We report a rare case of a protruding tumor from the right atrial free wall into the cardiac sac. A cardiac tumor was incidentally detected in the right atrium of a 64-year-old man by transthoracic echocardiography. The tumor was located in the right atrial anterior free wall, infiltrating the right artrial appendage near the tricuspid valve annulus. It had an irregular surface, did not have a tumor stalk, and was considerably mobile. We resected the tumor and performed cryosurgical ablation of the remnant tissue to reduce the risk of local recurrence. Histopathologic examination confirmed the tumor to be metastatic malignant fibrous histiocytoma (MFH). The postoperative course was uneventful, and the patient was discharged 11 days after surgery. Follow-up computed tomographic scans and transthoracic echocardiography did not reveal any evidence of local cardiac recurrence or distant metastasis.

This study was designed to evaluate the perioperative outcome of dialysis patients undergoing cardiac surgery, who were managed with our perioperative dialysis program. Between April 1994 and August 1999, 11 patients (7 men and 4 women with a mean age of 57.3±10.3 (36-73)) with hemodialysis (HD, n=8) and peritoneal dialysis (PD, n=3) underwent cardiac surgery. The duration of dialysis was 5.6±4.3 years. Operation included mitral valve replacement (n=1) and isolated coronary artery bypass grafting (n=10). Patients with HD had single hemodialysis on the day before operation. Patients with PD were maintained on PD in the usual manner until the day before surgery. Intraoperative hemofiltration during extra-corporeal circulation and normokalemic non-depolarizing cardioplegic solution were used in all patients to avoid post-operative hyperkalemia. All HD patients had dialysis on the first post-operative day (POD 1), and then every other day. PD patients had PD soon after arriving at the ICU. Levels of serum creatinine, urea nitrogen, acid-base balance were successfully controlled within acceptable ranges. No patients required emergency HD or any post-operative managements for hyperkalemia in the ICU. Six of 8 HD patients required an increase in vasopressor because of a tendency toward hypotension and 4 of 8 patients suffered from atrial fibrillation during the initial HD on POD 1. Eight of 11 patients could be extubated on the first POD. No hospital death occurred. The use of normokalemic cardioplegic solution was useful to avoid post-operative hyperkalemia. Our perioperative dialysis programme successfully managed the perioperative clinical course of dialysed patients undergoing cardiac surgery.

A 59-year-old man who had been treated medically for aortic stenosis and angina pectoris was hospitalized due to a high fever. He was treated immediately by intravenous infusion of antibiotics. Blood culture was positive for α-streptococcus. Echocardiography revealed severe aortic stenosis with vegetation on the aortic valve and minimal aortic regurgitation. The peak aortic pressure gradient was 80mmHg. The patient developed chest pain at rest and showed ischemic ST-segment depression on the electrocardiogram obtained after admission. Coronary angiography (CAG) was performed to assess the extent of coronary artery disease, and it showed 90% stenosis of the right coronary artery (RCA) and 75% stenosis of the circumflex branch (Cx). Both fever and angina pectoris were so resistant to maximal medical treatment that the patient was referred to our hospital for urgent surgical treatment. During surgery, a large vegetation was noted on the aortic valve, which was calcified, and a destructive ring abscess was observed around the coronary cusp. Aortic valve replacement (SJM-19mm) was performed after complete debridement of the abscess and repair of the resulting aortoventricular discontinuity. Double coronary bypass saphenous vein grafting to RCA and Cx was performed. The patient recovered without incident and was discharged 4 weeks after surgery.