What is the recommended treatment for a cardiac myxoma?

Surgical Resection is the Recommended Treatment for Cardiac Myxoma

Surgical excision is the definitive treatment for cardiac myxoma, as there is no effective medical therapy and surgery prevents serious complications including stroke and intracardiac blood flow obstruction. 1, 2

Overview of Cardiac Myxomas

• Cardiac myxomas are the most common primary cardiac tumors, occurring in 0.02% of people according to autopsy series 1
• They are typically benign but can cause serious complications including stroke, systemic embolism, and obstruction of intracardiac blood flow 3
• Most commonly found in the left atrium (78-82%), followed by right atrium (14%), and rarely in both atria (3.6%) 4, 5
• Patients with cardiac myxomas are at increased risk for stroke with an overall embolism rate of 25% 1

Diagnostic Approach

• Echocardiography is the diagnostic technique of choice, with transesophageal echocardiography offering enhanced sensitivity, particularly for smaller tumors 6
• Additional imaging such as cardiac MRI or CT may be used for further characterization before surgical planning 6
• Broad morphological variation exists, with more villous tumors having greater embolic potential 1

Treatment Recommendations

Primary Treatment

• Surgical excision is the only established and definitive treatment for cardiac myxoma 1, 2
• Surgery should be performed urgently after diagnosis to prevent complications such as embolic events or obstruction of the mitral orifice 4
• In patients with stroke or TIA found to have a left-sided cardiac tumor, resection is beneficial to reduce the risk of recurrent stroke (Class 2a; Level of Evidence C-LD) 1

Surgical Approach

• Complete wide excision is the standard approach to prevent recurrence 4
• The transseptal surgical approach is often preferred (78% of cases) as it allows total resection of the myxoma along with its pedicle 5
• Surgical options include:
  • Conventional median sternotomy (traditional approach) 7
  • Minimally invasive approaches (associated with shorter ICU stays and reduced blood loss) 7
  • Robotic-assisted surgery (emerging option but limited by costs and technical demands) 7

Outcomes and Follow-up

• Surgical excision carries a low operative risk with excellent short-term and long-term results 4
• Hospital stays average 13.7 ± 6.9 days 4
• Recurrence after surgical excision is extremely rare when complete resection is achieved 2, 5
• Regular follow-up examination including echocardiography is recommended to detect any recurrence 4

Special Considerations

• For patients with metastatic disease to the heart or with right-sided tumors, paradoxical embolism of tumor or venous thrombus through a PFO could occur 1
• In rare cases (up to 10%), cardiac myxomas may be associated with Carney complex, which is characterized by:
  • Younger age at presentation
  • Atypical and multiple tumor locations
  • Higher risk of recurrence 8
• The mechanism of stroke in patients with left-sided cardiac tumors is embolic, either from thrombus formed on the tumor or embolization of tumor fragments 1

Future Research Needs

• Better understanding of risk modification from antiplatelet or anticoagulation in particular tumor subtypes may provide alternative therapeutic options 1
• Minimally invasive and percutaneous treatment strategies need further investigation 1
• Management strategies for incidentally discovered small myxomas in asymptomatic patients require additional research 8
• The role of genetic testing and screening in syndromic myxomas needs further study 8