[Massive haemorrhage after bivalirudin anticoagulation in two heart transplant patients]. / Hemorragia masiva después de anticoagulación con bivalirudina en 2 casos de pacientes con trasplante cardiaco.

Heparin-induced thrombopenia is a common autoimmune complication. It is a prothrombotic state due to the formation of antibodies against heparin/platelet factor 4 complexes. In this situation drugs other than heparin must be used for anticoagulation during extracorporeal circulation (bypass) surgery. Two cases of heart transplantation are presented in whom bivalirudin was used as an anticoagulant during the cardiopulmonary bypass. Severe bleeding complications were observed in both patients. The diagnosis of heparin-induced thrombopenia needs to be improved, as well as the development of protocols for using new drugs other than heparin. For this reason, we have reviewed current protocols and alternative therapies to heparin.

Correlation of immunological markers with graft vasculopathy development in heart transplantation.

This study examined the imbalance between T effector cells (Th1 defined as CD3+ interferonγ+) and T regulatory cells (Treg defined as CD4+CD25(high)FoxP3+) as a valuable albeit limited marker of cardiac allograft vasculopathy (CAV) after heart transplantation (HTx). CAV remains, with neoplasms, the most important cause of death in patients surviving the first year after HTx. It is an immune-mediated pathology, although nonimmune factors may also play a role. The process included concentric fibrous intima hyperplasia that narrows the entire length of the affected arteries. Coronary angiography is the usual method of diagnosis. Because a transplanted heart is a denervated organ, CAV is not diagnosed until the disease reaches an advanced stage, in which case transplantation is the only option for treatment. Although the host's immune response against an allogeneic graft is the major cause of endothelial dysfunction, the objective of this study was to detect anti-allogeneic responses on peripheral blood, seeking to identify signs of CAV before classical methods to predict outcomes in HTx recipients. CD3, CD4, CD8, CD19, CD56, Th1, and the Treg mononuclear cell populations were studied in 37 de novo and 20 long-term (more than 3 years) HTx patients as well as 20 healthy volunteers using flow cytometry. A progressive increase in CD8 and Th1 percentages and decrease in the CD4 population were detected during follow-up. Although Th1 changes also reflect processes not related to CAV receiver operating characteristics analysis of Th1/Treg ratio showed an area under the curve of 0.976, with an estimated sensitivity of 100% and specificity of 90%. The positive prediction value was 58.8% and the negative prediction value, 100%. These results prove that the Th1/Treg ratio was an important marker to following host immune response after HTx. The results confirm the need to test other T lymphocyte subsets.

Inferior vena cava obstruction by a cardiac mass: unusual presentation of primary antiphospholipid syndrome.

We present a previously healthy 43-year-old woman with a cardiac mass that caused almost total occlusion of the inferior vena cava at its junction with the right atrium. The resected mass proved to be a thrombus. Preoperative imaging tests could not distinguish it from other intracardiac tumors such as myxoma. A postoperative immunological study revealed a primary antiphospholipid syndrome. This case presents an unusual diagnosis of antiphospholipid syndrome and a rare location of a cardiac thrombus.

Burden of myocardial damage in cardiac allograft rejection: scintigraphic evidence of myocardial injury and histologic evidence of myocyte necrosis and apoptosis.

BACKGROUND: Because myocardial damage determines morbidity and outcomes in heart transplant rejection, assessment of total burden of myocardial damage is highly desirable. In addition to myocyte necrosis, programmed cell death, or apoptosis, has recently been shown to contribute to cardiac allograft rejection. In the present study, we noninvasively determined myocardial damage by antimyosin scintigraphy and compared it with necrotic and apoptotic myocardial damage in endomyocardial biopsy (EMB) specimens. METHODS AND RESULTS: Forty scintigraphic and histologic studies were simultaneously performed. Of these, 19 patients had no EMB evidence of allograft rejection (group I, International Society of Heart and Lung Transplantation [ISHLT] grade 0/4), 12 had mild rejection (group II, ISHLT grades 1A and 1B), and 9 had evidence of moderate allograft rejection (group III, ISHLT grades 2, 3A, and 3B). None of the biopsies demonstrated severe allograft rejection (ISHLT grade 4/4). The severity of global myocyte damage in 40 patients was assessed by antimyosin scintigraphy. Endomyocardial biopsies were performed in these patients within 48 hours of imaging study; biopsy specimens were characterized for presence of myocyte necrosis and apoptosis. Evidence of myocyte necrosis was observed in 9 (23%) of 40 EMB specimens. Nineteen EMB specimens of group I had no inflammation and no myocyte necrosis, 12 of group II specimens showed interstitial mononuclear cell infiltration (only) but no myocyte necrosis, and all 9 of group III specimens had evidence of cellular infiltration and myocyte damage. Myocyte necrosis was assessed by hematoxylin-eosin and trichrome staining of EMB specimens. On the other hand, apoptosis of myocytes, as assessed by TUNEL staining of DNA fragments, was seen in 22 (55%) of the 40 biopsy specimens: 47%, 58%, and 67% in groups I, II and III, respectively. Abnormal antimyosin scan findings, indicating presence of myocardial damage, were observed in 9 of the 19 patients in group I and in all patients in groups II and III. Although positive antimyosin scan results in group III patients are concordant with the presence of histologic myocardial necrosis, myocardial uptake of antimyosin antibodies in groups I and II (no apparent myocyte damage at light microscopic examination) could reflect either sampling error of the biopsy or ongoing apoptotic myocyte damage. CONCLUSIONS: Apoptosis of myocytes is frequently observed during cardiac allograft rejection. The presence of apoptotic myocytes in the absence of histologic rejection activity in patients with antimyosin uptake suggests that apoptosis could be an additional mechanism of transplant-associated myocardial damage.

[Minimally invasive aortic valve replacement]. / Sustitución valvular aórtica mínimamente invasiva.

INTRODUCTION: Minimally invasive surgery is being applied to certain procedures in cardiac surgery. Aortic valve replacement presents the highest number of cases in which this approach is feasible. MATERIAL AND METHODS: Fifteen patients, aged 16 to 75 years, underwent aortic valve replacement through a 10 cm incision at the level of the second intercostal space. Cardiopulmonary bypass was instituted through cannulation of the aorta and the femoral vein. RESULTS: Adequate exposure of the aortic root was achieved in all cases. Valve replacement was accomplished with a mean ischemic time of 50 +/- 6 minutes and a pump time of 80 +/- 14 minutes. Mean chest drainage was of 310 +/- 251 ml. The patients were discharged between the third and the fifth day of the postoperative course. CONCLUSIONS: A transverse incision at the level of the second intercostal space provides an excellent exposure for aortic valve replacement. Surgical times are not excessively prolonged and patient's recovery is faster and less painful than with the standard midline sternotomy.

The Spanish Monostrut Study Group: a ten-year experience with 8,599 implants.

BACKGROUND: The Monostrut valve is a pyrolytic carbon, tilting-disc prosthesis with no welds. After the first implantation in Spain in May 1983, the Spanish Monostrut Study Group was established to evaluate prospectively the performance of the valve using uniform protocols. METHODS: During a 10-year period, 8,599 Monostrut valves were implanted in 7,317 patients in 22 centers. Mean age was 53.3 +/- 11 years. Of the total group, 3,229 underwent aortic valve replacement, 2,806 had mitral valve replacement, and 1,282 had double valve replacement. Follow-up was 96% complete, with a mean period of 4.3 years and a total of 29,155 patient-years. RESULTS: The operative mortality rate was 7.2%. The 10-year probability of freedom from valve-related complications and linearized rates (event/100 patient-years in parentheses) were as follows: structural deterioration, 100% (0); nonstructural dysfunction, 96% +/- 0.5% (0.51); thromboembolism, 82.9% +/- 1.5% (1.32); anticoagulant-related hemorrhage, 87.6% +/- 1.4% (0.98); and prosthetic valve endocarditis, 96.1% +/- 0.5% (0.48). There were five obstructive valve thromboses (0.017/100 patient-years). Actuarial freedom from reoperation was 95% +/- 0.5% at 10 years. Actuarial freedom from all valve-related morbidity was 70.2% +/- 1.6%; freedom from all valve-related morbidity and mortality (including operative and sudden deaths) was 62.6% +/- 2% (70.1% +/- 2% for aortic valve replacement, 56.9% +/- 2% for mitral valve replacement, and 59.8% +/- 3% for double valve replacement; p < 0.0001). Clinically, 5,988 patients (94%) are in New York Heart Association class I-II. CONCLUSIONS: The Monostrut valve has shown no structural failures and a low rate of valve-related complications over a 10-year period in a large patient population.

[Peritoneal migration of defibrillator implanted behind the rectus abdominis]. / Migración peritoneal de desfibrilador implantado tras recto abdominal.

Automatic Implantable Cardioverter Defibrillator (AICD) has become a therapeutic option to malignant ventricular tachyarrhythmias. Its bulky device responds for discomfort and the likelihood of generator extrusion or migration, when implanted under the subcutaneous tissue. Among alternative sites, pre-peritoneal location has several advantages but hides its own risks. We present a generator peritoneal migration from a pocket made behind the rectus abdominis.

[The diagnosis of rejection activity in the heart transplant by monoclonal antimyosin antibodies]. / Diagnóstico de la actividad de rechazo en el trasplante cardíaco mediante anticuerpos monoclonales antimiosina.

A novel noninvasive sensitive mean to detect cardiac rejection is described: myocardial uptake of 111In-labeled monoclonal antimyosin antibodies (MAA). All patients showing rejection at cardiac biopsy disclosed positive MAA studies. However, a large percentage of positive studies in the presence of negative biopsies were detected. This discrepancy can be ascribed to a false-negative biopsy result. During the first year posttrasplantation MAA studies are useful to predict severe rejection-related complications, but due to high sensitivity of MAA, treatment for rejection in this period must be based on biopsies, as criterium to treat for rejection on the basis of MAA scans would lead to excessive immunosuppression. After the first year of transplantation, individual patient management can ben implemented on the basis of risk stratification using MAA scans: Negative MAA scans entail an almost nil probability of detecting rejection during long-term follow-up (low-risk group), whereas positive MAA scans imply a probability of detecting near 1 episode of rejection and requirement for treatment per year. In summary, at our institution biopsies are avoided as from the first year after transplantation; after such period, MAA scans allow risk stratification and treatment for rejection based on the results of MAA scans in individual patients.

[A report of a rare case of primary angiosarcoma of left atrium and a review of the literature]. / Presentación de un caso raro de angiosarcoma primario de aurícula izquierda y revisión de la literatura.

A 66[correction of 60]-year-old female patient was admitted to hospital for clinical signs of pericardial tamponade. The pericardiocentesis revealed an hematic effusion and a left appendage mass was diagnosed by transesophageal echocardiography. At surgery, a left atrial tumour was resected which histological examination showed to be an undifferentiated angiosarcoma-endothelioma with difficult histological classification. The tumoral screening was negative and the patient was discharged from the hospital. Seven months later the patient was readmitted for two parasternal tumours which anatomopathologic study revealed to be subcutaneous metastases. The rare localization in the left atrium and subcutaneous metastatic spread were discussed.

[Cardiovascular surgery in Spain in 1992. The Registry of Operations of the Spanish Society of Cardiovascular Surgery (SECCV)]. / Cirugía cardiovascular en España en el año 1992. Registro de operaciones de la Sociedad Española de Cirugía Cardiovascular (SECCV).

The Spanish Society of Cardiovascular Surgery Registry of 1992 includes data from 41 centers. Within this year a total of 24,127 patients were operated on, with an average of 588 operations/center. Twelve thousand twenty-two of these were cardiac operations under extracorporeal circulation, with an average of 300 cases/hospital. The average of cardiac surgeons/hospital was 5.9 and the average of open heart operations/surgeon was 50. For the first time, the number of coronary bypass surgeries was superior to that of valvular procedures (5,049 vs 4,951). In the coronary bypass patients the average of grafts/patient was 2.43. The number of valvular prostheses implanted was 5,526 and 81% of these were mechanical. The number of patients operated on for congenital cardiac defects was 2,251 (1,278 open heart surgeries and 973 closed). The global mortality in the patients operated on under extracorporeal circulation was 7.6% (7.0% in valvular, 7.9% in congenital and 5.4% in coronary bypass). There were 6,054 patients subjected to surgery for peripheral vascular disease.

[Complications associated with nonfunctioning pacemaker electrodes retained within the cardiovascular system]. / Complicaciones asociadas con electrodos de marcapasos no funcionantes retenidos en el sistema cardiovascular.

INTRODUCTION AND OBJECTIVE: The aim of the present study was to evaluate the complications in patients with functionless pacing leads retained in the cardiovascular system. PATIENTS AND METHODS: We retrospectively studied 39 patients: 31 underwent surgery for electrical or mechanical failure (group I) and eight for cutaneous pocket infection (group II). The follow-up was 45 +/- 34 months. RESULTS: Only one patient (3%) from group I presented infectious complications probably related to the retained pacing lead. Seven patients (87%) in group II presented recurrence of the infection with persistent fever and/or septicemia due to skin erosion and unnoticed pacing lead infection (p < 0.0005). Removal of the infected generator was performed in 8/39 (21%) of the patients. Thoracotomy to explant the infected retained leads was required in five of them (62%). No patient presented lead migration or venous thrombosis during the follow-up. CONCLUSIONS: Retained pacing leads in the cardiovascular system are well tolerated. However, in spite of adequate antibiotic treatment, patients with local and pacemaker system infection may present recurrence of the infection with persistent fever and/or septicemia. Early surgical pacemaker system removal is recommended in these patients due to the high morbidity.

[The National Data Bank of the Spanish Society of Cardiovascular Surgery. The pilot experience]. / Banco Nacional de Datos de la Sociedad Española de Cirugía Cardiovascular. Experiencia piloto.

Since 1988, the Spanish Society of Cardiovascular Surgery has been enjoying through its National Intervention Registry a complete information about the number and type of cardiovascular surgical operations, yearly performed all over the country. However a computerized National Data Bank would probably offer a more specific, quick and complete information, although its organization is more complex. We want to demonstrate that the creation of a National Data Bank is possible in our country. The following condition has been essential to carry out this initial work on the National Data Bank: The previous existence of a National Intervention Registry, the edition of an universally accepted questionnaire of 33 questions with multiple answers for each question, which includes quantitative and qualitative aspects like mortality, the acquisition of the software Pats Programme by most cardiovascular centers, and finally the enthusiastic dedication of 6 surgical groups. The results of this work also shown in multiples figures, are the final product of the computerized fusion of 6 cardiovascular centers data on operations performed through the year 1991. The results clearly offer a more specific, detailed and extensive information about quantitative and qualitative aspects of the surgical data, than that obtained through the National Intervention Registry. These results should not be extrapolated at national level, as the surgical groups involved in this work are not homogeneous and its number is quite small. This initial study shows that the creation of the National Data Bank of the Spanish Society of Cardiovascular Surgery or other scientific society is possible in our country. Its usefulness is beyond any doubt.

Subacute cardiac rupture: repair with a sutureless technique.

Thirteen patients with ages between 53 and 74 years had development of free wall left ventricular rupture after a myocardial infarction (mean interval, 3.8 days). All patients showed clinical signs of cardiac tamponade. Diagnosis was established by bedside multiple pressure monitoring and echocardiography, which showed pericardial effusion with compression of the right ventricle. Cardiac catheterization was not performed. A new surgical technique was employed for the repair. After the pericardium was opened and cardiac tamponade was relieved, the myocardial tear was identified. A Teflon patch was applied over the area and glued to the heart surface with a surgical glue (cyanoacrylate). Cardiopulmonary bypass was not used except in a patient with a posterior tear. The method was consistently effective in controlling bleeding from the myocardial tear. All patients survived the operation and were discharged from the hospital a mean of 15 days after the operation. Follow-up extending up to 5 years (mean, 26 months) shows a 100% survival, 11 asymptomatic patients, and 2 patients with mild exertional angina. The technique is a simple, effective, and safe method for repair of subacute cardiac rupture and obviates the need for suturing on an infarcted ventricle.

[Cardiovascular surgery in Spain in 1991. Registry of operations of the Spanish Society of Cardiovascular Surgery (SECCV)]. / Cirugía cardiovascular en España en el año 1991. Registro de operaciones de la Sociedad Española de Cirugía Cardiovascular (SECCV).

The Spanish Society of Cardiovascular Surgery has sent a questionnaire to all 37 cardiovascular surgical groups to know the number and type of cardiovascular operations carried out in our country during 1991. The questionnaire was answered by 36 out of 37. In the year 1991, 21,771 cardiovascular patients have been operated upon and 10,913 interventions with extracorporeal circulation have been carried out: 42.4% in valvular disease, 37.2% in coronary and 11.2% in congenital. The number of operations was 5,415 for vascular disease, 4,627 for valvular, 3,168 for coronary, 1,896 for congenital and 3,741 for pacemaker implantation. The total number of operations in 1991 comparing to those performed during 1988 is similar; but the number of open heart operation and the number of these per cardiac unit and per million population during 1991 have increased 20.5, 13.9 and 24.3% respectively. Coronary and valvular operations have also increased 11 and 27% respectively, as well as the number of pacemaker implanted (30%). The number of congenital cases remains the same and the number of vascular operations has decreased by 7.9%.

The Monostrut Björk-Shiley valve. Seven years' experience.

The results of cardiac valve replacement with the Monostrut Björk-Shiley prosthesis (Shiley, Inc., Irvine, Calif.) during a 7-year period are presented. A total of 984 valves were implanted in 820 patients from May 1983 to April 1990. Aortic valve replacement was performed in 378 patients, mitral replacement in 294, and multiple replacement in 148. In addition, 180 patients (22%) underwent associated procedures. Mean age was 52.6 +/- 11 years. Operative (30 days) mortality was 5.9% (49 patients): 3.9% (15 patients) for aortic, 7.8% (23 patients) for mitral, and 7.4% (11 patients) for multiple valve replacement. All patients were given long-term anticoagulation therapy. Follow-up was 99% complete (eight patients were lost to follow-up), with a closing interval of 3 months, and totaled 2422 patient-years. Valve-related complications, expressed as percentage event-free (+/- standard error) at seven years were as follows: structural deterioration, 100%; nonstructural dysfunction, 98.3% +/- 0.6%; thromboembolism, 90.2% +/- 1.7%; anticoagulant-related hemorrhage, 88.7% +/- 2.8%; and prosthetic valve endocarditis, 98.1% +/- 0.8%. There were no cases of valve thrombosis. Actuarial survival (free from operative, valve-related, and sudden death) was 88.4% +/- 1.2% at 7 years. Freedom from reoperation was 96.8% +/- 0.1%. Probability of being free from all valve-related morbidity and mortality was 70% +/- 3%, and 708 (93%) of the survivors were in New York Heart Association class I or II. Serial Doppler echocardiograms were done prospectively in 243 patients (with 154 aortic and 120 mitral prostheses), both postoperatively and at regular intervals up to 3 years. Mean prosthetic gradients ranged from an average of 20.9 to 7 mm Hg in the aortic prostheses (21 to 29 mm) and from 6.1 to 4.8 mm Hg in the mitral prostheses (25 to 31 mm). The gradients in each patient did not change significantly during the follow-up period. Our 7 year's experience with the Monostrut valve shows a low rate of valve-related complications, a durable design, and good hemodynamic and functional results.

Hemodynamic effects of prostaglandin E1 and isoproterenol early after cardiac operations for mitral stenosis.

Patients with mitral stenosis and some degree of right ventricular failure may benefit from inotropic or pulmonary vasodilator drugs in the early postoperative period. Thirty patients undergoing an operation for mitral stenosis were randomized into three groups. In group I (n = 10), isoproterenol (5 micrograms/kg/min) was started in the immediate postoperative period. In group P (n = 10), prostaglandin E1 (0.08 microgram/kg/min) was given, and in group C, the control group (n = 10), no drugs were used. After the operation and before drug therapy was begun, basal measurements of cardiac index, mean pulmonary arterial and mean arterial pressures, and pulmonary vascular resistance were taken. Measurements were repeated at 6, 12, and 24 hours. Mean measurements of cardiac index (basal up to 24 hours) were as follows: 1.39 +/- 0.3, 1.92 +/- 0.4, 2.4 +/- 0.5, and 2.34 +/- 0.3 L/min/m2 for group C; 1.54 +/- 0.5, 2.64 +/- 0.4, 2.68 +/- 0.7, and 2.2 +/- 0.6 L/min/m2 for group I, and 1.57 +/- 0.3, 2.2 +/- 0.6, 2.72 +/- 0.7, and 2.27 +/- 0.4 L/min/m2 for group P (p less than 0.05 between groups C and I at 6 and 12 hours). Mean pulmonary artery pressures were as follows: 19.5 +/- 3.2, 24.8 +/- 7, 27.7 +/- 7.3 and 28.8 +/- 5.7 mm Hg in group C; 21.4 +/- 8.7, 25.7 +/- 7.2, 26.4 +/- 7, and 29.4 +/- 8.6 mm Hg in group I, and 19.1 +/- 4, 19.2 +/- 3, 20.4 +/- 6, and 20.7 +/- 5 mm Hg in group P (p less than 0.05, group P versus groups C and I at 6, 12, and 24 hours). Mean pulmonary vascular resistances were as follows: 3.9 +/- 2.4, 3.9 +/- 1, 3.36 +/- 2, and 3.2 +/- 1.4 Wood units in group C; 4.84 +/- 4, 3.37 +/- 2.2, 3.69 +/- 3, and 4.69 +/- 4.1 Wood units in group I, and 3.29 +/- 1.3, 1.71 +/- 0.5, 1.61 +/- 0.5, and 1.96 +/- 0.8 Wood units in group P (p less than 0.05, group P versus groups C and I at 6, 12, and 24 hours). There was no difference in mean systemic arterial pressure among the three groups. Our results indicate that patients subjected to mitral valve operations have a low cardiac index. Isoproterenol increases cardiac index but has little effect on pulmonary resistance. At low doses, prostaglandin E1 effectively decreases pulmonary vascular resistance without altering systemic arterial pressure or heart rate.

[An obstruction of a valve prosthesis implanted in the tricuspid position]. / Obstrucción de una prótesis valvular implantada en posición tricúspide.

Dysfunction of a prosthesis implanted in tricuspid position is a severe complication that may develop with minimal symptoms. A patient who presented clinical manifestations of heart failure for two weeks due to obstruction of a mechanical prosthesis in tricuspid position is described. Fibrinolytic treatment was given unsuccessfully, therefore prosthetic replacement was performed. In the removed prosthesis, a fibrotic pannus which developed in the strut and disc was seen. We review the clinical manifestations, the diagnosis and treatment of the dysfunction of a prosthesis implanted in tricuspid position.

[The long-term results of aortocoronary bypass surgery in patients with a severe preoperative left ventricular dysfunction]. / Resultados a largo plazo de la cirugía de bypass aortocoronario en pacientes con disfunción ventricular izquierda severa preoperatoria.

We analyze retrospectively the short- and long-term results of coronary artery bypass surgery in 50 patients with severe left ventricular dysfunction operated in a period of 11 years. Sixty-six percent of patients had unstable angina and 12% of total presented angina post-acute postmyocardial infarction. Thirty-eight percent of patients were in preoperative functional class III-IV of NYHA. Three-vessel disease was present in 70% of the patients, two-vessel in 30%, and the main trunk was affected in 12% of the global. Hospital mortality was 4% (2/50) due to low cardiac output syndrome. Follow-up was available in all the survivors and ranged 6 months-11 years (mean: 4.8 +/- 3.1). During follow-up, 13 patients died, but in only six was due to cardiac cause. The 35 patients followed were in functional class I-II of NYHA. Eighty-eight percent of the patients were angina free at follow-up. Actuarial analysis, after exclusion of 3 patients who died of causes no directly related to the heart, showed an intrahospital survival rates of 96%; at first year was 92, at 3rd was 78%, and 5th year survival rates were 75%. In conclusion, patients with symptomatic angina and preoperative severe left ventricular dysfunction, coronary artery bypass graft has a low hospital mortality, is effective in improving angina and heart failure, and the long-term survival is acceptable.

[The single coronary artery. Presentation of a case]. / Arteria coronaria única. Presentación de un caso.

A patient with a single coronary artery originating in the right coronary sinus is presented. The condition was diagnosed during aortic valve replacement surgery and later confirmed by coronary angiogram. The clinic significance in relation to the anomalous course of the coronary artery and the importance of correct diagnosis prior to cardiac surgery is discussed.

[Aortic subvalvular annular aneurysm after closed thoracic traumatism. Presentation of a case]. / Aneurisma anular subvalvular aórtico postraumatismo torácico cerrado. Presentación de un caso.

A case of a 29 year old man with congenital aortic stenosis who developed a subvalvular annular aneurysm of the left ventricle after being run by a car is presented. At surgery his aortic valve was replaced and the opening of the aneurysm was closed with a patch of Dacron. Due to the dense adhesions to the aorta and left atrium no attempts were made to excise the sac, that was not compromising the dynamics of any one of these structures.