Surgical Management of Left Atrial Myxoma through Right Mini-Thoracotomy in a Patient with Retrosternal Gastric Tube

Open-heart surgery in patients with a retrosternal gastric tube after esophagectomy presents a significant surgical challenge owing to the risk of conduit injury during median sternotomy. In such cases, a minimally invasive cardiac surgery (MICS) strategy to avoid sternotomy is of paramount importance and must be tailored according to individual anatomy.

A 71-year-old man with a history of robot-assisted subtotal esophagectomy and retrosternal gastric tube reconstruction was found to have a mobile left atrial mass attached to the interatrial septum. Preoperative CT showed that the gastric conduit was located immediately beneath the sternum, indicating a high risk of injury during median sternotomy. Therefore, a MICS approach via right mini-thoracotomy was selected to avoid sternotomy. The procedure was performed through a right inframammary incision via the fourth intercostal space. Cardiopulmonary bypass was established via femoral arterial cannulation and direct bicaval venous cannulation. The tumor was successfully resected through a transseptal approach, and the atrial septum was reconstructed using an autologous pericardial patch. A transesophageal echocardiography probe was inserted carefully without resistance or complications, even despite the presence of a reconstructed gastric conduit. Intraoperative findings confirmed that the gastric tube was intact. The postoperative course was uneventful. Histopathological examination confirmed the diagnosis of cardiac myxoma and its complete resection.

A sternotomy-avoiding MICS strategy via right mini-thoracotomy is a safe and effective approach for left atrial tumor resection in patients with a retrosternal gastric tube. Careful preoperative imaging and strategic surgical planning are essential to prevent catastrophic complications and optimize outcomes.