Increased mitral inflow velocity and prolonged pressure halftime on
pulsed wave Doppler recordings indicated a blockage of the blood flow to
the left ventricle. No color flow was observed through the mass. Bone
marrow biopsy, immunohistochemichal evaluation, genetic testing and
translocation analysis showed BCR-ABL translocation t(9;22) p210
transcription positive chronic myeloid leukemia. A left atrial neoplasm
(primary or metastatic) was the presumptive diagnosis, and surgical
exploration was planned. Coronary angiography revealed normal coronary
arteries.
After the patient was appropriately positioned, the right lung was
deflated. A 3- to 4-cm right inframammary thoracotomy lateral to the
nipple was made and the pleural cavity was entered through the
4th intercostal space (ICS). Trocars were placed in
the third and fifth ICS. A working port and camera trocar were placed
through the incision. Considering that a dynamic mitral retractor might
be necessary during the operation, another trocar was inserted through
the submammary 4th ICS. Femoral arterial and venous
cannulation was made to establish perfusion. An additional second venous
drainage cannula was inserted percutaneously in the SVC via right
internal jugular vein. Cardiopulmonary bypass was established and
pericardial entry and suture retractions were made. External inspection
of the mediastinium showed no evidence of infiltrating mass or
pericardial adhesions. Antegrade cardioplegia needle placement in the
ascending aorta was followed by introduction of a transthoracic aortic
cross clamp (Chitwood clamp) through the transverse sinus in the
2nd ICS in the posterior axillary line and deployed.
Myocardial protection was provided by systemic cooling (28°C) and
cold-blood cardioplegia. Left atriotomy was made and an intramural mass
was observed in the posterior wall of the LA bulging into the cavity. No
infiltration in and outside of the LA wall was found. The endocardium
was incised and several pieces of yellow-cream colored elastic tissue
were excised from a non-encapsulated cavity (Figure 2).
Figure 2: Intraoperative image. MV, Mitral Valve; *, yellow-cream
colored elastic tissue localized in the posterior left atrial wall;
dotted line, left atrial wall.