We read with great interest the very stimulating response to our paper from González et al. For RCC with intra-atrial tumour thrombus, they advocate their effort to avoid cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA) wherever possible and, to compensate for the safe bloodless field, their use of the refined technique of advanced liver dissection used in liver transplantation.

This discussion is an excellent reflection of a very demanding clinical condition that can be managed by different techniques and approaches, none of which is free from points of criticism. Irrespective of a given approach and specialty bias (urology, transplantology or cardiac surgery), however, the crucial issues of safety and radicality of the procedure have to be carefully balanced for any chosen strategy against unpredictable surgical misadventure.

CPB and DHCA can have various negative impacts, but in real current cardiac surgery they are very safe and routine procedures. Our reported series represents a subpopulation of patients about whom a cardiac surgeon was addressed by the urologist because the tumours were clearly intracardiac. In these patients, CPB and DHCA offers ultimate circulatory safety in the management of tumour thrombus removal, blood loss and potential surgical complications. In our experience, it is not possible to predict safely how easy or difficult the tumour thrombus extirpation will be. In a few cases, anticipated easy removal turned out to be difficult and time-consuming piece-meal extirpation.

Cardiopulmonary bypass is a not only safe but also very flexible technology that can be tailored for the condition of an individual patient: low-flow circulation periods or milder hypothermia can be used wherever uncomplicated extirpation can be expected.

Piggy-back liver dissection is surgically appealing; however, it remains debatable if it can be generally called easy or less invasive, outside of transplantology experience. The transdiaphragmatic approach allows access to the right atrium but not all sizes and consistencies of the tumour are suitable for manipulation from outside of the right atrium. Transoesophageal echocardiography monitoring is a valuable tool, but it poses the question of what is the exact moment at which the surgeon should start preventive (preferable) or salvage (conversion to CPB in the middle of the procedure) action.

With safety and radicality in mind for this very complex clinical condition, which even in the series by González et al. cannot be managed without operative mortality, we advocate careful planning, morphological evaluation and tailoring of the strategy according to the patient's situation as well as to the specific clinical expertise of the team.