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Zeineddine RM, Botros M, Shawwaf KA, Moosavi R, Aly MR, Farina JM, Lackey JJ, Sandstrom BA, Jaroszewski DE. Does a high Haller index influence outcomes in pectus excavatum repair? J Thorac Cardiovasc Surg 2024:S0022-5223(24)00292-7. [PMID: 38608864 DOI: 10.1016/j.jtcvs.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/21/2024] [Accepted: 04/04/2024] [Indexed: 04/14/2024]
Abstract
OBJECTIVE Severity for pectus excavatum includes Haller index (HI) > 3.25. An extremely high HI (≥8) may influence surgical approach and complications. This study reviews outcomes of patients with high HI after repair. METHODS A single institution retrospective analysis was performed on adult patients with HI ≥ 8 undergoing pectus excavatum repairs. For outcomes, a propensity score-matched control group with a HI ≤ 4 was utilized. RESULTS In total, 64 cases (mean age, 33.5 ± 10.9 years; HI, 13.1 ± 5.0; 56% women) were included. A minimally invasive repair was successful in 84%. A hybrid procedure was performed in the remaining either to repair fractures of the ribs (8 patients) and sternum (5 patients) or when osteotomy and/or cartilage resection was required (10 patients). In comparison with the matched cohort (HI ≤ 4), patients with high HI had longer operative times (171 vs 133 minutes; P < .001), more frequently required hybrid procedures (16% vs 2%; P = .005), experienced higher incidences of rib (22% vs 3%; P = .001) and sternal fractures (12% vs 0%; P = .003), and had increased repair with 3 bars (50% vs 19%; P < .001). There were no significant differences between the groups for length of hospital stay or postoperative 30-day complications. CONCLUSIONS Patients with an extremely high HI can be challenging cases with greater risks of fracture and need for osteotomy/cartilage resection. Despite this, minimally invasive repair techniques can be utilized in most cases without increased complications when performed by an experienced surgeon.
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Affiliation(s)
- Rawan M Zeineddine
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Michael Botros
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Kenan A Shawwaf
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Ryan Moosavi
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Mohamed R Aly
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Juan M Farina
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Jesse J Lackey
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Beth A Sandstrom
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Dawn E Jaroszewski
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz.
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Aly MR, Farina JM, Bostoros PM, Botros MM, Pulivarthi VS, Peterson MA, Lackey JJ, Jaroszewski DE. Risk Factors and Techniques for Safe Pectus Bar Removal in Adults After Modified Nuss Repair. Ann Thorac Surg 2023; 116:787-794. [PMID: 36549569 DOI: 10.1016/j.athoracsur.2022.11.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/26/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The Nuss repair involves implants designed for removal after 2 to 3 years. Although rare, significant complications can occur with bar removal, and the incidence of these complications may be higher in adults. This study was performed to review complications and risk factors associated with bar removal and discuss strategies to improve operative safety. METHODS A retrospective study was performed including all patients after pectus excavatum repair who underwent Nuss implant removal at Mayo Clinic Arizona (Phoenix, AZ) from 2013 to 2022. RESULTS In total, 1555 bars were removed (683 patients; 71% men; median age, 34 years[(range, 15-71 years]). Of the removals, 12.45% of patients had bars placed at outside institutions. Major complications were rare, with bleeding most common (2.05%), followed by pneumothorax (0.88%), infection (0.59%), and effusions (0.44%). Most major bleeding (85.71%) occurred from the bar track during removal and was controlled by packing the track. One patient required subsequent hematoma evacuation and transfusion. Bleeding secondary to lung injury was also successfully controlled with packing. Bar removal in 1 patient with significantly displaced bars required sternotomy and cardiopulmonary bypass as a result of aortic injury. Risk factors identified for bleeding included sternal erosion (P < .001), bar migration (P < .001), higher number of bars (P = .037), and revision of a previous pectus repair (P = 0.001). Bar migration was additionally associated with major complications (P < .001). Older age, although a risk factor for overall complications (P = 0.001), was not a risk factor for bleeding. CONCLUSIONS Bar removal can be safely performed in most patients; however, significant complications, including bleeding, may occur. Identifying potential risk factors and being prepared for rescue maneuvers are critical to prevent catastrophic outcomes.
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Affiliation(s)
- Mohamed R Aly
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Juan M Farina
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Peter M Bostoros
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Michael M Botros
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Venkata S Pulivarthi
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Michelle A Peterson
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Jesse J Lackey
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Dawn E Jaroszewski
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona.
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Ravanbakhsh S, Farina JM, Bostoros P, Abdelrazek A, Mi L, Lim E, Mead-Harvey C, Arsanjani R, Peterson M, Gotimukul A, Lackey JJ, Jaroszewski DE. Gender differences in objective measures of adult patients presenting for pectus excavatum repair. Ann Thorac Surg 2021; 114:1159-1167. [PMID: 34600903 DOI: 10.1016/j.athoracsur.2021.08.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 08/02/2021] [Accepted: 08/30/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Women have a reported incidence of pectus deformities 4-5 times less than men. Gender differences have not been well studied. METHODS A retrospective review was performed of adult patients (≥18 years) who underwent a pectus excavatum repair at Mayo Clinic in Arizona (January 1, 2010-December 31, 2019). RESULTS In total, 776 adults underwent pectus repair with 30% being women. Women presented older (mean age 35 vs 32 years, p=0.007) and more symptomatic. Despite this, women performed better on cardiopulmonary exercise testing (higher VO2 max and O2 pulse). Women had more severe deformities (Haller index 5.9 vs 4.3, p<0.001). However, in 609 patients undergoing attempted primary minimally invasive pectus repair, intraoperative fractures/osteotomies occurred equally between genders with the majority occurring in patients ≥30 years of age (11.5% in ≥30, 1.7% in <30, total 7%). Women were also less likely to require 3 bars for repair (12% vs 42%, p<0.001). Hospital length of stay and postoperative complication rates were not significantly different. Postoperatively women reported a greater daily intensity of pain, but only on the initial postoperative day used significantly more opioids than men. Cardiopulmonary exercise testing in 142 patients undergoing baseline and postoperative evaluation at bar removal showed equal and significant benefits in both genders. CONCLUSIONS Women presented for pectus excavatum repair older and with greater symptoms and severity. Despite this, women required fewer bars, with no significant differences in length of stay or complications. Cardiopulmonary benefits of repair were significant and equal for both genders.
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Affiliation(s)
| | | | - Peter Bostoros
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona
| | | | - Lanyu Mi
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona
| | - Elisabeth Lim
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona
| | | | - Reza Arsanjani
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona
| | | | | | - Jesse J Lackey
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona
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Jaroszewski DE, Ewais MM, Chao CJ, Gotway MB, Lackey JJ, Myers KM, Merritt MV, Sims SM, McMahon LE, Notrica DM. Success of Minimally Invasive Pectus Excavatum Procedures (Modified Nuss) in Adult Patients (≥30 Years). Ann Thorac Surg 2016; 102:993-1003. [DOI: 10.1016/j.athoracsur.2016.03.105] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 02/17/2016] [Accepted: 03/31/2016] [Indexed: 11/28/2022]
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Jaroszewski DE, Ewais MM, Lackey JJ, Myers KM, Merritt MV, Stearns JD, Gaitan BD, Craner RC, Gotway MB, Naqvi TZ. Revision of failed, recurrent or complicated pectus excavatum after Nuss, Ravitch or cardiac surgery. J Vis Surg 2016; 2:74. [PMID: 29078502 DOI: 10.21037/jovs.2016.03.17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 02/17/2016] [Indexed: 11/06/2022]
Abstract
Pectus excavatum (PE) can recur after both open and minimally invasive repair of pectus excavatum (MIRPE) techniques. The cause of recurrence may differ based on the initial repair procedure performed. Recurrence risks for the open repair are due to factors which include incomplete previous repair, repair at too young of age, excessive dissection, early removal or lack of support structures, and incomplete healing of the chest wall. For patients presenting after failed or recurrent primary MIRPE repair, issues with support bars including placement, number, migration, and premature removal can all be associated with failure. Connective tissue disorders can complicate and increase recurrence risk in both types of PE repairs. Identifying the factors that contributed to the previous procedure's failure is critical for prevention of another recurrence. A combination of surgical techniques may be necessary to successfully repair some patients.
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Affiliation(s)
- Dawn E Jaroszewski
- Department of Surgery, Division of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - MennatAllah M Ewais
- Department of Surgery, Division of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Jesse J Lackey
- Department of Surgery, Division of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Kelly M Myers
- Department of Surgery, Division of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Marianne V Merritt
- Department of Surgery, Division of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Joshua D Stearns
- Department of Anesthesia, Division of Cardiothoracic Anesthesia, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Brantley D Gaitan
- Department of Anesthesia, Division of Cardiothoracic Anesthesia, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Ryan C Craner
- Department of Anesthesia, Division of Cardiothoracic Anesthesia, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Michael B Gotway
- Department of Radiology, Division of Thoracic Imaging, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Tasneem Z Naqvi
- Department of Cardiology, Division of Echocardiogram, Mayo Clinic Arizona, Phoenix, Arizona, USA
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Jaroszewski DE, Notrica DM, McMahon LE, Hakim FA, Lackey JJ, Gruden JF, Steidley DE, Johnson KN, Mookadam F. Operative Management of Acquired Thoracic Dystrophy in Adults After Open Pectus Excavatum Repair. Ann Thorac Surg 2014; 97:1764-70. [DOI: 10.1016/j.athoracsur.2014.01.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 01/10/2014] [Accepted: 01/14/2014] [Indexed: 11/25/2022]
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