Staged cardiac and pulmonary resection for primary cardiac sarcoma

Primary cardiac sarcoma is exceptionally rare, and the need for anatomical lung resection to achieve complete removal markedly increases operative risk. To reduce bleeding into the pneumonectomy space and mitigate hazards of single-stage cardiac and pulmonary resections, we adopted a staged strategy performing lung resection only after cardiopulmonary bypass-related coagulopathy has resolved. This study evaluates the outcomes of this approach.

We retrospectively reviewed our institutional cardiac tumor database (April 1998 to October 2025) for primary cardiac sarcomas requiring anatomical lung resection. Fourteen patients underwent the "Texas Two-Step" approach-cardiac sarcoma resection followed by delayed pneumonectomy or lobectomy. Outcomes were compared with a historical cohort who underwent concomitant pneumonectomy during cardiac sarcoma resection (n = 7). Primary end points were operative and 1-, 2-, and 3-year survival, with recurrence as a secondary end point.

The median patient age was 42 years. Tumors involved the left atrium with pulmonary venous invasion in 50% and the pulmonary arteries in 50%. Pneumonectomy was required in 78.6%, and lobectomy in 21.4%. R0 resection was achieved in 64.3%. There was no operative mortality compared with 43% in the historical cohort. One-, 2-, and 3-year survival was 64%, 53.5%, and 42.8%, with significantly better survival than controls (P = .0075). Median survival was 28.1 months. Recurrence occurred in 50%, predominantly metastatic. The historical cohort required significantly more transfusions (median, 8 vs 1 unit, P = .006).

The Texas Two-Step strategy reduces operative mortality and transfusion needs in patients requiring lung resection for cardiac sarcoma and facilitates safer management in high-volume multidisciplinary centers.