Combined severe pectus excavatum correction and aortic root replacement in Marfan's syndrome

Simultaneous repair of congenital heart defects and pectus excavatum in young children

PURPOSE

The present study was undertaken to summarize our experience with the concurrent repair of pectus excavatum (PE) and congenital heart defects in young children over the past 15 years.

METHODS

A retrospective study was conducted that included patients who underwent combined repair of PE and a congenital heart defect in a large clinical center between 2002 and 2017. Intraoperative and postoperative patient characteristics, postoperative complications and surgical outcomes were recorded.

RESULTS

Twenty-one patients met the inclusion criteria. An open heart surgery and a modified sternal elevation with anterior sternal suspension were performed. No intraoperative complications occurred. Postoperatively, three patients developed pneumonia, two patients developed subcutaneous effusions, one patient sustained an asymptomatic pneumothorax, and one other patient had a transitory fever. In all cases, postoperative recovery was uneventful, and no perioperative mortality occurred. Bar removal was performed in 19 patients at an average of 2.55 years postoperatively: 18 of them achieved an excellent outcome, and 1 patient had a good final result.

CONCLUSION

A combined procedure of modified sternal elevation and cardiac repair may be performed safely in young children. Early repair of PE is feasible and effective in these patients.

Left parasternal approach for Bentall procedure in a patient of Marfan syndrome with severe pectus excavatum

Annuloaortic ectasia with ascending aortic aneurysm with severe aortic regurgitation with severe left ventricular dysfunction is a serious condition especially in patients with Marfan syndrome (MFS) simultaneously having severe pectus excavatum (PE) deformity. We report our left parasternal approach in such patient in whom median sternotomy was not feasible. We achieved excellent exposure of dislocated heart and great vessels enabling Bentall procedure. Since patient did not consent for combined correction of chest wall deformity, we plan to undertake it later. Therefore, we conclude that left parasternal approach is feasible for standard aortic root replacement surgery in severe PE.

Combined Nuss Procedure and Cardiac Procedure Through a Left Anterolateral Thoracotomy

Aortic root aneurysms associated with severe pectus excavatum caused by Marfan's syndrome can be challenging to correct in children. Recent reports suggest single-stage correction of both cardiac and chest wall deformities through a median sternotomy. We report a 9-year-old girl with Marfan's syndrome, an ascending aorta aneurysm, mitral regurgitation, and pectus excavatum, who underwent David's procedure with mitral valve repair and the Nuss procedure to correct the thoracic deformity. This single-stage combined procedure was performed through a left anterolateral thoracotomy. This surgical approach offers easy access to the heart and aorta, has good cosmetic results, and avoids a midline skin incision.

Combined mitral valve replacement associated with the Bentall procedure, diaphragmatic hernia repair and reconstruction of the pectus excavatum in a 26-year-old patient with Marfan syndrome

A 26-year-old man with Marfan syndrome was admitted as an emergency patient with ascending aorta aneurysm, severe mitral and aortic regurgitation, diaphragmatic hernia and pectus excavatum. After completion of diagnostics a combined surgical procedure was performed.

Cardiac surgery and repair of pectus deformities: When and how?

OBJECTIVES

There is currently a lack of recommendations about patients with pectus deformities requiring cardiac surgery. This study reports the results of our surgical strategy on this issue.

METHODS

Eleven patients, from three centers treated over a 9-year period were included in this study. Pectus deformities were operated with a modified Ravitch procedure. In the case of pectus excavatum repair and concomitant cardiac surgery, subperichondrial resection of abnormal rib cartilages was always performed before the sternotomy and an easily removable retrosternal metallic strut was inserted at the end of the procedure ensuring anterior chest wall stability. During follow-up patients had to estimate their current appearance with a numeric scale ranging from 0 to 100.

RESULTS

Mean age was 27 ± 9.4 years. Pectus excavatum was present in 8 patients and pectus arcuatum in 3. There were 6 Marfan syndrome patients. Nine patients had concomitant surgery and, 2 underwent pectus repair after a history of cardiac surgery. There was no operative mortality. In the case of concomitant surgery, heart exposure through median sternotomy was facilitated by abnormal rib cartilage resection. Median follow-up was 54 months (range 16.7-119.7). Mean cosmetic result evaluated by the patients was 97.3 (±2.5).

CONCLUSIONS

In adults, concomitant scheduled surgery is reliable and offers excellent long-term cosmetic results. Moreover, it allows a better thoracic exposition with no added perioperative risk. The modified Ravitch technique seems more adequate in these patients as it can be used in all types of pectus deformities.

Chest wall reconstruction in Marfan syndrome following aortic root replacement

Chest wall and spine deformities are common in Marfan syndrome, and often coexist with cardiac defects. Surgery is often needed to both the aortic root and the anterior chest wall, and early spinal surgery is not uncommon. We describe a case of severe thoracic cage deformity with aortic root dilatation, which was managed by a staged approach, with a very good final result.

Design novel dual agonists for treating type-2 diabetes by targeting peroxisome proliferator-activated receptors with core hopping approach

Owing to their unique functions in regulating glucose, lipid and cholesterol metabolism, PPARs (peroxisome proliferator-activated receptors) have drawn special attention for developing drugs to treat type-2 diabetes. By combining the lipid benefit of PPAR-alpha agonists (such as fibrates) with the glycemic advantages of the PPAR-gamma agonists (such as thiazolidinediones), the dual PPAR agonists approach can both improve the metabolic effects and minimize the side effects caused by either agent alone, and hence has become a promising strategy for designing effective drugs against type-2 diabetes. In this study, by means of the powerful “core hopping” and “glide docking” techniques, a novel class of PPAR dual agonists was discovered based on the compound GW409544, a well-known dual agonist for both PPAR-alpha and PPAR-gamma modified from the farglitazar structure. It was observed by molecular dynamics simulations that these novel agonists not only possessed the same function as GW409544 did in activating PPAR-alpha and PPAR-gamma, but also had more favorable conformation for binding to the two receptors. It was further validated by the outcomes of their ADME (absorption, distribution, metabolism, and excretion) predictions that the new agonists hold high potential to become drug candidates. Or at the very least, the findings reported here may stimulate new strategy or provide useful insights for discovering more effective dual agonists for treating type-2 diabetes. Since the “core hopping” technique allows for rapidly screening novel cores to help overcome unwanted properties by generating new lead compounds with improved core properties, it has not escaped our notice that the current strategy along with the corresponding computational procedures can also be utilized to find novel and more effective drugs for treating other illnesses.

Chest fast MRI: an imaging alternative on pre-operative evaluation of Pectus Excavatum

BACKGROUND

Standard imaging methods in evaluating chest wall deformities, such as Pectus Excavatum (PE) in paediatric and adolescent patients, include baseline 2-view chest radiography and chest CT scan. Only few studies to date investigated the value of fast MRIin the pre operative assessment of patient affected by PE.

OBJECTIVE

To evaluate the efficacy of chest fast MRI in pre-operative management of patient affected by PE. To obtain the Haller Index (HI) and Asymmetry Index (AI) from chest fast MRI protecting patients from radiation exposure.

MATERIALS AND METHODS

We analyzed the data of 42 consecutive patients with severe PE who underwent minimally invasive repair between March 2007 and March 2010. All 42 patients received chest fast MRI, but only the first 5 in view of the results, were studied also with chest ultrafast CT scan. In both examinations, data at the deepest point of the depression were collected.

RESULTS

Severity indices of the deformity using HI and AI, collected from CT scan and fast MRI in the first 5 patients, were comparable. In the remaining 37 fast chest MRI offered good images of the chest wall deformities with no radiation exposure, detailing anatomical information such as displacement and rotation of the heart or great vessels anomalies.

CONCLUSION

This study suggests the use of chest MRI in pre operative workup for patients with PE to obtain severity indices (Haller Index and Asymmetry Index avoiding radiation exposure to paediatric patients.