Literature about these rare cardiac tumors is mostly limited to isolated case reports, recently collected in a large systematic review(1). Of all primary tumors, 0.2 to 0.4 % are from cardiac origin. From these, only 8.4% are lipoma’s mostly presenting in the 40–70 year old age group with no gender predilection. Growth is slowly and asymptomatic in its early stages. Up to 57% of patients become symptomatic due to the mass effect on adjacent structures(1). Echocardiogram is the preferred diagnostic tool LV lipomas: tumor shape and size, adjacent structures and interference with in- and outflow tracts can be evaluated. In addition, CT or MRI can further objectivate tumor density, blood supply and (extra)cardiac invasion. Postoperative histological examination is crucial for diagnosis confirmation. MDM2 FISH test is needed in adjunct to histology to distinguish between lipoma and atypical lipomatous tumor(2).
Despite no official guideline for treatment of lipoma, current practice is surgical resection by either partial or full sternotomy. Some have reported thoracoscopic techniques, though sternotomy was still needed(3, 4). Other approaches such as by ventriculotomy have also been described, though we deem this approach high risk due to weakening of the ventricular wall and possible lesion of the coronary arteries(5).
Up to date, no non-sternotomy minimally invasive approach has been reported. The technique described in this report allows adequate access to the left ventricle via the left atrium through the mitral valve by use of a utility port (1.5cm) and 3 trocars entry points. Thorough inspection of the left ventricle is possible allowing for meticulous dissection of the LV lipoma from the left ventricular wall while keeping the lipoma itself intact, minimising the risk of embolization. Lipoma growth is from interior to exterior, hence an approach from inside the ventricle allows good differentiation between LV wall and lipoma. Sternotomy comorbidity is avoided allowing for lesser postoperative pain, faster mobilisation and recovery while evading the well-known sternotomy risks such as sternitis, sternal detachment and postoperative wound infection.