Cryoablation for a right atrial myxoma arising from the Koch’s triangle: a case report
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A 78-year-old caucasian patient with compromised cardiac function presenting recurrent episodes of pulmonary embolism was referred to our center for resection of a voluminous right atrial myxoma arising from the Koch’s triangle. To preserve the conduction system, we performed an excision of the myxoma associated with cryoablation of its stalk. This case is of special interest for discussing possibilities of preservation of the atrioventricular conduction system in such situations, provided that the contemporary literature does not propose concrete guidelines.
KeywordsMyxoma Cardiac tumors Pulmonary embolism Heart failure
Left ventricular ejection fraction
Left anterior descending
Left Internal mammary artery
Myxomas are the most common primary heart tumors, accounting for 50% of all benign cardiac tumors. They predominate in women with a peak incidence in the third and sixth decades of life. About 75–80% of them arise from the left atrium and 15–20% from the right. They are pedunculated, and their stalk usually rises from the atrial septum [1, 2].
We report the case of a 78-year-old caucasian woman with a previous medical history of multiple pulmonary embolism who was referred to our cardiac surgery department with a diagnosis of a 5.6 × 3.6 cm right atrial myxoma after a second episode of pulmonary embolism. In 2004, after the first pulmonary embolism, a right atrial mass compatible with an intracardiac tumor or thrombus was detected, without further follow-up apart from an anticoagulation therapy stopped in 2007 because of a mild digestive hemorrhage.
Cryoablation of cardiac myxomas has been previously reported in a patient presenting with recurrent myxomas with good short-term results , but it has never been used, to our knowledge, as an alternative to atrial wall excision for myxomas rising from the Koch’s triangle. On the grounds of the severely compromised cardiac function and the high probability of a complete atrioventricular block associated with a classical excision of the full thickness of the adjacent atrial wall, we decided to perform only an excision of the root of the myxoma pedicle with cryoablation of its stalk. This case is of special interest because it describes an alternative excision strategy for myxomas situated near the conduction system. Limited excision of the the myxome without resection of its stalk is associated with a prohibitive risk of early recurrence [4, 5]. As an alternative to a full thickness excision of the adjacent atrial wall to remove the myxome stalk which would necessitate a relatively extensive reconstruction to reach healthy tissue, we opted for a selective cryoablation of the stalk. In spite of the inherit risk of cryoablation to provoke conduction problems, this treatment remains less extensive than surgical excision and, therefore, of less risk to provoke a complete atrioventricular block. Certainly, the exact risk of tumor recurrence and conduction complications post cryoblation for treatment of myxomas rising close to conduction system needs further investigation.
Although in cardiac surgery there is little experience of cryoablation techniques concerning their oncologic result, previous reports from hepatic and other solid organ surgery support their efficacy [6, 7, 8]. Therefore, in difficult cases with critical cardiac function (particularly in older patients) and myxomas arising in precarious positions, cryoablation might be a reasonable alternative to radical surgical resection.
Written information consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
All collaborators who contributed for the conception, collection of data and writing of this manuscript were included as authors of the paper. There is not any source of funding to declare for any author.
- 5.Reber D, Birnbaum DE: Recurrent cardiac myxoma: why it occurs. A case report with literature review. J. Cardiovasc Surg (Torino). 2001, 42 (3): 345-348.Google Scholar
- 7.Li J, Zhou L, Chen J, Wu B, Zeng J, Fang G, Deng C, Huang S, Yao F, Chen Z, Leng Y, Deng M, Deng C, Zhang B, Zhou G, He L, Liao M, Chiu D, Niu L, Zuo J, Xu K: Pancreatic head cryosurgery: safety and efficiency in vivo–a pilot study. Pancreas. 2012, 41 (8): 1285-1291. 10.1097/MPA.0b013e31825544ae.CrossRefPubMedGoogle Scholar
- 8.Bang HJ, Littrup PJ, Goodrich DJ, Currier BP, Aoun HD, Heilbrun LK, Vaishampayan U, Adam B, Goodman AC: Percutaneous cryoablation of metastatic renal cell carcinoma for local tumor control: feasibility, outcomes, and estimated cost-effectiveness for palliation. J Vasc Interv Radiol. 2012, 23 (6): 770-777. 10.1016/j.jvir.2012.03.002.CrossRefPubMedGoogle Scholar
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