Gordon, Jeffrey P

Hua, Alina

Shemin, Richard J

Yang, Eric H

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UCLAUCLA Previously Published WorksTitleMinimally invasive robotically assisted surgical resection of left atrial endocardial papillary fibroelastomas.Permalinkhttps://escholarship.org/uc/item/5dn6j2j2JournalThe Journal of thoracic and cardiovascular surgery, 148(6)ISSN1097-685XAuthorsHua, AlinaShemin, Richard JGordon, Jeffrey Pet al.Publication Date2014-12-19 Peer reviewedeScholarship.org Powered by the California Digital LibraryUniversity of CaliforniaSURGICALTECHNIQUEMinimally invasive robotically assisted surgical resection of left atrialendocardial papillary fibroelastomasAlina Hua, MBBS,a Richard J. Shemin, MD,b Jeffrey P. Gordon, MD,c and Eric H. Yang, MD,c London,United Kingdom, and Los Angeles, CalifCardiac papillary fibroelastoma (PFE) is the third mostcommon type of primary cardiac tumor after myxoma andfibroma. It is known to be the most common valvular tumorand accounts for 5% of all tumors of the heart, althoughnonvalvular endocardial origins have been reported.1Although cardiac PFE is considered a benign tumor,surgical excision may be warranted because of its pro-pensity for causing embolic events and hemodynamiccomplications.CLINICAL SUMMARYAn 89-year-old woman with a history of hypertensionand breast cancer was seen after a witnessed syncopalepisode. Magnetic resonance imaging of the brainrevealed multiple infarcts within the posterior circulation.A transesophageal echocardiogram revealed 2 mobileechodensities, which were circular, pedunculated andfrondlike in morphology (Figure 1). These masses weresituated at the ostium of the left atrial appendage and atthe tip of the left atrial ridge between the left upper pulmo-nary vein and left atrial appendage. The appearance of thesemasses led to a suspicion of PFEs, although other types oftumors and thrombus could not be excluded.Invasive coronary angiography revealed mild, nonob-structive coronary disease. In the discussion of surgicalstrategies with cardiothoracic surgery, given that concurrentcoronary artery bypass was not necessary, a minimallyinvasive robotic assisted approach with the da VinciSurgical System (Intuitive Surgical Inc, Sunnyvale, Calif)to resect the masses was proposed to avoid a sternotomyapproach.The patient was positioned for a robotic mitral valveapproach. She was intubated with an endobronchial blockerto isolate the right lung. The superior vena cava wasaccessed with a 17F cannula, and a cutdown was performedFrom the Department of Medicine,a Imperial College London, London, UnitedKingdom; the Division of Cardiothoracic Surgery,b Department of Surgery, andthe Division of Cardiology,c Department of Medicine, University of California atLos Angeles, Los Angeles, Calif.Disclosures: Authors have nothing to disclose with regard to commercial support.Received for publication June 16, 2014; accepted for publication June 29, 2014.Address for reprints: Eric H. Yang, MD, Division of Cardiology, Department ofMedicine, University of California at Los Angeles, 100 Medical Plaza Suite 630,Los Angeles, CA 90095 (E-mail: Datsunian@gmail.com).J Thorac Cardiovasc Surg 2014;-:1-30022-5223/$36.00Copyright  2014 by The American Association for Thoracic Surgeryhttp://dx.doi.org/10.1016/j.jtcvs.2014.06.100The Journal of Thoracic and Cof the left femoral artery and vein. A small inframammaryincision was made, and the chest was accessed through theintercostal space. Cardiopulmonary bypass was establishedand the right lung deflated; the pericardium was opened andtacked laterally. Antegrade cardioplegia cannula andventing needle were placed, and the aorta was cross-clamped. Cold blood antegrade cardioplegia was initiated,arresting the heart.With the da Vinci robotic system, robotic ports wereplaced in the chest and the left atrium was opened.Examination of the anterior left atrial cavity identified thetwo masses along the base of the left atrial appendage andalong the inferior ridge of the left superior pulmonaryvein, which visually appeared gelatinous, friable andmyxomatous. The masses were excised and were extractedthrough a Lukens trap. The left atrial appendage was thenclosed. The atriotomy was then closed with GORE-TEXgrafting (W. L. Gore & Associates, Flagstaff, Ariz) andthe aortic root was unclamped. The heart was thendefibrillated to sinus rhythm.The masses were confirmed to be endocardial PFEs onhistopathologic investigation (Figure 2). The postoperativecourse was complicated by atrial fibrillation, whichresolved with amiodarone. The patient was subsequentlyextubated, and she was discharged on postoperative day11 in good condition. She currently continues to do wellwith minimal residual neurologic deficits and has had norecurrent neurologic events or evidence of cardiac tumorrecurrence as of 1 year of follow-up.DISCUSSIONA minimally invasive approach for atrial excision ofmasses may be an ideal strategy for patients who onlyrequire tumor resection because it eliminates the need fora sternotomy approach. Robotic minimally invasive mitralvalve repair has been associated with decreased hospitalstays, despite longer cardiopulmonary and aorticcrossclamp times, and with faster recovery times.2 It hasalready been shown to be a potentially useful techniquefor cardiac myxoma excision. Gao and associates3 wereable to demonstrate that the da Vinci Surgical Systemallowed complete resection of cardiac myxomas in 19consecutive patients with excellent clinical results, withno tumor recurrence at 18 months of follow-up.The application of minimally invasive surgery to PFEexcision has been limited to case reports. A fewpatients with PFE, including one with a mass in the rightardiovascular Surgery c Volume -, Number - 1FIGURE 1. Transesophageal echocardiography, midesophageal view, showing the 2 cardiac masses. A, A 2-dimensional biplanar view of the first cardiacmass (arrow), measuring approximately 83 7 mm, which is seen at the ostium of the left atrial appendage and is adjacent to the atrioventricular circumflexgroove. B, A 3-dimensional reconstruction of themass (arrow). C, A 2-dimensional view of the secondmass (arrow), measuring approximately 63 9mm, atthe tip of the left atrial ridge that divides the left atrial appendage and left upper pulmonary vein. D, A 3-dimensional reconstruction of the cardiacmass at theleft atrial ridge. Both masses were mobile and appeared circular, pedunculated, and frondlike in appearance. LA, Left atrium; LAA, left atrial appendage;LUPV, left upper pulmonary vein.Surgical Techniqueatrium,4 have been operated on through a minithoracotomyapproach. The use of robotically assisted surgery to removean aortic valve PFE has been reported.5 Although there ispotential in general for this technique in resecting cardiactumors, clinical suspicion must be high for a benign cardiactumor, and it is important to preserve the potential to changethe surgical approach to an open sternotomy in the eventthat the tumor is found to be malignant with myocardialor pericardial involvement.FIGURE 2. Hematoxylin and eosin stains of the surgically excised left atrial mafrondlike structures with a collagenous core, consistent with papillary fibroelas2 The Journal of Thoracic and Cardiovascular SurgerIn summary, we present the case of a patient who wasseen with a cerebrovascular embolic event caused by thepresence and atypical location of left atrial PFEs, whichwere successfully removed bymeans of a robotic minimallyinvasive approach. This surgical technique can potentiallybe used for carefully selected patients with benign tumorswho do not need surgical revascularization. In such cases,it has the potential to decrease bleeding, recovery time,and hospital stay.sses (original magnification34). Both (A andB) show evidence ofmultipletoma.y c - 2014Surgical TechniqueWe thank Annie Wu, MD, Michael Fishbein, MD, and AliSepahdari, MD, for their invaluable help in obtaining relevantdata for the article.References1. Mariscalco G, Bruno VD, Borsani P, Dominici C, Sala A. Papillary fibroelastoma:insight to a primary cardiac valve tumor. J Card Surg. 2010;25:198-205.The Journal of Thoracic and C2. Vernick W, Atluri P. Robotic and minimally invasive cardiac surgery. AnesthesiolClin. 2013;31:299-320.3. Gao C, Yang M, Wang G, Wang J, Xiao C, Wu Y, et al. Excision of atrial myxomausing robotic technology. J Thorac Cardiovasc Surg. 2010;139:1282-5.4. Kim RW, Jeffery ME, Smith MJ, Wilensky RL, Woo EY, Woo YJ. Minimallyinvasive resection of papillary fibroelastoma in a high-risk patient. J CardiovascMed (Hagerstown). 2007;8:639-41.5. Woo YJ, Grand TJ, Weiss SJ. Robotic resection of an aortic valve papillaryfibroelastoma. Ann Thorac Surg. 2005;80:1100-2.ardiovascular Surgery c Volume -, Number - 3

Minimally invasive robotically assisted surgical resection of left atrial endocardial papillary fibroelastomas.

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