Management of Right Atrial Myxoma
Surgical excision is the only definitive treatment for right atrial myxoma and should be performed urgently to prevent life-threatening complications including pulmonary embolism, right heart failure, and sudden death. 1, 2, 3
Immediate Surgical Intervention Required
All right atrial myxomas require surgical resection regardless of symptoms, as these tumors carry significant risk of pulmonary embolization (occurring in up to 25% of cases) and can cause fatal complications including massive pulmonary embolism and cardiogenic shock 1, 2, 4
Right atrial myxomas account for 10-20% of all cardiac myxomas and typically arise from the atrial septum, though 10% originate from the posterior wall, anterior wall, or appendages 5, 4
The mechanism of complications involves tumor fragmentation causing pulmonary emboli or mechanical obstruction of the tricuspid valve leading to right heart failure 4, 6
Preoperative Diagnostic Workup
Echocardiography is the diagnostic technique of choice and must include both modalities 2, 3:
Transthoracic echocardiography (TTE) for initial detection and characterization of tumor size, location, attachment site, and mobility 7
Transesophageal echocardiography (TEE) provides superior sensitivity for identifying satellite lesions, precise stalk attachment location, and tricuspid valve involvement—critical information for surgical planning 7
Cardiac MRI or CT should be obtained for additional characterization and surgical planning, particularly to assess for pulmonary emboli which commonly coexist with right atrial myxomas 2, 3, 4
Laboratory evaluation should include BNP and D-dimer levels, which are typically elevated in symptomatic cases 4
Surgical Technique and Approach
The standard surgical approach involves median sternotomy with cardiopulmonary bypass 8:
Complete tumor removal with adequate margin of atrial septum is essential to prevent recurrence (which occurs in approximately 3% of sporadic cases) 2, 5
Extensive resection of the myxoma attachment site on the atrial septum or atrial wall reduces recurrence likelihood 5
If massive pulmonary embolism is present, combined right atrial mass removal and pulmonary embolectomy should be performed, potentially requiring brief hypothermic circulatory arrest 6
Intraoperative TEE with Doppler and color flow imaging should be used immediately following tumor removal to assess for residual tumor fragments and evaluate tricuspid valve function to determine need for valve repair 7
Critical Management Pitfalls to Avoid
Do not use anticoagulation or antiplatelet therapy alone as definitive treatment—these do not address the mechanical obstruction, do not prevent embolic complications, and may increase bleeding risk 2
Do not delay surgery even in asymptomatic patients, as right atrial myxomas can cause sudden catastrophic pulmonary embolism or complete tricuspid valve obstruction 4, 6
Avoid incomplete resection of the tumor base, as this significantly increases recurrence risk 5
Postoperative Management and Follow-Up
Histopathologic confirmation is mandatory to exclude malignancy 2
Long-term clinical and echocardiographic follow-up is mandatory to monitor for recurrence, which typically occurs within the first few years if it happens 2, 5
Most patients have excellent prognosis after complete surgical excision, with significant symptom improvement and minimal long-term morbidity when surgery is performed before catastrophic complications develop 4, 8