Left atrial dissection with oozing rupture after cardiac myxoma resection: a case report of conservative management guided by transesophageal echocardiography

Left atrial dissection is an extremely rare complication after cardiac surgery, occurring predominantly after mitral valve procedures. Left atrial dissection after cardiac myxoma resection is exceptionally rare, with only a limited number of cases reported. Among these, only one involved oozing rupture and required surgical intervention. We report a case of left atrial dissection with oozing rupture after cardiac myxoma resection that was managed conservatively (without definitive repair of the dissection) because additional surgical intervention carried prohibitive risk, guided by serial transesophageal echocardiography (TEE). An 80-year-old woman underwent resection of a suspected left atrial myxoma with a wide base originating from the fossa ovalis and extending toward the right pulmonary vein orifice. The tumor was excised with partial-thickness atrial wall resection, and the endocardial defect was repaired using a bovine pericardial patch. Two hours after admission to the intensive care unit, the patient developed mediastinal bleeding with hypotension. Emergency re-exploration revealed a subepicardial hematoma on the posterior aspect of the heart, without an identifiable bleeding source. Intraoperative TEE established the diagnosis of left atrial dissection with oozing rupture. Given the patient’s tissue fragility and the absence of pressurized left ventricular inflow into the dissection cavity, a conservative (non-repair) strategy was selected, including blood product transfusion, intra-aortic balloon pump support, and gauze packing with an open sternum. On postoperative day 5, TEE demonstrated a marked reduction in the left atrial hematoma, allowing successful chest closure. The patient recovered without thromboembolic complications and was transferred to a rehabilitation facility on postoperative day 42. Histopathological examination confirmed cardiac myxoma resected with adequate margins. Although left atrial dissection with rupture generally necessitates surgical intervention, conservative (non-repair) management may be considered in highly selected patients when definitive repair carries prohibitive risk. Serial TEE is essential for diagnosis, monitoring treatment response, and guiding clinical decision-making in this potentially lethal condition.