Ann Thorac Surg 2008;85:651-653. doi:10.1016/j.athoracsur.2007.08.022
© 2008 The Society of Thoracic Surgeons
Case Reports
Suture Repair of Pectus Excavatum at the Time of Cardiac Surgery on an Infant
Shin Takabayashi, MD, PhDa,*,
Kazuto Yokoyama, MDa,
Hiroyuki Ohashi, MDb,
Yoshihide Mitani, MD, PhDb,
Hideto Shimpo, MD, PhDa
a Department of Thoracic and Cardiovascular Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
b Department of Pediatrics, Mie University Graduate School of Medicine, Tsu, Mie, Japan
Accepted for publication August 13, 2007.
* Address correspondence to Dr Takabayashi, Department of Thoracic and Cardiovascular Surgery, Mie University Graduate School of Medicine, 2-174, Edobashi, Tsu, Mie 514-8507, Japan (Email: shin1111{at}clin.medic.mie-u.ac.jp).
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Abstract
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An 11-month-old girl was diagnosed with pulmonary atresia with intact ventricular septum and symmetrical pectus excavatum that had developed after prior palliative operation. We performed a transannular patch repair and atrial septal defect closure. Simultaneously, to prevent postoperative right ventricular outflow tract compression, the sternum was elevated by two 1-0 braided polyester horizontal mattress sutures on the posterior side of the third and fourth costal cartilages. Postoperative respiratory distress did not occur and her hemodynamics was stable. Four months later, she is alive and well without recurrence of the thoracic deformity.
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Introduction
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Pectus excavatum is one of the most common congenital thoracic deformities, and it occasionally accompanies congenital heart disease [1]. It may cause cardiac compression by the sternum after cardiac surgery, resulting in postoperative hemodynamic instability. The ideal procedure for the repair of pectus excavatum at the time of cardiac surgery on infants is still controversial. We report a simple suture repair of pectus excavatum, which was simultaneously performed with cardiac repair for congenital heart disease in an infant. The procedure did not require sternal devascularization, and hemodynamic stability was postoperatively maintained.
A 12-day-old girl (weight, 2.1 kg) was diagnosed with pulmonary atresia with intact ventricular septum. We performed a right modified Blalock-Taussig shunt, ductus arteriosus ligation, and Brock procedure (closed pulmonary valvotomy). Delayed sternal closure was performed 2 days later. Symmetrical pectus excavatum remarkably developed at 1 month after the operation. At 11 months of age (weight, 5.9 kg) she had a normal-sized tripartite right ventricle, and pulmonary stenosis was of moderate degree. We performed a biventricular repair for pulmonary atresia with intact ventricular septum under cardiopulmonary bypass, consisting of right ventricular outflow tract reconstruction with a transannular patch and atrial septal defect closure.
We decided to perform a simultaneous pectus excavatum repair to prevent postoperative right ventricular outflow tract compression by the deformed sternum. We placed two 1-0 braided polyester horizontal mattress sutures on the posterior side of the third and fourth costal cartilages. To avoid injury to the intercostal and internal thoracic arteries, we took care that the needle did not to pass inferior to the costal cartilages or the junctions between the sternum and costal cartilages. The sutures were passed to the outside of the thoracic cavity through the intercostal spaces. We resected the posterior side of both parts of the divided sternum to closely adhere to each other after the sternal elevation. We then tied the two mattress sutures, which elevated the sternum. Five 1-0 braided polyglactin sutures previously stitched to the sternum were tied for sternal fixation (Fig 1). This achieved stability of the chest wall and avoided cardiac compression by the sternum.
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Fig 1. Left, frontal schema. I = first costal cartilage; II = second costal cartilage; III = third costal cartilage; IV = fourth costal cartilage. Right, horizontal schema. Arrows indicate progress of procedure. (CC = costal cartilage; S = sternum.)
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The patient was extubated on postoperative day 1 without respiratory distress or hemodynamic instability. On postoperative day 2 the dopamine administration was stopped and she was discharged from the intensive care unit. Figure 2
shows the chest before and after the pectus excavatum repair. One month after the repair, the sternum remained in a normal position and was stable. She continues to be alive and well without recurrence of the thoracic deformity at 4 months after the operation.
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Comment
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Pectus excavatum is one of the most common congenital thoracic deformities, which has been identified in 0.12% of autopsy cases [2]. In patients with congenital heart disease, 0.17% is reported to have associated anterior thoracic deformities and pectus excavatum repair with a prior median sternotomy [1].
To maintain hemodynamic stability after pediatric cardiac surgery, postoperative cardiac compression by the sternum should be avoided. Simultaneous pectus excavatum repair has been reported to improve right ventricular performance after cardiac surgery [3]. In our patient it was expected that cardiac compression by the deformed sternum would cause right ventricular failure because of the expanded right ventricular outflow tract after transannular patch repair. It is difficult to perform pectus excavatum repair using a retrosternal bar in infancy because of the rapid postoperative chest growth [4], and aggressive dissection of the perichondrium would result in an insufficient sternal blood supply, resulting in growth retardation of the chest wall [5]. In infants, the angle between the sternum and ribs is more vertical than in adults, and the bone and cartilage is softer. These characteristics make it possible to perform simple suture repair without dissection of the perichondrium. Therefore, our repair technique could be mainly indicated for pectus excavatum patients with congenital heart disease requiring cardiac operation in infancy. In addition, we think the technique could be applicable for older children if the patient has pliable chest wall structures.
Our suture technique performed at the time of cardiac operation on an infant did not require sternal devascularization, which would prevent future chest wall growth. Besides the cosmetic aspect, this technique is useful for maintaining hemodynamic stability by avoiding cardiac compression after cardiac surgery on infants.
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References
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- Shamberger RC, Welch KJ, Castaneda AR, Keane JF, Fyler DC. Anterior chest wall deformities and congenital heart disease J Thorac Cardiovasc Surg 1988;96:427-432.[Abstract]
- Kelly Jr RE, Lawson ML, Paidas CN, Hruban RH. Pectus excavatum in a 112-year autopsy series: anatomic findings and the effect on survival J Pediatr Surg 2005;40:1275-1278.[Medline]
- Hasegawa T, Yamaguchi M, Ohshima Y, Yoshimura N, Oka S, Ootaki Y. Simultaneous repair of pectus excavatum and congenital heart disease over the past 30 years Eur J Cardiothorac Surg 2002;22:874-878.[Abstract/Free Full Text]
- Kim do H, Hwang JJ, Lee MK, Lee DY, Paik HC. Analysis of the Nuss procedure for pectus excavatum in different age groups Ann Thorac Surg 2005;80:1073-1077.[Abstract/Free Full Text]
- Haller Jr JA, Colombani PM, Humphries CT, Azizkhan RG, Loughlin GM. Chest wall constriction after too extensive and too early operations for pectus excavatum Ann Thorac Surg 1996;61:1618-1625.[Abstract/Free Full Text]
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Abstract
Introduction
