Surg Today (2005) 35:1092–1094 DOI 10.1007/s00595-004-3086-9

How to Do It Intraoperative Endoscopic Resection of Left Ventricular Tumors Takahiko Misumi1, Mikihiko Kudo1, Kiyoshi Koizumi1, Masataka Yamazaki1, Motohito Nakagawa2, and Hiroya Kumamaru1 Divisions of 1 Cardiovascular Surgery and 2 Surgery, Hiratsuka City Hospital, 1-19-1 Minamihara, Hiratsuka 254-0065, Japan

Abstract Two cases involving patients who underwent a successful endoscopic resection of a left ventricular tumor are presented herein. One was an 82-year-old woman with a left ventricular papillary fibroelastoma, who underwent previous coronary artery bypass grafting. In an attempt to make the procedure less invasive, we used an endoscope. With a full sternotomy, cardiopulmonary bypass, and cardioplegic protection, the endoscope was inserted into the left ventricular cavity through the mitral valve. The other patient was a 63-year-old man with left ventricular papillary fibroelastoma, in whom we performed an endoscopic transaortic resection. The endoscope provided an excellent view, and the tumors were easily extracted in both cases without any complications. Key words Endoscope · Cardiac tumor · Cardiac surgery

Introduction With the advent of echocardiography, the chance of detecting asymptomatic intracardiac tumors has increased. The removal of a left ventricular tumor has been performed under direct vision through the atrium (transmitral) and ascending aorta (transaortic), or left ventriculotomy. We have applied intraoperative endoscopic techniques to remove a left ventricular tumor through the mitral and aortic valve in two patients. We have already reported the first case of an endoscopic transmitral resection of a left ventricular papillary fibroelastoma.1 In this paper, we describe this technique in detail.

Operative Technique The operation was performed via a median full sternotomy. Cardiopulmonary bypass was established with either bicaval or single right atrial cannulation and single arterial cannulation. While using cardioplegic protection, the left atrium or ascending aorta was opened. Under direct vision, the inside of the left ventricle was scarcely visible through the mitral or aortic valve. As a result, an endoscope (XQ240; Olympus, Tokyo, Japan) was inserted into the left ventricular cavity through the mitral or aortic valve. The endoscopic operator stood on the left side of the patient in order to manipulate the endoscope easily (Fig. 1). The endoscope provided an excellent view of the left ventricular cavity and a tumor (Fig. 2a). In our cases, the tumor was attached with a stalk to the left ventricular wall. If the tumor was located on the posterior wall, then visualization of the stalk was relatively difficult. In such cases, after filling the left ventricle with a nonconducting solution, for example, 5% d-sorbitol solution, the tumor thus began to float, allowing us to visualize the tumor. Next, the stalk was snared and cut with high-frequency surgery units (ERB ICC200, Tokyo, Japan) (Fig. 2b). The tumor was retrieved using biopsy forceps and then it was removed with the endoscope (Fig. 2c). A prompt histological examination showed the resected margin to be free of any neoplasm. If the resected area appears to be incomplete, then an additional resection can be performed by either endoscopy or a direct ventriculotomy. There were no complications associated with this technique.

Discussion

Reprint requests to: T. Misumi Received: February 13, 2004 / Accepted: November 16, 2004

The technique described above was performed on two patients. The first was an 82-year-old asymptomatic woman who underwent coronary artery bypass grafting

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about 10 years previously. Echocardiography detected a mobile tumor, measuring 1.5 cm in diameter, which was attached with a short stalk to the anterolateral wall of the left ventricle. Preoperative coronary arteriography

Fig. 1. The endoscope was inserted into the left ventricular cavity through the aortic valve. The operator stood on the left side of the patient and manipulated the endoscope

a

c

revealed all bypass grafts to be patent. In an attempt to make the procedure less invasive and prevent graft injury, a minimum dissection, which was confined to the right side of the heart and the site of the aortic crossclamp, was performed. Under cardiopulmonary bypass and cardioplegic arrest, the right-side left atrium was incised. However, under direct vision, the inside of the left ventricle was scarcely visible through the mitral valve. As a result, we inserted the endoscope through the mitral valve and resected the tumor by the method described above. The tumor was easily resected and retrieved. A histological examination revealed the tumor to be a papillary fibroelastoma and the margin was free of any neoplasm. The second patient was a 63-year-old man with transient atrial fibrillation. Echocardiography occasionally detected a mobile left ventricular tumor, which measured about 2.0 cm in diameter and was attached with a stalk to the posterolateral wall of the left ventricle. Under cardiopulmonary bypass and cardioplegic arrest, the ascending aorta was opened. Under direct vision, the tumor was difficult to detect through the aortic valve. Although this patient was not a high-risk case, we preferred using and endoscope to perform a left ventriculotomy. The tumor, a

b

Fig. 2a,b. Endoscopic view of the tumor. a The tumor was attached to the left ventricular wall. The arrows indicate the tumor. b The resected margin after removing the tumor. The arrow indicates the residual margin. c The operative specimen retrieved by the biopsy forceps

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papillary fibroelastoma, was thus easily resected and retrieved. A primary cardiac tumor is a rare disorder, especially in the case of a left ventricular tumor. The removal of left ventricular tumors has been performed through the left atrium, the aorta, or both. When a tumor is located comparatively deep inside the left ventricle, then the exposure of the tumor is difficult through either the mitral or aortic valve, and an additional left ventriculotomy may thus be required.2,3 In our first patient, of advanced age and with redo surgery, we used an endoscope to make the procedure less invasive. The manipulation of the endoscope was easier than expected. The identification and excision of the tumor was accomplished within a short time. In our second case, the need to use an endoscope did not seem definitive. However, based on our experience from the first case, our preference was to use an endoscope. To the best of our knowledge, there has been no previous report of an endoscopic resection of a left ventricular tumor in the literature except for our cases. Burke et al. used cardioscopy in a congenital lesion of the heart to avoid vigorous cardiac manipulation and an extensive incision.4 Li et al. reported a technique using video-assisted cardioscopy for the removal of a deep-seated left ventricular myxoma.5 However, neither of them used hard cardioscopy and the resection was not performed by the cardioscopy itself. The endoscope is generally accepted and recognized for its easy manipulation and flexibility. The technique of an endoscopic resection for gastrointestinal tumors has been well established among general surgeons. As a result, we applied this technique to cardiac surgery.

There are two approaches into the left ventricular cavity, namely the transaortic and transmitral approach. Having used both routes, we could find neither approach to be superior to the other. When utilizing this technique, the shape, quality, and location of the tumor seem to be very important. The tumor should be an appropriate size and have a stalk or a narrow neck base, and thus not be easily disrupted during the resection. For the sake of less invasive surgery, it is possible to perform an endoscopic resection in a port access field. However, we preferred to perform a standard sternotomy, due to the danger of possibly having to carry out a ventriculotomy. Our results may not justify the routine use of an endoscope for the resection of left ventricular tumors; however, in selected cases, this technique was found to be a useful option.

References 1. Kudo M, Misumi T, Koizumi K, Suzuki T, Nakagawa M. Intraoperative transmitral endoscopic resection of left ventricular tumor. J Jpn Thorac Cardiovasc Surg 2004;52:308–10. 2. Murphy MC, Sweeney MS, Putnam JB, Walker WE, Frazier OH, ott DA, et al. Surgical treatment of cardiac tumors: 25-year experience. Ann Thorac Surg 1990;49:612–8. 3. Cooley DA. Surgical treatment of cardiac neoplasms: 32-year experience. Thorac Cardiovasc Surg 1990;38:176–86. 4. Burke RP, Michielon G, Wernovsky G. Video-assisted cardioscopy in congenital heart operation. Ann Thorac Surg 1994;58:864– 8. 5. Li JY, Lin FY, Hsu RB, Chu SH. Video-assisted cardioscopic resection of recurrent left ventricular myxoma. J Thorac Cardiovasc Surg 1996;112:1673–4.