve annulus. In such cases, complete resection may compromise cardiac integrity by causing perforation, necessitating reconstruction and increasing the risk of uncontrollable bleeding. Tumors located on the LA lateral or posterior walls account for approximately 2.2% of cases,⁴ with few reports of LA wall reconstruction, all via conventional approaches.¹

Totally endoscopic LA myxoma resection remains limited in adoption. Large, broad-based tumors presents technical challenges, especially when LA reconstruction is necessary. In cases in which the tumors originate from the IAS and extend inferiorly (along the longitudinal axis), the transseptal approach allows for complete resection of both the septal tissue and the tumor-bearing atrial wall. In such instances, pericardial fat becomes visible, and the resulting myocardial defect is typically located near the mitral valve annulus (Figure 2, B).

Myxomas originating from the IAS and extending toward the lateral wall near the right inferior pulmonary vein often involve the LA posterior wall. A single-approach resection is technically limited and may result in incomplete excision. In this study, dual-approach excision enabled complete removal, with the resulting LA wall defect communicating directly with the oblique pericardial sinus (Figure 2, E).

LA reconstruction may lead to distortion of adjacent structures, including the mitral annulus and pulmonary vein orifices, and carries a risk of postoperative bleeding. To reduce structural distortion, patch repair was preferred over direct suturing. Extensive experience with totally endoscopic cardiac surgery is essential for minimizing bleeding risks from suture lines. This procedure was supported by a cumulative experience of nearly 600 cases, encompassing totally endoscopic atrial septal defect repair, LA myxoma resection, mitral valve surgery, LA reconstruction, and atrial fibrillation ablation.

Conclusions

For myxomas with a broad-based stalk, complete excision of the tumor and involve structures combined with left atrial reconstruction can be safely performed using a fully endoscopic approach.

Conflict of Interest Statement

The authors reported no conflicts of interest.

The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

Supplementary Data

Video 1

Totally endoscopic extensive myxoma resection and reconstruction of the left atrial wall. Video available at: https://www.jtcvs.org/article/S2666-2507(25)00542-5/fulltext.

Appendix E1

Table E1.

Preoperative patient characteristics

Variables	Patient 1	Patient 2	Patient 3	Patient 4
Age, y	58	59	43	42
Sex	Female	Female	Female	Female
Body surface area, m2	1.63	1.30	1.58	1.62
Family history of myxoma	None	None	None	None
History of stroke	None	None	None	None
Chief complaint	Chest pain	Chest pain	Fatigue	Shortness of breath
Characteristics of tumors on transthoracic echocardiography
Number of masses	1	1	1	1
Diameters (L ∗ W), mm	55 ∗ 31	42 ∗ 24	32 ∗ 16	61 ∗ 35
Peduncle	Sessile	Sessile	Sessile	Sessile
Mobility	Protrusion into LV	Immobile	Immobile	Protrusion into LV
Base attachment	IAS + lateral LA wall	IAS + lateral and posterior LA walls	IAS + posterior LA wall	IAS + posterior LA wall
MV regurgitation	Mild	None	None	Moderate
MV gradient, mm Hg	22	3	5	20
Tricuspid regurgitation	Mild	Mild	Mild	Severe
PAP, mm Hg	40	25	31	65

L, Length; W, width; LV, left ventricle; IAS, interatrial septum; LA, left atrium; MV, mitral valve; PAP, pulmonary arterial pressure.

Table E2.

Operative and postoperative parameters

Parameters	Patient 1	Patient 2	Patient 3	Patient 4
Approaches	Transseptal + left atrial	Transseptal + left atrial	Transseptal	Transseptal
Atrial septal closure	Patch	Direct suture	Patch	Direct suture
Mitral valve repair	None	None	None	Ring
Tricuspid valve repair	None	None	None	Ring
ACC time, min	94	110	65	92
CPB time, min	150	195	130	155
Ventilation time, h	13	7	12	36
ICU stay time, d	2	3	2	3
Drainage volume, mL	90	190	310	180
Postoperative hospital stay time, days	6	7	6	8
Follow-up time, mo	50	49	27	11
Complications	None	None	None	None
Myxoma recurrence	None	None	None	None

ACC, Aortic crossclamping; CPB, cardiopulmonary bypass; ICU, intensive care unit.