Cardiac tumors—sex‐related characteristics and outcomes after surgical resection

Cardiac tumors represent a rare and heterogeneous pathological entity, with a cumulative incidence of up to 0.02%. Gender was previously reported to influence outcomes after tumor surgery. This study aimed to investigate for gender‐related differences in outcomes after cardiac surgery.


| INTRODUCTION
Cardiac tumors are a rare entity with incidences between 0.17 and 0.19%. 1 The majority of which is benign. 2 Nevertheless, patients with malignant primary cardiac tumors face a poor prognosis. Due to their rareness, clinicians may only see a few cases during their professional careers, and the majority of scientific literature is based on case studies and descriptions. Over the last decades, there has been a rise in the prevalence of benign and malignant cardiac tumors related to improved imaging modalities. 3 Concerning preoperative diagnostics, echocardiography is the primary diagnostic tool in most cases. Transthoracic echocardiography (TTE) enables the assessment of size, location, mobility, and pericardial involvement. 4 Also, it shows hemodynamic effects of the suspected mass and can detect even small masses (<1 cm).
Transesophageal echocardiography (TEE) is used when valvular involvement is suspected in patients with atrial involvement or mobile masses. 5 After a cardiac mass is suspected, patients may be referred to magnetic resonance imaging (MRI) for an exact evaluation of the cardiac chambers and the pericardium to enable exact surgical planning. 6 Besides MRI, computed tomography (CT) offers a diagnostic alternative that is optimal for detecting calcified masses and assessing chest and lung tissue as well as corresponding vascular structures and enables the exclusion of obstructive coronary artery disease in the same setting. 7 Gender disparities have been reported in the face of other cardiovascular diseases, such as coronary artery disease or valvular heart disease. 3,8,9 The relationship between gender and cardiac tumor outcomes has been investigated; this analysis focuses on intraoperative details to improve the understanding and patients outcome after surgical tumor resection. 10,11 Although sex differences have already been reported in the case of cardiac tumors, survival differences after surgical resection, with long-term follow-up, are lacking.
We used our clinical database-one of the largest single-center databases of cardiac tumors to evaluate sex differences in cardiac tumor prevalence and survival after surgical resection between 2009 and 2021.

| METHODS
The local ethics commission board approved the retrospective analysis of consecutive cases treated at our institution. All relevant perioperative data were obtained from our clinical software systems.
Between 2009 and 2021, 183 consecutive patients with cardiac masses were identified and included to be analyzed retrospectively with respect to sex-related differences.

| Variables of interest
The retrospective analysis was performed using an institutional patient database. The variables evaluated in this study include preoperative baseline characteristics (Table 1), heart tumor characteristics (Table 2), and characteristics of tumors in other locations than the heart (Table 3), as well as intra-and postoperative characteristics (Table 4).

| Statistical analysis
The statistical analysis was performed using Statistical Package for Social Sciences, version 23.0 (SPSS IBM). All data were presented as continuous or categorical variables. Categorical data were expressed as total numbers and percentages. Continuous

| RESULTS
The mean follow-up of our analysis was 56.6 ± 44.1 months. Overall 35 patients of the whole cohort were lost of follow-up due to a variety of reasons. 3.2 | Heart tumor characteristics of male and female patients with a cardiac tumor

| Characteristics of tumor in other locations, male versus female patients with a cardiac tumor
The frequency and characteristics of tumors in other locations within the analyzed patient cohort suffering from heart tumor are displayed in

| Intra-and postoperative characteristics of male and female patients with a cardiac tumor
As displayed in  = 1.000). The length of overall hospital was significantly longer for male with 12 ± 7.9 days than for female with 11 ± 4.5 days, p < 0.001. In total, all-cause mortality was 18% for male and 9.1% for female, p = 0.083, showing no significant difference (Figure 1).

| Multinominal regression analysis for gender
To further evaluate gender-related differences in the occurrence of cardiac tumors, we performed a multinomial regression analysis (Table 5). Where gender was shown to have a significant effect on the development of myxoma in patients (OR: 3.93, CI: 95% 2.10-7.33, p = 0.03).

| DISCUSSION
Analyzing 183 patients that underwent cardiac surgery due to a cardiac tumor at our center and focusing on gender-related differences, we found no significant differences between male and female patients regarding demographic data but detected significant differences in tumor location (Table 1). While cardiac tumors were most likely found within the left atrium in male patients, a large percentage of female patients presented with tumors located at the atrial septum. However, there was no significant difference between tumor entity or histopathological tumor type and overall survival ( Figure 1).
Myxomas were the most common type of cardiac tumors in our analysis, and they are more common in women, which is in accordance with other studies in this field. [13][14][15] The most common type of malignant tumor in our analysis was sarcoma. Angiosarcoma is the dominating cardiac sarcoma subtype in literature, followed by leiomyosarcoma. Intimal sarcoma, rhabdomyosarcoma, and synovial sarcoma are important differential diagnoses.
Metastasis of sarcoma into cardiac locations is very rare. 16 17 This underlines the importance of a multiprofessional interdisciplinary treatment team for cardiac tumors to find the optimal, individually tailored treatment for each patient. 28 Given the rarity of cardiac tumors, compared to the overall case volume of a large cardiac surgery center in combination with only about half of the patients presenting with specific symptoms, a high degree of suspicion during initial diagnostics is needed to detect cardiac tumors.
As symptoms may be absent or vary and cardiac tumors may sometimes not be distinguished from infectious endocarditis, the importance of image modalities should be mentioned and underlined to detect and distinguish the type of tumor or mass before surgery.
Overall, this large cohort of cardiac tumors demonstrates good surgical results and undermines cardiac surgery as the firstline therapy for benign and malignant cardiac tumors in an interdisciplinary treatment model.

| CONCLUSION
Cardiac tumors are rare, and accurate diagnostics are complex due to various cardiac masses. Cardiac myxomas can more often be found in women, and minimally invasive resection is often a feasible treatment option. Surgical excision is feasible and safe for cardiac tumors with good long-term survival and relatively low complications and thus remains the gold standard for therapy. Nevertheless, gender-related modalities should be investigated to ensure the best-preoperative planning and therapy.

ACKNOWLEDGEMENT
Open Access funding enabled and organized by Projekt DEAL.