Excision of Calcified Left Atrial Myxomas: A Surgical Challenge

Excision of Calcified Left Atrial Myxomas: A Surgical Challenge | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Excision of Calcified Left Atrial Myxomas: A Surgical Challenge Marco Lizwan, See Hooi Ewe, Samuel Jun Wei Tho, Francis Hong Xin Yap, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8022939/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Apr, 2026 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted 14 You are reading this latest preprint version Abstract Atrial myxomas are the most frequent primary cardiac tumors and are typically cured by surgical resection. Prognosis is excellent in most cases, but complex tumors that involve adjacent valvular or septal structures may lead to challenging repairs and adverse outcomes. We present two patients with atrial myxomas who underwent surgery with strikingly different results. The first, a 72-year-old woman, had a broad-based, calcified left atrial myxoma encroaching on the mitral annulus. Following resection, annular stability was preserved with annuloplasty and patch reinforcement, resulting in successful repair and excellent recovery. The second, a 68-year-old man, underwent excision of a calcified myxoma but developed complete heart block, anterior mitral leaflet perforation requiring repair, and an acquired Gerbode defect. Despite reoperation with pericardial patch repair and tricuspid annuloplasty, he later required redo mitral and tricuspid valve replacements with ECMO support and ultimately died of multiorgan failure. These cases illustrate contrasting outcomes after atrial myxoma surgery. While curative resection is common, complex tumors near the mitral annulus or atrioventricular septum may cause structural injury, conduction disturbances, and rare complications such as Gerbode defect. Careful preoperative imaging, meticulous intraoperative assessment, and long-term vigilance are essential to optimize outcomes. atrial myxoma mitral valve repair pacemaker Gerbode defect surgical outcomes Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Primary cardiac tumors are rare, with an incidence of 0.001–0.003% in an autopsy series ( 1 ) and nearly half are atrial myxomas ( 2 ). Most commonly, they originate from the left atrium, typically at the interatrial septum near the fossa ovalis ( 3 ). Clinical manifestations can be diverse and they are often summarized by a triad of obstructive, embolic and constitutional symptoms ( 4 ). The risk of systemic embolization, sudden death and progressive valvular obstruction is relatively low, making surgical resection the treatment of choice. Perioperative mortality is reported to be less than 5% and patients typically have excellent long-term survival ( 5 , 6 ). Despite their benign histology, myxomas can create significant surgical challenges. Tumors with broad-based attachments or those encroaching on the mitral annulus may destabilize the valve apparatus, necessitating annuloplasty or replacement. Conduction block may occur when resection involves the atrioventricular septum, sometimes requiring permanent pacemaker implantation ( 7 , 8 ). Even more rarely, postoperative complications such as acquired Gerbode defect or pacemaker-lead–induced tricuspid regurgitation can lead to progressive heart failure and adverse outcomes ( 9 – 11 ). Here, we report two contrasting cases of atrial myxoma resection at our institution. The first case demonstrates successful tumor excision and valve-preserving repair, whilst the second illustrates a cascade of complications culminating in fatal outcome. Together, these cases emphasize the spectrum of risks associated with complex myxoma surgery. Case Presentation In both cases, informed consent was obtained from the patient and/or family member to include the information in this article. Institutional Review Board approval was not required. Case 1 A 72-year-old Chinese female with a history of hypertension was referred after screening echocardiography showed an intracardiac mass. Dobutamine stress echocardiography demonstrated preserved left ventricular ejection function (LVEF) and the incidental finding of a 2.1 x 1.4 cm echodense mass within the left atrium (Fig. 1 A and B). The mass was attached to the interatrial septum near the aortic root junction, suspicious for an atrial myxoma. Cardiac magnetic resonance imaging (cMRI) confirmed a well-defined, ovoid mass (1.2 x 1.8 cm) attached to the atrial septum, consistent with myxoma (Fig. 1 C and D). Coronary angiography was unremarkable. Preoperative transesophageal echocardiography (TEE) demonstrated a broad-based, calcified, heterogenous mass (2.2 x 1.9 cm) adherent to the inferior interatrial septum adjacent to the anterior mitral leaflet. The lesion was non-obstructive, with trivial valvular regurgitation and a patent foramen ovale with bidirectional shunting (Fig. 1 E, Video 1). The patient underwent elective surgery via median sternotomy. A 2 x 2 cm calcified, broad-based mass was excised en bloc (Fig. 2 A-B). Following complete tumor excision, the anterior mitral annulus was macerated and weakened, leaving only a thin 3 mm lip of fragile tissue from the hinge point of the anterior mitral valve. To avoid further distortion of mitral valve geometry during atrial reconstruction, a 28 mm Physio II annuloplasty ring (Edwards Lifesciences, Irvine, USA) was implanted. A large CardioCel® (LeMaitre Vascular, Massachusetts, USA) patch was then anchored to the annuloplasty ring to reinforce the interatrial septum and left atrial roof (Fig. 2 C). The right atrium was also patched for a tension-free closure (Fig. 2 D). Post-bypass TEE confirmed complete tumor resection, trivial mitral regurgitation (MR) and preserved ventricular function. Histopathology confirmed features in keeping with calcified atrial myxoma (Supplemental 1). Her postoperative course was uneventful except for transient renal dysfunction and tachy-brady syndrome requiring dual-chamber permanent pacemaker (PPM) implantation on post-operative day (POD) 7. Pre-discharge transthoracic echocardiography (TTE) showed a well-functioning mitral valve repair (mean gradient 3 mmHg, valve area 3.0 cm 2 ) with preserved LVEF. She was discharged to the community hospital for further rehabilitation in stable condition on POD 14. She remained well at follow-up. Case 2 A 68-year-old Chinese male with a background of hypertension presented with exertional dyspnea and palpitations. TTE revealed a large, calcified left atrial mass located close to the aortic valve (Fig. 3 A-B). cMRI confirmed a sessile mass in the left atrium measuring about 2.6 x 1.7 x 1.7 cm in size attached to the anterior aspect of the interatrial septum (Fig. 3 C-D). He underwent median sternotomy and excision of the mass. Intraoperatively, the mass was noted to be hard, solid, irregular (Supplemental 2A) with a broad-based attachment to the interatrial septum. Post-bypass TEE confirmed satisfactory valve competence. Histopathology confirmed diagnosis of atrial myxoma with dystrophic calcification and osseous metaplasia (Supplemental 2B-D) Following resection, he developed complete heart block requiring temporary pacing. While awaiting PPM implantation, TTE revealed new, moderate-to-severe mitral regurgitation (MR) with evidence of anterior leaflet perforation. Given the hemodynamic significance, he was scheduled for reoperation within the same admission. At the second surgery, pre-operative TEE (Video 2) and intraoperative inspection confirmed anterior mitral leaflet perforation. Mitral valve repair with a pericardial patch was performed, with tricuspid annuloplasty. Post-operative TEE following this second surgery confirmed good valve competence; however, a small Gerbode defect (2 mm) was noted with shunting from the left ventricle to right atrium demonstrated on color Doppler (Fig. 4 , Video 3), which was managed expectantly. He subsequently underwent dual-chamber PPM implantation and was discharged uneventfully. Over the following three months, the patient developed progressive right-sided heart failure due to worsening tricuspid regurgitation, exacerbated by pacemaker lead impingement. Repeat imaging also revealed severe MR despite prior repair. A third surgery was performed, with redo mitral valve replacement and tricuspid valve replacement. Post-cardiotomy extracorporeal membrane oxygenation support was instituted for severe biventricular dysfunction. Despite maximal support, he succumbed to multiorgan failure in the postoperative period. Discussion These two cases highlight the divergent outcomes following surgery for atrial myxoma, reflecting the benign nature of most tumors but also the potential for complex postoperative courses when surrounding structures are affected. Surgical Complexity and Structural Involvement Although atrial myxomas are histologically benign, their anatomical relationships often dictate operative complexity. In our first case, calcification and annular encroachment necessitated innovative repair using an annuloplasty ring to preserve the integrity and function of the mitral valve. Patch repair of the interatrial septum, left atrial roof, and right atrium was then performed to achieve tension-free closure. Such approach is rarely described but may provide durable outcomes when tumors compromise annular integrity ( 7 ). On the other hand, our second case demonstrated how leaflet perforation leads to recurrent regurgitation, reoperations and ultimately, poor outcomes. Valve involvement, though uncommon, is associated with increased surgical morbidity and mortality ( 12 ). Conduction Disturbances and Pacemaker Requirement Both of our patients required PPM. Conduction block after myxoma surgery is reported in up to 26% of patients, particularly when atrial septal resection involves conduction tissue ( 8 ). Tachy-brady syndrome in our first patient and complete heart block in our second patient highlight the variable manifestations. This risk warrants preoperative counselling and close rhythm monitoring in the postoperative period. Series Highlights Our cases add to the atrial myxoma literature in several unique ways. Our first case illustrates successful use of an annuloplasty ring in tumor-related annular destabilization, a rarely reported but effective strategy. It also stresses the importance of pre-emptive tension-free patch closure to decrease the risk of intracardiac injury and postoperative bleeding. Our second case demonstrates the potential for delayed mitral valve dysfunction following weakening of adjacent tissue caused by extensive resection of an encroaching sessile calcified tumor. It also highlights pacemaker-lead-induced tricuspid regurgitation, an increasingly recognized but underappreciated long-term complication of pacing ( 10 ). The intraoperative discovery of an acquired Gerbode defect is a particularly rare and serious complication, with only sporadic reports in the literature ( 9 ). Despite multiple surgical interventions, the combination of structural valve disease, pacing complications, ventricular dysfunction and multiorgan failure culminated in poor outcome. Clinical Implications These contrasting cases highlight several important lessons in managing patients with calcified, broad based atrial myxomas. First, the proximity of a myxoma to the mitral annulus requires meticulous dissection to balance oncologic clearance with preservation of valve function. Tension-free, preferably patch closure of the cardiac chambers is recommended. Second, intraoperative and postoperative echocardiography are indispensable for early detection of valvular or structural complication. Third, patients requiring PPM after myxoma surgery should be monitored closely for device-induced valvular dysfunction. A Heart Team approach comprising cardiac surgeons, imaging specialists, electrophysiologists, intensivists and heart failure physicians is essential for providing multidisciplinary expertise. Finally, rare but devastating complications such as acquired Gerbode defect must be recognized promptly to guide management. Conclusion Surgical resection of atrial myxomas is generally safe and curative. However, when tumors are broad-based, calcified or involve adjacent structures, complex repairs may be required, potentially increasing the risks of complications. Tumors near the mitral annulus can be safely resected en bloc with careful technique and pre-emptive reconstruction. Structural injury, conduction block and rare complications such as Gerbode defect may necessitate complex reoperations. These cases emphasize the importance of individualized surgical planning, vigilant follow-up and early recognition of complications to optimize long-term outcomes. Abbreviations cMRI Cardiac magnetic resonance imaging IRB Institutional Review Board LVEF Left ventricular ejection fraction MR Mitral regurgitation POD Post-operative day PPM Permanent pacemaker TEE Transesophageal echocardiography TTE Transthoracic echocardiography Declarations Ethical Approval Written informed consents were obtained from patient to include the information in this manuscript. Institutional Review Board (IRB) approval was not required. Data Availability Statement Additional data are available from the corresponding author on reasonable request. Competing Interests SHE receives speaker fees from Philips Healthcare, GE Healthcare, Edwards Lifesciences and Abbott Medical. The other authors declare no competing interests. Fundings This research did not receive any grants from any funding agencies. Author Contributions ML wrote and revised the manuscript. SHE provided echocardiographic images, descriptions of echocardiographic findings and revised the manuscript. SJWT, FHXY and SHL provided histological images, descriptions of pathological findings, and revised the manuscript. YLC, ZBAZ and PYKP supervised and revised the manuscript writing. All authors were involved in the patient’s care and have read and approved the final manuscript. Acknowledgement We would like to thank all individuals who were involved in the care for our patients. References Lam KY, Dickens P, Chan AC. Tumors of the heart. A 20-year experience with a review of 12,485 consecutive autopsies. Arch Pathol Lab Med. 1993;117(10):1027–31. Reynen K. Cardiac myxomas. N Engl J Med. 1995;333(24):1610–7. Pinede L, Duhaut P, Loire R. Clinical presentation of left atrial cardiac myxoma. A series of 112 consecutive cases. Med (Baltim). 2001;80(3):159–72. Keeling IM, Oberwalder P, Anelli-Monti M, Schuchlenz H, Demel U, Tilz GP, et al. Cardiac myxomas: 24 years of experience in 49 patients. Eur J Cardio-Thorac Surg Off J Eur Assoc Cardio-Thorac Surg. 2002;22(6):971–7. Bjessmo S, Ivert T. Cardiac myxoma: 40 years’ experience in 63 patients. Ann Thorac Surg. 1997;63(3):697–700. Elbardissi AW, Dearani JA, Daly RC, Mullany CJ, Orszulak TA, Puga FJ et al. Survival after resection of primary cardiac tumors: a 48-year experience. Circulation. 2008 Sept 30;118(14 Suppl):S7-15. Garatti A, Nano G, Canziani A, Gagliardotto P, Mossuto E, Frigiola A, et al. Surgical excision of cardiac myxomas: twenty years experience at a single institution. Ann Thorac Surg. 2012;93(3):825–31. Argueta E, Ratheal K, Prieto S, Paone R, Jenkins LA, Oyenuga O. Recurrent atrial myxoma, right atriotomy, and sinus node dysfunction: A case of interdisciplinary care. Southwest Respir Crit Care Chron 2018 July 20;6(25):42–6. Yuan SM. Left ventricular to right atrial shunt (Gerbode defect): congenital versus acquired. Postępy W Kardiologii Interwencyjnej Adv Interv Cardiol. 2014;10(3):185–94. Delling FN, Hassan ZK, Piatkowski G, Tsao CW, Rajabali A, Markson LJ, et al. Tricuspid Regurgitation and Mortality in Patients With Transvenous Permanent Pacemaker Leads. Am J Cardiol. 2016;117(6):988–92. Saker E, Bahri GN, Montalbano MJ, Johal J, Graham RA, Tardieu GG, et al. Gerbode defect: A comprehensive review of its history, anatomy, embryology, pathophysiology, diagnosis, and treatment. J Saudi Heart Assoc. 2017;29(4):283–92. Jiang CX, Wang JG, Qi RD, Wang W, Gao LJ, Zhao JH, et al. Long-term outcome of patients with atrial myxoma after surgical intervention: analysis of 403 cases. J Geriatr Cardiol JGC. 2019;16(4):338–43. Additional Declarations Competing interest reported. SHE receives speaker fees from Philips Healthcare, GE Healthcare, Edwards Lifesciences and Abbott Medical. Supplementary Files S1.jpg Supplemental 1. Histopathology of atrial myxoma in Case 1. (A) Photomicrograph shows groups of myxoma cells in an expansive myxoid background. (B) Higher magnification shows myxoma cells intimately related to blood vessels. (C) The lesion shows large areas of calcification. S2.jpg Supplemental 2. (A) Excised atrial myxoma specimen in Case 2 following gross dissection. Histopathology of atrial myxoma in Case 2. (B) Hypocellular lesion with groups and singly disposed myxoma cells embedded within a loose fibromyxoid stroma with patchy erythrocyte extravasation. (C) Higher magnification shows stromal hyalinization. (D) The lesion also shows extensive calcification with foci of metaplastic ossification Video1.mp4 Video Legends Video 1. Preoperative transesophageal echocardiography (TEE) in Case 1. TEE demonstrated a broad-based, calcified, heterogenous mass (2.2 x 1.9 cm) adherent to the inferior interatrial septum adjacent to the anterior mitral leaflet. Video2.mp4 Video 2. Pre-operative TEE in Case 2 prior to first redo surgery showing perforation at A3 (near medial commissure) and 3D enface and with color across (appears to close to the site of mass removal site at left atrium with a loose suture). Video3.mp4 Video 3. Post-operative TEE in Case 2 after first redo surgery showing mild residual MR (2 jets) with acquired Gerbode defect (left ventricle to right atrium shunt) postoperatively. VisualAbstract.png Visual Abstract Cite Share Download PDF Status: Published Journal Publication published 13 Apr, 2026 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted Editorial decision: Revision requested 25 Jan, 2026 Reviews received at journal 24 Jan, 2026 Reviewers agreed at journal 24 Jan, 2026 Reviewers agreed at journal 24 Jan, 2026 Reviewers agreed at journal 24 Jan, 2026 Reviews received at journal 23 Jan, 2026 Reviewers agreed at journal 22 Jan, 2026 Reviewers agreed at journal 22 Jan, 2026 Reviewers agreed at journal 22 Jan, 2026 Reviewers agreed at journal 22 Jan, 2026 Reviewers invited by journal 22 Jan, 2026 Editor assigned by journal 10 Nov, 2025 Submission checks completed at journal 10 Nov, 2025 First submitted to journal 03 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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00:12:14","extension":"xml","order_by":37,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":52433,"visible":true,"origin":"","legend":"","description":"","filename":"8d92b2aae4814f3db9e5026221ce72101structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8022939/v1/e83ec6b956f70522003c9917.xml"},{"id":101172082,"identity":"6c0228ce-f439-4d93-8322-895ca47ebd47","added_by":"auto","created_at":"2026-01-27 00:12:14","extension":"html","order_by":38,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":64887,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8022939/v1/a3983500e53dd26b9e7c2da2.html"},{"id":101172057,"identity":"0ebf3867-0f43-41d9-a613-364fc7f4831b","added_by":"auto","created_at":"2026-01-27 00:12:13","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":523335,"visible":true,"origin":"","legend":"\u003cp\u003e(A-B) Dobutamine stress echocardiography showed incidental finding of a 2.1 x 1.4 cm echodense mass attached to the interatrial septum near the aortic root junction, suspicious for an atrial myxoma. Cardiac magnetic resonance imaging (cMRI) confirmed well-defined 1.2 x 1.8 cm ovoid mass attached to the atrial septum, which was isointense on T1-weighted sequences (C) and hyperintense on T2-weighted imaging (D), with minimal heterogenous gadolinium uptake, consistent with myxoma. (E) Pre-operative transesophageal echocardiography (TEE) demonstrated 2.2 x 1.9 cm, broad-based, calcified, heterogenous mass adherent to the inferior interatrial septum adjacent to the anterior mitral leaflet.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8022939/v1/887318929f63ff85c2af7ae2.png"},{"id":101296915,"identity":"e4763e8f-a264-4442-87ca-1b3ce00d4663","added_by":"auto","created_at":"2026-01-28 09:23:10","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":719936,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Intraoperatively, a broad-based, calcified hard mass was found attached to the interatrial septum and encroaching on the anterior mitral leaflet. (B) A 2 x 2 cm mass was excised \u003cem\u003een bloc\u003c/em\u003e. (C) A large CardioCel® patch was anchored to the annuloplasty ting to reinforce the interatrial septum and left atrial roof. (D) The right atrium was also patched with CardioCel® patch.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8022939/v1/3139226ad769213d674a84fe.png"},{"id":101172043,"identity":"af063296-3b99-4cca-a7f3-3db17f802ce3","added_by":"auto","created_at":"2026-01-27 00:12:13","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":372931,"visible":true,"origin":"","legend":"\u003cp\u003e(A-B) Transthoracic echocardiography (TTE) revealed a large, friable left atrial mass close to the aortic valve. cMRI confirmed a sessile mass in the left atrium measuring about 2.6 x 1.7 x 1.7 cm in size attached to the anterior aspect of the interatrial septum, which is predominantly isointense relative to myocardium on (C) T1-weighted and (D) T2-weighted images with and without fat saturation.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8022939/v1/60ce3a4aeaf3a3a07a90cb61.png"},{"id":101172045,"identity":"2dd673d0-535b-4cf4-af09-7414e61527bf","added_by":"auto","created_at":"2026-01-27 00:12:13","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":561186,"visible":true,"origin":"","legend":"\u003cp\u003e(A) TTE revealed an acquired Gerbode defect (left ventricle to right atrium shunt).\u003cstrong\u003e \u003c/strong\u003e(B) Intraoperative finding during second redo surgery showing Gerbode defect (black arrow with white circle).\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8022939/v1/4d96ec4dff758b5475d6e279.png"},{"id":107350785,"identity":"f9442460-566b-43ce-97d4-b9c96ec96286","added_by":"auto","created_at":"2026-04-20 16:04:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2712685,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8022939/v1/e4c77997-0132-47f2-9c96-01586af536b4.pdf"},{"id":101207185,"identity":"81e5f44d-41d4-468e-a19d-7ef19be58fe9","added_by":"auto","created_at":"2026-01-27 09:58:13","extension":"jpg","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":213174,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplemental 1\u003c/strong\u003e. Histopathology of atrial myxoma in Case 1. (A) Photomicrograph shows groups of myxoma cells in an expansive myxoid background. (B) Higher magnification shows myxoma cells intimately related to blood vessels. (C) The lesion shows large areas of calcification.\u003c/p\u003e","description":"","filename":"S1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8022939/v1/7642398962d204102c6572b6.jpg"},{"id":101206526,"identity":"c47b41a8-be73-48e0-9353-4066395afec8","added_by":"auto","created_at":"2026-01-27 09:56:26","extension":"jpg","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":262545,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplemental 2.\u003c/strong\u003e (A) Excised atrial myxoma specimen in Case 2 following gross dissection. Histopathology of atrial myxoma in Case 2. (B) Hypocellular lesion with groups and singly disposed myxoma cells embedded within a loose fibromyxoid stroma with patchy erythrocyte extravasation. (C) Higher magnification shows stromal hyalinization. (D) The lesion also shows extensive calcification with foci of metaplastic ossification\u003c/p\u003e","description":"","filename":"S2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8022939/v1/5a3c982c2fec46158a4fb517.jpg"},{"id":101206544,"identity":"7dfce4ca-ea31-4da5-9b6d-3b727475c3d3","added_by":"auto","created_at":"2026-01-27 09:56:27","extension":"mp4","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":1899193,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eVideo Legends\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVideo 1. \u003c/strong\u003ePreoperative transesophageal echocardiography (TEE) in Case 1. TEE demonstrated a broad-based, calcified, heterogenous mass (2.2 x 1.9 cm) adherent to the inferior interatrial septum adjacent to the anterior mitral leaflet.\u003c/p\u003e","description":"","filename":"Video1.mp4","url":"https://assets-eu.researchsquare.com/files/rs-8022939/v1/d776dbdcfab690cb7cdfa17e.mp4"},{"id":101172053,"identity":"97b1bba7-ec09-4375-9cb5-c89d489e27d1","added_by":"auto","created_at":"2026-01-27 00:12:13","extension":"mp4","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":4830574,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eVideo 2. \u003c/strong\u003ePre-operative TEE in Case 2 prior to first redo surgery showing perforation at A3 (near medial commissure) and 3D enface and with color across (appears to close to the site of mass removal site at left atrium with a loose suture).\u003c/p\u003e","description":"","filename":"Video2.mp4","url":"https://assets-eu.researchsquare.com/files/rs-8022939/v1/4f31597f3a3a1b7a4eada204.mp4"},{"id":101206615,"identity":"dcb44a0c-1acc-40d3-ae00-1c4ba662eef2","added_by":"auto","created_at":"2026-01-27 09:56:32","extension":"mp4","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":3906025,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eVideo 3. \u003c/strong\u003ePost-operative TEE in Case 2 after first redo surgery showing mild residual MR (2 jets) with acquired Gerbode defect (left ventricle to right atrium shunt) postoperatively.\u003c/p\u003e","description":"","filename":"Video3.mp4","url":"https://assets-eu.researchsquare.com/files/rs-8022939/v1/55fcadc35f3686d49c357ca8.mp4"},{"id":101205865,"identity":"c0f635c5-cd80-4a8b-bf2d-1ff7e590d986","added_by":"auto","created_at":"2026-01-27 09:50:26","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":196117,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eVisual Abstract\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"VisualAbstract.png","url":"https://assets-eu.researchsquare.com/files/rs-8022939/v1/4a46bfb45db1261f7dbc3cb1.png"}],"financialInterests":"Competing interest reported. SHE receives speaker fees from Philips Healthcare, GE Healthcare, Edwards Lifesciences and Abbott Medical.","formattedTitle":"Excision of Calcified Left Atrial Myxomas: A Surgical Challenge","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePrimary cardiac tumors are rare, with an incidence of 0.001\u0026ndash;0.003% in an autopsy series (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) and nearly half are atrial myxomas (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Most commonly, they originate from the left atrium, typically at the interatrial septum near the fossa ovalis (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Clinical manifestations can be diverse and they are often summarized by a triad of obstructive, embolic and constitutional symptoms (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The risk of systemic embolization, sudden death and progressive valvular obstruction is relatively low, making surgical resection the treatment of choice. Perioperative mortality is reported to be less than 5% and patients typically have excellent long-term survival (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite their benign histology, myxomas can create significant surgical challenges. Tumors with broad-based attachments or those encroaching on the mitral annulus may destabilize the valve apparatus, necessitating annuloplasty or replacement. Conduction block may occur when resection involves the atrioventricular septum, sometimes requiring permanent pacemaker implantation (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Even more rarely, postoperative complications such as acquired Gerbode defect or pacemaker-lead\u0026ndash;induced tricuspid regurgitation can lead to progressive heart failure and adverse outcomes (\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHere, we report two contrasting cases of atrial myxoma resection at our institution. The first case demonstrates successful tumor excision and valve-preserving repair, whilst the second illustrates a cascade of complications culminating in fatal outcome. Together, these cases emphasize the spectrum of risks associated with complex myxoma surgery.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003e In both cases, informed consent was obtained from the patient and/or family member to include the information in this article. Institutional Review Board approval was not required.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eCase 1\u003c/h2\u003e \u003cp\u003eA 72-year-old Chinese female with a history of hypertension was referred after screening echocardiography showed an intracardiac mass. Dobutamine stress echocardiography demonstrated preserved left ventricular ejection function (LVEF) and the incidental finding of a 2.1 x 1.4 cm echodense mass within the left atrium (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA and B). The mass was attached to the interatrial septum near the aortic root junction, suspicious for an atrial myxoma.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eCardiac magnetic resonance imaging (cMRI) confirmed a well-defined, ovoid mass (1.2 x 1.8 cm) attached to the atrial septum, consistent with myxoma (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC and D). Coronary angiography was unremarkable. Preoperative transesophageal echocardiography (TEE) demonstrated a broad-based, calcified, heterogenous mass (2.2 x 1.9 cm) adherent to the inferior interatrial septum adjacent to the anterior mitral leaflet. The lesion was non-obstructive, with trivial valvular regurgitation and a patent foramen ovale with bidirectional shunting (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eE, Video 1).\u003c/p\u003e \u003cp\u003eThe patient underwent elective surgery via median sternotomy. A 2 x 2 cm calcified, broad-based mass was excised \u003cem\u003een bloc\u003c/em\u003e (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA-B). Following complete tumor excision, the anterior mitral annulus was macerated and weakened, leaving only a thin 3 mm lip of fragile tissue from the hinge point of the anterior mitral valve. To avoid further distortion of mitral valve geometry during atrial reconstruction, a 28 mm Physio II annuloplasty ring (Edwards Lifesciences, Irvine, USA) was implanted. A large CardioCel\u0026reg; (LeMaitre Vascular, Massachusetts, USA) patch was then anchored to the annuloplasty ring to reinforce the interatrial septum and left atrial roof (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC). The right atrium was also patched for a tension-free closure (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eD).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePost-bypass TEE confirmed complete tumor resection, trivial mitral regurgitation (MR) and preserved ventricular function. Histopathology confirmed features in keeping with calcified atrial myxoma (Supplemental 1). Her postoperative course was uneventful except for transient renal dysfunction and tachy-brady syndrome requiring dual-chamber permanent pacemaker (PPM) implantation on post-operative day (POD) 7. Pre-discharge transthoracic echocardiography (TTE) showed a well-functioning mitral valve repair (mean gradient 3 mmHg, valve area 3.0 cm\u003csup\u003e2\u003c/sup\u003e) with preserved LVEF. She was discharged to the community hospital for further rehabilitation in stable condition on POD 14. She remained well at follow-up.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCase 2\u003c/h3\u003e\n\u003cp\u003eA 68-year-old Chinese male with a background of hypertension presented with exertional dyspnea and palpitations. TTE revealed a large, calcified left atrial mass located close to the aortic valve (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA-B). cMRI confirmed a sessile mass in the left atrium measuring about 2.6 x 1.7 x 1.7 cm in size attached to the anterior aspect of the interatrial septum (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eC-D).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eHe underwent median sternotomy and excision of the mass. Intraoperatively, the mass was noted to be hard, solid, irregular (Supplemental 2A) with a broad-based attachment to the interatrial septum. Post-bypass TEE confirmed satisfactory valve competence. Histopathology confirmed diagnosis of atrial myxoma with dystrophic calcification and osseous metaplasia (Supplemental 2B-D)\u003c/p\u003e \u003cp\u003eFollowing resection, he developed complete heart block requiring temporary pacing. While awaiting PPM implantation, TTE revealed new, moderate-to-severe mitral regurgitation (MR) with evidence of anterior leaflet perforation. Given the hemodynamic significance, he was scheduled for reoperation within the same admission.\u003c/p\u003e \u003cp\u003eAt the second surgery, pre-operative TEE (Video 2) and intraoperative inspection confirmed anterior mitral leaflet perforation. Mitral valve repair with a pericardial patch was performed, with tricuspid annuloplasty. Post-operative TEE following this second surgery confirmed good valve competence; however, a small Gerbode defect (2 mm) was noted with shunting from the left ventricle to right atrium demonstrated on color Doppler (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, Video 3), which was managed expectantly. He subsequently underwent dual-chamber PPM implantation and was discharged uneventfully.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOver the following three months, the patient developed progressive right-sided heart failure due to worsening tricuspid regurgitation, exacerbated by pacemaker lead impingement. Repeat imaging also revealed severe MR despite prior repair. A third surgery was performed, with redo mitral valve replacement and tricuspid valve replacement. Post-cardiotomy extracorporeal membrane oxygenation support was instituted for severe biventricular dysfunction. Despite maximal support, he succumbed to multiorgan failure in the postoperative period.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThese two cases highlight the divergent outcomes following surgery for atrial myxoma, reflecting the benign nature of most tumors but also the potential for complex postoperative courses when surrounding structures are affected.\u003c/p\u003e\n\u003ch3\u003eSurgical Complexity and Structural Involvement\u003c/h3\u003e\n\u003cp\u003eAlthough atrial myxomas are histologically benign, their anatomical relationships often dictate operative complexity. In our first case, calcification and annular encroachment necessitated innovative repair using an annuloplasty ring to preserve the integrity and function of the mitral valve. Patch repair of the interatrial septum, left atrial roof, and right atrium was then performed to achieve tension-free closure. Such approach is rarely described but may provide durable outcomes when tumors compromise annular integrity (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). On the other hand, our second case demonstrated how leaflet perforation leads to recurrent regurgitation, reoperations and ultimately, poor outcomes. Valve involvement, though uncommon, is associated with increased surgical morbidity and mortality (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eConduction Disturbances and Pacemaker Requirement\u003c/h3\u003e\n\u003cp\u003eBoth of our patients required PPM. Conduction block after myxoma surgery is reported in up to 26% of patients, particularly when atrial septal resection involves conduction tissue (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Tachy-brady syndrome in our first patient and complete heart block in our second patient highlight the variable manifestations. This risk warrants preoperative counselling and close rhythm monitoring in the postoperative period.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSeries Highlights\u003c/h2\u003e \u003cp\u003eOur cases add to the atrial myxoma literature in several unique ways. Our first case illustrates successful use of an annuloplasty ring in tumor-related annular destabilization, a rarely reported but effective strategy. It also stresses the importance of pre-emptive tension-free patch closure to decrease the risk of intracardiac injury and postoperative bleeding. Our second case demonstrates the potential for delayed mitral valve dysfunction following weakening of adjacent tissue caused by extensive resection of an encroaching sessile calcified tumor. It also highlights pacemaker-lead-induced tricuspid regurgitation, an increasingly recognized but underappreciated long-term complication of pacing (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The intraoperative discovery of an acquired Gerbode defect is a particularly rare and serious complication, with only sporadic reports in the literature (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Despite multiple surgical interventions, the combination of structural valve disease, pacing complications, ventricular dysfunction and multiorgan failure culminated in poor outcome.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eClinical Implications\u003c/h3\u003e\n\u003cp\u003eThese contrasting cases highlight several important lessons in managing patients with calcified, broad based atrial myxomas. First, the proximity of a myxoma to the mitral annulus requires meticulous dissection to balance oncologic clearance with preservation of valve function. Tension-free, preferably patch closure of the cardiac chambers is recommended. Second, intraoperative and postoperative echocardiography are indispensable for early detection of valvular or structural complication. Third, patients requiring PPM after myxoma surgery should be monitored closely for device-induced valvular dysfunction. A Heart Team approach comprising cardiac surgeons, imaging specialists, electrophysiologists, intensivists and heart failure physicians is essential for providing multidisciplinary expertise. Finally, rare but devastating complications such as acquired Gerbode defect must be recognized promptly to guide management.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSurgical resection of atrial myxomas is generally safe and curative. However, when tumors are broad-based, calcified or involve adjacent structures, complex repairs may be required, potentially increasing the risks of complications. Tumors near the mitral annulus can be safely resected \u003cem\u003een bloc\u003c/em\u003e with careful technique and pre-emptive reconstruction. Structural injury, conduction block and rare complications such as Gerbode defect may necessitate complex reoperations. These cases emphasize the importance of individualized surgical planning, vigilant follow-up and early recognition of complications to optimize long-term outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003ecMRI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eCardiac magnetic resonance imaging\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eIRB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eInstitutional Review Board\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eLVEF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eLeft ventricular ejection fraction\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eMR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eMitral regurgitation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003ePOD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003ePost-operative day\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003ePPM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003ePermanent pacemaker\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eTEE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eTransesophageal echocardiography\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eTTE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 393px;\"\u003e\n \u003cp\u003eTransthoracic echocardiography\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consents were obtained from patient to include the information in this manuscript. Institutional Review Board (IRB) approval was not required.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdditional data are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSHE receives speaker fees from Philips Healthcare, GE Healthcare, Edwards Lifesciences and Abbott Medical.\u003c/p\u003e\n\u003cp\u003eThe other authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFundings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any grants from any funding agencies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eML wrote and revised the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSHE provided echocardiographic images, descriptions of echocardiographic findings and revised the manuscript.\u003c/p\u003e\n\u003cp\u003eSJWT, FHXY and SHL provided histological images, descriptions of pathological findings, and revised the manuscript.\u003c/p\u003e\n\u003cp\u003eYLC, ZBAZ and PYKP supervised and revised the manuscript writing.\u003c/p\u003e\n\u003cp\u003eAll authors were involved in the patient’s care and have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all individuals who were involved in the care for our patients.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLam KY, Dickens P, Chan AC. Tumors of the heart. A 20-year experience with a review of 12,485 consecutive autopsies. Arch Pathol Lab Med. 1993;117(10):1027\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReynen K. Cardiac myxomas. N Engl J Med. 1995;333(24):1610\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePinede L, Duhaut P, Loire R. Clinical presentation of left atrial cardiac myxoma. A series of 112 consecutive cases. Med (Baltim). 2001;80(3):159\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKeeling IM, Oberwalder P, Anelli-Monti M, Schuchlenz H, Demel U, Tilz GP, et al. Cardiac myxomas: 24 years of experience in 49 patients. Eur J Cardio-Thorac Surg Off J Eur Assoc Cardio-Thorac Surg. 2002;22(6):971\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBjessmo S, Ivert T. Cardiac myxoma: 40 years\u0026rsquo; experience in 63 patients. Ann Thorac Surg. 1997;63(3):697\u0026ndash;700.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElbardissi AW, Dearani JA, Daly RC, Mullany CJ, Orszulak TA, Puga FJ et al. Survival after resection of primary cardiac tumors: a 48-year experience. Circulation. 2008 Sept 30;118(14 Suppl):S7-15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGaratti A, Nano G, Canziani A, Gagliardotto P, Mossuto E, Frigiola A, et al. Surgical excision of cardiac myxomas: twenty years experience at a single institution. Ann Thorac Surg. 2012;93(3):825\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArgueta E, Ratheal K, Prieto S, Paone R, Jenkins LA, Oyenuga O. Recurrent atrial myxoma, right atriotomy, and sinus node dysfunction: A case of interdisciplinary care. Southwest Respir Crit Care Chron 2018 July 20;6(25):42\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYuan SM. Left ventricular to right atrial shunt (Gerbode defect): congenital versus acquired. Postępy W Kardiologii Interwencyjnej Adv Interv Cardiol. 2014;10(3):185\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDelling FN, Hassan ZK, Piatkowski G, Tsao CW, Rajabali A, Markson LJ, et al. Tricuspid Regurgitation and Mortality in Patients With Transvenous Permanent Pacemaker Leads. Am J Cardiol. 2016;117(6):988\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaker E, Bahri GN, Montalbano MJ, Johal J, Graham RA, Tardieu GG, et al. Gerbode defect: A comprehensive review of its history, anatomy, embryology, pathophysiology, diagnosis, and treatment. J Saudi Heart Assoc. 2017;29(4):283\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJiang CX, Wang JG, Qi RD, Wang W, Gao LJ, Zhao JH, et al. Long-term outcome of patients with atrial myxoma after surgical intervention: analysis of 403 cases. J Geriatr Cardiol JGC. 2019;16(4):338\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"atrial myxoma, mitral valve repair, pacemaker, Gerbode defect, surgical outcomes","lastPublishedDoi":"10.21203/rs.3.rs-8022939/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8022939/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAtrial myxomas are the most frequent primary cardiac tumors and are typically cured by surgical resection. Prognosis is excellent in most cases, but complex tumors that involve adjacent valvular or septal structures may lead to challenging repairs and adverse outcomes. We present two patients with atrial myxomas who underwent surgery with strikingly different results. The first, a 72-year-old woman, had a broad-based, calcified left atrial myxoma encroaching on the mitral annulus. Following resection, annular stability was preserved with annuloplasty and patch reinforcement, resulting in successful repair and excellent recovery. The second, a 68-year-old man, underwent excision of a calcified myxoma but developed complete heart block, anterior mitral leaflet perforation requiring repair, and an acquired Gerbode defect. Despite reoperation with pericardial patch repair and tricuspid annuloplasty, he later required redo mitral and tricuspid valve replacements with ECMO support and ultimately died of multiorgan failure. These cases illustrate contrasting outcomes after atrial myxoma surgery. While curative resection is common, complex tumors near the mitral annulus or atrioventricular septum may cause structural injury, conduction disturbances, and rare complications such as Gerbode defect. Careful preoperative imaging, meticulous intraoperative assessment, and long-term vigilance are essential to optimize outcomes.\u003c/p\u003e","manuscriptTitle":"Excision of Calcified Left Atrial Myxomas: A Surgical Challenge","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-27 00:12:08","doi":"10.21203/rs.3.rs-8022939/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-25T14:42:36+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-24T21:53:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"96103036916897484877608770362167035929","date":"2026-01-24T07:51:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"73408907411860588850512571507185571789","date":"2026-01-24T07:44:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"241372953456283498315192803923068106705","date":"2026-01-24T06:55:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-23T11:02:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"267124648990115606071073903656602754215","date":"2026-01-22T10:42:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"181617017352528376140539968963332182567","date":"2026-01-22T08:16:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"97878743622761174759274594183883929791","date":"2026-01-22T08:15:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"250778235062639110920980405642541846800","date":"2026-01-22T06:55:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-22T06:47:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-10T14:57:32+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-10T14:54:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2025-11-03T23:30:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6434a561-e62d-46af-acc6-5cfc85323f7d","owner":[],"postedDate":"January 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T16:01:52+00:00","versionOfRecord":{"articleIdentity":"rs-8022939","link":"https://doi.org/10.1186/s13019-026-04073-1","journal":{"identity":"journal-of-cardiothoracic-surgery","isVorOnly":false,"title":"Journal of Cardiothoracic Surgery"},"publishedOn":"2026-04-13 15:57:56","publishedOnDateReadable":"April 13th, 2026"},"versionCreatedAt":"2026-01-27 00:12:08","video":"","vorDoi":"10.1186/s13019-026-04073-1","vorDoiUrl":"https://doi.org/10.1186/s13019-026-04073-1","workflowStages":[]},"version":"v1","identity":"rs-8022939","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8022939","identity":"rs-8022939","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}