BackgroundRenal cell carcinoma is a potentially lethal cancer with aggressive behavior and it tends to metastasize. Renal cell carcinoma involves the inferior vena cava in approximately 15 % of cases and it rarely extends into the right atrium. A majority of renal cell carcinoma are detected as incidental findings on imaging studies obtained for unrelated reasons. At presentation, nearly 25 % of patients either have distant metastases or significant local-regional disease with no symptoms that can be attributed to renal cell carcinoma.Case presentationA 64-year-old Indian male with a past history of coronary artery bypass graft surgery, congestive heart failure, and diabetes mellitus complained of worsening shortness of breath for 2 weeks. Incidentally, a transthoracic echocardiography showed a “thumb-like” mass in his right atrium extending into his right ventricle through the tricuspid valve with each systole. Abdomen magnetic resonance imaging revealed a heterogenous lobulated mass in the upper and mid-pole of his right kidney with a tumor extending into his inferior vena cava and right atrium, consistent with our diagnosis of advanced renal cell carcinoma which was later confirmed by surgical excision and histology. Radical right nephrectomy, lymph nodes clearance, inferior vena cava cavatomy, and complete tumor thrombectomy were performed successfully. Perioperatively, he did not require cardiopulmonary bypass or deep hypothermic circulatory arrest. He had no recurrence during the follow-up period for more than 2 years after surgery.ConclusionsAdvanced extension of renal cell carcinoma can occur with no apparent symptoms and be detected incidentally. In rare circumstances, atypical presentation of renal cell carcinoma should be considered in a patient presenting with right atrial mass detected by echocardiography. Renal cell carcinoma with inferior vena cava and right atrium extension is a complex surgical challenge, but excellent results can be obtained with proper patient selection, meticulous surgical techniques, and close perioperative patient care.Electronic supplementary materialThe online version of this article (doi:10.1186/s13256-016-0888-5) contains supplementary material, which is available to authorized users.

A 72-year-old Chinese man presented with mild symptoms of heart failure. Transthoracic echocardiography showed signs of cardiac tamponade though clinically he was relatively well. The option of pericardiocentesis was not carried out due to a narrow window for aspiration with only a thin layer of effusion seen surrounding the apex and right ventricle on subcostal view.Pericardial window was done via a left anterolateral thoracotomy. Intraoperatively, 500 cm of purulent fluid was drained. Microbiology screens were all negative. We present the atypical clinical course of this elderly man presenting with a large pyopericardium.

DesCripTionA 56-year-old man presented with acute left-sided chest pain at rest with associated dyspnoea. His heart rate was 35 beats/min and ECG revealed a complete heart block. A temporary cardiac pacing was implemented on the right side via transcutaneous leads. He was also diagnosed with non-ST elevation myocardial infarction due to raised cardiac enzymes and was managed with medical therapy. The pacemaker was removed after 3 days when he reverted to sinus rhythm. Coronary angiogram was subsequently performed and revealed a critically obstructed triple coronary vessel disease. Echocardiography revealed an ejection fraction of 40%, competent valves and normal chamber size. Coronary artery bypass graft (CABG) surgery was performed via median sternotomy. Interestingly, there were no innominate veins identified intraoperatively and a dilated coronary sinus was seen on transoesophageal echocardiography. Cardiopulmonary bypass was initiated following aortic and two-stage right atrial venous cannulation. The heart was cooled and intentionally stopped by antegrade cardioplegia. On lifting the heart, a left superior vena cava was identified adjacent to the left atrial appendage (figure 1). Two vein grafts were grafted to the posterior descending artery and distal left circumflex. The left internal mammary artery harvested was grafted to left anterior descending artery.Persistent left superior vena cava (PLSVC) is a rare congenital vascular anomaly due to the failure of left superior cardinal vein caudal to the innominate vein to regress in utero.

who had undergone coronary artery bypass grafting surgery (CABG) with use of saphenous vein grafts (SVGs) from March 2016 to May 2017 were included into the study, with total number of 127 patients. Their medical records were collected and reviewed. These patients were then divided into two groups, CVH and MIVH group, based on the vein harvesting technique done. The harvesting technique was decided based on operating surgeon's preference. CVH group (n=68) had conventional open saphenous vein harvesting. MIVH group had minimally invasive endoscopic saphenous vein harvesting. All deaths were excluded from the study.Vein harvesting was performed by experienced medical assistants. Perioperative care was similar for all patients.

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