Excision of left atrial and right ventricular myxoma through biatrial approach: correction please!

We read with great interest the case report by Diaz and co-authors [1] reporting successful removal of multi-centric myxoma in a young female. Interestingly the authors used the right atrial trans-septal approach and not the biatrial approach as they claim. Whether this was a typographical mistake, editorial oversight or a conceptual error on the part of the authors we feel that it provides us the opportunity to describe to the general readership of the article the historical background, technique and modifications of the actual biatrial approach for excising large as well as multicentric atrial myxomas. Left atrial access alone does not enable complete heart inspection, requires significant tumor manipulation in the event of a large mass, and may not permit radical resection. Similarly, a right atriotomy with septal incision may not accommodate removal of a large tumor mass without fragmentation. Kabbani and Cooley [2] excised a left atrial myxoma using a biatrial approach in 1973, and Jones and colleagues [3] described many advantages associated with this technique. The classical biatrial approach involves a left atriotomy incision made posterior to the interatrial groove. This incision is usually 3–5 cm and is not used to mobilize the tumor. The diagnosis and location of the myxoma are confirmed using this incision. Next, a right atriotomy is performed and the right atrium and the ventricle are explored for the possibility of tumor extension from left atrium or for a second myxoma. A right-angle clamp or the operator’s finger is introduced under direct visualization through left atriotomy and provides a reference point that allows right atrial excision of the tumor with an adequate rim of interatrial septum [2, 3]. Over the years several modifications of the biatrial incision have been described. The first of these is the inverted T-shaped incision. The inverted T-shaped incision was first described by Campanella and co-authors to expose the mitral valve in a small left atrium, and then it was used by Morishita and associates in resecting a large left atrial myxoma [3]. Other modifications include those described by St Rammos [4] and Massetti and colleagues [5]. Whether the surgeon is confronting a huge myxoma or secondary mitral valve damage, the biatrial incision or one of its modifications gives better exposure. Furthermore, these incisions enable controlled tumor removal, excellent mitral valve exposure, and four-chamber inspection [3–5], while reducing the risk of sinus node damage that accompanies a vertical right atrial incision and secure closure of the atrial septal defect directly or using Dacron [3] or autologous patch [5].