Left ventricular (LV) mass excision: operative sequence

1. Confirm anatomy and operative plan
   • TTE/TEE, often cardiac MRI or CT, define the mass, stalk/base, relation to mitral valve, aortic valve, papillary muscles, septum, coronaries, and LV apex.
   • Assess embolic risk and whether concomitant CABG or valve repair/replacement is required.
   • Intraoperative TEE is used before and after excision.
2. Exposure
   • Usually median sternotomy, though selected cases use minimally invasive access.
   • Open pericardium and inspect the heart.
3. Institution of cardiopulmonary bypass
   • Systemic heparinization.
   • Aortic and venous cannulation, commonly bicaval venous cannulation if intracardiac exposure is planned.
   • Apply aortic cross-clamp and deliver cardioplegia for myocardial arrest.
4. Choose the route to the LV mass Choose the route that gives complete visualization of the attachment while minimizing ventricular and valvular injury:
   • Transaortic: preferred for LV outflow tract or subaortic masses.
   • Transmitral, through left atrium: useful for LV inflow, posterior, papillary muscle, or subvalvular lesions.
   • Direct LV ventriculotomy: reserved for deep, apical, lateral-wall, or broad-based masses not safely accessible through the aorta or mitral valve.
   • Endoscopic assistance may improve visualization and help avoid ventriculotomy in selected cases.
5. Expose and inspect the lesion
   • Avoid manipulating a mobile mass before cross-clamping because of embolization risk.
   • Identify its stalk/base and its relationship to chordae, papillary muscles, myocardium, and coronary vessels.
6. Complete excision
   • Remove the lesion en bloc where feasible, including its stalk or attachment base.
   • Avoid fragmentation and thoroughly irrigate/suction the LV cavity to remove debris.
   • For benign tumors such as myxoma, complete removal of the attachment is important to reduce recurrence.
   • Send the specimen for frozen section if malignancy is suspected or if that result will change the extent of resection, then permanent histopathology.
7. Repair the resection site
   • Small superficial myocardial defects: primary repair if it does not distort LV geometry.
   • Larger or transmural defects: patch repair, often with autologous or bovine pericardium.
   • Repair or replace the mitral/aortic valve only if it has been damaged or involved by the mass.
   • If a ventriculotomy was made, close it carefully, usually reinforced, while preserving LV shape and avoiding coronary injury.
8. De-air, reperfuse, and assess
   • De-air left-sided chambers, remove cross-clamp, and wean from bypass.
   • Post-excision TEE checks:
     • no residual mass
     • preserved LV function
     • no new regional wall-motion abnormality
     • competent mitral and aortic valves
     • no LVOT obstruction or ventricular septal defect
9. Postoperative care
   • ICU monitoring for low-output syndrome, bleeding, ventricular arrhythmias, stroke/systemic embolism, and valve dysfunction.
   • Review final histology and arrange surveillance imaging. Anticoagulation depends on the pathology and associated indication, not merely on the fact that a mass was excised.

Key surgical principle

Postoperative management after left ventriculotomy

1. Immediate ICU handover and monitoring

• Record operation details: indication and pathology of mass, site and type of ventriculotomy closure, bypass/cross-clamp times, intraoperative TEE findings, blood loss/transfusion, rhythm events, inotrope requirement, and planned anticoagulation.
• Continuous ECG, pulse oximetry, temperature, invasive arterial pressure, central venous pressure if present, urine output, chest-drain output, and serial arterial blood gases/lactate.
• Ensure drains are patent and on prescribed suction. A structured cardiac-surgery handover includes the surgical course, blood loss, drains, medication plan, planned tests, nutrition, and goals for the next 6-12 hours. Miller’s Anesthesia, 10th Edition, p. 7487.

2. Hemodynamic and LV-function management

• Assess preload, heart rate/rhythm, blood pressure, perfusion, capillary refill, urine output, lactate trend, and bedside echo findings.
• Obtain urgent TTE/TEE if low output, escalating vasoactive support, new murmur, unexplained hypotension, or concern for residual mass/ventricular dysfunction.
• Correct reversible causes:
  • hypovolemia or bleeding
  • poor LV contractility or ischemia
  • tamponade
  • ventricular arrhythmia
  • hypoxia, acidosis, hypocalcemia, hypothermia
  • excessive afterload
• Use inotropes or vasopressors according to the cardiac ICU team and ventricular function. Consider mechanical circulatory support early for refractory low-output state.

3. Bleeding and tamponade surveillance

• Check chest-drain output frequently, hemoglobin/hematocrit, platelets, PT/INR, aPTT, fibrinogen, ionized calcium, temperature, and thromboelastography/ROTEM if available.
• Replace blood products or coagulation factors based on active bleeding and laboratory or viscoelastic testing.
• Suspect cardiac tamponade with hypotension, rising CVP, low pulse pressure, falling urine output, rising lactate, oliguria, or abrupt reduction/cessation of chest-drain output despite clinical deterioration.
• Perform urgent echocardiography and seek immediate surgical review if tamponade or surgical bleeding is suspected.

4. Rhythm surveillance and management

• Continuous rhythm monitoring and maintenance of normal temperature, oxygenation, acid-base status, calcium, magnesium, and potassium.
• Treat sustained VT/VF or unstable rhythms using pediatric/adult resuscitation protocols as appropriate.
• Temporary epicardial pacing wires should be checked and readily available when placed.
• New ST-T changes, VT, or new LV dysfunction should prompt assessment for coronary compromise, air embolism, ischemia, electrolyte imbalance, or a problem at the ventriculotomy/resection site.

5. Respiratory management

• Mechanical ventilation initially, followed by planned extubation only when hemodynamically stable, normothermic, adequately awake, with controlled bleeding and acceptable gas exchange.
• Use lung-protective ventilation and good analgesia to facilitate coughing and early mobilization.
• Monitor for atelectasis, pulmonary edema from LV dysfunction, pleural effusion, and infection.

6. Fluids, renal function, and metabolic care

• Strict input-output charting and daily weight.
• Avoid both hypovolemia, which can worsen low output, and excessive fluid loading, which can worsen ventricular dysfunction and pulmonary edema.
• Monitor electrolytes, glucose, renal function, lactate, and acid-base status serially.
• Treat acute kidney injury early by optimizing perfusion, avoiding nephrotoxins where possible, and consulting nephrology if oliguria or worsening renal indices persist.

7. Imaging and assessment of repair

• Immediate postoperative echo if unstable or if intraoperative TEE was concerning.
• Predischarge transthoracic echo should document:
  • LV ejection/function and regional wall motion
  • integrity of the ventriculotomy closure
  • absence of pericardial effusion
  • absence of residual mass or thrombus
  • mitral/aortic valve function
  • LVOT gradient if the lesion was near the outflow tract

8. Anticoagulation and antiplatelet therapy

• Tumor completely excised: anticoagulation is not routine unless another indication exists.
• LV thrombus: anticoagulation is commonly required, but timing must be balanced against postoperative bleeding and agreed by surgery/cardiology.
• Mechanical valve, atrial fibrillation, or other thromboembolic indication: restart therapy using a cardiac-surgical protocol after hemostasis is secure.
• Confirm final histopathology and discuss with cardiology/oncology if malignant or infiltrative disease is found.

9. Pain, infection, and rehabilitation

• Multimodal analgesia with frequent pain assessment. Avoid respiratory depression and hypotension.
• Continue perioperative antibiotic protocol, wound care, glycemic control, and early removal of unnecessary lines/drains.
• Early physiotherapy, mobilization, pulmonary toilet, nutrition, and family education.

10. Discharge and follow-up

• Review final pathology at multidisciplinary meeting if the excised LV mass is neoplastic.
• Arrange cardiology/cardiothoracic follow-up with serial echocardiography.
• Educate patient/family to seek urgent care for syncope, palpitations, chest pain, dyspnea, fever, wound discharge, or new neurologic symptoms.