The effect of surgical repair of the chest on postural stability among patients with pectus excavatum

Pectus excavatum is the most encountered of chest wall deformities. It may produce respiratory and cardiovascular symptoms, hence surgical repair of this defect is performed. The procedure involving the insertion of metal bars under the sternum (the Nuss procedure) usually brings significant improvement to patients. However, the effect of the repair on the postural stability of patients has not been studied so far. To investigate the problem of patients' stability in the postoperative period male patients with pectus excavatum (n = 21) and healthy controls (n = 22) were included in the study. Using posturography methods, we showed a negative impact of the pectus excavatum repair surgery on patients' postural stability in the first postoperative phase. The centre of pressure displacement parameters used to measure postural stability were lower after the repair for both, the frontal and sagittal plane as well as for the velocity of displacements in the sagittal plane in the double stance with eyes open. Poorer postural stability was also found in patients with pectus excavatum when compared to healthy controls. Our findings may be useful for functional monitoring in the evaluation and surgical management of pectus excavatum patients and also when designing the rehabilitation of patients undergoing the Nuss procedure.

Demographics of Anterior Chest Wall Deformity Patients: A Tertiary Children's Hospital Experience

INTRODUCTION

Anterior chest wall deformities consist of abnormal development of the chest, with the most common congenital deformities being pectus excavatum (PE) and pectus carinatum (PC). Surgical series are common, but less research is present assessing the demographics of all who present for initial evaluation. The purpose of this study is to describe the patient characteristics of those who present for ambulatory surgical evaluation.

METHODS

Data were collected from initial patient visits to an established multispecialty chest wall deformities program at a large Children's Hospital from 2017 to 2021. Variables assessed included primary diagnosis, age, sex, race/ethnicity, and whether surgical correction was performed.

RESULTS

A total of 1510 children were evaluated: 50.0% (n = 755) with PE, 43.3% (n = 653) with PC, 2.7% (n = 41) with mixed chest wall deformities, 0.7% (n = 10) with Poland syndrome, 1.1% (n = 17) with Currarino-Silverman syndrome, and 2.3% (n = 34) with other anterior chest wall deformities. Males and females presented at mean age of 12.8 (4.2) and 10.9 (5.5) years, respectively (P = 0.001). White children represented 61.1% of the overall population while Hispanic children represented 26.3%. White, non-Hispanic children represented 61.9% and 71.5% and Hispanic children represented 26.0% and 26.3% of the PE and PC populations, respectively.

CONCLUSIONS

Most patients seen in an urban chest wall deformities clinic were White, non-Hispanic; however, the proportion of other groups such as Hispanic and Asian is greater in this cohort than previously described. Further research is ongoing to ascertain the extent to which disease predisposition versus access to care play roles in this population.

Influence of psychosocial characteristics of patients and opinions of their relatives on indication for surgical treatment of pectus excavatum

BACKGROUND

To assess the subjective experience of patients and their parents or relatives about the existing pectus excavatum deformity and to contribute to the definition of indications for surgical treatment of this deformity.

METHODS

The initial sample of psychosocial characteristics consisted of self-assessments and observations of patients (and parents) regarding their health, self-image, health care, possible environmental response to their physical appearance, expectations regarding treatment. A modified version of the original Nuss questionnaire on quality of life was used in the psychological part of the examination.

RESULTS

The study included a sample of 58 patients aged 10 to 30 years, and a sample of 58 family members of the patient (parents, relatives). The experience of poor emotional status, withdrawals, and bad self-image in patients older than 15 years than younger were significant. The tendency for female patients to have a worse experience is pronounced and significant. The largest percentage of parents have an 'indecisive' or 'weakly expressed' attitude towards surgery. Parents at a significantly higher rate show greater concern for female children.

CONCLUSION

A systematic evaluation of the psychosocial perception of patients and their relatives (who will consent for the operation) may be a useful diagnostic assessment before correcting an anterior chest wall malformation.

Pectus Excavatum: Consensus and Controversies in Clinical Practice

BACKGROUND

Pectus excavatum is the most common congenital anterior chest wall deformity. Currently, a wide variety of diagnostic protocols and criteria for corrective surgery are being used. Their use is predominantly based on local preferences and experience. To date, no guideline is available, introducing heterogeneity of care as observed in current daily practice. The aim of this study was to evaluate consensus and controversies regarding the diagnostic protocol, indications for surgical correction, and postoperative evaluation of pectus excavatum.

METHODS

The study consisted of 3 consecutive survey rounds evaluating agreement on different statements regarding pectus excavatum care. Consensus was achieved if at least 70% of participants provided a concurring opinion.

RESULTS

All 3 rounds were completed by 57 participants (18% response rate). Consensus was achieved on 18 of 62 statements (29%). Regarding the diagnostic protocol, participants agreed to routinely include conventional photography. In the presence of cardiac impairment, electrocardiography and echocardiography were indicated. Upon suspicion of pulmonary impairment, spirometry was recommended. In addition, consensus was reached on the indications for corrective surgery, including symptomatic pectus excavatum and progression. Participants moreover agreed that a plain chest radiograph must be acquired directly after surgery, whereas conventional photography and physical examination should both be part of routine postoperative follow-up.

CONCLUSIONS

Through a multiround survey, international consensus was formed on multiple topics to aid standardization of pectus excavatum care.

Academic performance in children with pectus excavatum: a real-world research with propensity score matching

BACKGROUND

The optimal timing of surgery for pectus excavatum (PE) is controversial. A large proportion of children will not undergo surgery before puberty. However, untimely surgery may lead to a decline in the children's social adaptation and competitiveness because the children have already developed psychological and physiological impairments due to PE at an early age. The study retrospectively compared the academic performance in PE children undergoing the Nuss procedure versus nonsurgical observation.

METHODS

This retrospective real-world research study included 480 PE patients with definite surgical indications, in whom it was first recommended that they undergo surgery between the ages of 6 and 12 years old. Academic performance was collected at baseline and 6 years later. A generalized linear regression was calculated to screen the factors affecting the performance. A propensity score matching (PSM) analysis was conducted to reduce the potential for confounding factors between surgical and nonsurgical PE patients.

RESULTS

Haller index (HI) and pulmonary function were recognized as factors affecting baseline performance according to the generalized linear regression. For PE children with surgical indications, their academic performance significantly declined after 6 years of nonsurgical observation (52.1% ± 17.1% versus 58.3% ± 16.7%, p = 0.042). The academic performance in the surgery group was better than that in the nonsurgery group 6 years after PSM (60.7% ± 17.7% versus 52.1% ± 17.1%, p = 0.008).

CONCLUSIONS

The severity of PE will affect the academic performance of children.For PE children with definite surgical indications between the ages of 6 and 12 years old, surgical intervention rather than nonsurgical observation is more conducive to the development of children's academic performance.

Increased incidence of mitral valve prolapse in children with pectus chest wall deformity

BACKGROUND

Pectus anomalies constitute 95% of chest anomalies. Pectus carinatum (PC) and excavatum (PE) are often asymptomatic in childhood. However, symptoms and signs such as chest pain, dyspnea, and mitral valve prolapse (MVP) can be seen in pectus anomalies. Demographic characteristics and accompanying cardiac signs in children with pectus deformity were investigated.

METHODS

In this study, the clinical findings for children with pectus deformity, and the incidence of MVP and other concomitant heart diseases detected in echocardiographic examinations were evaluated.

RESULTS

Eighty-two children with PE, 27 with PC, and 107 healthy children were included in this study. In the echocardiographic examination of PE, PC patients, and healthy children, MVP was detected with frequencies of 25%, 33%, and 2% respectively.

CONCLUSIONS

The study showed that pectus anomalies were associated with an increased incidence of MVP. All patients with pectus deformity should therefore undergo a screening echocardiogram in adolescence to assess for the presence of MVP.

Chest wall deformities and their possible associations with different genetic syndromes

OBJECTIVE

Our primary objective was to identify discrete and syndromic cases of Pectus excavatum (PE) and Pectus carinatum (PC). We also intended to highlight the significance of further genetic exploration in clinically suspected syndromic cases of PC and PE. Pectus excavatum (PE) and Pectus carinatum (PC) are the most common morphological chest wall deformities. Although various hypotheses have been put forth, the pathogenesis of both entities is largely unknown. Clinicians often refer such cases for further genetic evaluation to exclude an associated underlying connective tissue disorder or a syndrome. Additionally, a detailed anamnesis with focused family history and thorough dysmorphological physical examination was done. PE and PC are considered isolated abnormalities if there is the absence of features of other syndromes, eliminating the need for further genetic evaluations. It is believed that the pattern of inheritance of these non-syndromic isolated PE and PC cases with positive family history could be multifactorial in nature. The recurrence risk of such isolated cases is thought to be low. Further diagnostic studies are indicated as PE and PC could be a part of a syndrome. Among the many syndromes, the most common monogenic syndromes associated with PE and PC are Marfan's and Noonan's.

PATIENTS AND METHODS

After obtaining the consent, we compiled a database of the patients who presented with chest wall deformities during the period 2017-2019. We selected 70 cases with PC and PE deformities to identify the discrete and syndromic PC and PE cases. During the study, we perused the cytogenetic and/or molecular analyses, that had been conducted to confirm the clinically suspected syndromic cases. We also scrutinized for the presence of PC and PE cases that are associated with the rare syndrome (s).

RESULTS

Various genetic abnormalities were identified in 28 (40%) of the 70 cases that had been diagnosed with chest wall abnormalities. Along with PE and PC, other thoracic wall abnormalities were also identified, such as the broad chest, bell-shaped thorax, and elongated or enlarged thorax. One case of a rare genetic disorder of Morquio syndrome associated with PC was also identified. Novel (previously unpublished) genomic variants are reported here.

CONCLUSIONS

It is important to delve deeper when encountering cases of PE and PC by conducting a further genetic exploration of such cases to identify syndromic associations that cause other structural and functional disorders, diagnosis of which might be missed during the early developmental period. Early identification of such disorders may help us correcting the defects, slowing the progression of disease processes, and preparing better to deal with the potential outcome.

Use of a customised 3D-printed external splint for the correction of a severe pectus excavatum in a 3-month-old kitten

Background:

Pectus excavatum is a rare congenital or developmental deformity of the chest wall that has been reported in both dogs and cats. The clinical symptoms vary in severity and are correlated with the grade of the deformity. The most severe cases are at a very high risk of intra- and post-operative complications that could be fatal.

Case Description:

A 3-month-old kitten was presented for severe dyspnea and exercise intolerance. After the radiographic diagnosis of severe pectus excavatum, a splint was designed based on the computed tomography scan of the kitten. A locking mechanism was applied on a dedicated pocket on the splint and secured with commercial glue. Five sutures were placed, the most caudal three with a surgical approach to the corresponding sternebra. The three caudal traction sutures were progressively tensioned during the first 2 weeks, and then tied. The splint was removed 1 month postoperatively; neither surgical nor splint-associated complications were observed. The kitten well tolerated the splint and the owner reported no further episodes of dyspnea or exercise intolerance. Vertebral and frontosagittal indexes were 3.2 and 9.1 at presentation, respectively, and 10.2 and 2.0 at 4 months postoperatively.

Conclusion:

The use of a patient-specific 3D-printed external splint associated with a progressive correction of the pectus excavatum can be a better solution for the treatment of severe cases of pectus excavatum, where a sudden distension of the rib cage could cause re-expansion injuries.

Analysis of chest wall elevation after the Nuss procedure using 3D body scanning technique in patients with pectus excavatum

PURPOSE

For the evaluation of the chest wall deformity, we adopted a non-invasive 3D body scanning system. The objective of this study is to evaluate surgical effect on the whole thorax using 3D scanning technique before and after Nuss procedure.

METHODS

We performed 3D body scanning using Structure Sensor (Occipital Inc, USA) in 11 symmetric patients (average age 13 ± 3.2) under general anesthesia before and after Nuss procedure. Using the scanned data, the improved chest wall was analyzed using 3D-Rugle (Medic Engineering, Japan) imaging software. Preoperative and postoperative 3D data were super-imposed and a thoracic elevating distance in the line of the axial and sagittal section through the deepest point was calculated. Pre- and postoperative external sternal angle (ESA) were calculated from the scanned data.

RESULTS

Mean thoracic elevation distance at the deepest point was 38.6 ± 6.1 mm and it was 28.4 ± 5.1 mm and 19.4 ± 4.9 mm at 4 cm and 8 cm cranial side, respectively. Average ESA improved from 3.9 ± 1.6 degrees to 15.0 ± 1.1 degrees after the operation.

CONCLUSION

Chest depression was effectively elevated 39 mm at the deepest point after Nuss procedure. An indirect elevation effect by pectus bars was found on the wide area of the anterior chest.

Computer-aided diagnosis of pectus excavatum using CT images and deep learning methods

Pectus excavatum (PE) is one of the most common chest wall defects. Accurate assessment of PE deformities is critical for effective surgical intervention. Index-based evaluations have become the standard for objectively estimating PE, however, these indexes cannot represent the whole information of chest CT images and may associated with significant error due to the individual differences. To overcome these limitations, this paper developed a computer-aided diagnosis (CAD) system based on the convolutional neural network (CNN) to automatically learn discriminative features and classify PE images. We also adopted block-wise fine-tuning methods based on the transfer learning strategy to reduce the potential risk of overfitting caused by limited data and experimentally explored the best fine-tuning degree. Our method achieved a high level of classification accuracy with 94.76% for PE diagnosis. Furthermore, we proposed a majority rule-based voting method to provide a comprehensively diagnostic results for each patient, which integrated the classification results of the whole thorax. The promising results support the feasibility of our proposed CNN-based CAD system for automatic PE diagnosis, which paves a way for comprehensive assessments of PE in clinics.

The effect of pectus excavatum deformity on lung volume: fact or myth?

BACKGROUND AND PURPOSE

Most of the previous studies evaluating lung volume of pectus excavatum (PE) patients were based on spirometric measurements. We aimed to calculate lung volume of patients with PE and compare them with lung volume of patients without chest wall deformity using CT volumetry.

METHODS

After institutional review board approval, preoperative chest CT of PE patients who underwent minimal invasive procedure between January 2012 and February 2018, were evaluated retrospectively. As a control group, age and sex matched patients who underwent chest CT scan in the same period were enrolled. Total, right and left lung volumes were calculated using an automated software. Haller indexes were measured for both groups. Lung volumes and Haller indexes compared between the two groups. We also compared left and right lung volumes in both groups. We evaluated whether there is a correlation across the Haller index and total lung volume.

RESULTS

Total, right and left lung volumes were not statistically different between the two groups. While left lung volumes were significantly smaller in PE group (p = 0.041), there was no significant difference between the left and right lung volume in the control group (p = 0.12). Haller index and total lung volume showed no significant correlation between patients with the same age and gender (p = 0.14, R = -0.3).

CONCLUSIONS

PE deformity does not reduce lung volume when compared to age and sex matched control group. Quantitative CT volumetric evaluation of lung gives valuable data about lung volume.

Poorer sleep quality among adult patients with pectus excavatum in Taiwan: A pilot study

OBJECTIVES

Patients with pectus excavatum have a poorer quality of life than the general population. Sleep quality is a critical component of quality of life. This pilot study compared the sleep quality of adult patients with pectus excavatum with that of the general population in Taiwan.

METHODS

Participants comprised 30 healthy adults, 21 adult outpatients with pectus excavatum, and 33 adults with pectus excavatum receiving Nuss surgery. The Pittsburgh Sleep Quality Index measured subjective sleep quality; the Visual Analog Scale for Pain, Brief Symptom Rating Scale-5, Beck Depression Inventory II, and 36-Item Short Form Survey measured quality of life; and the Epworth Sleepiness Scale measured excessive daytime sleepiness. Outcome measurements were obtained at baseline for all groups and 6 months after Nuss surgery for inpatients.

RESULTS

Patients with pectus excavatum had poorer sleep quality and worse quality of life than controls. Poorer sleep quality was not related to the severity of pectus excavatum per se, but to psychologic issues (beta = 0.18, P < .001 in multiple linear regression analysis). Measurement time had no effect on sleep quality (beta = 0.31, P = .594 for outpatient group; beta = 0.27, P = .665 for inpatients). Sleep quality of patients with pectus excavatum improved after Nuss surgery (Pittsburgh Sleep Quality Index: 4 vs 7, P = .002).

CONCLUSIONS

Our findings suggested an association between poor sleep quality and pectus excavatum; thus, sleep quality should be evaluated before and after the Nuss procedure.

[Pectus excavatumn and carinatum in children and adolescents : what to say, what to do ?]

In children presenting with a pectus excavatum (PE) or pectus carinatum (PC) an underlying syndrome including Marfan's syndrome needs to be excluded. In adolescents, severe chest wall deformities may cause cardiac or respiratory problems but most commonly they have a psychological impact. The conservative treatment is a Vacuum Bell for PE, and a Dynamic Compression System for PC ; they play an increasing role in young patients. These devices need to be worn multiple hours per day for several months for an optimal result. Surgery is usually reserved for adolescents. The Nuss procedure for PE, also known as minimal invasive repair of PE offers excellent results. Sterno-chondro-plasty with stabilisation of the sternum with struts clipped to the ribs offers the same good results for PC. In our opinion, a multidisciplinary approach is preferable.

[Differential approach for chest wall reconstruction for pectus excavatum in adults]

AIM

To perform the prospective non-randomized single-center trial of pectus excavatum correction in adults.

MATERIAL AND METHODS

For the period March 2012 - March 2016 64 patients aged 18-44 years were treated. Median age was 23 years. Male/female ratio was 41/23. All patients were included into standard survey protocol: chest MDCT, MRI of thoracic spine, pulmonary function test, echocardiography. Quality of life and complications rate after the Nuss procedure (n=50, 78.1%, group 1) and radical thoracoplasty using nikelid-titanium bar (n=14, group 2) were evaluated.

RESULTS

There was earlier recovery in the 1st group: 3 (2; 4) and 6 (5; 7) days after minimally invasive and radical thoracoplasty, respectively. Postoperative Dindo-Clavien I-IIIa complications developed in 46 (71.8%) patients. Most of them did not require additional procedures.

CONCLUSION

Nuss procedure is safe method and can be performed with good results in adults.

Off-pump minimally invasive direct coronary artery bypass in patients with cosmetic prosthesis for pectus excavatum

Pectus excavatum can be associated with coronary artery diseases that can become difficult to manage in urgent situations. We describe the use of an off-pump minimally invasive direct coronary artery bypass (MIDCAB) through the fourth intercostal space incision in a patient with pectus excavatum and acute coronary syndrome who previously underwent a cosmetic prosthesis implantation. The patient refused any surgical procedure that could compromise the integrity of his cosmetic prosthesis and a left mini-thoracotomy was a good option to avoid the removal of the prosthesis. The preservation of the integrity of the thoracic cage enhanced chest wall stability and pulmonary function and permitted avoidance of inadvertent cardiac structure iatrogenic injuries. MIDCAB was optimal for the exposure of the left internal thoracic artery and the left anterior descending artery. The deformity of the chest should not be considered as an absolute contraindication to off-pump MIDCAB when other surgical options are not viable, even in emergency situations.

[Children severe OSAHS with pectus excavatum: a case report]

The primary etiopathology of pediatric OSAHS includes tonsil or adenoid hypertrophy. Severe OSAHS contributes to or aggravates thoracic deformity, which is rarely reported. In the current report, This children sleep snoring more than 4 years, increasing with thoracic severe depression during sleep 2 days. Clinical examination indicated tonsil and adenoid hypertrophy, and polysomnography revealed OSAHS . The symptoms of OSAHS and severe inhalation-related sternum depression disappeared rapidly after tonsillectomy. Our findings indicated that OSAHS were the major causes underlying funnel chest in children. The rarity of the incidence may result in missed diagnosis or misdiagnosis. Polysomnography was recommended for the child diagnosed with funnel chest accompanied by upper airway stenosis.

Transcatheter Aortic Valve Replacement via Left Anterior Thoracotomy in a Patient With Severe Pectus Excavatum

With the development of the transcatheter aortic valve replacement, innovative approaches can be geared to atypical and challenging cases. We describe a case of transcatheter aortic valve replacement via a left anterior thoracotomy in a patient with pectus excavatum and unusual intrathoracic anatomy where surgical and traditional transcatheter aortic valve replacement approaches were deemed inapplicable.

Metrical evaluation of Slovak patients with pectus excavatum

PURPOSE

We have started to assess the severity of pectus excavatum by means of anthropometric methods prior to CT examination since 2012. The aim of the study was to establish a significance of anthropometry as first-line diagnostic method. Afterwards, we analyzed statistical significance of differences in selected anthropometric indicators before and after surgical intervention. The analysis was also focused on the data from CT scans.

METHODS

The followed group represented 27 patients, including 6 girls and 21 boys aged 7-18 years (mean age 15.59 years). Evaluation of anthropometric measurements was realized by somatometry, and other metrical measurements were calculated from thoracic CT scans of patients. All measurements were managed with the approval of the Ethics Committee.

RESULTS

The significant differences were found in sagittal diameter and thoracic index in 64.0 % of the patients. Data analyzed from CT showed that flat chest prevailed in both gender (100 %). The largest group represented asymmetric type of pectus excavatum (40.74 %). The superiority of the asymmetric type to the right was confirmed. The values of the Haller index were in range 2.00-5.17 (mean value 3.64). 81.5 % of patients met criterion for surgical correction. Most patients with pectus excavatum had a milder form of deformation.

CONCLUSIONS

Anthropometry provides feasible and non-invasive method of pectus deformities evaluation. Based on the study results, anthropometry should be performed prior to CT examination in order to select patients for surgical treatment. Anthropometric measurements are helpful in accurate documentation of growth, longitudinal observation of the patient, and can support decision concerning the type of surgery.

Comparison of Postoperative Period in Patients with Pectus Excavatum Treated with Nuss Technique and Ravitch Technique

BACKGROUND

Pectus excavatum (PE) is the most common defect of the chest wall. Surgery for PE can be performed with an open or endoscopic technique. The choice of the surgical approach influences the postoperative course. The aim of the paper is to analyze the postoperative period in two groups of patients treated for PE. Group 1 consisted of patients who underwent endoscopic surgery, and Group 2 was composed of patients who underwent open surgery. A secondary aim is to compare the surgical outcomes between the two groups.

MATERIAL AND METHODS

The study group consisted of 40 patients treated in a single centre that uses a uniform postoperative analgesic protocol. The duration of surgery, blood loss, duration of hospital stay, complications, pain intensity and consumption of opioid and non-opioid analgesics were analyzed. The mean duration of follow-up was 9 months (6 -25 months).

RESULTS

Age at surgery, weight and height did not differ between the groups. In Group 1 the duration of surgery and blood loss were lower than in Group 2. In Group 1 complications occurred in 25% of the patients. Pain intensity was higher in Group 1 (4.23 vs. 3.67), as was the consumption of strong opioids (0.52 mg/kg body weight vs. 0.25 mg/kg body weight). Subjective evaluation was satisfactory in 85% of the patients in Group 1 and 90% in Group 2.

CONCLUSIONS

1. Both techniques led to a satisfactory outcome. 2. The duration of surgery and blood loss were higher in the open surgery group, but pain intensity and consumption of strong analgesics were higher among the patients treated with the endoscopic technique. 3. Preparation for surgery should involve planning appropriate analgesic treatment in the post-operative period.

Repair of pectus excavatum during HeartMate II left ventricular assist device placement

Pectus excavatum deformity often remains clinically asymptomatic even in cases of a severely diminished thoracic volume and frequently remains uncorrected. In the patient population that requires left ventricular assist device (LVAD) placement, a diminished thoracic volume can be problematic and lead to significant challenges in pump and outflow cannula positioning. Here we present a case of pectus excavatum correction during LVAD placement to show that this deformity can be successfully addressed with minimal, if any, additional operative risk at the time of LVAD implant.

[Respiratory manifestations of Marfan's syndrome]

Marfan's syndrome is a rare genetic disorder caused by a mutation of the gene FBN1, coding for the protein fibrillin-1. Cardiovascular, musculoskeletal and ophthalmic manifestations are the most commonly observed, but minor diagnostic criteria also include pulmonary manifestations. Pneumothorax, frequently relapsing, affects 5 to 11% of patients. Rib cage abnormalities (pectus excavatum or pectus carinatum) and apical blebs may contribute to their occurrence. Treatment does not require any specific procedure but there is an increased risk of recurrence. Pectus excavatum affects up to 60% of the patients, without any functional impairment in most cases. Surgery may be required (using the Nuss procedure) in case of cardiovascular or psychological symptoms. Marfan's syndrome is frequently associated with obstructive sleep apnoea, which may itself contribute to aortic dilatation. Some studies suggest a potential role of craniofacial abnormalities in the pathogenesis of sleep apnea in these patients. Pulmonologists should consider Marfan's syndrome when treating patients for recurrent spontaneous pneumothorax or rib cage abnormalities, since early detection of cardiac abnormalities improves the prognosis significantly.

Brugada phenocopy in a patient with pectus excavatum: systematic review of the ECG manifestations associated with pectus excavatum

Brugada phenocopies (BrP) have emerged as new clinical entities that are etiologically distinct from true Brugada syndrome (BrS). BrP are characterized by an ECG pattern that is phenotypically identical to true BrS (type 1 or type 2); however, BrP are caused by various other factors such as mechanical mediastinal compression, myocardial ischemia, pericarditis, myocarditis, pulmonary embolism, and metabolic disturbances. We report a case of an electrocardiographic BrP in a patient with pectus excavatum deformity in the absence of true BrS using currently defined BrP diagnostic criteria. A systematic review of ECG manifestations associated with pectus excavatum is also discussed.

Nuss procedure in adult pectus excavatum: a simple artifice to reduce sternal tension

Nowadays the Nuss operation represents the standard surgical choice for pectus excavatum repair in children and teenagers. Some concerns have been raised regarding its applicability in adults, as compared with younger patients, in view of the higher rate of complications after surgery. We describe an easy trick that has been performed on a 36-year old man with a moderate pectus excavatum after an unsatisfactory Nuss procedure. It consisted of a T-shaped partial anterior sternotomy, performed after positioning of the stainless steel bar, in order to promote a hinge mechanism of the sternum to reduce the tension over the reinforcement. This procedure was successful with well-controlled postoperative pain and great patient satisfaction. No complications were recorded at 1-year follow-up. In our opinion, this simple trick could represent a valid surgical option for pectus excavatum repair in late adolescents and adults to obviate the occurrence of major sternal tension.

Minimally invasive repair for pectus excavatum -- aesthetic and/or functional?

INTRODUCTION

Pectus excavatum is the most frequent anterior thoracic wall congenital malformation. This malformation is increasing its effects with the aging process and has its peak during teenage, when the clinical symptoms become more acute and psychological effects are really important. Across the course of time many treatment techniques have been proposed, among which conservative or surgical correction techniques. The minimally invasive repair of pectus excavatum, "Nuss technique", developed after 1987, is the most frequently performed technique world wide.

MATERIAL AND METHOD

This article analyzes 52 patients, admitted to the University Emergency Military Hospital "Carol Davila" - Thoracic Surgery Department, diagnosed, investigated and surgically treated according to Nuss procedure. Therapeutic and diagnostic protocols will be presented and analyzed: clinical and paraclinical evaluation, indications and contraindications of Nuss procedure, as well as possible intraoperative and postoperative complications.

RESULTS AND CONCLUSIONS

Nuss procedure's benefits will be presented, as well as improvements of functional and aesthetic parameters. Nuss procedure has a series of advantages: minimally invasive surgical procedure reduced operative time, minimal blood loss and fast socio-professional reinstatement.

[Lady Windermere syndrome]

We describe the case of a 68 year old lady with a pectus excavatum, chronic cough, dyspnoea, and fever. The CT scan showed fibronodular infiltrates and bronchectases. Bacterial culture revealed a Mycobacterium avium-intracellulare infection. A tritherapy was initiated and, 10 months later, the patient had greatly improved.

The internal mammary artery perforator (IMAP) breast-flap harvested from an asymmetric hyperplastic breast for correction of a mild funnel chest deformity

Pectus excavatum deformity is the most frequent congenital anomaly of the thoracic wall. If the invasive surgical procedures of thoracoplasty are not indicated or the patient refuses them, alternative treatment options should be considered. In such cases, local or distant transposition of autologous tissue could be appropriate. This report presents a selected case of funnel chest deformity and concomitant unilateral breast hyperplasia. Both deformities were corrected simultaneously using a pedicled internal mammary artery perforator (IMAP) flap dissected from the hyperplastic breast. This is a safe, reliable, low-morbidity, one-stage option for adult women that uses an easy-to-harvest flap for simultaneous correction of mild funnel chest deformity and concomitant breast hyperplasia with a single resulting scar.

How to perform breast augmentation safely for a pectus excavatum patient

BACKGROUND

Pectus excavatum is the most common chest wall deformity. Women with pectus excavatum may have associated hypoplastic breasts and often desire breast augmentation. This report describes how to perform breast augmentation safely for a pectus excavatum patient.

METHODS

In the past 5 years, the authors have treated 11 women with hypoplastic breasts and pectus excavatum. Their ages have varied from 21 to 39 years. The women generally were healthy without cardiovascular function impairment. Four of the women had breast asymmetry, with a smaller right breast. It was decided to use wide silicone implants to augment the breast and to camouflage the chest wall deformity. The implants were placed under the pectoralis major muscle in all cases.

RESULTS

The follow-up period varied from 10 months to 4.5 years. No acute or late complications related to the breast augmentation were encountered. All the patients were satisfied with the result, and none desired further surgical treatment for pectus excavatum. For two patients, a small depression in the upper part of the breast was persistent after surgery due to insufficient implant coverage.

CONCLUSION

Most women with pectus excavatum desire to have the deformity corrected with minimal or no scarring. The chest is known to be an area prone to hypertrophic or keloid scars. The reported approach is simple and safe, easily camouflaging the deformity. It is a short procedure that results in high satisfaction.

Severe bronchomalacia treated by combination of Nuss procedure and aortopexy: an unusual therapy combination

Aortopexy is the treatment of choice for clinically significant tracheobronchomalacia from external vascular compression. When a marked chest depression is present, aortopexy may be less effective. We report 2 patients with pectus excavatum and vascular compression of the trachea who, despite their young age, benefited from combined Nuss bar insertion and aortopexy.

Cardiovascular magnetic resonance in patients with pectus excavatum compared with normal controls

PURPOSE

To assess cardiothoracic structure and function in patients with pectus excavatum compared with control subjects using cardiovascular magnetic resonance imaging (CMR).

METHOD

Thirty patients with pectus excavatum deformity (23 men, 7 women, age range: 14-67 years) underwent CMR using 1.5-Tesla scanner (Siemens) and were compared to 25 healthy controls (18 men, 7 women, age range 18-50 years). The CMR protocol included cardiac cine images, pulmonary artery flow quantification, time resolved 3D contrast enhanced MR angiography (CEMRA) and high spatial resolution CEMRA. Chest wall indices including maximum transverse diameter, pectus index (PI), and chest-flatness were measured in all subjects. Left and right ventricular ejection fractions (LVEF, RVEF), ventricular long and short dimensions (LD, SD), mid-ventricle myocardial shortening, pulmonary-systemic circulation time, and pulmonary artery flow were quantified.

RESULTS

In patients with pectus excavatum, the pectus index was 9.3 ± 5.0 versus 2.8 ± 0.4 in controls (P < 0.001). No significant differences between pectus excavatum patients and controls were found in LV ejection fraction, LV myocardial shortening, pulmonary-systemic circulation time or pulmonary flow indices. In pectus excavatum, resting RV ejection fraction was reduced (53.9 ± 9.6 versus 60.5 ± 9.5; P = 0.013), RVSD was reduced (P < 0.05) both at end diastole and systole, RVLD was increased at end diastole (P < 0.05) reflecting geometric distortion of the RV due to sternal compression.

CONCLUSION

Depression of the sternum in pectus excavatum patients distorts RV geometry. Resting RVEF was reduced by 6% of the control value, suggesting that these geometrical changes may influence myocardial performance. Resting LV function, pulmonary circulation times and pulmonary vascular anatomy and perfusion indices were no different to controls.

Preliminary results after Nuss procedure

INTRODUCTION

Pectus excavatum (PE) is the most frequent anterior chest deformity and occurs in approximately 1 in 1000 live births. In 1998 Donald Nuss introduced a new minimal invasive operative technique for PE which avoids any cartilage resection or sternum osteotomy.

PURPOSE

The purpose of this study is to assess the short and medium time results after minimal invasive correction of pectus excavatum and to present our improvements to the original Nuss technique.

MATERIAL AND METHODS

During a two years period seven PE patients were treated by us using Nuss technique. The intervention represents a premiere because it was the first Nuss operation performed by a team composed exclusively by Romanian surgeons. We present you the seven cases, our operative technique and the short and medium term outcomes.

MAIN RESULTS

No itraoperative incidences were recorded. Postoperative course was good for all patients. Complication occurred in three cases: two pleural effusions and a wound dehiscence. They have been all successfully resolved with no further events. Overall the therapeutic and cosmetic results were considered good by patients and their parents.

CONCLUSION

Preliminary results indicate that Nuss operation for PE correction is a safe surgical technique with excellent cosmetic outcomes. More cases and long time results are necessary to fully evaluate this technique.

Etiology of chest wall deformities--a genetic review for the treating physician

Chest wall deformities such as pectus excavatum, pectus carinatum, and cleft sternum can be isolated malformations or dysmorphic features of genetic associations, monogenic disorders, and various numeric and structural chromosomal aberrations. In contrast to the most important syndromes such as Marfan syndrome or Noonan syndrome that can be associated with a chest wall deformity and for which the causative genes are known, etiology of isolated chest wall deformities is still a matter of research. Therefore, an interdisciplinary approach, particularly in patients with additional symptoms is strongly recommended to choose the best therapeutic approach for each patient and its family.

Radiological changes after Nuss operation for pectus excavatum

The objective of this study was to evaluate sternovertebral distance and the chest wall deformation after Nuss procedure.

MATERIALS AND METHODS

Anteroposterior and lateral chest radiographs were performed before Nuss procedure, 1, 6, and 12 months after operation and finally 1 month after bar removal. Sternovertebral distance and transversal chest dimension were measured on radiographs, as well as Haller and vertebral indexes were calculated.

RESULTS

A total of 84 children with funnel chest were operated on. Preoperative sternovertebral distance was 79.81+/-6.96 mm; 1 month after operation, 97.84+/-17.08 mm; 6 months, 110.55+/-13.85 mm; and 12 months, 113.6+/-14.61 mm. After removal of the bar, the distance was 105+/-11.95 mm. The mean increase in sternovertebral distance during the first month was 18 mm (P<0.0001); 1-6 months, 12.8 mm (P=0.0006); and 6-12 months, 3 mm (P=0.48). The mean decrease in sternovertebral distance after removal of the bar was 8.6 mm (P=0.47). The decrease in transversal chest dimension during the first month was significant (13.3+/-12.86 mm, P=0.012).

CONCLUSIONS

The sternovertebral distance was significantly increased after Nuss operation. Restoration of deformation proceeds during all the first year after operation. The dynamics of deformation is better depicted by means of vertebral index rather than Haller index.

Dynamic right ventricular outflow tract (infundibular) stenosis and pectus excavatum in a dog

This is the first published report of a dog with dynamic right ventricular outflow tract (infundibular) stenosis, right ventricular hypertrophy, and pectus excavatum. A juvenile dog presented with a grade V/VI left base systolic heart murmur, tachycardia, and pectus excavatum. Diagnosis of the aforementioned conditions was based on radiography, electrocardiography, and echocardiography. At 9 1/2 wk of age the heart murmur was no longer audible and the right ventricular stenosis and hypertrophy had dissipated and regressed, respectively. Resolution may be associated with growth of the dog. A good prognosis is foreseen.

[Cardiac symptoms due to pectus excavatum in a man over the age of 55]

A healthy 59-year-old man, a retired general practitioner, suffered from increasing palpitations, fatigue and postural dyspnoea: bending over led to a significant increase in his shortness of breath. Cardiological and pulmonological examination, performed at regular intervals, showed occasional supraventricular arrhythmia and nodal tachycardia but did not yield a satisfactory explanation for the symptoms. In the years that followed, the physical impairment became a considerable handicap. Finally, the patient himself suggested a possible explanation on the basis of an Internet search: his pectus excavatum. A literature search confirmed this hypothesis. A lateral chest X-ray in bending position and a CT-scan of the chest revealed compression of the heart by the sternum. Ten years after the onset of symptoms, a modified Ravitch operation finally brought nearly complete recovery.

Clinical impact of optical imaging with 3-D reconstruction of torso topography in common anterior chest wall anomalies

BACKGROUND

Standard modalities to assist in determining the extent of chest wall developmental deformities in patients include x-ray and computed tomography (CT). The purpose of this study is to describe an optical imaging technique that provides accurate cross-sectional images of the chest, and to compare these with standard CT-derived images of chest wall abnormalities.

PATIENTS AND METHODS

Ten patients (5 pectus excavatum and 5 pectus carinatum) underwent imaging that included limited CT and optical cross-sectional imaging. Severity indices of the deformity using the standard Haller index (HI) were calculated from CT scans. A similar severity measurement of deformity was derived from the outline of torso cross sections (ie, from skin to skin measurements) obtained from optical images. To assess the severity of carinatum defects, a modified pectus index was derived, which measures the anterior chest protrusion from the central chord of the chest cross section. We performed regression analyses, comparing the indices obtained from CT and optical imaging methodologies.

RESULTS

Optical measures of cross-sectional deformities correlated well with standard HI (r2 = 0.94) and even better with the modified pectus index (r2 = 0.96). Adaptation of the HI for pectus carinatum deformity evaluation was effective, and consistent with the torso surface deformity measures.

CONCLUSIONS

Torso models from optical imaging offer 3-D images of the chest wall deformity with no radiation exposure. This preliminary study showed promising results for the use of torso surface measurement as an alternative index of pectus deformities; if validated in larger studies, these measures may be useful for following chest wall abnormalities, using repeated studies in patients.

Classification of the dysmorphology of pectus excavatum

BACKGROUND/PURPOSE

To describe the dysmorphology of pectus excavatum, the most common congenital chest wall anomaly.

METHODS

A stratified sample of 64 patients, representative of a patient population with pectus excavatum of the Children's Hospital of King's Daughters in Norfolk, VA, was described and classified. The sample was stratified by sex to represent a 4:1 male-to-female ratio. The sample was further stratified to represent categories of age (3-10, 11-16, and 17 years and older). Preoperative photos and baseline chest computed tomography scans were examined and categorized according to the chief criteria, including asymmetry/symmetry of the depression, localized vs diffuse morphology, sternal torsion, cause of asymmetric appearance, and the length of the depression.

RESULTS

Useful morphologic distinctions in pectus excavatum are localized depressions vs diffuse depressions, short and long length, symmetry, sternal torsion, slope/position of absolute depth, and unique patterns such as the horns of steer depression.

CONCLUSIONS

These classifications simplify the diagnosis of pectus excavatum, aid in corrective surgery, and should improve correlation of phenotype and genotype in future genetic analysis.

Positional hyperventilation-induced hypoxaemia in pectus excavatum

The presented case is of a young male (aged 19 yrs) with a pectus excavatum who showed significant exercise intolerance, despite normal pulmonary function at rest, including carbon monoxide diffusing capacity. Clinical exercise testing led to a strong suspicion of a right-to-left shunt due to an abnormally wide alveolo-arterial oxygen gradient (26.4 kPa) at peak oxygen uptake, with severe arterial hypoxaemia (arterial oxygen tension 12.54 kPa). A right-to-left shunt was confirmed by transoesophageal echocardiography demonstrating a permeable foramen ovale, despite normal right heart pressures. The right-to-left venous flow was mainly dependent on the upright body position and the deep inspiration. Indeed, i.v. dobutamine infusion to selectively affect cardiac output and hyperventilation induced by tidal volume expansion at constant breathing rate in the supine position did not result in arterial oxygen desaturation or shunting. Closure of the foramen ovale through atrial umbrella placement dramatically improved clinical and physiological abnormalities. This observation demonstrates that a hyperventilatory manoeuvre in the upright position is able to detect a permeable foramen ovale favouring flow in the inferior vena cava in the direction of the abnormal pre-existing atrial channel in a patient with a pectus excavatum.

[Indications for the surgical treatment of the funnel chest]

AIM OF THE STUDY

to establish the indications for surgical treatment of the funnel chest.

PATIENTS AND METHODS

There was a retrospective and prospective analysis performed of the methods of investigation and treatment of 504 patients operated for the funnel chest during the period of 35 years (1968-2002). In order to make a right diagnosis and to establish the indications for surgical treatment a standard algorithm of investigations was prepared: examination, collecting the detailed life history, establishing a type and a degree of deformation, chest and column radiological examination, ECG, spirography and heart ultrasound examination.

RESULTS

On basis of physical examination and anamnestic data the most clinical signs and complaints were established. The heart compression was found in preoperative X-rays in 476 (94.4%) patients, the heart was rotated and dislocated in 441 (87.5%) patients. Postoperatively 96.1% of patients were free of the heart compression symptoms and for 71.8% the heart rotation has disappeared. The pathological ECG findings were recorded for 382 (71.8%) patients and abnormal spirograms were taken for 31 (8.5%) patients.

CONCLUSIONS

The following indications for the funnel chest surgical treatment were established: - obvious funnel chest diagnozed by physical examination, - complaints and disturbances clear from anamnestic data, - heart rotation and compression established by radiological examination, - pathological findings in cardiorespiratory system (ECG, echocardiography, and spirography). An optimal age for operation was found out to be between 3 and 7 years.

Pectus excavatum surgically repaired using sternum realignment and splint techniques in a young cat

Successful surgical repair of pectus excavatum deformities has so far only been reported in very young animals. This case report describes an alternative technique for repairing pectus excavatum in a young cat. The cat had shown moderate deformity with slight respiratory impairment when young and had experienced clinical problems with age. A sternum realignment technique involving a pin associated with an external splint was used. This alternative technique was a safe and efficient procedure in the five-month-old cat.

Coronary artery bypass via resternotomy after pectus excavatum repair

Pectus excavatum is a chest wall deformity that commonly warrants pediatric surgical correction for cosmesis or respiratory impairment via sternotomy. The repair typically consists of sternal wedge osteotomy and subsequent placement of a Steinman pin across the sternum with fixation to the ribs bilaterally. Coronary artery bypass grafting (CABG) after surgical repair of the sternum with a metal implant poses an intriguing surgical challenge. Literature review reveals only one such previously described case. We present a case of coronary revascularization in an adult who previously underwent pectus excavatum repair with ligation of the internal mammary arteries. Our coronary revascularization was accessed through a resternotomy after surgical removal of the metal implant previously placed during the pectus excavatum repair. Autologous greater saphenous vein was used as a conduit for bypass. The patient did well postoperatively and was discharged on postoperative day 4. The pectus repair remained intact even after the median sternotomy was performed. This was confirmed at the 1-year follow-up for the patient. Resternotomy after pectus excavatum repair with a prosthetic implant poses a challenge to cardiothoracic surgeons. Many such repairs have been described in the pediatric population. As our society ages and coronary artery disease becomes more prevalent, this unique situation may be more commonly encountered. We present an approach to coronary artery bypass grafting via median resternotomy after pectus excavatum repair.

Management of laryngomalacia: experience with 22 cases

Laryngomalacia is the most frequent cause of stridor in childhood, and in most of the cases, spontaneous resolution occurs by the age of 2 years. Approximately 10% of the cases (severe laryngomalacia) require surgery. This condition is of unknown etiology and its diagnosis is made by fiberoptic laryngoscopy, which shows shortening of the aryepiglottic folds, and/or redundant arytenoid mucosa, and/or anterior-posterior epiglottic prolapse. Aim: Our objective was to verify the main clinical and anatomical affections and to highlight the clinical parameters for clinical follow-up and surgical indication in patients with laryngomalacia. Study design: Transversal cohort study. Material and Method: Twenty-two children diagnosed with laryngomalacia in the Pediatric Otorhinolaryngology of UNIFESP-EPM, from January 2001 to December 2003, whose clinical and surgical follow-up were performed by the same examiner, were enrolled in this study. Results: Out of twenty-two evaluated children, 2 (9.1%) presented with severe laryngomalacia and pectus excavatum (funnel chest). At polysomnography, no child presented any significant respiratory event during sleeping. Those two children with severe laryngomalacia were submitted to supraglottoplasty with resection of the aryepiglottic folds. Conclusion: We concluded that stridor and shortening of the aryepiglottic folds are preponderant in children with laryngomalacia. The polysomnographic exam did not prove to be a good parameter for clinical follow-up, neither for surgical indication. The most important parameters were pectus excavatum and failure to thrive. Supraglottoplasty is effective and has low morbidity rate.

Open repair of pectus excavatum with minimal cartilage resection

OBJECTIVE

To summarize the clinical experience with a new open repair for pectus excavatum (PE), with minimal cartilage resection.

SUMMARY BACKGROUND DATA

A wide variety of modified techniques of the Ravitch repair for PE have been used over the past 5 decades, with the complications and results being inconsistent. Extensive subperiosteal costal cartilage resection and perichondrial sheath detachment from the sternum may not be necessary for optimal repair.

METHODS

During a 12-month period, 75 consecutive patients with symptomatic PE underwent open repair using a new less invasive technique. After exposing the deformed costal cartilages, a short chip was resected medially adjacent to the sternum and laterally at the level where the chest had a near normal contour, allowing the cartilage to be elevated to the desired level with minimal force. A transverse anterior sternal osteotomy was used on most patients. A substernal support strut was used for 66 patients; the strut was placed anterior to the sternum in 9 patients under age 12 and over age 40 years. The strut was routinely removed within 6 months.

RESULTS

With a mean follow-up of 8.2 months, all but 1 patient regarded the results as very good or excellent. Mean operating time was 174 minutes; mean hospitalization was 2.7 days. There were no major complications or deaths.

CONCLUSIONS

The open repair using minimal cartilage resection is effective for all variations of PE in patients of all ages, uses short operating time, provides a stable early postoperative chest wall, causes only mild postoperative pain, and produces good physiologic and cosmetic results.

Atypical pectus excavatum in two Welsh terrier littermates

Two six-week-old intact Welsh terrier littermates, a male and a female, were presented for congenital ventral thoracic wall deformities characterised by noticeable funnel-like depressions of the cranial sternum associated with inversion of the rib cage. No exercise intolerance or cardiac murmurs were noted. Thoracic radiographic examination revealed a significant dorsal deviation of the first to the fifth sternebrae. At 12 weeks of age, the thoracic depressions had improved markedly in both puppies. Thoracic radiography to reassess the sternal deviation was at this stage within normal limits, demonstrating complete radiographic resolution of the sternal deformity.

Common pleural cavity in combination with pectus excavatum

A very rare case is being described; common pleural cavity was accidentally diagnosed in a 3-year-old boy operated for funnel chest (pectus excavatum). During 36 years 516 patients were operated in our department and we often notice pectus excavatum associated with other types of congenital pathology but only one had the common pleural space. In normal human beings pleural space is divided into left and right chambers separated by the mediastinum with no communication in between. In some mammals such as pigs, cows etc. a congenital communication is found between the pleural cavities, but this type of communication is very rare in humans and most often is of acquired origin. Pleural communication may also develop after major cardiothoracic surgery. In this case a 3-year-old male patient was admitted for the elective surgery on pectus excavatum. Clinical examination showed a very deep funnel chest. Both the heart and the mediastinum are left-shifted by the deformed breastbone; it is clearly demonstrated on a plain and lateral X-ray. On the left, beside the main vessels, an indistinct patch is noted. Typical M. Ravitch procedure was performed, by accident the pleural space was opened. Both pleural cavities had an evident communication along the anterior mediastinum. The torn pleura was sutured, the excess air removed by a puncture. Postoperative period was uneventful, additional treatment was not needed; currently the boy is feeling well. The postoperative X-ray showed the heart and the mediastinum to return to normal position.