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• W1964600802 abstract "Talwalkar and associates [1Talwalkar N.G. Livesay J.J. Treistman B. Lacle C.E. Mobilization of the anterior mitral leaflet for excision of a left ventricular myxoma.Ann Thorac Surg. 1999; 67: 1476-1478Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar] recently published an alternative operative approach for excision of rare left ventricular myxoma. A left atrial approach was used with mobilization of the anterior mitral valve leaflet to enhance exposure of the subvalvar region and facilitate excision of a left ventricular myxoma, which was entangled within the chordal apparatus and lay between the anterolateral papillary muscle and the left ventricular wall. After tumor excision, the detached mitral leaflet was reattached to the annulus. A separate transventricular or transaortic approach was thus avoided. We congratulate Talwalkar and associates on their positive result.This method seems to be especially valuable if the myxoma is attached to the anterolateral papillary muscle tissue. In this special case, where a left-sided transatrial exposure alone may be difficult to achieve without risking damage to the subvalvar apparatus of the mitral valve, the method offers an elegant approach. Tear stress to the thin chordae, and possibly disrupture of the tumor, might otherwise occur while opening the mitral valve apperture with a clamp. According to the authors, other aspects of using a transleaflet access, include avoiding a ventriculotomy with possible damage to small coronary artery branches, or a transaortic approach with an increased risk for systemic embolization.On the other hand, we would like to draw attention to some hazards inherent in this method, and we therefore only consider it useful in those patients where other means are not likely to be successful. We list some items of concern below as we found a detailed discussion also missing from the article. (1) Scar healing of mitral valve tissue will eventually damage the valve apparatus; and (2) A transaortic approach may be feasible in these cases as well. Clamping the ascending aorta for bypass and applying thorough suction throughout removal of the myxoma will usually prevent systemic embolization.Recently, we operated on a patient for mitral valve myxoma using a transaortic resection. The tumor emerged from the ventricular side of the anterior valve leaflet. Intraoperatively, after dissection of the left atrium and transverse aortotomy, the large broad-based myxoma, 4 cm in diameter, became visible as it nearly reached the supraventricular area of the ascending aorta. Transaortic inspection revealed that the relatively soft tumor arose with a broad basis from parts of the anterior papillary muscle and from the backside of the anterior mitral valve leaflet. Tumor resection was followed by inspection of both atria.In our opinion, in most cases of ventricular myxoma, a transaortic approach may still be the method of choice. However, if the myxoma involves the ventricular side of the mitral valve, or is attached to chordae or the papillary muscle without direct view or direct access, or when gentle separation cannot otherwise be achieved, this alternative method should be used. Postoperatively, a scar is left on the anterior mitral valve leaflet, which might represent a weak point for future problems such as endocarditis, shrinkage, or deformation of the leaflet. Only long-term follow-up will show the value of taking the alternative route. Talwalkar and associates [1Talwalkar N.G. Livesay J.J. Treistman B. Lacle C.E. Mobilization of the anterior mitral leaflet for excision of a left ventricular myxoma.Ann Thorac Surg. 1999; 67: 1476-1478Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar] recently published an alternative operative approach for excision of rare left ventricular myxoma. A left atrial approach was used with mobilization of the anterior mitral valve leaflet to enhance exposure of the subvalvar region and facilitate excision of a left ventricular myxoma, which was entangled within the chordal apparatus and lay between the anterolateral papillary muscle and the left ventricular wall. After tumor excision, the detached mitral leaflet was reattached to the annulus. A separate transventricular or transaortic approach was thus avoided. We congratulate Talwalkar and associates on their positive result. This method seems to be especially valuable if the myxoma is attached to the anterolateral papillary muscle tissue. In this special case, where a left-sided transatrial exposure alone may be difficult to achieve without risking damage to the subvalvar apparatus of the mitral valve, the method offers an elegant approach. Tear stress to the thin chordae, and possibly disrupture of the tumor, might otherwise occur while opening the mitral valve apperture with a clamp. According to the authors, other aspects of using a transleaflet access, include avoiding a ventriculotomy with possible damage to small coronary artery branches, or a transaortic approach with an increased risk for systemic embolization. On the other hand, we would like to draw attention to some hazards inherent in this method, and we therefore only consider it useful in those patients where other means are not likely to be successful. We list some items of concern below as we found a detailed discussion also missing from the article. (1) Scar healing of mitral valve tissue will eventually damage the valve apparatus; and (2) A transaortic approach may be feasible in these cases as well. Clamping the ascending aorta for bypass and applying thorough suction throughout removal of the myxoma will usually prevent systemic embolization. Recently, we operated on a patient for mitral valve myxoma using a transaortic resection. The tumor emerged from the ventricular side of the anterior valve leaflet. Intraoperatively, after dissection of the left atrium and transverse aortotomy, the large broad-based myxoma, 4 cm in diameter, became visible as it nearly reached the supraventricular area of the ascending aorta. Transaortic inspection revealed that the relatively soft tumor arose with a broad basis from parts of the anterior papillary muscle and from the backside of the anterior mitral valve leaflet. Tumor resection was followed by inspection of both atria. In our opinion, in most cases of ventricular myxoma, a transaortic approach may still be the method of choice. However, if the myxoma involves the ventricular side of the mitral valve, or is attached to chordae or the papillary muscle without direct view or direct access, or when gentle separation cannot otherwise be achieved, this alternative method should be used. Postoperatively, a scar is left on the anterior mitral valve leaflet, which might represent a weak point for future problems such as endocarditis, shrinkage, or deformation of the leaflet. Only long-term follow-up will show the value of taking the alternative route. ReplyThe Annals of Thoracic SurgeryVol. 68Issue 6Preview Full-Text PDF" @default.
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• W1964600802 title "Transaortic access for excision of a left ventricular myxoma" @default.
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