Increased mitral inflow velocity and prolonged pressure halftime on pulsed wave Doppler recordings indicated a blockage of the blood flow to the left ventricle. No color flow was observed through the mass. Bone marrow biopsy, immunohistochemichal evaluation, genetic testing and translocation analysis showed BCR-ABL translocation t(9;22) p210 transcription positive chronic myeloid leukemia. A left atrial neoplasm (primary or metastatic) was the presumptive diagnosis, and surgical exploration was planned. Coronary angiography revealed normal coronary arteries.
After the patient was appropriately positioned, the right lung was deflated. A 3- to 4-cm right inframammary thoracotomy lateral to the nipple was made and the pleural cavity was entered through the 4th intercostal space (ICS). Trocars were placed in the third and fifth ICS. A working port and camera trocar were placed through the incision. Considering that a dynamic mitral retractor might be necessary during the operation, another trocar was inserted through the submammary 4th ICS. Femoral arterial and venous cannulation was made to establish perfusion. An additional second venous drainage cannula was inserted percutaneously in the SVC via right internal jugular vein. Cardiopulmonary bypass was established and pericardial entry and suture retractions were made. External inspection of the mediastinium showed no evidence of infiltrating mass or pericardial adhesions. Antegrade cardioplegia needle placement in the ascending aorta was followed by introduction of a transthoracic aortic cross clamp (Chitwood clamp) through the transverse sinus in the 2nd ICS in the posterior axillary line and deployed. Myocardial protection was provided by systemic cooling (28°C) and cold-blood cardioplegia. Left atriotomy was made and an intramural mass was observed in the posterior wall of the LA bulging into the cavity. No infiltration in and outside of the LA wall was found. The endocardium was incised and several pieces of yellow-cream colored elastic tissue were excised from a non-encapsulated cavity (Figure 2).
Figure 2: Intraoperative image. MV, Mitral Valve; *, yellow-cream colored elastic tissue localized in the posterior left atrial wall; dotted line, left atrial wall.