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Ann Thorac Surg 1999;68:1082-1083
© 1999 The Society of Thoracic Surgeons

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Case Reports

A complication of pectus excavatum operation: endomyocardial steel strut

^a Department of Thoracic and Cardiovascular Surgery, University of Istanbul, Istanbul Medical School, Istanbul, Turkey

Address reprint requests to Dr Toker, nönü Cad. Yildiz Sok. STFA B-6 Blok Daire 13, Kozyatai, stanbul 81090, Turkey
e-mail: korkutbostanci{at}superonline.com

	Abstract

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An 18-year-old patient who had correction of pectus excavatum deformity in our department 4 years earlier was admitted because of stabbing chest pain. He had not attended to postoperative controls and had not come for extraction of the steel strut, although he had been contacted. He was diagnosed to have a broken steel strut, and the strut was noted to be embedded in the myocardium. This unreported complication of pectus excavatum operation forced us to review sternal support techniques.

	Introduction

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Ravitch reported that pectus excavatum deformity might occur in as frequently as 1 of 300 to 1 of 400 live births [1]. It is commonly present at birth or appears within the first year of life [2]. The correction of the deformity is indicated to prevent orthopedic, physiologic, cosmetic, and psychiatric disturbances.

We performed 65 thoracic deformity correction operations in our department in the past 10 years. Of these 65, 4 patients were 2–5 years of age, 13 patients were 5–10 years of age, and 20 patients were over 15 years of age. Forty-five of the patients had Ravitch sternoplasty for pectus excavatum deformity. We performed internal fixation by using stainless steel struts of appropriate size placed retrosternally. The struts were produced in the technical department of the hospital with 1–1.8-mm thickness, 6–10-mm width, and 10–20-cm length, according to the patients’ thoracic size.

An 18-year-old man was admitted to our department because of stabbing chest pain for 2 months. He had been operated on for pectus excavatum deformity 4 years earlier, and had not come to clinic postoperatively, although he had been contacted. From the reports of the patient, it was understood that his sternum had been fixed internally with steel strut, and it had not been extracted because of the patient’s resistance to our invitations for extraction. There was no pathological finding in physical examination. In postero-anterior and lateral chest roentgenograms, the steel strut was noted to be broken into two pieces (Fig 1). An electrocardiogram was normal. The patient was taken into the theater immediately, and the right side of the strut was taken out easily through a little subareolar incision, under general anesthesia. The left side of the broken strut was noted to be in the pericardium when extraction was attempted through a similar left-sided incision; therefore, we refused to extract the strut before the complete evaluation of its location. The patient was awakened, extubated, and had echocardiographic and computed tomographic examinations, and the left half of the broken strut was noted to be in the right ventricule, just under the pulmonary valves (Fig 2). The patient was again taken into the theater and femoral arterial cannulation was performed. After the right anterior thoracotomy, bicaval cannulation was performed and the pericardium was opened. The right ventricule had tight attachments with pericardium and sternum. The incision was completed to transverse bisternal anterior thoracotomy, and the anterior wall of the right ventricle was dissected free. The half of the broken steel strut was seen embedded in the myocardium (Fig 3). The strut was pulled out of the myocardium under cardiopulmonary bypass steady-state condition and hemorrhage was stopped with pledgeted sutures. No postoperative complication occured and the patient was discharged on the 7th postoperative day.

View larger version (128K): [in this window] [in a new window]   Fig 1. Preoperative left lateral chest roentgenogram showing the two halves of the broken steel strut.

View larger version (122K): [in this window] [in a new window]   Fig 2. The computed tomograph showing the half of the broken steel strut in the right ventricle.

View larger version (106K): [in this window] [in a new window]   Fig 3. Operative photograph showing the half of broken steel strut embedded in the myocardium.

	Comment

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Stainless steel struts of appropriate size placed retrosternally for internal fixation are extracted after 6 months on outpatient basis. Other materials for fixation of sternum and anterior thorax are: autologous costal cartilage, Kirschner wire, Steinman pins, and, lately, bioabsorbable bars. Bioabsorbable bars were supposed to have the advantages of not requiring a second operation and tolerance to magnetic resonance imaging, but also have the disadvantage of overgranulation when broken [6]. We still prefer to use steel struts, as they are cheap, easy to find, and easy to place and extract, but such an unbelievable complication should always be kept in mind.

Another point of view is the tendency of such foreign objects to migrate towards the heart. The Kirschner wire of clavicle, which was found in the pulmonary artery, and the pacemaker, which was reported to migrate to pericardium, must always be remembered in patients having foreign objects in their bodies [7, 8].

We reported this case because it is an interesting complication of pectus excavatum operation. Patients who have steel struts as internal fixators for such thoracic deformity corrections should be followed up closely, and the struts should be extracted as soon as fibrous tissue occurs.

	References

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1. Ravitch M.M. Pectus excavatum. In: Ravitch M.M., ed. Congenital deformities of the chest wall and their operative correction. Philadelphia: WB Saunders, 1977:78-205.
2. Shamberger R.C. Chest wall deformities. In: Shields T.W., ed. General thoracic surgery. Malvern, PA: Williams & Wilkins, 1994:529-557.
3. Welch K.J. Satisfactory correction of pectus excavatum deformity in the childhood. J Thorac Surg 1958;36:697-713.
4. Atkins P.C., Blades B.A. Stainless steel strut for correction of pectus excavatum. Surg Gynecol Obstet 1961;113:111-113.[Medline]
5. Fonkulsrud E.W., Salmon T., Guo W., Gregg J. Repair of the pectus deformities with sternal support. J Thorac Cardiovasc Surg 1994;107:37-42.[Abstract/Free Full Text]
6. Matsui T., Kitano M., Nakanuro T., Shimigu Y., Hyon S.H., Ikado Y. Bioabsorbable struts made from poly L-lactide and their application for treatment of chest deformity. J Thorac Cardiovasc Surg 1994;108:162-168.[Abstract/Free Full Text]
7. Barlas C., Kalayci G., Onursal E., Bedirhan M.A. Intrapulmonary Kirschner wire. Vasc Surg 1986;20:61-65.
8. Van Hore G.F., Witherall C., Merrick S.M. Migration of epicardial pacemaker to the pericardial space in an infant. Pacing Clin Electrophysiol 1994;17:1808-1810.[Medline]

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