Endoscopic port access resection of left atrial myxoma: Clinical outcomes and a single surgeon's learning curve experience

Abstract

Objectives: To evaluate the safety and efficacy of the port access approach for left atrial (LA) myxoma resection and to analyze the learning curve for this procedure.

Methods: Thirty-six consecutive patients with LA myxoma who underwent port access surgery between April 2018 and March 2023 were enrolled in this retrospective study. The procedure included (1) unilateral or bilateral femoral artery cannulation; (2) the use of three 5-mm trocars and a 20- to 30-mm port; (3) a transseptal, biatrial, or LA approach depending on the location of the tumor base; and (4) complete or subendocardial tumor resection. CUSUM analysis was used to evaluate the aortic cross-clamp (ACC) time and cardiopulmonary bypass (CPB) time learning curves. Variables among the learning curve phases were compared.

Results: The average ACC and CPB times were 49 (range, 45-79) minutes and 127 (range, 120-164) minutes, respectively. There was 1 case of conversion to sternotomy due to aortic root bleeding and 1 case of unilateral pulmonary edema. CUSUM_ACCtime analysis included 3 phases: phase I, the initial learning period (cases 1-11); phase II, the technical competence period (cases 12-23); and phase III, the challenging period (cases 24-36).

Conclusions: The port access approach is safe and feasible for LA myxoma resection. According to the learning curve analysis, 11 cases are required to achieve technical competence, and 23 cases are required to address highly challenging cases.

Keywords: learning curve; left atrial myxoma; minimally endoscopic cardiac surgery; port access.

Graphical abstract

Tumor resection and removal through endoscopic surgery.

Figure 1

Port and trocar installation. A, The midaxillary line and extended submammary fold (dotted lines) were drawn preoperatively. The red arrow indicates the site of superior vena cava cannulation. B, The port and trocars included (1) the main working port (red line in A) at the fifth intercostal space on the anterior axillary line, (2) a 5.5-mm trocar for the left-hand instruments and Chitwood clamp (yellow circle in A), (3) a 5-mm or 10-mm trocar for the endoscopic camera and CO₂ insufflation (green circle in A), and (4) a 5-mm port for the left vent (black circle in A and white star in B). An antegrade cardioplegia needle was placed on the ascending aorta through the main working port (black arrow).

Figure 2

The operative steps. A, Opening of the interatrial septum (IAS). B, Complete tumor resection with a 5- to 10-mm rim. Subendocardial resection was indicated for myxoma not originating from the IAS. The cut surface was electrically burned and closed using a direct suture or autopericardium patch. C, Removal of the tumor from the left atrium and out of the chest wall using a retrieval bag. D, The soft, lobulated mass. SVC, Superior vena cava; IVC, inferior vena cava.

Figure 3

Tumor attachment sites on the interatrial septum (IAS). Blue oval, tumors attached to the IAS and the left atrial (LA) vestibule; yellow oval, tumors completely attached to the IAS; green oval, tumors attached to the IAS and right pulmonary vein (PV); red oval, tumors attached to the IAS and posterior LA wall; gray oval, tumors attached to the IAS, posterior LA wall, and inferior right pulmonary vein (IRPV). White dashed line, the LA approach through Waterston's groove. SRPV, Superior right pulmonary vein; IVC, inferior vena cava.

Figure 4

CUSUM (cumulative sum) analysis of aortic cross-clamp (ACC) time (A) and cardiopulmonary bypass (CPB) time (B).

Figure 5

Research highlights. SRPV, Superior right pulmonary vein; IRPV, inferior right pulmonary vein; IVC, inferior vena cava; LA, left atrial; CUSUM, cumulative sum; ACC, aortic cross-clamp; CPB, cardiopulmonary bypass.

Figure E1

Surgical scars at discharge.

Figure E2

The learning curve for aortic cross-clamp time.