LA Myxoma

Pushpa1, Rathika2, Mounika3

1Operation Theater In charge, Kauvery Heart city, Trichy, Tamil Nadu

2Operation Theater Senior Staff, Kauvery Heart city, Trichy, Tamil Nadu

3Operation Theater Physician Assistance, Kauvery Heart city, Trichy, Tamil Nadu

Abstract

Neoplastic involvement of the heart can be divided into primary cardiac tumors arising in the heart and secondary cardiac tumors that have metastasized to the heart. Primary cardiac tumors can be further stratified into benign and malignant tumors.

Approximately 50% of the benign tumors are myxomas and approximately 75% of the malignant tumors are sarcomas.  The clinical incidence of these tumors is approximately 1 in 500 surgical cases.

Background

History

The first echocardiographic diagnosis of an intracardiac tumor was made in 1959. Crafoord in Sweden first successfully removed a left atrial myxoma in 1954 using cardiopulmonary bypass, Kay in Los Angeles first removed a left ventricle myxoma in 1959.By 1964, 60 atrial myxomas had been removed successfully with a steady increase because of increasing safety of cardiopulmonary bypass and increased use of echocardiography for detection. Operations are currently routinely performed on the vast majority of patients with atrial myxoma with minimal mortality.

Myxoma

Myxoma are the most common primary cardiac tumors. They are benign. Although they have been reported in both sexes and in all age groups, they most often occur in women in the third to sixth decade of life.

Myxoma arising from the endocardium and usually extends into cardiac chambers. The tumors range from 1 to 15cm, but they are most commonly about 5cm in diameter. Most left atrial myxomas are located on the border of the fossa ovalis ,but they can originate from any place on the atrial wall. Myxomas arising from cardiac valves are rare.

Case Presentation

A 31 years old female with no known comorbidities. During her second pregnancy checkup echo revealed a mass in LA 30 × 20 mm attached to IAS. Patient was advised surgery for LA Myxoma. She had surgical history of LSCS (2019.2024) and cholecystectomy (2021).

On examination

Patient conscious, oriented

PR: 82/min, BP: 110/70mmhg, SpO2:99% at RA

Height: 158cm, Weight: 67kg

Pre OP Medications

Tab. Supradyn

Pre OP Investigations

Hb: 11.4g/dl

Urea: 10mg/dl, Creatinine: 0.72mg/dl

Na: 138mmol/L, K: 4.18mmol/l

HbA1c:5.9%

Serology: Negative

CAG: Not done

ECG

X-Ray

           Before                                                                   After

USG: Left Renal Calculi

ECHO Report

Impression

  • 35*29 mm mass attached to IAS on the left atrium side
  • No significant valvular obstruction
  • Good LV function EF-60%
  • Grade 2 diastolic dysfunction
  • Mild MR/Mild TR/Mild PAH

Operation Notes

Sx: Excision of LA myxoma

  1. Chest opened by median sternotomy
  2. Pericardial patch harvested.
  3. Aorta, RA/IVC cannulation done.
  4. Ante grade delnido plegia given.
  5. Cooled to 32°Celsius
  6. Both caval looped and snared.
  7. RA opened. Intra atrial septum incised.

Findings

Left atrial myxoma (5*3cm) seen arising from theseptum and extending upto the mitral valve

Procedure

  • LA myxoma with a portion of the septum excised.
  • Defect in the septum closed with a pericardial patch using
  • 5-0 prolene sutures.
  • RA closed in 2layers using 5-0 prolene sutures.
  • Patient rewarmed. Weaned from CPB.
  • DE cannulation done.
  • Sites reinforced
  • Chest closed with steel wires after placing 1 right pleural
  • &1 mediastinal drains.
  • Specimen sent for HPE.

LA Mass

Benefits of excision of LA Myxoma

The results of surgical excision are good with a low risk of morbidity and mortality (0% to 3%). Recurrence of atrial myxomas is infrequent. Therefore, regular echocardiographic follow up is recommended in latter group.

Post-operative period

  • POD:
  1. Patient received from HCOT with AMBU bag ventilation then connected with mechanical ventilator.
  • Mode – SIMV (PRVC+PS)
  • Fio2 -100%, PEEP- 5cmof H2O, TV-450ml
  1. Patient vitals were stable.
  2. She was managed with necessary supports
  • Adrenaline 1.5ml/hr.
  • NTG 0.1ml/hr.
  1. Total ICD drain – 20ml
  2. Every 4h patient was given back care and ET suctioning
  3. Antibiotic Inj. Supacef 1.5g IV TDS administered.

1st POD

  1. Patient vitals are stable.
  2. Extubation done.
  3. She was managed with Inj.Adrenaline 1.5ml/hr. and Inj.Fentanyl 2ml/hr.
  4. Early morning patient was given mouth care, combing and dressing done.
  5. Total ICD drain -120ml.

2nd POD

  1. Patient vitals are stable.
  2. K – 3.3mmol/L .Inj.KCL 10 mEq in 100ml NS correction given.
  3. ICD removed.

3rd POD

  1. Patient vitals are stable.
  2. K- 3.6mmol/L ,Inj.KCL 20mEq in 100ml NS correction given
  3. CVC removed.

4th POD

  1. Patient vitals are stable.
  2. Patient c/o vomiting, Inj.Emeset 4mg IV stat given.
  3. Patient shift to ward with stable status and no complaints.
S.NName of the
Investigation
0 - POD1st POD2nd POD3rd POD4th POD
1Hb-10.59.49.79.9
2PCV-28.929.530.9
3Urea-23.5423.5419.2623.54
4Creatinine-0.730.570.570.55
5Na137138135135138
6K3.23.93.83.83.61
7Ph7.417.38---
8PO2360176---
9PCo23234---
10HCO322.121.5---
11Glucose261168---

Nursing challenges

Decreased Cardiac Output or ineffective cardiac function

Rationale: The myxoma can obstruct blood flow through heart valves (e.g., mitral valve), leading to reduced blood pumped by the heart.

Ineffective breathing pattern or impaired gas exchange

Rationale: Left-sided myxomas can cause left-sided heart failure, leading to pulmonary edema, which impairs gas exchange and causes symptoms like dyspnea (shortness of breath).

Activity intolerance

Rationale: The increased workload on the heart from obstruction and potential heart failure results in reduced exercise tolerance and fatigue.

Risk for ineffective tissue perfusion (or Risk for Stroke/Embolism):

Rationale: The tumor can fragment or dislodge, sending emboli (clots) to other parts of the body, such as the brain, causing a stroke.

Fatigue

Rationale: Can be a result of decreased cardiac output, chronic inflammation from the tumor, or constitutional symptoms like weight loss.

Excess fluid volume

Rationale: Right-sided myxomas can lead to right-sided heart failure, resulting in fluid retention and systemic edema (swelling).

Risk for impaired skin integrity

Rationale: May arise from decreased peripheral perfusion or immobility secondary to severe symptoms.

Nursing management

Pre-operative nursing management

Patient education

Explain the diagnosis, prognosis, surgical procedure, and potential risks and benefits in a clear and understandable way.

Symptom management

Address specific symptoms such as dyspnea, chest pain, or embolic phenomena through appropriate medical interventions and supportive care.

Psychological support

Provide emotional support and reassurance to help alleviate anxiety related to the surgery and potential outcomes.

Risk assessment

Identify and manage risk factors such as a history of stroke or thrombocytopenia, which may require specific peri-operative interventions like platelet transfusions.

Post-operative Nursing Management

Cardiac monitoring

Continuously monitor vital signs, heart rate, rhythm, and cardiac output to detect any signs of complications or functional decline.

Respiratory care

Encourage deep breathing exercises, use of an incentive spirometer, and regular repositioning to prevent atelectasis and pneumonia.

Pain management

Administer analgesics as prescribed to control post-operative pain, which is crucial for patient comfort and mobilization.

Fluid and electrolyte balance

Monitor fluid intake and output and maintain electrolyte balance to prevent complications.

Mobility and rehabilitation

Implement early mobilization and physical therapy to prevent deep vein thrombosis (DVT), enhance lung aeration, improve functional efficiency, and prevent pressure sores.

Wound care

Provide meticulous care to the surgical incision to prevent infection and promote healing.

Psychosocial support

Continue to provide emotional support and monitor the patient’s psychological well-being during the recovery period.

Education for dDischarge:

Educate the patient and family on medication, wound care, activity restrictions, signs of complications, and the importance of long-term follow-up and echocardiographic monitoring for the possibility of recurrence.

Reference

  • Shah IK, Dearani JA, Daly RC, Suri RM, Park SJ, Joyce LD, et al. Cardiac myxomas: a 50-year experience with resection and analysis of risk factors for recurrence. Ann Thorac Surg. (2015) 100:495–500. doi: 10.1016/j.athoracsur.2015.03.007 – DOI – PubMed
  • Tyebally S, Chen D, Bhattacharyya S, Mughrabi A, Hussain Z, Manisty C, etal. Cardiac tumors: JACC cardio Oncology state-of-the-art review. JACC CardioOncol. (2020) 2:293–311. doi: 10.1016/j.jaccao.2020.05.009 – DOI – PMC – PubMed
  • Carney JA, Gordon H, Carpenter PC, Shenoy BV, Go VL. The complex of myxomas, spotty pigmentation, and endocrine over activity. Med (Baltimore). (1985) 64:270–83. doi: 10.1097/00005792-198507000-00007 – DOI – PubMed
  • Stratakis CA, Kirschner LS, Carney JA. Clinical and molecular features of the Carney complex: diagnostic criteria and recommendations for patient evaluation. J Clin Endocrinol Metab. (2001) 86:4041–6. doi: 10.1210/jcem.86.9.7903 – DOI – PubMed
  • Bouys L, Bertherat J. Management of endocrine disease: Carney complex: clinical and genetic update 20 years after the identification of the CNC1 (PRKAR1A) gene. Eur J Endocrinol. (2021) 184:R99–R109. doi: 10.1530/EJE-20-1120 – DOI – PubMed

 

Nightingale Journals

Kauvery Hospital
Find Doctor
Book Appointment