OPERATIVE TECHNIQUE
A team of highly specialized cardiothoracic surgeons used a modified cardiac autotransplantation technique for tumor resection. Standard midline sternotomy was used. The patient was placed on cardiopulmonary bypass after arterial cannulation of the mid-aortic arch and bicaval cannulation, being careful to cannulate as superior as possible in the SVC. Tumor dissection began while on cardiopulmonary bypass prior to aortic cross-clamp. Antegrade cardioplegia was administered every 20 minutes.
The modified autotransplantation approach was performed by transecting the SVC, aorta and main pulmonary artery, leaving the IVC in situ. Following this, the left and right atria were entered allowing for tumor resection. The tumor had invaded the adventitia of the main pulmonary artery. The superior half of the right atrium and inferior half of the superior vena cava (SVC), inferior to the azygous vein, were resected en bloc with the tumor as was the roof of the left atrium, main pulmonary artery, circumflex coronary artery and portions of the aortic root (Figure 2 , A-B ). Both the left and right superior pulmonary vein-left atrial junctions were resected with the specimen. Complete macroscopic tumor resection was accomplished.
With the heart attached by the inferior pulmonary veins and IVC, it was raised such that the left atrium was anterior. Bovine pericardium was used to reconstruct the anterior and superior aspects of the left atrium. The superior pulmonary veins were reconstructed and re-anastomosed to the left atrium. The main pulmonary artery, ascending aorta, aortic root, and right atrium were reconstructed using bovine pericardium in this sequence. A piece of great saphenous vein was then anastomosed in end-to-end fashion from the left circumflex artery in the atrioventricular groove to the reconstructed noncoronary sinus of the ascending aorta. Total cross-clamp, pump, and re-perfusion times were 251 minutes, 383 minutes, and 72 minutes, respectively. Severe coagulopathy was managed with seven units of platelets, five units of plasma, 16 units of blood, and prothrombin complex. An epicardial dual-chamber pacemaker was also implanted at the operation due to SA node resection.
The resected tumor was measured as 110 x 60 x 57-mm and weighed 293.8g. Pathology report confirmed the diagnosis of spindle cell, pericardial synovial sarcoma with 8 mitoses per 10 high power fields, 80% viable tumor, and no necrosis. The tumor was staged as ypT1. Despite best surgical efforts, some frozen sections (aorta and left atrial roof) had microscopic positive margins.