What are the indications for surgery in left atrial (LA) myxoma?

Indications for Surgery in Left Atrial Myxoma

Surgical excision is recommended for all diagnosed left atrial myxomas due to the high risk of embolic complications (30-40% embolization rate) and potential for catastrophic outcomes including stroke, systemic embolism, and intracardiac blood flow obstruction. 1

Primary Indication: Diagnosis Itself

Once a left atrial myxoma is diagnosed, surgery should be performed urgently regardless of symptoms. 1, 2 The diagnosis alone constitutes the indication because:

• Approximately 30-40% of myxomas embolize, with embolic stroke being the presenting symptom in many patients 1
• Embolic complications can occur at any time with tumor progression, making myxomas an indication for urgent surgery 3
• The tumors have friable surfaces that pose continuous embolic risk 1
• Surgical excision is the only definitive treatment with no effective medical alternatives 4

Specific Clinical Scenarios Requiring Surgery

Symptomatic Patients

Surgery is indicated when patients present with:

• Embolic events: Stroke, TIA, or systemic embolization to brain, kidneys, spleen, or peripheral vessels 1, 3
• Obstructive symptoms: Dyspnea, syncope, pre-syncope, or heart failure symptoms from mechanical obstruction of mitral valve blood flow 5, 6, 7
• Constitutional symptoms: Fatigue, fever, or night sweats 5, 7
• Arrhythmias: Symptomatic bradycardia or other rhythm disturbances caused by the tumor 7

Asymptomatic Patients

Even asymptomatic patients require surgical excision upon diagnosis because:

• The risk of catastrophic embolic events exists regardless of symptoms 3, 5
• Tumor characteristics (size >5 cm, racemous/villous morphology, mobility) increase embolic potential but do not change the fundamental indication for surgery 1, 5
• Early diagnosis and surgical intervention are key to improving prognosis 7

Surgical Approach and Timing

• Urgency: Surgery should be performed urgently upon diagnosis, not electively, due to unpredictable timing of embolic complications 3
• Technique: Surgical resection via median sternotomy with cardiopulmonary bypass is standard 4
• Outcomes: Operative mortality is very low (1-3% at experienced centers), with excellent prognosis and extremely rare recurrence after complete excision 4, 5

High-Risk Features Requiring Immediate Intervention

Certain tumor characteristics warrant particularly urgent surgical planning:

• Left atrial location (89% of cases) with attachment to interatrial septum 5
• Size >5 cm in diameter correlates with more pronounced symptoms and higher embolic risk 5
• Mobile or villous morphology has greater embolic and thromboembolic potential 1, 5
• Right atrial myxomas >5 cm have higher frequency of embolic events 5

Critical Pitfall to Avoid

Do not delay surgery for "observation" or attempt medical management with anticoagulation alone. While anticoagulation may be considered in specific contexts, it does not eliminate embolic risk and surgical excision remains the definitive treatment 1, 2. The only established treatment is surgical resection, and delaying surgery risks catastrophic embolic complications including massive stroke, multi-organ infarction, or sudden death 3, 6.