Cardiac tumors: analysis of surgical treatment

Aim. To analyze the preoperative status, intraoperative tumor characteristics and further clinical manifestations in patients after surgery for a cardiac tumor. Material and methods. The study included 54 patients who were operated on for a heart tumor from 2014 to 2020. We assessed clinical performance, diagnostic investigations before and after (during hospitalization) surgery, tumor size and histological characteristics. Results. Among patients operated on for cardiac tumors, women predominated (74%). Among comorbidities, hypertension (79,3%), chronic kidney disease (48,3%), and obesity (25,9%) were most common. There were following clinical manifestations before surgery: shortness of breath palpitations and heart rhythm disturbance 26 chest pain 25 (43,1%), chest discomfort 28 (49,1%), edema 6 patients (10,3%). ovalis area (50%). Surgical treatment of neoplasms was effective. So, prevalence of atrial fibrillation decreased by 25%, while left atrial size decreased by 0,6 mm. Postoperative complications and in-hospital deaths were not registered. Relationships and none.

For a long time, cardiac tumors were characterized by a multiform clinical presentation and were detected more often at autopsies and extremely rarely during cardiac surgery [1][2][3].
An increase in life expectancy, the influence of pre-existing and novel factors contribute to an increase in the risk of cancer, including cardiac tumors.Many authors associate an increase in the detection rate of cardiac tumors with research and technological progress, which contributes to the improvement of preoperative diagnostics using modern investigations and with highly qualified specialists [4].
Identification of cardiac tumors remains a difficult task, since there are no pathognomonic signs and the disease can be asymptomatic for a long time.Therefore, when the patient first visits a doctor, the correct diagnosis is established only in 3-10% of cases [5].
Cardiac tumors are rare compared to other heart diseases.Primary cardiac tumors can be both benign and malignant and are 30 times less common than secondary (metastatic) tumors.According to autopsy data, the prevalence of primary cardiac tumors ranges from 0,001 to 0,03% [2,[6][7][8][9][10].According to a 6-year continuous sample study, an echocardiography detected cardiac tumors in 54 patients (14 men and 40 women; mean age, 59,7 years).Despite the low prevalence, timely detection of tumors is very important, since there are effective methods of treatment.Therapy for benign cardiac tumors is surgical resection, and how urgently the intervention should be performed is determined by the patient's symptoms and the type of tumor.
The aim of the study was to analyze the preoperative status, intraoperative tumor characteristics and further clinical manifestations in patients after surgery for a cardiac tumor at the Federal Center of Cardiovascular Surgery from 2014 to 2020 (Krasnoyarsk).

Material and methods
This retrospective analysis included 54 case records of patients who underwent surgery for a cardiac tumor from 2014 to 2020.We studied clinical and investigational data before and after surgery during hospitalization, as well as assessed the size and histological characteristics of the tumor.Mathematical analysis of the data was performed using the IBM SPSS program.Quantitative variables were examined for distribution normality using the Kolmogorov-Smirnov and Shapiro-Wilk tests.Data are presented as M±SD.Differences were considered significant at p<0,05.

Results
Among those operated on for cardiac tumors, women predominated (74%); 42,6% of patients were aged 55 to 64 years (Table 1).Among comorbidities, hypertension prevailed and was revealed in 79,3% of patients, chronic kidney disease -in 48,3%, and obesity -in 25,9% (Table 1).Heart failure (HF) was revealed in 55,2% of patients as a manifestation of the underlying disease and concomitant disorder.In most patients, there was class I-II HF.
Echocardiography was the main method for detecting cardiac tumors (Table 2).
In all patients, on-pump cardiac surgery was performed.Aortic cross-clamp time was 63,83±8,0 min, and artificial circulation time -89,7±9,5 min.In most patients, tumor removal was performed with excision of underlying tissues, as well as with the closure of atrial septal and endomyocardial defect and with a continuous locking stitch.
The maximum size of the removed tumor, which was noted in this study, was 7,5×4,0 cm, while the minimum was 0,5×0,7 cm.

Discussion
This 6-year analysis revealed that cardiac tumors are more common in women (74,1%), while the mean age of patients is 59,7 years.Among comorbidities, hypertension prevails, which was detected in 79,3% of patients.The most frequent clinical manifestation of pathology before surgery was shortness of breath in 81% of patients.
Before the operation, laboratory blood parameters in the vast majority of patients was within normal range.Anemia was noted in 15,5% of patients.
According to histological examination, myxoma prevails, which was detected in 86,4% of the operated patients.The predominant tumor location was observed in LA fossa ovalis (50% of patients).
Surgical treatment of tumors led to favorable results as follows: AF prevalence decreased by 25%; according to echocardiography, the LA size decreased by 0,6 mm; postoperative complications and in-hospital mortality were not recorded.
According to literature data, the treatment of cardiac tumors is an urgent issue that has been studied for a long time.Soloviev G.    experience of cardiac tumor surgery in the Chelyabinsk Regional Clinical Hospital, which involved 129 patients aged 1-78 years.There were 111 patients with benign tumors, and 18 with malignant ones.The most common benign tumor was myxoma (78,3%).In 96,9% of patients, the indication for surgery was HF and arterial embolism.There were on-pump operations with normo-and hypothermia,  as well as with pharmaco-cold cardioplegic protection.The most frequent postoperative compli cations were paroxysmal arrhythmias (27,9%), of which ~50% were due to AF.There were following risk factors for malignant tumors: disease duration <8 months in combination with stage 2b HF or with RA tumor location.In-hospital mortality rate was 6,2% (n=8), 4 of which occurred in the period from 1981 to 1983, when the on-pump technique was being mastered.

Case report
We report a case of a rare myxoma locationat the LV apex, which, according to the literature, occurs in 1%.
On The patient has been working as a teacher at school for 30 years, undergoes medical examinations every year.Previously, no cardiac pathology has been detected.Since 2012, the patient noted shortness of breath during household exertion, increased fatigue, pain in chest and under the left shoulder blade not related with physical activity but with relief at rest, blood pressure increase up to 200/100 mm Hg.Since 2016, she began to note episodes of severe weakness during hypertensive crisis, periodic presyncope episodes, and a signi ficant decrease in body weight.In March 2016, she was hospitalized in the Abakan Central District Hospital with a hypertensive crisis, where an echo car diography revealed a LV tumor.In April 2017, repeated echocardiography was performed (06.04.2017): end-diastolic dimension (EDD) -4,8 cm, ejection fraction (EF) -60%, end-diastolic volume (EDV) -85 ml, RA -4,5 cm, LA -4,9 cm, right ventricle (RV) -3,4 cm.In the LV apex region, an additional hyperechoic pedunculated (0,4x0,8 cm) formation ~2,2x2,0 cm with a clear contour at the border of 7 and 13 LV segments was revealed.Mixoma.She was consulted by a cardiac surgeon, who revealed indications for surgical treatment.On April 7, 2017, coronary angiography was performed (no coronary artery pathology was revealed).On May 4, 2017, the operation was performed by Gross Yu.V.The aorta was opened with a transverse aortotomy approach.The LV cavity was revised by transaortic approach.Near LV apex, pedunculated (3-4 mm) tumor-like spherical filamentous formation attached along the posterior wall up to 2 cm in diameter was identified.The tumor was excised in a single block with a part of the adjacent septal trabecula.The attachment point has been processed with radiofrequency energy.The diagnosis of myxoma was confirmed with histological examination.
This case report describes the symptoms of myxoma, diagnostic algorithm, surgery types and good long-term outcomes of surgical treatment.

Conclusion
The presented retrospective 6-year analysis of cardiac tumor surgery is consistent with the literature data.Myxomas (86,4%) predominated in the tumor pattern.Postoperative complications and in-hospital deaths were not registered.
Relationships and Activities: none.

Table 2 Echocardiographic data before surgery
may 2, 2017, female patient was admitted to the cardiac surgery department of the Federal Center of Cardiovascular Surgery in Krasnoyarsk with a following diagnosis: LV tumor.Stage 2A, class II heart failure.Background: stage III hypertension, very high risk.Hemodynamically insignificant headand-neck artery atherosclerosis.Concomitant diagnosis: stage 1 discirculatory encephalopathy of athe rosclerotic and hypertensive genesis with mild cognitive impairment, vestibulocerebellar syndrome.