Difference between revisions of "Excision of intracardiac tumor"

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{{Infobox surgical procedure
{{Infobox surgical procedure
| anesthesia_type =  
| anesthesia_type = General
| airway =  
| airway = ETT
| lines_access =  
| lines_access = Large bore peripheral IV, arterial line, CVC, +/- Swan
| monitors =  
| monitors = Standard ASA monitors, arterial line, CVP, PA pressure monitoring
| considerations_preoperative =  
| considerations_preoperative =  
| considerations_intraoperative =  
| considerations_intraoperative = CPB
| considerations_postoperative =  
| considerations_postoperative = Disposition to ICU, often remains intubated
}}
}}


Provide a brief summary of this surgical procedure and its indications here.
Provide a brief summary here.
 
== Overview ==
Excision of an intracardiac tumor is a surgical procedure aimed at removing benign or malignant masses within the heart. These tumors, although rare, can interfere with cardiac function and pose risks of embolism, arrhythmia, or obstructive phenomena. Complete surgical resection is often necessary for definitive treatment and symptom relief.  Cardiopulmonary bypass(CPB) is used to arrest the heart for optimal surgical conditions.  Clinical presentation of cardiac tumors can be a triad of common symptoms: obstructive, embolic, systemic symptoms, however patients can also present asymptomatically.
 
=== Indications<!-- List and/or describe the indications for this surgical procedure. --> ===
 
* Intracardiac tumors causing obstructive symptoms
** Incidence and prevalence of cardiac tumors is one of the lowest of all solid organ tumors(0.001-0.03%)<ref name=":0">{{Cite journal|last=Joshi|first=Mihika|last2=Kumar|first2=Siddhant|last3=Noshirwani|first3=Arish|last4=Harky|first4=Amer|date=2020-10-01|title=The Current Management of Cardiac Tumours: a Comprehensive Literature Review|url=https://pmc.ncbi.nlm.nih.gov/articles/PMC7598975/|journal=Brazilian Journal of Cardiovascular Surgery|volume=35|issue=5|pages=770–780|doi=10.21470/1678-9741-2019-0199|issn=1678-9741|pmc=7598975|pmid=33118743}}</ref>
** Tumors are divided into neoplastic and non-neoplastic lesions
*** Benign neoplasm: myxoma, rhabdomyoma, fibroma, lipoma, hamartoma<ref name=":0" />
*** Malignant primary neoplasms: angiosarcomas, rhabdomyosarcomas, lymphoma, Li-Fraumeni Syndrome<ref name=":0" />
* Embolization risk from tumor fragments
** Right sided tumors embolize to the lungs resulting in PE<ref name=":0" />
** Left sided tumors embolize to systemic circulation and can result in CVA, AKI, or peripheral arterial occlusion<ref name=":0" />
* Arrhythmogenic potential
** Tumors of or in close proximity to the AV node can result in heart block<ref name=":0" />
* Malignant or benign intracardiac masses diagnosed incidentally via echocardiography, MRI, or CT
 
 
<nowiki>*</nowiki>Medical management can be used for small, immobile masses.  Typically followed by serial echocardiography for evaluation of growth and development*<ref name=":0" />
 
=== Surgical procedure<!-- Briefly describe the major steps of this surgical procedure. --> ===
 
* TEE (transesophageal echocardiography) used intraoperatively to guide resection and assess results.
* CPB as a topic is beyond the scope of this article but will be discussed briefly with the general steps below
*# Median sternotomy
*#Exposure of the heart
*#Aortic cannulation
*#Right atrial cannulation
*#Insertion of aortic root and the LV vent<ref>{{Cite web|title=Surgical setup for cardiopulmonary bypass through central cannulation|url=https://mmcts.org/tutorial/1663|access-date=2025-06-25|website=MMCTS|language=en}}</ref>
*#Resection of hypertrophic ventricular septum


== Preoperative management ==
== Preoperative management ==
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!System
!System
!Considerations
!Considerations
|-
|Airway
|General endotracheal anesthesia required, assess patient's ability to be bag-masked and intubated.
|-
|-
|Neurologic
|Neurologic
|
|Preoperative neurologic exam, increased risk of CVA given cardiac surgery and use of CPB
|-
|-
|Cardiovascular
|Cardiovascular
|
|Congestive heart failure symptoms may be present: orthopnea, pulmonary edema, pulmonary embolism(PE), LVOT obstruction
|-
|-
|Pulmonary
|Pulmonary
|
|Symptoms related to CHF presentation: dyspnea, orthopnea, hemoptysis(due to pulmonary edema), PE
|-
|-
|Gastrointestinal
|Gastrointestinal
|
|History of esophageal disease, difficulty swallowing, cirrhosis/varices may limit use of TEE
|-
|-
|Hematologic
|Hematologic
|
|Starting H/H, coagulation status given high hemorrhage chance during surgery and use of CPB
|-
|-
|Renal
|Renal
|
|Increased risk of AKI in cardiac surgery and use of CPB
|-
|-
|Endocrine
|Endocrine
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=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===
=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===


=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===
* EKG
* Imaging:
** Chest X-ray
** Chest CT
** Cardiac MRI
** Transesophageal echocardiogram(TEE)
** PET for evaluation of metastatic disease
* Labs:
** CBC, coagulation studies


=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
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=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
* Standard ASA monitors
* Arterial line
* Central access CVP +/- PA pressures(indicated for RV or LV failure)
* Transesophageal echo(TEE)


=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
* General anesthesia with endotracheal intubation.
* Propofol or thiopental may be used, with careful consideration of dose given the myocardial depressant effects and decreased afterload they cause. Etomidate is also an option given its relative lack of effect on the cardiovascular system.


=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
* Supine position for surgical access.
* Shoulder roll
* Arms tucked


=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===


=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
* Typical disposition after cardiac surgery with CPB is the CV-ICU.  Patient's are often intubated and sedated in transport from OR to ICU. 


== Postoperative management ==
== Postoperative management ==


=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
* Intensive care unit (ICU) monitoring initially.
** Often intubated
** Frequently requiring pressors or inotropic agents post-CPB.
* Continuous ECG monitoring for arrhythmias.


=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
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|-
|Unique considerations
|Unique considerations
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|Indications
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Latest revision as of 10:33, 26 June 2025

Excision of intracardiac tumor
Anesthesia type

General

Airway

ETT

Lines and access

Large bore peripheral IV, arterial line, CVC, +/- Swan

Monitors

Standard ASA monitors, arterial line, CVP, PA pressure monitoring

Primary anesthetic considerations
Preoperative
Intraoperative

CPB

Postoperative

Disposition to ICU, often remains intubated

Article quality
Editor rating
Unrated
User likes
0

Provide a brief summary here.

Overview

Excision of an intracardiac tumor is a surgical procedure aimed at removing benign or malignant masses within the heart. These tumors, although rare, can interfere with cardiac function and pose risks of embolism, arrhythmia, or obstructive phenomena. Complete surgical resection is often necessary for definitive treatment and symptom relief. Cardiopulmonary bypass(CPB) is used to arrest the heart for optimal surgical conditions. Clinical presentation of cardiac tumors can be a triad of common symptoms: obstructive, embolic, systemic symptoms, however patients can also present asymptomatically.

Indications

  • Intracardiac tumors causing obstructive symptoms
    • Incidence and prevalence of cardiac tumors is one of the lowest of all solid organ tumors(0.001-0.03%)[1]
    • Tumors are divided into neoplastic and non-neoplastic lesions
      • Benign neoplasm: myxoma, rhabdomyoma, fibroma, lipoma, hamartoma[1]
      • Malignant primary neoplasms: angiosarcomas, rhabdomyosarcomas, lymphoma, Li-Fraumeni Syndrome[1]
  • Embolization risk from tumor fragments
    • Right sided tumors embolize to the lungs resulting in PE[1]
    • Left sided tumors embolize to systemic circulation and can result in CVA, AKI, or peripheral arterial occlusion[1]
  • Arrhythmogenic potential
    • Tumors of or in close proximity to the AV node can result in heart block[1]
  • Malignant or benign intracardiac masses diagnosed incidentally via echocardiography, MRI, or CT


*Medical management can be used for small, immobile masses. Typically followed by serial echocardiography for evaluation of growth and development*[1]

Surgical procedure

  • TEE (transesophageal echocardiography) used intraoperatively to guide resection and assess results.
  • CPB as a topic is beyond the scope of this article but will be discussed briefly with the general steps below
    1. Median sternotomy
    2. Exposure of the heart
    3. Aortic cannulation
    4. Right atrial cannulation
    5. Insertion of aortic root and the LV vent[2]
    6. Resection of hypertrophic ventricular septum

Preoperative management

Patient evaluation

System Considerations
Airway General endotracheal anesthesia required, assess patient's ability to be bag-masked and intubated.
Neurologic Preoperative neurologic exam, increased risk of CVA given cardiac surgery and use of CPB
Cardiovascular Congestive heart failure symptoms may be present: orthopnea, pulmonary edema, pulmonary embolism(PE), LVOT obstruction
Pulmonary Symptoms related to CHF presentation: dyspnea, orthopnea, hemoptysis(due to pulmonary edema), PE
Gastrointestinal History of esophageal disease, difficulty swallowing, cirrhosis/varices may limit use of TEE
Hematologic Starting H/H, coagulation status given high hemorrhage chance during surgery and use of CPB
Renal Increased risk of AKI in cardiac surgery and use of CPB
Endocrine
Other

Labs and studies

  • EKG
  • Imaging:
    • Chest X-ray
    • Chest CT
    • Cardiac MRI
    • Transesophageal echocardiogram(TEE)
    • PET for evaluation of metastatic disease
  • Labs:
    • CBC, coagulation studies

Patient preparation and premedication

Regional and neuraxial techniques

Intraoperative management

Monitoring and access

  • Standard ASA monitors
  • Arterial line
  • Central access CVP +/- PA pressures(indicated for RV or LV failure)
  • Transesophageal echo(TEE)

Induction and airway management

  • General anesthesia with endotracheal intubation.
  • Propofol or thiopental may be used, with careful consideration of dose given the myocardial depressant effects and decreased afterload they cause. Etomidate is also an option given its relative lack of effect on the cardiovascular system.

Positioning

  • Supine position for surgical access.
  • Shoulder roll
  • Arms tucked

Maintenance and surgical considerations

Emergence

  • Typical disposition after cardiac surgery with CPB is the CV-ICU. Patient's are often intubated and sedated in transport from OR to ICU.

Postoperative management

Disposition

  • Intensive care unit (ICU) monitoring initially.
    • Often intubated
    • Frequently requiring pressors or inotropic agents post-CPB.
  • Continuous ECG monitoring for arrhythmias.

Pain management

Potential complications

Procedure variants

Variant 1 Variant 2
Unique considerations
Indications
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References

  1. ↑ Jump up to: 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Joshi, Mihika; Kumar, Siddhant; Noshirwani, Arish; Harky, Amer (2020-10-01). "The Current Management of Cardiac Tumours: a Comprehensive Literature Review". Brazilian Journal of Cardiovascular Surgery. 35 (5): 770–780. doi:10.21470/1678-9741-2019-0199. ISSN 1678-9741. PMC 7598975. PMID 33118743.
  2. ↑ "Surgical setup for cardiopulmonary bypass through central cannulation". MMCTS. Retrieved 2025-06-25.

Top contributors: Giovanni Perottino, Mitchel DeVita and Chris Rishel

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