Original Cardiovascular

Right Anterolateral Minithoracotomy versus

Median Sternotomy Approach for Resection of
Left Atrial Myxoma
Nian Guo Dong1 Kai Lun Zhang1 Long Wu1 Hao Hong1

1 Department of Cardiovascular Surgery, Union Hospital, Tongji Address for correspondence Hao Hong, MD, Department of
Medical College, Huazhong University of Science and Technology, Cardiovascular Surgery, Union Hospital, Tongji Medical College,
Wuhan, Hubei, PR China Huazhong University of Science and Technology, 1277 Jiefang Road,
Wuhan, 430022, China (e-mail: [email protected]).
Thorac Cardiovasc Surg

Abstract Background Minimally invasive surgery has become the standard approach for several
cardiac diseases. In this retrospective study, we compared right anterolateral mini-

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thoracotomy (RALT) with standard median sternotomy (SMS) for resection of left atrial
myxoma (LAM).
Materials and Methods From January 2009 to June 2015, the clinical data of patients
who underwent RALT (n ¼ 30) and SMS (n ¼ 36) for resection of LAM in our hospital
were collected. The preoperative clinical data and operative results were compared
between the two groups.
Results There were no significant differences in aortic cross-clamp and cardiopulmo-
nary bypass time between the two groups. The total incision length was significantly
shorter in RALT group compared with SMS group (p < 0.001). For RALT and SMS groups,
respectively, the intensive care unit length of stay was 29.2  6.5 versus 43.5  6.9
hours (p < 0.001), and the postoperative hospital length of stay was 5 days (inter-
quartile range [IQR]: 4–6) versus 8 days (IQR: 7–10) (p < 0.001). The total cost in RALT
group was 27,000 RMB (IQR: 25,000–29,000) versus 33,000 RMB (IQR: 31,000–35,000)
Keywords in SMS group (p < 0.001). There were no significant differences in mortality and
► minimally invasive postoperative complications between the two groups.
surgery Conclusion RALT approach for LAM resection can be performed safely with favorable
► myxoma cosmetic outcome, accepted clinical results, and lower cost. It should be considered as a
► incisions promising alternative to SMS and merit additional study.

Introduction metic outcome and possible complications of SMS are major

troublesome.6 Nowadays, the minimally invasive approach
Left atrial myxoma (LAM) is the most common type of heart for various surgical procedures has gained accepted momen-
tumor in adults and surgical removal should be performed as tum and is becoming a conventional practice in mitral, aortic,
soon as possible because of the risk of valvular obstruction or tricuspid, and coronary surgery.7 The minimally invasive
embolization.1–3 The long-term prognosis is excellent after approach, via a right anterolateral minithoracotomy (RALT)
complete tumor excision and recurrences are rare.3–5 Exci- in the fourth intercostal space, is another option for LAM
sion of LAM is traditionally made through standard median resection in our hospital. In this study, we reported our
sternotomy (SMS), cardiopulmonary bypass (CPB), and car- experiences for patients who underwent RALT or SMS for
dioplegic arrest of the heart. However, the unpleasant cos- LAM resection between January 2009 and June 2015 in our

received © Georg Thieme Verlag KG DOI http://dx.doi.org/

March 21, 2016 Stuttgart · New York 10.1055/s-0036-1584269.
accepted after revision ISSN 0171-6425.
April 22, 2016
RALT versus Median Sternotomy Approach for Resection of Left Atrial Myxoma Dong et al.

hospital. The aims of this retrospective study were to compare mitral valve was inspected and examined revealing a compe-
the safety, efficacy, cosmetic outcome, and cost between the tent valve. Atrial septal was reconstructed with a Dacron
two approaches. patch, (Boston Scientific Ltd., St. Albans, United Kingdom),
before closure of the left atrium. The left atriotomy was closed
using double-layer continuous Prolene 4–0 (Ethicon, Somer-
Materials and Methods
ville, New Jersey, United States) running sutures. Once the
Preoperative Clinical Data patient was weaned from CPB, a TEE control was always
After obtaining approval from the Institutional Review Board, performed to look for residual tumor, adequate removal of air,
we retrospectively collected the medical data of 30 patients and a residual interatrial shunt. Pericardial and pleural drains
who underwent RALT and 36 patients who underwent SMS were inserted. The thoracotomy was closed and the femoral
between January 2009 and June 2015. LAM was diagnosed vessels were decannulated.
using transthoracic echocardiography (TTE) performed by
experienced echocardiographers. Patients underwent LAM Standard Median Sternotomy Group
resection by the same surgical team in RALT and SMS groups. Surgery was performed via full median sternotomy, under
Selection for one of the two approaches was chosen by CPB, mild hypothermia, topical cooling, and hyperkalemic
specialists’ recommendation and the patients. All patients cardioplegia. Aortic and bicaval cannulation was always
were fully informed about two approaches and gave consent performed. Special attention was taken to avoid cardiac

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before the operation. manipulation before aortic cross-clamping to prevent tumor
fragmentation and systemic embolization. The exposure and
resection of the LAM, as well as the reconstruction of atrial
Surgical Technique
septal, were the same as described in RALT group. Once CPB
Right Anterolateral Minithoracotomy Group had ceased, the chest and pericardium were drained. The
After induction of general anesthesia, a double-lumen endo- pericardium was closed, and the thoracotomy incision was
tracheal tube was placed to allow for single-lung ventilation. closed in the routine fashion.
The patients were placed in the supine position with the right
side of the body elevated approximately 30 degrees. Trans- Postoperative Evaluation and Follow-Up
esophageal echocardiography (TEE) was performed in all Postoperatively, the patients were monitored in the intensive
patients. care unit (ICU). Pathological examination of the resected
The RALT approach was always a small thoracotomy in the tumor was performed. All patients underwent baseline clini-
fourth intercostal space. A right submammary incision was cal examination, electrocardiography, chest radiography, and
made through the fourth intercostal space. The subcutis was TTE before discharge and at 3 and 12 months postdischarge.
cut straight down to the fascia to avoid injury of mammary
gland tissue in female. Subcutaneous fat and the mammary Statistical Analysis
gland tissue were dissected from the fascia up to the fourth Continuous variables with normal distributions were expressed
rib. The pectoralis muscle was cut in horizontal direction. as mean  standard deviation, and continuous variables with
Subsequently, the thoracic cavity was entered through the nonnormal distributions were expressed as median and inter-
fourth intercostal space. The lung was retracted posteriorly quartile range (IQR). To compare continuous variables between
using wet sponges to expose the pericardium. The pericar- groups that had a normal distribution, an independent t-test was
dium was opened longitudinally 2 cm above the phrenic used. Continuous variables that did not exhibit a normal distri-
nerve which is always visible. An adequate exposure was bution were compared with a Mann–Whitney U test. All dichot-
achieved by traction on pericardial stay sutures. After heparin omous variables were compared using 2 analysis. Data were
administration, cannulations were performed. Aorta was analyzed using SPSS software (Version 17.0; SPSS Inc, Chicago,
cannulated through femoral artery. The superior vena cava Illinois, United States). A p < 0.05 was considered statistically
was cannulated through right jugular vein. The inferior vena significant.
cava was cannulated through femoral vein. An aortic perfu-
sion needle was inserted in the aorta through the purse string
Results
suture. When core body temperature had decreased to 32°C,
Chitwood clamp (Scanlan International, Inc., St. Paul, Minne- ►Table 1 demonstrates the preoperative clinical data in each
sota, United States) was introduced through the small incision group. Patients in RALT group had a mean age of 56  6.5
in the third intercostal space on the anterior axillary line and years, and 24 (80%) were female. The SMS group consisted of
occluded the ascending aorta under direct view. Cold blood 36 patients with a mean age of 53.9  5.9 years, and 27 (75%)
cardioplegic solution was used for myocardial protection. were female. Age, sex, body mass index, ejection fraction,
After snaring of the superior and inferior vena cava, the left preoperative creatinine, history of prior heart failure, coro-
atrium was opened through an 8 cm longitudinal incision, nary artery disease, hypertension, diabetes mellitus, cerebro-
posterior to Waterstone groove and the mitral retractor was vascular accident, and chronic obstructive pulmonary disease
applied. A meticulous dissection was made to ensure com- did not differ significantly between RALT and SMS groups.
plete debridement without any residues. Complete myxoma Pathological examination demonstrated that the resected
resection was assessed and confirmed by direct vision. The tumor was LAM in all patients. ►Table 2 demonstrates the

Thoracic and Cardiovascular Surgeon

 RALT versus Median Sternotomy Approach for Resection of Left Atrial Myxoma Dong et al.

Table 1 Preoperative clinical data

RALT group SMS group p-Value

(n ¼ 30) (n ¼ 36)
Age (y) 56.0  6.5 53.9  5.9 0.171
Female 24 (80) 27 (75) 0.629
BMI 21.7  1.8 22.6  2.1 0.083
EF 63 (56–65) 60 (55–63) 0.061
Preoperative creatinine (mg/mL) 0.77  0.13 0.75  0.12 0.481
Prior heart failure 2 (6.7) 3 (8.3) 1.000
Coronary artery disease 1 (3.3) 2 (5.6) 1.000
Hypertension 12 (40) 18 (50) 0.417
Diabetes mellitus 5 (16.7) 8 (22.2) 0.572
CVA 3 (10) 3 (8.3) 1.000
COPD 1 (3.3) 1 (2.8) 1.000

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Abbreviations: BMI, body mass index; COPD, chronic obstructive pulmonary disease; CVA, cerebrovascular accident; EF, ejection fraction; RALT, right
anterolateral minithoracotomy; SMS, standard median sternotomy.
Note: Data presented as mean  standard deviation, median (interquartile), or n (%).

Table 2 Operative results

RALT group SMS group p-Value

(n ¼ 30) (n ¼ 36)
Cross-clamp time (min) 50.2  5.8 47.6  5.9 0.078
CPB (min) 87.8  10.4 83.6  8.4 0.076
Units PRBC transfused 3.1  0.7 3.3  0.6 0.077
ICU length of stay (h) 29.2  6.5 43.5  6.9 < 0.001
Myxoma dimension
Length (mm) 44.5  2.7 45.9  3.6 0.073
Width (mm) 31.2  4.2 29.4  5.1 0.124
Length of hospital stay (d) 5 (4–6) 8 (7–10) < 0.001
Mortality 0 0
Total incision length (cm) 12 (11–13) 18 (16–20) < 0.001
Postoperative complications 2 (6.7) 3 (8.3) 1.000
Reoperation for bleeding 0 0
Prolong ventilation 1 (3.3) 1 (2.8) 1.000
Pneumonia 0 0
Cardiac arrhythmia 1 (3.3) 2 (5.6) 1.000
CVA 0 0
Renal failure 0 0
Wound infection 0 0
Residual tumor 0 0
Recurrent tumor 0 0
Residual interatrial shunt 0 0
Total cost (RMB) 27,000 (25,000–29,000) 33,000 (31,000–35,000) < 0.001

Abbreviations: CPB, cardiopulmonary bypass; CVA, cerebrovascular accident; ICU, intensive care unit; PRBC, packed red blood cells; RALT, right
anterolateral minithoracotomy; RMB, Renminbi, the Chinese currency; SMS, standard median sternotomy.
Note: Data presented as mean þ standard deviation, median (interquartile), or n (%).

Thoracic and Cardiovascular Surgeon

RALT versus Median Sternotomy Approach for Resection of Left Atrial Myxoma Dong et al.

operative profiles in each group. The aortic cross-clamp and not significantly increased with RALT approach (►Table 2). In
CPB time for RALT group were 50.2  5.8 and 87.8  10.4 addition, when compared with SMS group, our study did
minutes, respectively; for SMS group, they were 47.6  5.9 demonstrate a shorter length of ICU and postoperative
and 83.6  8.4 minutes, p ¼ 0.078 and p ¼ 0.076, respective- hospital stay in RALT group. These reductions in the lengths
ly. The dimensions of myxoma were similar in two groups of stay are most likely due to the following reasons: (1)
(p ¼ 0.073 and p ¼ 0.124). The incisions included RALT inci- enhanced recovery noted with minimally invasive surgery;
sion, incision for Chitwood clamp, incision for intraoperative (2) less surgical trauma and less pain; and (3) a faster return to
drainage, incision for postoperative drainage, and femoral normal activity.12–14 As length of stay may be considered a
incision. The total incision length was significantly shorter in surrogate marker for resource use, a prolonged length of stay
RALT group compared with SMS group (p < 0.001). There was increases hospital cost at all levels.15,16 Previous reports
no conversion from RALT approach to SMS. For RALT and SMS showed that shorter hospital stay resulting from a minimally
groups, respectively, the ICU length of stay was 29.2  6.5 invasive approach has been equated to a 7 and 34% cost
versus 43.5  6.9 hours (p < 0.001), and the postoperative saving, respectively.17,18 Similar results were noted in our
hospital length of stay was 5 days (IQR: 4–6) versus 8 days study, when we analyzed the cost data in two groups. The
(IQR: 7–10) (p < 0.001). The total cost in RALT group was reduction in the length of ICU and hospital stay in RALT group
27,000 RMB (IQR: 25,000–29,000) versus 33,000 RMB (IQR: did equate to a reduction in total hospitalization cost.
31,000–35,000) in SMS group (p < 0.001). This was a short-term, single-center, retrospective study of

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There was no significant difference in the number of blood a heterogeneous group of patients. The follow-up was limited
transfusions and the incidence of reoperation for bleeding to 12 months. Thus, a prospective randomized controlled
between the two groups. In two groups, follow-up was clinical trial with long-term follow-up to compare RALT with
completed for all patients at 3 and 12 months after discharge. SMS approach will be needed to make more definitive
Composite postoperative complications were 2 (6.7%) in RALT recommendations.
group and 3 (8.3%) in SMS group (p ¼ 1.000). There were also
no significant differences in the incidence of individual
Conclusion
components of postoperative complications between the
two groups. There was no evidence of residual tumor, recur- RALT approach for the resection of LAM can be performed
rent tumor, residual interatrial shunt, and death in the two safely with favorable cosmetic outcome, accepted clinical
groups during hospitalization and follow-up. results, and lower cost. It should be considered as a promising
alternative to SMS and merit additional study.

Discussion
LAM resection via SMS has been demonstrated as a safe surgery,
Funding
with minimal mortality and a minimal rate of recurrence and
This work was supported by grants from the National
this approach is considered as a routine approach in such cases.8
Natural Science Foundation of China (grand number
As technology advances, the minimally invasive approach is
81300174, 31330029) and Research Fund for the Doctoral
becoming more popular in routine cardiac surgery practice.
Program of Higher Education of China (fund number
Although initially more complicated for the surgeon, this type
20120142120078).
of surgery can potentially lessen incisional pain, minimize inci-
sional length, improve cosmetic results, decrease morbidity,
enhance functional recovery, and shorten hospital stay.9 The
Conflict of Interest
RALT approach is an excellent route to the interatrial cavity. It has
None declared.
provided surgeons with a satisfying surgical field and provided
the patients with cosmetic satisfaction, especially for young
women. Small and low chest wall incisions were used in RALT
approach. The incision can be hidden, with minimal dermatic References
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Thoracic and Cardiovascular Surgeon