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.

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.

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.

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.