Hypothermic Cardiac Arrest to Remove RightAtrial Thrombi Due to Abdominal Malignancies

The first use of hypothermia in cardiac surgery is attributed to Dr. John Lewis who performed an atrial septal defect closure on September 2, 1952 at the University of Minnesota (Gott, 2005). Cardiopulmonary by-pass (CPB) and hypothermic cardio-circulatory arrest (HCCA) has been introduced for the first time in clinical practice for aortic arc substitution (Pierangeli et al., 1974). More recently the same technique has been proposed to remove atrial thrombi originated from renal carcinomas (Marshall et al., 1984), adrenal carcinomas (Shahinian et al., 1989), hepatocellular carcinoma (Hamazaki et al., 1995) and other abdominal malignancies such as caval leiomyosarcoma, uterine endometrial sarcoma or intravenous leiomyomatosis, ovarian or testicular tumors (Hassan et al.,, 2010; Vargas-Barron et al., 1990; Ariza et al., 1982; Kanda et al., 1991). There is still a debate pro and cons the use of hypothermic arrest with some favours the normothermic (Lubahn et al., 2006; Stewart et al., 1991) and some others the hypothermic, because of the operative field appears better exposed and almost completely bloodless so the blood loss resulted much lower. Furthermore they claim a better visualization of some critical areas with an easier removal of the tumoural thrombus, that may invade the hepatic veins or the coronaric sinus, may either remain attached to the tricuspid valve or may have embolized into the pulmonary artery (Chiappini et al., 2002; Kalkat et al., 2008; Leo et al., 2010; Topcouglu et al., 2004). In all these occasions HCCA offers the possibility of a better tumoural cleaning with the possibility of R0 resection. The incomplete removal of this tumoural thrombi in fact is correlated to an early recurrence and a worst postoperative survival (Skinner et al., 1989). Furthermore the hepatic, renal and splacnic damage from warm ischemia due to the Pringle’s manoeuvre and/or aortic/mesenteric cross-clamping (usually necessary when CPB is used without cardio-circulatory arrest) is reduced when the HCCA is instead used (Chiappini et al., 2002, Davlouros et al., 2005). This permits its use even in the setting of mild hepatic damage (Leo et al., 2010).