Minimally Invasive Pectus Excavatum Correction and Endoscopic Port Access Mitral Valve Surgery

This case study describes the successful short-term outcome of staged minimally invasive pectus excavatum correction and endoscopic mitral valve repair in a patient with severe mitral valve regurgitation and pectus excavatum.

Coronary artery bypass grafting after sternal turnover procedure and a review of the literature

We report a case of complete revascularization after a sternal turnover procedure through median sternotomy in a patient with multivessel coronary artery disease. The patient had unusual anatomical features, such as the anterior protrusion of the middle-to-distal sternum and absent bilateral internal thoracic arteries (ITAs). The single-blade sternum retractor and the Omni-Tract retractors are simple and reliable tools for lifting and widening the thoracic wall around the xiphoid process. The bilateral radial arteries and the great saphenous vein were used as bypass grafts. Computed tomography was used to visualize the sternum supplied by the superior epigastric arteries (SEAs); presurgical abdominal ultrasonography revealed the course and crossing point of the developed SEAs. Since ITAs were absent, we preserved the SEAs to prevent sternal ischemia. No sternal complications or graft occlusion were observed during follow-up.

Aortic root replacement and valvuloplasty in a woman with severe pectus excavatum

We describe a case of a 43-year old woman with Marfan's syndrome, tricuspid valve regurgitation and severe pectus excavatum who required an aortic root replacement and valvuloplasty for an ascending aortic aneurism with aortic valve regurgitation and tricuspid valve regurgitation. There was a severe angulation of the sternum which was close to 1.5 cm to the column vertebrae. Such cases are quite rare and always a challenge for surgeons to achieve adequate exposure of the heart and prevent excessive cardiac compression. We present our access, a safe and efficient exposure of the heart in order to achieve the best outcome.

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.

Endoscopic atrioventricular valve surgery in adults with difficult-to-access uncorrected congenital chest wall deformities

OBJECTIVES

This study presents the first report on in-hospital and long-term outcomes of endoscopic port access atrioventricular valve surgery (EPAAVVS) in adult patients with uncorrected congenital chest wall deformities (CCWDs).

METHODS

Our current surgical team performed EPAAVVS in 7 consecutive adult patients (mean age 51.3 ± 16.4 years, 14.3% female, 50% older than 60 years, mean EuroSCORE II 0.8 ± 0.1%) with uncorrected CCWDs between 1 November 2009 and 30 November 2015. The mean left ventricular ejection fraction was 66.0 ± 8.5%. Surgical indications included isolated or combined symptomatic mitral valve (MV) regurgitation (n = 7, 100%), left ventricular outflow tract (LVOT) obstruction (n = 1, 14.3%) and patent foramen ovale (n = 3, 42.9%). Fibro-elastic deficiency accounted for 57.1% of MV pathology and 5 patients (74.1%) presented with New York Heart Association (NYHA) Class III symptoms. CCWDs included isolated pectus excavatum (n = 5, 71.4%) and mixed pectus excavatum and carinatum (n = 2, 28.6%). The mean Haller-index and correction index scores were 2.7 ± 0.5 and 21.4 ± 10.2%, respectively.

RESULTS

Procedures performed included MV repair (n = 7, 100%), tricuspid valve (TV) repair (n = 1, 14.3%) and left ventricular septal myomectomy (n = 1, 14.3%). There were no sternotomy conversions or complications with chest wall entry or atrioventricular valve exposure. The mean cardiopulmonary bypass and cross-clamp times were 162.1 ± 48.1 and 113.7 ± 33.5 min, respectively. No patient required mechanical ventilation or intensive care treatment longer than 24 h. There were no surgical revisions, in-hospital respiratory or chest wall morbidities. The mean length of hospital stay was 7.4 ± 1.0 days. A total of 208 patient-months (mean 29.7 ± 26.5) were available for long-term clinical and echocardiographic analysis. There were no 30-day or long-term mortalities and no patient required reintervention for residual atrioventricular valve pathology. All patients were classified as NYHA I during recent consultations, and echocardiographic follow-up confirmed no residual MV regurgitation greater than Grade 1 in any patient.

CONCLUSIONS

EPAAVVS in adults with uncorrected CCWD is safe, feasible and durable and can successfully be performed by experienced teams to achieve Haller index and correction index scores of up to 3.3 and 38.3%, respectively, with favourable long-term clinical and echocardiographic outcomes. The mere presence of uncorrected CCWDs should not deter surgeons from offering these patients the full benefits of minimally invasive cardiac surgery.