Approach
The only definitive treatment of cardiac myxoma is surgical removal. Surgery should be done as soon as possible. The timing of surgery is dictated by the general condition of the patient, associated medical conditions, and availability of an experienced surgeon. Prior to surgery, or in cases where surgery is not an option, any associated clinical conditions such as heart failure, arrhythmias, or embolic phenomena should be treated.
Treatment
Generally, after median sternotomies, the myxoma is surgically excised using cardiopulmonary bypass and cardioplegic arrest. The tumour is removed by either right or left atriotomy or combined atriotomy, depending on the site and extent of the tumour. The choice of technique also depends on associated conditions that need surgical intervention such as valve repair or replacement, and coronary artery bypass graft. Post-operatively, there is no definitive recommendation for anticoagulation if the myxoma is removed. However, post-operative aspirin or anticoagulation should be considered if an embolic event has occurred or if there are other indications for such therapy, though the evidence base for such an approach is lacking.
Medical therapy may be required for the treatment of associated conditions, which include arrhythmias, heart failure, and embolism.
Arrhythmias are treated with the appropriate anti-arrhythmic drug until surgery can be performed.
If there is any evidence of residual heart failure, then appropriate long-term therapies (e.g., beta-blockers, ACE inhibitors, and furosemide) may be needed in individual cases.
No guidelines or recommendations exist regarding treatment of embolic phenomena in cases of myxoma. The definitive treatment is surgical removal of the cardiac tumour.
The treatment of embolic phenomena depends on the vascular territory involved. In cases where large vessels are involved, anticoagulation is started based on an initial diagnosis of vascular occlusion, but the definitive treatment is surgical removal of the myxomatous tissue.[12]
The occlusive mass, unlike acute coronary thrombosis, is not composed mainly of platelet-rich thrombus. Hence, both intracoronary thrombolysis and mechanical revascularisation may be unsuccessful in patients presenting with myocardial infarction due to cardiac myxoma.[13][14]
Patients who have extensive comorbidities with poor prognosis and who are unfit for cardiac surgery are treated conservatively, with medical therapy directed at these specific complications if they occur. The role of anticoagulation in these patients is not established and should be individualised.
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