Ann Thorac Surg 2004;77:1827-1829
© 2004 The Society of Thoracic Surgeons
Case report
Simultaneous repair of pectus excavatum and congenital heart defect in adults by using the convex bar
Toru Okamura, MDa*,
Yuzo Nagase, MDa,
Fujio Mitsui, MDa,
Masao Shibairi, MDa,
Kazuo Utsumi, MDa,
Hiroshi Watanabe, MDa
a Department of Cardiovascular Surgery, Matsudo City Hospital, Chiba, Japan
Accepted for publication June 3, 2003.
* Address reprint requests to Dr Okamura, Department of Cardiovascular Surgery, Matsudo City Hospital, 4005 Kamihongo, Matsudo, Chiba 271-8511, Japan
e-mail: tokamura{at}rr.iij4u.or.jp
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Abstract
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Simultaneous repair of pectus excavatum and cardiac lesions remains technically difficult. In adults, most repairs of pectus deformity and heart lesions have been performed through long incisions, sternal splits, excision of deformed cartilages, and sternal turnover, which can result in poor cosmetic appearance because of sternal devascularization. We performed concomitant repair of pectus excavatum and an atrial septal defect through a short midline incision in an adult. The sternum was fixed by using absorbable plates and screws and was supported by a convex steel bar. The cosmetic appearance remained excellent after the operation. The technique and a review of the literature are included.
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Introduction
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The combination of cardiac disease and pectus excavatum represents a major clinical challenge to surgeons. A pectus deformity may complicate cardiac surgery by making midline sternotomy technically more difficult. This report describes simultaneous repair of a sternal deformity and heart defects through a short skin incision. The technical aspects and operative considerations are discussed.
The patient was a 47-year-old woman with severe pectus excavatum. She complained of chest discomfort. Computed tomography (CT) was performed (Fig 1).
This patient's CT index was 5.2. (Haller and colleagues [1] introduced a CT index derived by dividing the transverse chest diameter by the anterior diameter. In their study, an index of 3.25 correlated with a severe deformity that necessitated operation.) Echocardiography and cardiac catheterization showed an atrial septal defect. Preoperative pulmonary function test results were almost normal. A simultaneous repair of the sternal deformity and atrial septal defect was scheduled.
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Fig 1. Chest computed tomography (CT) shows severe asymmetric pectus excavatum (CT index, 5.2) with severe cardiac compression and displacement. (R = right.)
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The operation was performed through a short vertical midline incision approximately 8 cm in length. The subcutaneous tissue above the sternum and all deformed cartilages (cartilages 3 to 7) were dissected widely. This wide dissection cleared the operating field. Rectus muscle flaps were mobilized bilaterally, and subperichondrial resection of all deformed cartilages (cartilages 3 to 7) was performed. The sternal ends of the malformed cartilages were disconnected, and the subperichondrial tissue was separated and mobilized. Excision of the malformed cartilages was completed, and the intercostal muscles were dissected free of the sternum. This method was based on Ravitch's procedure [2]. We chose a left sternal approach because of the position of the heart. Cardiopulmonary bypass was instituted by way of the right femoral artery and bicaval cannulations. Under ventricular fibrillation, the atrial septal defect was closed with an autopericardial patch. After termination of cardiopulmonary bypass and reversal of heparin, sternal repair was completed by using the techniques described by Shamberger and colleagues [3] and Nuss and associates [4]. First, transverse sternal osteotomy was performed at the level of the third intercostal space with resection of a triangular wedge without splits. The posterior table was angulated anteriorly, and the sternum was elevated to the desired position. The sternum was fixed with 2 absorbable plates and 8 absorbable screws. Second, the lower edge of the sternum was supported by using the convex bar. Reattachment of the perichondrial sheaths to the sternum, followed by approximation of the rectus abdominis and pectoralis muscle flaps, completed the repair (Fig 2).
After 18 months, the bar was removed easily under general anesthesia. The late outcome and cosmetic results were excellent (Fig 3).
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Comment
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The concomitant presence of chest wall deformities such as pectus excavatum and cardiac abnormalities that necessitate surgical intervention creates a dilemma for surgeons. With pectus excavatum deformity, the displacement of the heart into the left chest and the posterior concavity of the sternum make a simple midsternotomy approach unsatisfactory for concomitant repair of a cardiac lesion. Some surgeons suggest performing staged procedures [5]. Historically, there have been concerns about complications, such as increased bleeding, increased sternal infections, or very extended operative times. However, Willekes and colleagues [6] reported that their incidence of complications in 9 patients with simultaneous pectus and heart lesion repairs was very low.
Numerous modifications have been used for the simultaneous repair of heart defects and pectus excavatum [6, 7]. In particular, the recurrence of pectus excavatum was reported by some surgeons [6, 8]. The poor results were in patients who had repair of heart lesions and repair of pectus excavatum without a sternal support bar. With the use of a temporary sternal bar, the results were superior to those with pectus repair performed without a sternal bar. A sternal bar provides immediate postoperative stabilization. Some studies have documented similar findings with the use of a metal bar [6, 8].
In view of exposure for the cardiovascular procedures and postoperative sternal viability, combined repairs must be performed. First, various exposure techniques, including sternal turnover and horizontal or vertical sternal splits, have been proposed. The subcutaneous tissue above the sternum and all deformed cartilages (cartilages 3 to 7) were dissected widely. This wide dissection improved the exposure to the heart. If the heart defect is very simple and has a very low associated risk of death, our technique is simple and provides adequate exposure for intracardiac defects. Second, viability of the sternum and cartilage can be maintained by preserving the internal mammary arteries. The steel bar, which was used by Nuss and colleagues [4], is inserted with the convexity facing posteriorly though bilateral skin incisions. Their bar was removed easily under general anesthesia.
In adults, our approach for the simultaneous repair of a congenital heart defect and pectus excavatum has proven safe and satisfying. The technique uses a vertical midline incision with subperichondrial cartilage resection, anterior sternal wedge resection without splits, sternal fixation with absorbable plates and screws, and a temporary metal bar for retrosternal support. Use of this procedure allows excellent exposure and minimal bleeding.
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References
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- Haller J.A., Jr, Kramer S.S., Lietman S.A. Use of CT scans in selection of patients for pectus excavatum surgery: a preliminary report. J Pediatr Surg 1987;22:904-908.[Medline]
- Ravitch M.M. The operative treatment of pectus excavatum. Ann Surg 1949;129:429-444.[Medline]
- Shamberger RC, Welch KJ. Surgical correction of pectus excavatum. J Pediatr Surg 1988;23:615–22
- Nuss D., Kelly R.E., Jr, Croitoru D.P., Katz M.E. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg 1998;33:545-552.[Medline]
- Jones G.W., Hoffman L., Devereux R.B., Isom O.W., Gold J.P. Staged approach to combined repair of pectus excavatum and lesions of the heart. Ann Thorac Surg 1994;57:212-214.[Abstract]
- Deleon M.M., Magliato K.E., Roughneen P.T., et al. Simultaneous repair of pectus excavatum and congenital heart disease. Ann Thorac Surg 1997;64:557-559.[Abstract/Free Full Text]
- Willekes C.L., Baker C.L., Mavroudis C. A 26-year review of pectus deformity repairs, including simultaneous intra-cardiac repairs. Ann Thorac Surg 1999;67:511-518.[Abstract/Free Full Text]
- Fonkalsrud E.W., Dunn J.C.Y., Atkinson J.B. Repair of pectus excavatum deformity: 30 years of experience with 375 patients. Ann Surg 2000;231:443-448.[Medline]
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Abstract
Introduction
