Objectives
Cardiac myxoma is the most common primary benign cardiac tumor and managed by surgical excision. However, it can occur within any cardiac chamber, a majority of them are located in LA (75%), in RA (15), biatrial (2.5%), very rare in ventricles and valve. Atrial myxomas arise from interatrial septum, at the border of fossa ovalis[1] . Depending on size, site, and mobility of the mass, myxomas give manifestation of obstruction or embolization, or constitutional symptoms. If the myxoma is large pedunculated and mobile, can obstruct the valve, resulting in sudden death. Therefore, myxomas should be resected surgically, once diagnosis confirmed[2] . Diagnosis is done mainly by echocardiography (TTE-TEE) or other imaging; like computed tomography (CT), and magnetic resonance imaging () (Figure 1) . Resection of myxomas is safe, with very low mortality and morbidity [3] . Early diagnosis is challenged because its symptoms are nonspecific. Clinical manifestation includes fever, chest distress, dyspnea, anemia, syncopal attack, and embolism [9]. Large myxomas may be asymptomatic if the growth is very slow [5] . Atrial myxomas are usually considered as an indication for urgent surgery [10] . It is very rare procedure; its incidence in cardiac surgery operation is about 0.3% [4] . Advanced imaging provides more accurate evaluation of size, site, shape, and attachment. So, exploration of all chambers may not be required intraoperative. MI approach should be considered as a treatment option [5].
Several surgical approaches (isolated left or right atriotomy, right atriotomy with trans-septal incision, and bi-atrial approach) and chest incision (median sternotomy and mini-thoracotomy) have been used for myxoma resection [11]. Myxomas usually are managed by complete excision through a median ST. However, the poor cosmetic effect and possible complications of ST are occasionally troublesome. The concept of MICS has been introduced recently to cardiac surgery. MICS has potential benefits such as increased patient satisfaction, less pain, decreased length of ICU and hospital stays, improved quality of life, and so decreased costs. The safety and efficacy of MICS approach, in comparison to ST approach, for atrial myxoma resection has proven challenging [6-7-8].