Anesthetic experiences of severe mitral regurgitation and atrial septal defect newly appeared during the operation after myxoma removal surgery

Cardiac myxomas are the most common primary cardiac tumors, accounting for approximately 50% of all such tumors [1-3]. Around 75% of cardiac myxomas are detected in the left atrium (LA), and 15-20% in the right atrium (RA). Most myxomas arise from the interatrial septum at the fossa ovalis, but in some cases, myxomas have been reported to be attached to valve leaflets or in other locations in the atrium or ventricle [2,3]. The clinical signs and symptoms vary based on location, size, and mobility of myxoma. Most patients are symptomatic, and the triad of symptoms consists of embolism, intracardiac obstruction, and constitutional manifestations. Considering that cerebral and systemic embolism and even sudden death can be caused by cardiac myxomas, surgery is urgently need [1,3]. A 61-year old woman without any medical history, she com plained palpitations that started 20-days prior to her visit. On examination, her heart rate was regular, and her breath sounds were clear with no audible cardiac murmur. The patient denied having any symptoms that suggested a peripheral, cerebral, systemic, or coronary arterial embolism. A transthoracic echocardiogram (TTE) showed a pedunculated circular mass attached to the interatrial septum within the LA measuring 27.87 mm × 20.14 mm. It also showed a normal sinus rhythm with normal ventricular wall thickness and contraction. The LA was enlarged, and the mitral valve (MV) leaflets were mildly thickened and calcified with no regurgitation. From the TTE, clinical impres sion was cardiac myxoma. On arrival in the operating room, electrocardiogram, pulse oxymeter, and non-invasive blood pressure were monitored, and a left radial arterial line was placed before anesthetic induction. Anesthetic induction was begun with 15 mg of ectomidate, 30 μg/kg of fentanyl, and 0.2 mg/kg of vecuronium, and anesthesia was maintained with 10 μg/kg/hr of fentanyl, 50 μg/kg/hr of midazolam, and 0.2 mg/kg/hr of vecuronium. During the operation, a transesophageal echocardiogram (TEE) was performed to confirm the presence of cardiac mass and to detect changes in ventricular wall motion and cardiac valves. The echocardiographic appearance of the mass was typical for atrial myxoma. In mid-esophageal short axis view, a 1.80 cm × 3.63 cm sized circular mass from the interatrial septum was observed (Fig. 1A). In mid-esophageal four chamber and long axis views, a left atrial mass was observed with no MV regurgita tion. In the TEE, no other cardiac problems were detected. Arterial cannulation was done in upper ascending aorta, and bicaval venous cannulation was done in superior vena cava and lower RA. Cardiopulmonary bypass (CPB) then followed, with an aortic cross clamp and an infusion of cold cardioplegia via aortic root cannula. Right atrial wall and interatrial septum were incised, and left atrial mass including left atrial dome was removed. The defects associated with left atrial dome, and the in cision in the interatrial septum and right atrial wall were closed with sutures using prolene. After release of aortic cross clamp and direct current cardioversion, the heart beat recovered. A repeat TEE showed the removal of left atrial mass and an intact interatrial septum with no shunting; however, severe MR was