LAUSR

Chen et al. described a staged surgery for advanced cardiac intimal sarcoma involving the right atrium and the inferior vena cava (IVC). A 19‐year‐old patient had presented with a large right atrium and suprarenal IVC mass. Clinical presentation and computed tomography showed the presence of Budd‐Chiari syndrome (BCS) and compromised flow through the tricuspid valve. The patient's clinical picture got worse (dyspnea and hypoxemia) and required an emergency tumor resection. The authors did a partial resection, because the tumor was fragile and difficult to resect. During the first stage of surgery, pathology confirmed the diagnosis of malignant cardiac intimal sarcoma. The IVC from the atrium to the major hepatic confluence was replaced with a 20 mm Goretex graft, because the tumor thrombus (TT) was invading the wall of the IVC and right atrium. The patient received adjuvant chemotherapy and radiotherapy making the second surgery less complex. The patient is currently doing fine and has been tumor‐free for 2 years after this heroic surgery for an initially unresectable tumor. In this particular case, the tumor extended downward into the IVC obstructing the major hepatic veins, causing BCS which was identified by the authors. The use of cardiopulmonary bypass may be needed in cases with BCS, which would avoid further liver congestion and allow for safer removal of the TT obstructing the major hepatic veins (Chen et al. fig. 1A). Primary cardiac sarcomas are rare. Intimal sarcomas are, in fact, extremely rare, and most of the cases described in the literature are seen in the pulmonary artery and aorta. This tumor could have started in the IVC and extended into the right atrium. There are only four reported cases of intimal sarcoma of the IVC. These tumors can cause venous system obstruction, and the clinical presentation depends on the tumor size, site, fragility (like in this case), and rate of extension into other organs. It is important to remember that in cases of these tumors, theTT can cause blood thrombosis to develop in the IVC as the TT (different from thrombosis) extends into the IVC and obstructs it. TheTT can cause blood thrombus below its location, making the surgery more difficult because of the high risk of development of massive pulmonary emboli during the attempt to surgical resect the tumor. The authors started the patient on an anticoagulant (endoxaban) with complete resolution of the blood thrombus before the second surgical procedure. Again, we want to commend the authors for their meticulously planned staged surgery and uneventful postoperative course of this difficult to treat patient with advanced cardiac intimal sarcoma involving the right atrium and the IVC.