J.C. Yeung et al. / Interactive CardioVascular and Thoracic Surgery
Figure 1: CT image demonstrating severe asymmetric pectus excavatum (Haller index 11.8) with near-vertical angulation of the sternum (>70°) and left mediastinal cardiac luxation.
675
this phenomenon was due to cardiac luxation into the left chest by the pectus excavatum deformity (Fig. 1). We hypothesize that the mediastinum was allowed to return to the midline after sternotomy and exposure for aortic repair. Therefore, when the retractor was subsequently removed, the more deformed right hemisternum directly compressed the right ventricle. This compression was relieved by the correction of the excavatum (Fig. 2). This phenomenon was also observed by Stephens et al. [5], and in their report, an unplanned, emergency Ravitch procedure was performed. It is presently unclear as to what are the specific risk factors for haemodynamic collapse following sternotomy in a patient with severe pectus deformity. It appears that the common features between the two cases include (i) significant mediastinal shift resulting in cardiac luxation and (ii) Haller index of >10. It is possible that the presence of either of these risk factors may predict for haemodynamic compromise upon sternal closure. We suggest that patients with severe pectus excavatum undergoing cardiovascular surgery should be considered for simultaneous repair with a planned collaboration of both thoracic and cardiac surgeons. Conflict of interest: none declared.
REFERENCES
abnormal rib cartilages to facilitate sternotomy and to complete the Ravitch procedure with substernal bar after separation from CPB. Indeed, this strategy could have prevented the compression of the right heart after closure as seen in our case and also would have simplified our sternotomy. Ultimately, however, we had chosen to repair the sternum after CPB in order to minimize intraoperative chest wall blood loss while systemically heparinized. Some other groups have proposed performing an ‘open’ Nuss procedure; the open chest facilitates placement of the curved bar with minimal dissection [4]. We have some reservations regarding this approach. The longer curved Nuss bar may prevent meaningful external cardiac compression in an arrest situation and may impede rapid re-exploration. In addition, constant upward pressure on the sternum and internal thoracic arteries could predispose the patient to sternal dehiscence and infection. Finally, dense adhesions may form between the pericardium, or worse, the myocardium, and this could complicate bar removal [2]. In contrast, our straight, short bar is used simply as a strut; the pectus is reduced surgically. This also simplifies removal, planned for 3 years after the operation. In our patient, simultaneous repair was necessary due to cardiovascular collapse during attempted closure. We propose that
eComment. Simultaneous repair of pectus deformities and cardiac surgery under cardiopulmonary bypass Authors: Alain J. Wurtz, Natacha Rousse, Julien De Wolf and Valentin Loobuyck Cardiac and Thoracic Surgery Division, Lille University Teaching Hospital, CHU Lille, Lille, France doi: 10.1093/icvts/ivw081 © The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. Yeung et al. report the management of severe pectus excavatum (PEx) at the time of an aortic repair in a patient with Marfan’s syndrome and the difficulties encountered during the procedure [1]. As underlined by the authors, the Ravitch-type repair is the more reliable technique in the setting of concomitant pectus deformity correction and cardiopulmonary bypass surgery [2-4]. In the case of PEx, we usually carry out a staged repair of the pectus deformity by first performing the subperichondrial resection of the enlarged/deformed costal cartilages (third to sixth and extremities of seven). Once these paired cartilages are resected, the sternum can be easily elevated, thus facilitating sternotomy and placement of a standard sternal-retractor allowing satisfactory operative exposure. Cardiac procedure with CPB is then performed. Last, after heparin reversal and sternal closure as usual, the PEx repair is achieved by performing additional resection of the second cartilages, if needed, transverse wedge osteotomy across the anterior table of the upper sternum and placement of a straight metal support bar positioned anterior to the ribs laterally and secured to sternum with an absorbable suture [3]. Finally, in severe asymmetric PEx, such as that reported
CASE REPORT
Figure 2: Postoperative CT demonstrating satisfactory reduction in pectus deformity, however, with persistence of the curvature of the anterior arc of ribs on the right (Haller index 3.4) and relief of mediastinal displacement.
[1] Shamberger RC, Welch KJ, Castaneda AR, Keane JF, Fyler DC. Anterior chest wall deformities and congenital heart disease. J Thorac Cardiovasc Surg 1988;96:427–32. [2] Craner R, Weis R, Ramakrishna H. Emergent cardiopulmonary bypass during pectus excavatum repair. Ann Card Anaesth 2013;16:205–8. [3] Rousse N, Juthier F, Prat A, Wurtz A. Staged repair of pectus excavatum during an aortic valve-sparing operation. J Thorac Cardiovasc Surg 2011; 141:e28–30. [4] Sacco Casamassima MG, Wong LL, Papandria D, Abdullah F, Vricella LA, Cameron DE et al. Modified Nuss procedure in concurrent repair of pectus excavatum and open heart surgery. Ann Thorac Surg 2013;95: 1043–9. [5] Stephens EH, Preventza O, Sarateanu CS, LeMaire SA, Coselli JS. Emergent pectus excavatum repair after aortic root replacement in Marfan patient. J Card Surg 2012;27:222–4.
676
J.C. Yeung et al. / Interactive CardioVascular and Thoracic Surgery
by the authors, we correct the abnormal curvature of the anterior arc of ribs by performing an anterior wedge osteotomy, followed by gentle fracture of the posterior costal cortex. The running suture of the perichondrial sheaths maintains the anterior segment of ribs in a proper position resulting in a satisfactory thorax contour [5]. In our experience, despite full anticoagulation, bleeding was not an issue with careful preservation of the perichondrium, which protected the internal thoracic and intercostal vessels from damage. Moreover, the subperichondrial excision of the paired costal cartilages reduced the traction forces on the sternum resulting in consistent sternum healing [3,4]. Nonetheless, interesting issues mentioned by Yeung et al. deserve additional comments. We agree with the authors that the “open” Nuss procedure is inadequate, which impedes prompt reentry, or cardiopulmonary resuscitation manoeuvres, if needed. Furthermore, the curved Nuss bar presents a risk of sternal dehiscence from the pushing forces of the bar to the anterior chest wall [2]. As underlined by the authors, the straight metal bar used in the setting of Ravitch-type repair is more reliable in achieving sternal stability and simplifies removal. In our experience, given the fact that the the cartilage regeneration with osseous metaplasia is achieved within 2 months, such a straight metal bar is routinely removed under local anaesthesia as an outpatient procedure, six months after the initial operation [4]. Finally, the criteria for concomitant pectus and CPB surgery as stated by the authors (significant mediastinal shift resulting in cardiac luxation and Haller index >10) seems rather restrictive. With
regard to our experience in the field, we are convinced that concomitant surgery is a reliable strategy in adolescent and adults, offering satisfactory long- term results in all types of pectus deformities [4]. Conflict of interest: none declared. References [1] Yeung JC, Marcuzzi D, Peterson MD, Ko MA. Management of severe asymmetric pectus excavatum complicating aortic repair in a patient with Marfan’s syndrome. Interact CardioVasc Thorac Surg 2016;22:674–6. [2] Okay T, Ketenci B, Imamoglu OU, Aydemir B, Tuygun AK, Ozay B et al. Simultaneous open-heart surgery and pectus deformity correction. Surg Today 2008;38:592–6. [3] Rousse N, Juthier F, Prat A, Wurtz A. Staged repair of pectus excavatum during an aortic valve-sparing operation. J Thorac Cardiovasc Surg 2011;141:e28–e30. [4] Hysi I, Vincentelli A, Juthier F, Benhamed L, Banfi C, Rousse N et al. Cardiac surgery and repair of pectus deformities: When and how? Int J Cardiol 2015;194:83–6. [5] Benhamed L, Hysi I, Wurtz AJ. eComment. Substernal metal support after pectus excavatum open repair. Interact CardioVasc Thorac Surg 2013;17:1058.
Figure 1: CT image demonstrating severe asymmetric pectus excavatum (Haller index 11.8) with near-vertical angulation of the sternum (>70°) and left mediastinal cardiac luxation.
675
this phenomenon was due to cardiac luxation into the left chest by the pectus excavatum deformity (Fig. 1). We hypothesize that the mediastinum was allowed to return to the midline after sternotomy and exposure for aortic repair. Therefore, when the retractor was subsequently removed, the more deformed right hemisternum directly compressed the right ventricle. This compression was relieved by the correction of the excavatum (Fig. 2). This phenomenon was also observed by Stephens et al. [5], and in their report, an unplanned, emergency Ravitch procedure was performed. It is presently unclear as to what are the specific risk factors for haemodynamic collapse following sternotomy in a patient with severe pectus deformity. It appears that the common features between the two cases include (i) significant mediastinal shift resulting in cardiac luxation and (ii) Haller index of >10. It is possible that the presence of either of these risk factors may predict for haemodynamic compromise upon sternal closure. We suggest that patients with severe pectus excavatum undergoing cardiovascular surgery should be considered for simultaneous repair with a planned collaboration of both thoracic and cardiac surgeons. Conflict of interest: none declared.
REFERENCES
abnormal rib cartilages to facilitate sternotomy and to complete the Ravitch procedure with substernal bar after separation from CPB. Indeed, this strategy could have prevented the compression of the right heart after closure as seen in our case and also would have simplified our sternotomy. Ultimately, however, we had chosen to repair the sternum after CPB in order to minimize intraoperative chest wall blood loss while systemically heparinized. Some other groups have proposed performing an ‘open’ Nuss procedure; the open chest facilitates placement of the curved bar with minimal dissection [4]. We have some reservations regarding this approach. The longer curved Nuss bar may prevent meaningful external cardiac compression in an arrest situation and may impede rapid re-exploration. In addition, constant upward pressure on the sternum and internal thoracic arteries could predispose the patient to sternal dehiscence and infection. Finally, dense adhesions may form between the pericardium, or worse, the myocardium, and this could complicate bar removal [2]. In contrast, our straight, short bar is used simply as a strut; the pectus is reduced surgically. This also simplifies removal, planned for 3 years after the operation. In our patient, simultaneous repair was necessary due to cardiovascular collapse during attempted closure. We propose that
eComment. Simultaneous repair of pectus deformities and cardiac surgery under cardiopulmonary bypass Authors: Alain J. Wurtz, Natacha Rousse, Julien De Wolf and Valentin Loobuyck Cardiac and Thoracic Surgery Division, Lille University Teaching Hospital, CHU Lille, Lille, France doi: 10.1093/icvts/ivw081 © The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. Yeung et al. report the management of severe pectus excavatum (PEx) at the time of an aortic repair in a patient with Marfan’s syndrome and the difficulties encountered during the procedure [1]. As underlined by the authors, the Ravitch-type repair is the more reliable technique in the setting of concomitant pectus deformity correction and cardiopulmonary bypass surgery [2-4]. In the case of PEx, we usually carry out a staged repair of the pectus deformity by first performing the subperichondrial resection of the enlarged/deformed costal cartilages (third to sixth and extremities of seven). Once these paired cartilages are resected, the sternum can be easily elevated, thus facilitating sternotomy and placement of a standard sternal-retractor allowing satisfactory operative exposure. Cardiac procedure with CPB is then performed. Last, after heparin reversal and sternal closure as usual, the PEx repair is achieved by performing additional resection of the second cartilages, if needed, transverse wedge osteotomy across the anterior table of the upper sternum and placement of a straight metal support bar positioned anterior to the ribs laterally and secured to sternum with an absorbable suture [3]. Finally, in severe asymmetric PEx, such as that reported
CASE REPORT
Figure 2: Postoperative CT demonstrating satisfactory reduction in pectus deformity, however, with persistence of the curvature of the anterior arc of ribs on the right (Haller index 3.4) and relief of mediastinal displacement.
[1] Shamberger RC, Welch KJ, Castaneda AR, Keane JF, Fyler DC. Anterior chest wall deformities and congenital heart disease. J Thorac Cardiovasc Surg 1988;96:427–32. [2] Craner R, Weis R, Ramakrishna H. Emergent cardiopulmonary bypass during pectus excavatum repair. Ann Card Anaesth 2013;16:205–8. [3] Rousse N, Juthier F, Prat A, Wurtz A. Staged repair of pectus excavatum during an aortic valve-sparing operation. J Thorac Cardiovasc Surg 2011; 141:e28–30. [4] Sacco Casamassima MG, Wong LL, Papandria D, Abdullah F, Vricella LA, Cameron DE et al. Modified Nuss procedure in concurrent repair of pectus excavatum and open heart surgery. Ann Thorac Surg 2013;95: 1043–9. [5] Stephens EH, Preventza O, Sarateanu CS, LeMaire SA, Coselli JS. Emergent pectus excavatum repair after aortic root replacement in Marfan patient. J Card Surg 2012;27:222–4.
676
J.C. Yeung et al. / Interactive CardioVascular and Thoracic Surgery
by the authors, we correct the abnormal curvature of the anterior arc of ribs by performing an anterior wedge osteotomy, followed by gentle fracture of the posterior costal cortex. The running suture of the perichondrial sheaths maintains the anterior segment of ribs in a proper position resulting in a satisfactory thorax contour [5]. In our experience, despite full anticoagulation, bleeding was not an issue with careful preservation of the perichondrium, which protected the internal thoracic and intercostal vessels from damage. Moreover, the subperichondrial excision of the paired costal cartilages reduced the traction forces on the sternum resulting in consistent sternum healing [3,4]. Nonetheless, interesting issues mentioned by Yeung et al. deserve additional comments. We agree with the authors that the “open” Nuss procedure is inadequate, which impedes prompt reentry, or cardiopulmonary resuscitation manoeuvres, if needed. Furthermore, the curved Nuss bar presents a risk of sternal dehiscence from the pushing forces of the bar to the anterior chest wall [2]. As underlined by the authors, the straight metal bar used in the setting of Ravitch-type repair is more reliable in achieving sternal stability and simplifies removal. In our experience, given the fact that the the cartilage regeneration with osseous metaplasia is achieved within 2 months, such a straight metal bar is routinely removed under local anaesthesia as an outpatient procedure, six months after the initial operation [4]. Finally, the criteria for concomitant pectus and CPB surgery as stated by the authors (significant mediastinal shift resulting in cardiac luxation and Haller index >10) seems rather restrictive. With
regard to our experience in the field, we are convinced that concomitant surgery is a reliable strategy in adolescent and adults, offering satisfactory long- term results in all types of pectus deformities [4]. Conflict of interest: none declared. References [1] Yeung JC, Marcuzzi D, Peterson MD, Ko MA. Management of severe asymmetric pectus excavatum complicating aortic repair in a patient with Marfan’s syndrome. Interact CardioVasc Thorac Surg 2016;22:674–6. [2] Okay T, Ketenci B, Imamoglu OU, Aydemir B, Tuygun AK, Ozay B et al. Simultaneous open-heart surgery and pectus deformity correction. Surg Today 2008;38:592–6. [3] Rousse N, Juthier F, Prat A, Wurtz A. Staged repair of pectus excavatum during an aortic valve-sparing operation. J Thorac Cardiovasc Surg 2011;141:e28–e30. [4] Hysi I, Vincentelli A, Juthier F, Benhamed L, Banfi C, Rousse N et al. Cardiac surgery and repair of pectus deformities: When and how? Int J Cardiol 2015;194:83–6. [5] Benhamed L, Hysi I, Wurtz AJ. eComment. Substernal metal support after pectus excavatum open repair. Interact CardioVasc Thorac Surg 2013;17:1058.
