Contemporary surgical management of advanced end stage emphysema: an evidence based review.

Emphysema is a progressive unrelenting component of chronic obstructive pulmonary disease and a major source of mortality and morbidity globally. The prevalence of moderate to severe emphysema is approximately 5% in Malaysia and likely to increase in the future. Hence advanced emphysema will emerge as a leading cause of hospital admission and a major consumer of healthcare resources in this country in the future. Patients with advanced disease have a poor quality of life and reduced survival. Medical therapy has been largely ineffective for many patients however certain subgroups have disease amenable to surgical palliation. Effective surgical therapies include lung volume reduction surgery, lung transplantation and bullectomy. This article is a comprehensive evidence based review of the literature evaluating the rationale, efficacy, safety and limitations of surgery for advanced emphysema highlighting the importance of meticulous patient selection and local factors relevant to Malaysia.

Deep sternal wound infection requiring revision surgery: impact on mid-term survival following cardiac surgery.

OBJECTIVE: To assess the impact of deep sternal wound infection on in-hospital mortality and mid-term survival following adult cardiac surgery. METHODS: Prospectively collected data on 4586 consecutive patients who underwent a cardiac surgical procedure via a median sternotomy from 1st January 2001 to 31st December 2005 were analysed. Patients with a deep sternal wound infection (DSWI) were identified in accordance with the Centres for Disease Control and Prevention guidelines. Nineteen variables (patient-related, operative and postoperative) were analysed. Logistic regression analysis was used to calculate a propensity score for each patient. Late survival data were obtained from the UK Central Cardiac Audit Database. Mean follow-up of DSWI patients was 2.28 years. RESULTS: DSWI requiring revision surgery developed in 1.65% (76/4586) patients. Stepwise multivariable logistic regression analysis identified age, diabetes, a smoking history and ventilation time as independent predictors of a DSWI. DSWI patients were more likely to develop renal failure, require reventilation and a tracheostomy postoperatively. Treatment included vacuum assisted closure therapy in 81.5% (62/76) patients and sternectomy with musculocutaneous flap reconstruction in 35.5% (27/76) patients. In-hospital mortality was 9.2% (7/76) in DSWI patients and 3.7% (167/4510) in non-DSWI patients (OR 1.300 (0.434-3.894) p=0.639). Survival with Cox regression analysis with mean propensity score (co-variate) showed freedom from all-cause mortality in DSWI at 1, 2, 3 and 4 years was 91%, 89%, 84% and 79%, respectively compared with 95%, 93%, 90% and 86%, respectively for patients without DSWI ((p=0.082) HR 1.59 95% CI (0.94-2.68)). CONCLUSION: DSWI is not an independent predictor of a higher in-hospital mortality or reduced mid-term survival following cardiac surgery in this population.

Isolated severe ischemic tricuspid regurgitation: successful surgical repair.

Tricuspid regurgitation (TR) is a common association of left-sided valvular lesions that is occasionally seen with ischemic heart disease. However, isolated ischemic TR requiring surgical intervention is extremely rare, with very few reported cases. The case is presented of a 59-year-old woman who, after extensive non-cardiac investigations, was eventually diagnosed with severe functional TR due to chronic myocardial ischemia. The patient underwent successful surgical treatment.

Quadricuspid aortic valve: a rare cause of aortic insufficiency.

Quadricuspid aortic valve, a rare congenital cardiovascular anomaly, is an uncommon cause of aortic regurgitation that can be diagnosed accurately with preoperative transesophageal echocardiography. Such a case is presented, and the literature on this topic reviewed.

Right atrial myxoma arising from the Eustachian valve in a patient with colonic polyposis.

Right atrial myxoma arising from the Eustachian valve is rare, with only two reported cases; moreover, any association with colonic polyps is uncommon, with only one such case documented. A case is described of a 68-year-old male who presented with chronic anemia; an initial investigation revealed colonic polyps, but anemia persisted after polypectomy. Further investigation revealed a right atrial myxoma arising from the Eustachian valve and prolapsing into the right ventricle through the tricuspid valve. After successful removal of the lesion, hematological indices returned to normal. In cases of persisting anemia, other rare causes such as atrial myxoma should be sought.

Malignant internal mammary lymph nodes during mobilization of the internal mammary artery.

Malignant internal mammary node involvement may occur with a primary neoplasm or with metastasis. The incidental discovery of malignant internal mammary nodes from an unknown primary origin has not been previously described. Cardiac surgeons should be aware of pathologic internal mammary artery (IMA) nodes and any abnormally enlarged nodes encountered in the course of IMA mobilization should be sent for histological examination. The incidental discovery of malignancy does not preclude the use of the IMA as a bypass conduit. Once a diagnosis of malignancy is established, meticulous exhaustive investigation may be indicated to identify the primary lesion and definitive treatment instituted if appropriate.

Bilateral isolated coronary ostial stenosis following mediastinal irradiation.

Isolated coronary ostial narrowing is rare and may represent a separate disease entity from atherosclerotic coronary artery disease. The case of a 41-year-old female with no coronary risk factors who developed severe bilateral isolated coronary ostial stenosis following mantle radiotherapy for Hodgkin's disease is described. She underwent urgent coronary artery bypass grafting and has remained well for 3 years.

Synchronous sclerosing haemangiomas of the lung: an unusual presentation of a rare tumour.

Pulmonary sclerosing haemangioma  is a rare lung tumour with a preponderance for Asian oriental women. Typically a well-circumscribed, solitary lesion with benign characteristics, there are concerns of malignant potential including regional lymph node metastases. Four histological subtypes exist. Diagnosis can be challenging as patients are usually asymptomatic and radiological findings are non-specific. Surgical resection alone is diagnostic and therapeutic. We present a case of this rare tumour with an uncommon presentation as two synchronous tumours initially misdiagnosed as a pulmonary adenocarcinoma.

Successful anticoagulation with fresh frozen plasma for cardiopulmonary bypass in a patient with heparin resistance: a cautionary tale.

Heparin resistance (HR) is an increasingly common occurrence due to a greater awareness of the benefits of antithrombosis prophylaxis in hospitalised patients with low molecular weight and unfractionated heparin. Furthermore as more high-risk patients with prior heparin exposure undergo cardiac surgery we can expect to encounter more such cases. Adequate anticoagulation is essential for the safe conduct of any operation requiring cardiopulmonary bypass and is usually achieved with systemic heparinisation. We report a case of successful anticoagulation with the intraoperative administration of fresh frozen plasma in a high-risk coronary patient with HR and highlight the perils of unwitting overheparinisation in such cases. This case highlights the importance of clinical awareness of this phenomenon and the available alternative anticoagulants.

Simultaneous aortic valve and arch replacement with bilateral nephrectomy for massive polycystic kidney disease, aortic regurgitation and dissecting aneurysm.

Aneurysmal dissection of the ascending aorta and arch may be associated with polycystic kidney disease. We report a case of massive polycystic kidneys leading to respiratory and gastrointestinal embarrassment in combination with aneurysmal dilatation of a chronic arch dissection managed by simultaneous bilateral nephrectomy and arch replacement.

Idiopathic primary chylopericardium with associated chylothorax following coronary artery surgery--successful conservative treatment.

A 58-year-old Asian male underwent an uneventful triple coronary bypass that included a pedicled left internal mammary artery (LIMA) graft. On the third postoperative day, following resumption of full oral intake he developed a high output left-sided chylothorax. Initial therapy with a medium chain trigylceride diet and intercostal drainage showed no improvement. CT scan demonstrated a chylopericardium that was drained percutaneously. Complete resolution occurred 2 weeks later with adequate drainage and institution of total parenteral nutrition avoiding further surgery. We discuss the etiology and management of this rare complication following coronary surgery.

Mitral and tricuspid valve surgery in homozygous sickle cell disease: perioperative considerations for a successful outcome.

Homozygous sickle cell disease (SCD) presents a multitude of challenges in patients undergoing cardiac surgery with cardiopulmonary bypass. Special consideration must be made in such patients and routine practice modified to prevent hypoxia, hypothermia, acidaemia and low-flow states which may potentially trigger a fatal sickling crisis perioperatively. We discuss several perioperative management strategies including a preoperative exchange transfusion, high flow normothermic bypass and warm blood cardioplegia that was utilized in a woman with homozygous SCD who underwent a successful double valve procedure.