Primary cardiac tumors are exceedingly rare, with an incidence ranging from 0.0017% to 0.28% in various autopsy studies. Among these, myxomas are the most common type, accounting for approximately 50-70% of primary cardiac tumors. Myxomas predominantly arise in the left atrium, representing around 75% of cases, while the right atrium accounts for 10-20%. Right atrial myxomas (RAM) are particularly rare and present unique diagnostic and therapeutic challenges due to their location and potential for embolic complications.[1-4]

The clinical presentation of RAM is often nonspecific, including symptoms such as dyspnea, palpitations, and chest pain. In some cases, patients may remain asymptomatic, with the tumor being discovered incidentally during routine imaging or investigation for unrelated conditions. Given the potential for significant morbidity, including heart failure and embolic events, early diagnosis and prompt surgical intervention are essential.[5-7]

Despite the rarity of RAM, the consequences of delayed diagnosis can be severe, including life-threatening embolic events, such as pulmonary embolism, stroke, or systemic embolization. Additionally, large tumors can obstruct blood flow through the heart, leading to symptoms of heart failure. The pathophysiology of these tumors underscores the need for heightened clinical suspicion and the importance of imaging in detecting these lesions early, even in asymptomatic patients. Echocardiography, particularly transesophageal echocardiography (TEE), is crucial for accurate diagnosis and preoperative planning.[8-12]

Surgical resection remains the cornerstone of treatment for cardiac myxomas, with excellent long-term outcomes reported in the literature. However, due to the rarity of right atrial myxomas, there is limited data on their clinical characteristics, management, and outcomes.^9-13 This study aims to contribute to the existing literature by presenting a case series of 13 patients with right atrial myxomas managed by surgical excision at the Department of Cardiothoracic and Vascular Surgery (CTVS), GB Pant Hospital, New Delhi. We focus on the clinical presentation, surgical techniques employed, and long-term outcomes in this cohort.

Study Design and Patient Population

This is a retrospective case series of 13 patients who underwent surgical resection of right atrial myxomas at the Department of Cardiothoracic and Vascular Surgery (CTVS), GB Pant Hospital, New Delhi, between January 2017 and December 2023. The study included 10 female and 3 male patients, aged between 22 and 70 years, with a mean age of 45.5 years. 

Preoperative Evaluation

Each patient underwent a comprehensive preoperative evaluation, including a detailed clinical history and physical examination. Transthoracic echocardiography (TTE) was the primary imaging modality used to assess the size, location, attachment site, and mobility of the myxoma. In selected cases, transesophageal echocardiography (TEE) was performed to further delineate the tumor characteristics and assess for any associated cardiac abnormalities. Coronary angiography was conducted in patients over 40 years of age or those with risk factors for coronary artery disease to rule out concomitant coronary lesions.

Surgical Technique

All patients underwent surgical resection of the myxoma via a median sternotomy approach under general anesthesia. Cardiopulmonary bypass (CPB) was established using standard aortic and bicaval cannulation. In most cases, the heart was arrested with cold blood cardioplegia, while one case was managed on a beating heart. The right atrium was opened, and the myxoma, along with its attachment site, was completely excised. Special care was taken to avoid fragmentation and embolization of the tumor during manipulation. The atrial defect created by the excision was repaired using an autologous pericardial patch.

In cases where associated cardiac lesions were present, concomitant procedures were performed. These included tricuspid valve repair in patients with significant tricuspid regurgitation and coronary artery bypass grafting (CABG) in those with concomitant coronary artery disease.

Postoperative Care and Follow-Up

Postoperatively, all patients were transferred to the intensive care unit (ICU) for monitoring and supportive care. Mechanical ventilation was gradually weaned off, and patients were extubated based on clinical criteria. Continuous cardiac monitoring was conducted to detect any arrhythmias or hemodynamic instability. The patients were mobilized early to prevent complications such as deep vein thrombosis and pneumonia.

Patients were discharged from the hospital once they were hemodynamically stable and free of major complications. They were followed up at regular intervals post-discharge, with clinical evaluations and echocardiographic assessments performed to monitor for any signs of recurrence. The follow-up duration ranged from 12 to 72 months, with a mean follow-up period of 48 months.

Data Collection and Statistical Analysis

Data on patient demographics, clinical presentation, intraoperative details, and postoperative outcomes were collected from medical records and institutional databases. Descriptive statistics were used to summarize the data. Continuous variables were expressed as mean ± standard deviation, and categorical variables were expressed as frequencies and percentages. Statistical analysis was performed using SPSS software (version 25.0; IBM Corp, Armonk, NY, USA).

This study included 13 patients who underwent surgical excision of right atrial myxomas at GB Pant Hospital, New Delhi, between January 2017 and December 2023. The patient cohort consisted of 10 females (76.9%) and 3 males (23.1%), with a mean age of 45.5 ± 14.2 years (range: 22–70 years).

The most common presenting symptom was dyspnea, observed in 9 patients (69.2%), followed by palpitations in 6 patients (46.2%), and chest pain in 4 patients (30.8%). Four patients (30.8%) were asymptomatic and were diagnosed incidentally. Preoperative echocardiography revealed moderate to severe tricuspid regurgitation in 3 patients (23.1%) and associated coronary artery disease in 2 patients (15.4%).

Table 1: Patient Demographics and Clinical Presentation

All 13 patients underwent successful surgical resection of right atrial myxomas under cardiopulmonary bypass. The mean cardiopulmonary bypass time was 65.3 ± 20.7 minutes (range: 40–110 minutes), and the mean aortic cross-clamp time was 35.4 ± 17.8 minutes (range: 20–75 minutes).

The majority of the tumors were attached to the atrial septum (8 patients, 61.5%), followed by attachments near the vena cava (3 patients, 23.1%) and near the tricuspid annulus (2 patients, 15.4%). The mean tumor size was 4.3 ± 1.4 cm (range: 2.1–6.5 cm).

Table 2: Tumor Characteristics and Surgical Details

There were no early postoperative deaths. The mean duration of mechanical ventilation was 10.2 ± 4.3 hours (range: 5–18 hours), and the mean ICU stay was 36.5 ± 15.4 hours (range: 24–72 hours). The mean hospital stay was 7.6 ± 2.1 days (range: 5–12 days). One patient (7.7%) developed atrial fibrillation postoperatively, which was managed medically.

Table 3: Postoperative Outcomes

Follow-up data were available for all 13 patients, with a mean follow-up period of 48.3 ± 18.6 months (range: 12–72 months). No myxoma recurrences were observed during this period. All patients reported significant symptom improvement and were classified as NYHA functional class I or II at their last follow-up visit. One patient (7.7%) required pharmacological management for persistent atrial fibrillation but remained stable without further complications.

Table 4: Follow-Up Outcomes

Overall, the surgical excision of right atrial myxomas in this cohort resulted in excellent clinical outcomes, with no recurrences, minimal complications, and significant symptom relief over the follow-up period. These results reinforce the efficacy and safety of early surgical intervention in the management of right atrial myxomas. 

(a)

(b)

Figure-1: ECHO and CT Scan of Right Atrial Myxoma.

(a)

(b)

Figure-2(a,b): Surgical excision of right atrial myxomas.

Right atrial myxomas (RAM) are an uncommon subset of cardiac tumors, accounting for only 10-20% of all cardiac myxomas. The rarity of these tumors, combined with their often nonspecific clinical presentation, makes early diagnosis and management challenging. This case series of 13 patients treated at GB Pant Hospital, New Delhi, provides valuable insights into the clinical presentation, surgical management, and long-term outcomes of RAM, contributing to the relatively limited body of literature on this rare condition.

The clinical presentation of right atrial myxomas can be highly variable, ranging from asymptomatic cases to those presenting with severe obstructive or embolic phenomena. In our series, dyspnea was the most common presenting symptom, occurring in 69.2% of patients, followed by palpitations and chest pain. These findings are consistent with previous studies that highlight the nonspecific nature of symptoms, which are often related to the tumor's location and size, leading to intracardiac obstruction or systemic embolization.[7-11]

Interestingly, 30.8% of our patients were asymptomatic and diagnosed incidentally, underscoring the importance of imaging in detecting these tumors, particularly in patients undergoing evaluation for unrelated cardiac conditions. Echocardiography, both transthoracic (TTE) and transesophageal (TEE), played a crucial role in the diagnosis and preoperative assessment of myxomas in our study. It allowed for detailed evaluation of the tumor’s size, attachment site, and potential hemodynamic impact, which is essential for surgical planning. The predominance of tumors attached to the atrial septum (61.5%) aligns with other reports, where the atrial septum is the most common site of origin for both right and left atrial myxomas.[5-9]

Surgical resection remains the definitive treatment for right atrial myxomas, as it effectively eliminates the risk of embolization and resolves hemodynamic obstruction. In our series, all 13 patients underwent successful tumor excision with no intraoperative complications. The use of cardiopulmonary bypass (CPB) facilitated safe and complete resection of the myxomas, with care taken to avoid tumor fragmentation and subsequent embolic complications. The mean CPB time of 65.3 ± 20.7 minutes and aortic cross-clamp time of 35.4 ± 17.8 minutes are comparable to other series, reflecting the complexity of these procedures, especially in cases where concomitant cardiac lesions are addressed.[13-15]

In our study, concomitant procedures were necessary in several patients, highlighting the importance of a comprehensive surgical approach. Specifically, 23.1% of patients required tricuspid valve repair due to significant regurgitation, and 15.4% underwent coronary artery bypass grafting (CABG) to manage concurrent coronary artery disease. These additional procedures did not increase perioperative risk, further supporting the safety and efficacy of addressing associated cardiac pathologies during myxoma resection.[16-18]

The absence of early postoperative mortality in our series is notable and reflects the safety of surgical intervention in a specialized center. The mean duration of mechanical ventilation (10.2 ± 4.3 hours) and ICU stay (36.5 ± 15.4 hours) are within expected ranges, indicating that most patients had an uneventful postoperative course. Early mobilization and discharge (mean hospital stay of 7.6 ± 2.1 days) further underscore the positive outcomes of surgical treatment.[19-21]

The postoperative outcomes in our series were excellent, with minimal complications and no early mortality. Atrial fibrillation was the most common postoperative complication, occurring in one patient (7.7%). This incidence is in line with other studies, where atrial fibrillation is recognized as a common postoperative arrhythmia following cardiac surgery. In our case, it was managed successfully with medical therapy, and no additional surgical interventions were required.[22-24]

The long-term follow-up of our patients, with a mean duration of 48.3 ± 18.6 months, revealed no recurrences of myxoma, a finding consistent with the low recurrence rates reported after complete surgical resection. This result reinforces the importance of meticulous surgical technique in preventing tumor recurrence, which is a concern in the long-term management of cardiac myxomas. All patients in our cohort reported significant symptomatic improvement and were classified as NYHA functional class I or II during follow-up, indicating sustained relief from symptoms and a return to normal activity levels.[22-24]

The fact that one patient required ongoing management for atrial fibrillation highlights the need for continued postoperative surveillance, particularly in monitoring for arrhythmias or other complications that may arise as patients recover. This underscores the value of a multidisciplinary approach in the postoperative management of these patients, ensuring comprehensive care that addresses both the primary tumor and any associated cardiac conditions.[20-24]

Our findings are consistent with those reported in other case series of right atrial myxomas. The gender distribution in our study, with a predominance of female patients (76.9%), aligns with the known higher prevalence of myxomas in women. The lack of recurrence in our cohort, despite a follow-up period extending up to 72 months, is particularly reassuring and supports the current surgical standards for managing these tumors.[13-17]

Previous studies have also emphasized the importance of early surgical intervention to prevent complications such as embolism, heart failure, or sudden death. Our results reinforce these recommendations, showing that prompt surgical management leads to excellent long-term outcomes with minimal risk of recurrence or complications.[13-19]

Study Limitations

Despite the strengths of our study, including a well-documented follow-up and comprehensive surgical data, there are limitations to consider. The retrospective nature of the study introduces the potential for selection bias, and the relatively small sample size limits the ability to generalize our findings to larger populations. Additionally, while our follow-up period was adequate for assessing mid-term outcomes, longer follow-up would be necessary to fully evaluate the risk of late recurrence, which, although rare, has been documented in some cases.

This case series demonstrates that surgical resection of right atrial myxomas is associated with excellent clinical outcomes, including low perioperative morbidity, no recurrence, and significant symptom relief during long-term follow-up. The findings underscore the importance of early diagnosis and prompt surgical intervention in preventing complications and ensuring favorable long-term outcomes in patients with RAM.

Given the low recurrence rates and excellent postoperative outcomes observed in our study, surgical excision should remain the standard of care for managing right atrial myxomas. Moving forward, continued research and collaboration across institutions will be essential to further refine surgical techniques, identify predictors of recurrence, and explore novel approaches that may enhance recovery and quality of life for patients with this rare cardiac tumor.

he authors declare that they have no conflict of interest

No funding sources

The study was approved by the Mch CTVS , GIPMER,  Delhi

1. Casavecchia, G. et al.; "Cardiac Tumors." J Cardiovasc Echogr. 2.1 (2020) Pp. S45-S53.

2. Gupta, R. et al.; "Primary Malignant Cardiac Tumors: A Rare Disease With an Adventurous Journey." J Am Heart Assoc. 2.1 (2020) Pp. e016032.

3. Aiello, V.D. et al.; "Cardiac Myxoma." Autops Case Rep. 2.1 (2016) Pp. 5-7.

4. Nimisha, S. et al.; "Primary Cardiac Tumors: A Case Series and Review of Literature." Int J Med Sci Clin Res Stud. 2.1 (2022) Pp. 287-294.

5. Khan, H. et al.; "Clinical Presentation of Atrial Myxomas: Does It Differ in Left or Right Sided Tumor?" Int J Health Sci (Qassim). 2.1 (2018) Pp. 59-63.

6. Nina, V.J. et al.; "Atypical Size and Location of a Right Atrial Myxoma: A Case Report." J Med Case Rep. 2.1 (2012) Pp. 26.

7. Ojji, D.B. et al.; "A Probable Right Atrial Myxoma Prolapsing Through the Tricuspid Valve Into the Right Ventricle: A Case Report." Cases J. 2.1 (2008) Pp. 386.

8. Aggarwal, S.K. et al.; "Clinical Presentation and Investigation Findings in Cardiac Myxoma: New Insights From the Developing World." Am Heart J. 2.1 (2008) Pp. 1102-1107.

9. Azevedo, O. et al.; "Massive Right Atrial Myxoma Presenting as Syncope and Exertional Dyspnea: Case Report." Cardiovasc Ultrasound. 2.1 (2010) Pp. 23.

10. Murayama, H. et al.; "Right Atrial Myxoma Associated With Atrial Septal Defect: A Case Report and Review of the Literature." Ann Thorac Cardiovasc Surg. 2.1 (2001) Pp. 166-169.

11. Stolf, N.A. et al.; "Right Atrium Myxoma Originating From the Inferior Vena Cava: An Unusual Location With Therapeutic and Diagnostic Implications." Rev Bras Cir Cardiovasc. 2.1 (2000) Pp. 255-258.

12. Ma, G. et al.; "Pulmonary Embolism as the Initial Manifestation of Right Atrial Myxoma: A Case Report and Review of the Literature." Medicine (Baltimore). 2.1 (2019) Pp. e18386.

13. Guhathakurta, S. et al.; "Surgical Treatment of Right Atrial Myxoma." Tex Heart Inst J. 2.1 (2000) Pp. 61-63.

14. Numaguchi, R. et al.; "Surgical Treatment of a Giant Right Atrial Myxoma." Surg Case Rep. 2.1 (2020) Pp. 165.

15. Jung, J. et al.; "Successful Surgical Treatment of a Right Atrial Myxoma Complicated by Pulmonary Embolism." Korean J Thorac Cardiovasc Surg. 2.1 (2013) Pp. 63-67.

16. Bjessmo, S. et al.; "Cardiac Myxoma: 40 Years' Experience in 63 Patients." Ann Thorac Surg. 2.1 (1997) Pp. 697-700.

17. Samanidis, G. et al.; "Surgical Treatment of Primary Intracardiac Myxoma: 19 Years of Experience." Interact Cardiovasc Thorac Surg. 2.1 (2011) Pp. 597-600.

18. Garatti, A. et al.; "Surgical Excision of Cardiac Myxomas: Twenty Years Experience at a Single Institution." Ann Thorac Surg. 2.1 (2012) Pp. 825-831.

19. Tulin, R. et al.; "Predictors of Late Mortality in Patients With Surgically Resected Cardiac Myxomas: A Single-Center Experience." Cureus. 2.1 (2022) Pp. e20866.

20. Oktaviono, Y.H. et al.; "Clinical Characteristics and Surgical Outcomes of Cardiac Myxoma: A Meta-Analysis of Worldwide Experience." Eur J Surg Oncol. 2.1 (2024) Pp. 107940.

21. Jiang, C.X. et al.; "Long-Term Outcome of Patients With Atrial Myxoma After Surgical Intervention: Analysis of 403 Cases." J Geriatr Cardiol. 2.1 (2019) Pp. 338-343.

22. Alhasso, A.A. et al.; "Operative Management and Outcomes in Patients With Myxomas: A Single-Center Experience." Front Surg. 2.1 (2023) Pp. 1084447.

23. Lee, K.S. et al.; "Surgical Resection of Cardiac Myxoma—A 30-Year Single Institutional Experience." J Cardiothorac Surg. 2.1 (2017) Pp. 18.

24. Vroomen, M. et al.; "Long-Term Follow-Up of 82 Patients After Surgical Excision of Atrial Myxomas." Interact Cardiovasc Thorac Surg. 2.1 (2015) Pp. 183-188.