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• Does excision of an atrial myxoma qualify as an emergency procedure?
  Mohammad B. Izzat, Hazem Aljasem and Ahmad W. Izzat
  Published on: 10 December 2021

• Published on: 10 December 2021

  Does excision of an atrial myxoma qualify as an emergency procedure?

  • Mohammad B. Izzat, Associate Professor of Cardiac Surgery Damascus University Faculty of Medicine
  • Other Contributors:
    • Hazem Aljasem, Senior Resident in Cardiac Surgery
    • Ahmad W. Izzat, Research Assistant

  To the Editor
  We read with interest the recent review by Griborio-Guzman AG et al [1] of the clinical presentation, diagnosis and management of cardiac myxomas. The authors highlighted that cardiac myxomas should be managed with prompt resection. Yet, the question of whether excision of an atrial myxoma qualifies as an emergency procedure remains unanswered.
  In an attempt to address this question, we constructed a “best evidence topic” according to a structured protocol, as described previously [2]. A comprehensive MEDLINE literature search was conducted utilizing the PubMed interface (1966-August 2021) using the keywords: [(atrial myxoma) OR (cardiac myxoma) OR (heart myxoma)] AND [(resection) OR (removal) OR (excision)] AND [(emergency) OR (urgent) OR (immediate) OR (prompt)]. References of selected articles were then reviewed to detect relevant publications that did not come up with the original search. Two hundred and fifty-six papers were found using the reported search. From these, 11 papers were identified that provided best evidence to answer the question, all of them were single-group case-series.
  In one of the earliest clinical series, Semb et al [3] emphasized that surgery should be performed as soon as the diagnosis is made, and observed that tumour fragmentation and embolization was more likely to occur when a lobulated, gelatinous and fragile myxoma was located in the central bloodstream.
  Livi et al [4] reported that sudden death could...

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  To the Editor
  We read with interest the recent review by Griborio-Guzman AG et al [1] of the clinical presentation, diagnosis and management of cardiac myxomas. The authors highlighted that cardiac myxomas should be managed with prompt resection. Yet, the question of whether excision of an atrial myxoma qualifies as an emergency procedure remains unanswered.
  In an attempt to address this question, we constructed a “best evidence topic” according to a structured protocol, as described previously [2]. A comprehensive MEDLINE literature search was conducted utilizing the PubMed interface (1966-August 2021) using the keywords: [(atrial myxoma) OR (cardiac myxoma) OR (heart myxoma)] AND [(resection) OR (removal) OR (excision)] AND [(emergency) OR (urgent) OR (immediate) OR (prompt)]. References of selected articles were then reviewed to detect relevant publications that did not come up with the original search. Two hundred and fifty-six papers were found using the reported search. From these, 11 papers were identified that provided best evidence to answer the question, all of them were single-group case-series.
  In one of the earliest clinical series, Semb et al [3] emphasized that surgery should be performed as soon as the diagnosis is made, and observed that tumour fragmentation and embolization was more likely to occur when a lobulated, gelatinous and fragile myxoma was located in the central bloodstream.
  Livi et al [4] reported that sudden death could occur due to complete obstruction of valvular orifice, and this convinced the authors of the necessity of a prompt operation once the diagnosis is made, regardless of the size and location of the tumour.
  Sugimoto et al [5] believed that a cardiac myxoma should be excised as soon as possible because it may produce serious complications. While optimal timing of surgery after the onset of embolic complications (especially cerebral or myocardial infarction) remained controversial, the authors believed that early surgery may have to be performed when there is a threat of new embolic events.
  Lijoi et al [6] advocated that surgical excision is undertaken as soon as possible after diagnosis in order to avoid such complications as systemic embolization and valvular incompetence with rapid deterioration.
  Meyns et al [7] noted that embolization was not related to the size of the myxoma, but was dictated by the friability of the tissues. The authors recommended immediate excision of atrial myxoma once the diagnosis is established.
  Keeling et al [8] highlighted that embolization risk was increased in patients presenting with a cardiac rhythm other than sinus rhythm, and in large, left-sided, polypoid and mitral valve myxomas. Their study concluded that immediate resection of cardiac myxomas should be performed to prevent sudden death and embolic events and that, by immediate resection, these risks may be very low.
  Selkane et al [9] advocated that surgery for cardiac myxoma should comply with the usual recommendations for preoperative coronary angiography, and that emergency surgery should be available to acute symptomatic patients and those at a high risk of embolization.
  Khan et al [10] performed immediate surgical treatment in all their patients, and this was associated with low rates of morbidity and mortality. The authors recommended that surgical excision should be carried out without delay, while coronary angiography was advised if coronary artery disease is suspected or if patient’s age was over 40 years.
  Kuroczyński et al [11] recommended urgent resection of cardiac myxomas after establishing the diagnosis to prevent complications such as embolization or obstruction of the mitral orifice. They also recommended performing pre-operative coronary angiography in patients aged over 40 with risk factors for coronary heart disease.
  Garatti et al [12] recommended that surgical excision of cardiac myxomas must be done as soon as possible after the diagnosis is established because of the high risk of valvular obstruction or systemic embolization.
  Lastly, Rushel et al [13] believed that immediate surgical excision was indicated in all patients to prevent sudden death and embolic complications.
  In summary, our “best evidence topic” review indicates that, even though comparative data is lacking, there is sufficient data to indicate that excision of an atrial myxoma qualifies as an emergency procedure in acute symptomatic patients, where acute valvular obstruction was conceivable (such as in large mobile left atrial myxomas) and where tumour embolization was more likely to occur (e.g. lobulated and gelatinous myxomas). Excision of other atrial myxomas can be performed on an urgent basis, which allows for a thorough preoperative optimization and assessment (including coronary angiography).

  References
  1. Griborio-Guzman AG, Aseyev OI, Shah H, Sadreddini M. Cardiac myxomas: clinical presentation, diagnosis and management. Heart. 2021 Sep 7:heartjnl-2021-319479. doi: 10.1136/heartjnl-2021-319479
  2. Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact CardioVasc Thorac Surg 2003, 2:405-9
  3. Semb BKH. Surgical considerations in the treatment of cardiac myxoma. J Thorac Cardiovasc Surg 10984; 87:251-259
  4. Livi U, Bortolotti U, Milano A, Valente M, Prandi A, Frugoni C, de Mozzi P, Valfre C, Mazzucco A, Gallucci V. Cardiac myxomas: results of 14 years' experience. Thorac Cardiovasc Surg. 1984; 32:143-7
  5. Sugimoto T, Ogawa K, Asada T, Mukohara N, Nishiwaki M, Higami T, Kawamura T. Surgical treatment of cardiac myxoma and its complications. Cardiovasc Surg. 1993; 1:395-8
  6. Lijoi A, Scoti P, Faveto C, Canale C, Parodi E, Passerone GC, Dottori V, Venere G. Surgical management of intracardiac myxomas. A 16-year experience. Tex Heart Inst J. 1993; 20:231-4
  7. Meyns B, Vancleemput J, Flameng W, Daenen W. Surgery for cardiac myxoma. A 20-year experience with long-term follow-up. Eur J Cardiothorac Surg. 1993; 7:437-40
  8. Keeling IM, Oberwalder P, Anelli-Monti M, Schuchlenz H, Demel U, Tilz GP, Rehak P, Rigler B. Cardiac myxomas: 24 years of experience in 49 patients. Eur J Cardiothorac Surg. 2002; 22:971-7
  9. Selkane C, Amahzoune B, Chavanis N, Raisky O, Robin J, Ninet J, Obadia JF. Changing management of cardiac myxoma based on a series of 40 cases with long-term follow-up. Ann Thorac Surg. 2003; 76:1935-8
  10. Khan MA, Khan AA, Waseem M. Surgical experience with cardiac myxomas. J Ayub Med Coll Abbottabad. 2008; 20:76-9
  11. Kuroczyński W, Peivandi AA, Ewald P, Pruefer D, Heinemann M, Vahl CF. Cardiac myxomas: short- and long-term follow-up. Cardiol J. 2009; 16:447-54
  12. Garatti A, Nano G, Canziani A, Gagliardotto P, Mossuto E, Frigiola A, Menicanti L. Surgical excision of cardiac myxomas: twenty years’ experience at a single institution. Ann Thorac Surg. 2012; 93:825-31
  13. Rushel SS, Mandal SC, Moinuddin S, Alamgir MK. Surgical Treatment of Cardiac Tumours: a 17-year Experience at Department of Cardiac Surgery, NICVD, Dhaka. Mymensingh Med J. 2019; 28:562-566

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  Conflict of Interest:
  None declared.

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