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.