Usually patients with cardiac disease and other co-morbidities have been managed in staged procedures[
7]. However in recent years a new direction has been taken to combine operations when feasible. We must be aware of the increased operative risk for non-cardiac procedures performed on individuals with major CAD associated with myocardial damage and impaired ventricular functions as documented by Foster et al.[
12]. Postponed tumor resection may amplify the risk of exposure to the immunosuppressive effects of CPB, which may have a harmful effect on tumor growth and spreading[
2,
7‐
9,
13], especially when patient requires prolonged postoperative care[
14]. It is of great importance to mention that late complications of extracorporeal circulation contribute indirectly to the expansion of the existing malignancy according to the international bibliography[
15‐
17]. Additionally the doubling of costs has to be considered, as well as the advantage in avoiding a second procedure. In the last two decades abundant literature has favoring the results of simultaneous operations involving CAD and cancers[
1,
2,
7,
8,
11,
18]. The early and mid-term outcomes of combined neoplastic resection and cardiac operation have demonstrated that this approach is both feasible and safe in carefully selected patients[
18]. Litmathe et al.[
7] presented a series of six patients who had undergone combined procedures using extracorporeal circulation and urologic tumor resection. Four of which had undergone tumor nephrectomy and CABG simultaneously, whereas the other two had undergone tumor nephrectomy and aortic valve replacement (AVR). All six patients demonstrated satisfactory long-term survival. Rao and colleagues analyzed 30 patients who underwent simultaneous lung resection and cardiac surgery and demonstrated that CPB did not have detrimental effect on 5-year survival[
17]. It is important to differentiate cases of combined CAD and lung cancer and those with gastrointestinal tract (GIT) malignancy. In GIT malignancy two cavities are opened and that is case of more frequent contamination and infection. Our results are in agreement with the latter as well as many other studies from the literature demonstrating similar successful operations and good prognosis. Recent studies have demonstrated the favorability of OPCAB over CABG under CPB in simultaneous operations[
8,
11], however CPB has been shown to affect neutrophils and platelets and results in complement activation, which may be beneficial in patients with malignancies[
18]. From the many clinical investigations published, it appears clear that patients undergoing OPCAB tend to receive a lesser number of bypass grafts[
19]. Thus due to the high number of grafts required by our patient, it was ultimately decided that CABG under CPB is a safer approach. According to the published literature, surgeons usually employ variations of a sub-costal approach or a median laparotomy to extract the kidney in combined nephrectomy and cardiac procedures[
7]. The technique of extended sternotomy allows for easier manipulation of the surgical field as well as quick access to the heart in case complications arise. We also believe that performing the operation through the extended sternotomy technique promises early somatic and social rehabilitation and yields a better cosmetic effect, as well as theoretically decreasing the possible spread of the cancer. Certain disadvantage such as increased risk of bleeding due to systemic heparinization in a two cavity-operation has to be considered when planning simultaneous operations under CPB. Additionally the immediate perioperative load of quite a traumatic operation including several organ systems could be serious and impair the outcome[
7]. Nevertheless simultaneous treatment of both diseases has several advantages: it decreases general anesthesia related risks such as pneumonia or drug-induced complications; prevents both neoplastic disease progression and risk of MI, decreases the risk of post-cardio-surgical bleeding after intra-operative anticoagulation by early removing of the tumor and reduces the two stage surgical stress of the patient[
20]. In accordance with the majority of the data published in the literature, combined procedures did not negatively influence hospital morbidity and mortality. Simultaneous operations eliminate the necessity of a second operation and do not delay the postoperative oncological therapy. Long-term results are primarily determined by histological diagnosis and by the extent of the tumor[
21,
22].