Chirurgische Therapie von primären und sekundären Herztumoren, retrospektive Untersuchung im Zeitraum von 1994 bis 2009 in den Herzchirurgischen Kliniken des Klinikums Kassel und des Universitätsklinikums Marburg

The heart surgery has undergone significant changes over the past 20 years. New diagnostic techniques, new surgical strategies and improved perioperative care have changed the conventional heart surgery, necessitating an updated analysis of the results of surgical treatment of primary and secondary heart tumors in our hospitals. 33 patients (12 male and 21 female) underwent surgery between 1994 and 2009 for cardiac neoplasm. The results and experiences were analyzed retrospectively. The average age of patients at the time of surgery was 63.09 years (median 64, 28-76 years). Another 6 underwent surgery for suspected myxoma during this period. Histologically, however, an organized thrombus was found in four cases. In one case a cyst of the mitral valve as an expression of a degenerative process was discovered, in another, a christa and some thickening of the atrial septum was noted. The specific patient history and clinical symptoms of heart tumors revealed a broad spectrum, demonstrating the utility of the timely use of modern imaging techniques. All 39 patients underwent surgery with the conventional median sternotomy and cardiopulmonary bypass. While benign tumors were resected curatively, the complete resection of malignant neoplasms was only rarely achieved in spite of extensive resection / reconstruction. The evaluation of diagnostic imaging demonstrated varying degrees of utility. Chest X-rays failed to reveal any tumor calcifications. The comparison of CT and MRI findings with transesophageal echocardiograpy imaging and the surgical pathology revealed that in benign tumors, CT and MRI provided no further surgically useful information. However, for the evaluation of malignant cardiac tumors, CT and MRI offer great benefits, allowing the surgeon to rule out further metastases and to assess the feasibility of complete surgical removal. A complete preoperative CT scan is of course indispensable if malignancy is suspected. Coronary angiography was carried out in 33 of 39 patients (84.62%) and laevocardiography in 31 of 39 patients (79.49%). All left heart catheterizations were performed without complications. Evidence of tumor embolization into the coronary arteries was found in one case. Significant coronary heart disease was diagnosed in two cases and concomitant coronary artery bypass surgery was performed. Based on our results, a fixed age limit for carrying out coronary angiography cannot be recommended. The risk factors for coronary heart disease should be carefully assessed and the indication for left heart catheterization must be made individually. Myxoma-like lesions could not be differentiated from true neoplasms preoperatively or during surgery in most cases. The definitive diagnosis was confirmed histologically following resection. In the group of benign tumors, no patient died in the first 12 postoperative months. In the group of malignant tumors, one patient with angiosarcoma died in tabula due to refractory ventricular fibrillation. Another patient with myosarcoma died in the early postoperative course due to acute right heart failure following the resection of major portions of the right ventricle. All other patients (n=4) died postoperatively within one year. Postoperative complications were similar to those encountered following other cardiac surgical procedures with CPB. A surprisingly high proportion (14.8%) of early postoperative cardiac pacemaker implantations in the group of benign tumors (4 of 27 patients) was noted. Analysis showed that in 4 cases which were performed using the Guiraudon atrial access technique, this complication was associated with the use of this surgical technique. The Dubost technique, which provides access to the right atrium and the septum using a transverse rather than a longitudinal incision, preserves adequate blood supply to the sinus node. Based on our results, we would recommend the Dubost technique for optimal access to the left atrial mass. Recurrent myxoma was not reported in our patient collective. However, due to lack of a structured follow-up program at our hospitals, meaningful statistical analysis could not be performed. Because of the possibility of recurrence even years after primary therapy, lifetime annual echocardiographic follow-up is indicated. In summary, the surgical excision of benign cardiac tumors is associated with very low mortality and moderate morbidity. It is a safe and curative treatment and remains the therapy of choice. However, therapy of malignant cardiac tumors is often palliative in nature, performed to relieve obstruction. Adjuvant radio- and/or chemotherapy has been used to prolong survival but it continues to have poor results despite individualization of approach.