CARDIOVASCULAR JOURNAL OF AFRICA • Volume 35, No 1, January – April 2024 32 AFRICA it is commonplace for patients to die or experience a major complication while awaiting surgery due to the risk of sudden cardiac death.19 As a result, some studies suggest that emergency surgery is required when a patient has a myxoma large enough to cause complete intracardiac obstruction.27 Pinede et al. reviewed 112 cases of left atrial myxoma from 1959 to 1998 and reported that the time interval between the onset of symptoms and surgical removal of the myxoma ranged from zero to 126 months, with a median of four months.9 In their 2017 study, Lee et al. reported that they performed elective surgery on 65 patients and emergency surgery on 28 patients with severe symptoms or embolic risk. However, they did not specify the time before elective surgery in this study.28 There are no studies directly investigating the impact of surgical timing on patient prognosis in cardiac myxomas, but the general opinion is that speedy surgical excision should be performed after diagnosis because of the high risk of valve occlusion or systemic embolisation.19 In our study, the mean duration of time up to surgery for symptomatic patients was 17.79 ± 6.36 days, while it was 49.53 ± 26.97 days for asymptomatic patients. In addition, no emergency surgical excision was carried out in any patient in our study. A surgical approach in cardiac myxomas should be chosen according to myxoma location and size, the surgeon’s preference and experience, the presence of concomitant heart diseases and the genetic structure of the myxoma.29 The basic principle of surgical treatment for cardiac myxomas is complete tumour removal to avoid intra-operative embolisation and the presence of tumour remnants.30 Adequate resection with microscopically and macroscopically negative clean margins is the cornerstone of myxoma resection to prevent the risk of recurrence after surgery, and the tumour should be removed with a 0.5- to 1-cm tissue margin.29 Due to the anatomical location of the myxoma, extensive resection may sometimes be required, and in such cases the resected part can be reconstructed with a patch.16 However, resection of myxomas on the atrioventricular valves or around the conduction tissue can be technically difficult and very risky, and limited resection at the subendocardial level may be inevitable, instead of extensive tissue removal. Very close follow up is required in these patients to exclude possible recurrence.29 Cardiac myxomas are excised by open-heart surgery under CPB, and the surgical approach is to make an incision in the left atrium behind the interatrial groove to visualise the tumour in the left atrium.31 However, in cases where the left atrial myxoma is large and access to the left atrium is limited, and in right atrial myxomas, right atriotomy is the other surgical approach.19 If the myxoma is papillary or its base is sessile, the tumour can be reached with a bi-atrial approach.31 However, the ideal surgical approach in left atrial myxomas is controversial and no consensus has been reached on the best surgical approach.29 In left atrial myxomas, the bi-atrial approach, which includes bi-atriotomy, right atrial trans-septal approach and superior trans-septal approach provide some advantages over the uni-atrial approach in the majority of patients.30 Jones et al. defined the advantages of the bi-atrial approach in their study as follows: direct visual identification of the tumour pedicle, minimal manipulation of the tumour, adequate excision margins, examination of all heart chambers, and safe closure of the atrial septal defect.32 Siminelakis et al., in their new and intriguing study, defined the ideal surgical approach for cardiac myxomas as right atrial or bi-atrial incisions, excision of the fossa ovalis and surrounding tissues, and closure of this area with a pericardial patch.33 Although the bi-atrial approach offers excellent exposure, criticism remains against this approach as it is responsible for the high incidence of arrhythmias and conduction disorders after resection of left atrial myxomas.29 Choosing the appropriate surgical approach for myxomas is very important for the patient’s prognosis and tumour recurrence. The surgical approach to myxomas should allow examination of all four heart chambers and minimal manipulation of the tumour, provide adequate exposure for complete resection without residue, minimise the chance of recurrence, and be safe and effective.34 In our study, 22 of 25 patients had excision of a left atrial myxoma with a left atrial approach and three with a bi-atrial approach. In all patients with right atrial myxomas, the myxoma was removed with a right atrial approach. In our study, no malignant arrhythmias were observed after surgery. In seven (18.9%) cases, only atrial fibrillation occurred as a postoperative rhythm disorder. The tumour was resected with a bi-atrial approach in two patients who developed postoperative atrial fibrillation, a left atrial approach in three patients, and a right atrial approach in two patients. The outcome after cardiac myxoma resection is quite good, with a 20-year survival rate of around 85%, and a low atrial myxoma recurrence rate after surgical resection (5%).24 Local recurrence of cardiac myxomas is very rare, but may be due to incomplete resection, multicentricity, origin outside the left atrium, familial tumours, or part of a disease complex such as Carney complex.35 Elbardissi et al. reported in their study that myxoma recurrence rate after resection was 13%, but it was much more common in familial myxomas compared to sporadic myxomas (22 vs 3%).36 In their study involving 98 patients who underwent surgery for cardiac myxoma, Garatti et al. reported that the recurrence rate was 1% in their 15-year follow up.1 In another study, Jiang et al. reported that the recurrence rate was 1.5% in the long-term follow up of 403 patients who underwent myxoma resection.37 In another study, Vroomen et al. reported that they did not see any recurrence after 20 years of follow up in patients with myxoma.38 Yüksel et al., in their study involving 43 patients who were operated on for cardiac myxoma, reported that they followed up the patients for an average of 102.3 ± 66.5 months, and no recurrence was observed in any of their patients during this period. They also reported that these patients had 95, 92 and 78% survival rate at five, 10 and 15 years, respectively.29 In our study, no recurrence occurred in any of our patients during their long-term follow up (follow-up times, median: 119.5, min–max: 10–172 months). None of our patients had Carney complex or a familial history of atrial myxoma. The postoperative complication rate in cardiac myxoma resections is quite low and the postoperative period is generally uneventful, with minor complications.26 Rhythm disturbances, especially atrial fibrillation, are the most common complications after cardiac myxoma surgery, and they are rarely seen in neurological disorders, bleeding, myocardial infarction and other minor complications.1 Previous studies reported that the 30-day mortality rate after excision of cardiac myxomas ranged from zero to 10%.26 Shah et al. reported a 30-day mortality rate of 0.5% in their study
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