Outcomes of totally endoscopic resection of benign right-sided cardiac massesusing a 3D endoscopic system

Objective: To evaluate the early and mid-term outcomes of totally endoscopic surgical resection of benign right-sided cardiac masses using a three-dimensional (3D) endoscopic system at the Cardiovascular Center, E Hospital. Materials and Methods: The medical records of 18 consecutive patients with a preoperative diagnosis of right atrial myxoma who were approved for totally endoscopic surgery following multidisciplinary consultation at the Cardiovascular Center, E Hospital, between January 2019 and July 2026 were retrospectively reviewed. Two patients were excluded. One developed cardiac arrest during anesthesia induction, was successfully resuscitated, and subsequently underwent primary median sternotomy; this case was therefore not considered a conversion from the endoscopic approach. The other had a mediastinal lesion invading the heart, with postoperative histopathology revealing a type B2 thymoma, and was therefore excluded from the benign intracardiac mass group. The remaining 16 patients were included in the analysis. The preoperative diagnosis was used to identify the initial study cohort, whereas postoperative histopathology determined eligibility for inclusion in the benign intracardiac lesion analysis. Clinical characteristics, preoperative echocardiographic findings, operative variables, early postoperative outcomes, and mid-term follow-up data were collected and analyzed. Results: The mean age was 55.4 ± 11.1 years (range, 38–75) and 75.0% (12/16) of patients were female. Dyspnea was reported in 9/16 (56.3%) patients. The mean maximum tumor size was 42.8 ± 22.5 mm (14–80) and preoperative left ventricular ejection fraction was 69.9 ± 8.9%. The lesion was completely resected in 15/16 (93.8%) patients; the remaining 1/16 (6.3%) patient — in whom no intracavitary right atrial mass was found intraoperatively and a lesion was identified on the posterior surface of the anterior tricuspid leaflet extending toward the right ventricular outflow tract — underwent biopsy only. Pathology revealed 11 myxomas (68.8%), 2 cases of lipomatous hypertrophy of the interatrial septum (12.5%), 1 papillary fibroelastoma (6.3%), 1 ectopic hepatic tissue (6.3%), and 1 case of myocardial inflammation with myxoid degeneration (6.3%). Surgery was performed on the beating heart without aortic cross-clamping in 14/16 cases (87.5%), whereas 2/16 (12.5%) required aortic cross-clamping with cardioplegic arrest. The mean cardiopulmonary bypass time was 102.2 ± 32.0 min in the beating-heart group and 218.5 ± 87.0 min in the cross-clamp group. Early complications occurred in 3 patients (18.8%) — postoperative bleeding requiring reoperation in one patient (who underwent two reoperations, both through the same three trocar incisions without additional enlargement or sternotomy), hemothorax in one patient, and pneumothorax in one patient.; there were no technical failures, no conversion to sternotomy, and no 30-day mortality. Follow-up clinical status and vital status were available for all 16 patients; 15/16 (93.8%) attended a follow-up visit with echocardiography at E Hospital or a local facility, and 1/16 (6.3%) was interviewed by telephone. At the last follow-up, 14/16 (87.5%) patients were NYHA class I and 2/16 (12.5%) were NYHA class II. Among the 14 patients with complete resection and echocardiographic follow-up, no tumor recurrence was detected; the biopsy-only patient underwent echocardiography 7 months after operation, with no intracardiac mass identified. Mean follow-up duration in the 15 patients with an in-person follow-up visit was 33.3 ± 27.8 months (range, 1–84). Conclusions: In this single-center retrospective study, totally endoscopic resection of benign right-sided cardiac masses using a three-dimensional visualization system achieved a complete resection rate of 93.8% and an early complication rate of 18.8%, with no technical failures or deaths. No tumor recurrence was detected on follow-up echocardiography among the 14 patients who underwent complete resection and attended follow-up. These preliminary findings suggest that this technique is feasible in appropriately selected patients at centers experienced in minimally invasive cardiac surgery. Larger prospective multicenter studies are needed to confirm the safety and effectiveness of this approach.