Simultaneous repair of pectus excavatum with congenital heart surgery for a 72-year-old patient: Case report

Case presentation

A 72-year-old female, who is 76 kg, presented to her primary care provider with shortness of breath and worsening activity tolerance. Through a thorough investigation, including a transesophageal echocardiogram (TEE), she was found to have a severely hypertrophied muscle bundle in the right ventricle with no concurrent ventricular septal defect (Supplement 1). She had reduced right ventricular systolic function, and the mean gradient through the right ventricular outflow tract (RVOT) was 73 mmHg. She then underwent a cardiac catheterization, which found that the systolic peak-to-peak gradient at the RVOT stenosis was 69 mmHg. The cardiac catheterization also revealed that she had normal pulmonary artery pressures and normal coronary arteries. In addition to her cardiac findings, she also had severe pectus excavatum with a Haller Index ¹ of 5.09 on computed tomography scan (Figure 1). Her pulmonary function testing also revealed restrictive lung disease.

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Figure 1.

Preoperative axial computed tomography scan showed severe pectus excavatum and RVOTS. Haller Index was 5.09.

Therefore, it was determined that she would undergo repair of both of her anomalies at the same time via median sternotomy with subsequent small bilateral sub-mammary incisions under general anesthesia. The chest entry was very difficult due to her severe pectus excavatum. After full-dose heparin, cardiopulmonary bypass was initiated by cannulating the aorta and obtaining bi-caval drainage with a left ventricular vent through the right upper pulmonary vein. We then cross-clamped the ascending aorta for cardioplegia and then resected the hypertrophied right muscle bundle at the ostium infundibulum through a longitudinal ventriculotomy. After this resection, we patch-augmented the right ventriculotomy. We unclamped the ascending aorta after de-airing and came off cardiopulmonary bypass. Her postoperative TEE showed good biventricular function and 6 mmHg of mean gradient through the RVOT (Supplement 2). Protamine sulfate was administered, and all cannulas were removed.

Next, we proceeded to her Nuss bar placement ² and it started with completing bilateral cryoablation ³ by cryoSPHERE (AtriCure, Inc., Mason, OH, USA) under direct visualization from the third to eighth intercostal spaces for pain analgesia. The cryo machine operates with nitrous oxide, and the probe temperature ranges about −65 °C. It has three cycles, freeze, auto defrost, and a venting feature. Freeze/thaw cycle was 120 s/freeze. The rationale for levels was to cover incisions for median sternotomy and Nuss bar, as freezing of the intercostal nerves innervates the motor and sensory. We then made additional small bilateral sub-mammary incisions and placed an 11-inch Nuss bar with bilateral stabilizers (Figure 2). We closed the sternum with interrupted wires and an additional five sternal plates (Zimmer Biomet CMF and Thoracic, Jacksonville, FL, USA) to support the sternum (Figure 3). The plates were four-hole straight plates with a profile of 1.6 with a 2.4 mm screw. The total surgery time for the combined procedures was 6 h and 34 min. Bypass time was 110 min, and cross-clamp time was 49 min. The patient was extubated on the same day of surgery. She was discharged home on postoperative day 7 with minimal pain on a regimen of acetaminophen, baclofen, and tramadol. Quality of life was improved at discharge. Two months after discharge, her follow-up transthoracic echocardiogram showed 2 mmHg of mean gradient through the RVOT. Patient did not need any pain medication for daily activity at the follow-up (Supplement 3). We have been monitoring her electrocardiogram, transthoracic echocardiogram, and two-view chest X-ray. She had no late complications 1 year after this simultaneous surgery.

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Figure 2.

The Nuss bar was placed after cardiac surgery.

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Figure 3.

Sternal plates reinforced with sternal wire for the concave sternum.

Discussion

Pectus excavatum can be a significant chest wall abnormality and typically presents independently of other issues. However, patients with pectus excavatum rarely have congenital or acquired heart disease. There are a few articles that describe concurrent surgery for the two issues.^4–6 When the Nuss Bar procedure is combined with open-heart surgery, there is an added risk of complexity, operating time, cardiopulmonary bypass, and extended recovery time. On the other hand, it is unclear if some symptoms will be resolved unless both medical issues are addressed since there is much overlap in symptomatology. There is also concern that the effects of pectus excavatum on the heart and lungs may complicate recovery after a cardiac procedure. Moreover, an older adult may struggle to recover from two large, separate surgeries. Pectus excavatum surgery is very painful for an older adult and can cause issues with mobility, breathing, and complications from narcotic usage. Utilizing bilateral cryoablation alleviates pain from both the Nuss Bar procedure and the median sternotomy for cardiac repair. As a result of using cryoablation, this 72-year-old patient was able to be discharged 1 week after surgery. She used tramadol for breakthrough pain very occasionally at home. There is certainly concern for bleeding when performing the two procedures simultaneously due to the use of full heparin for cardiopulmonary bypass. However, the Nuss bar procedure versus the Ravitch procedure^7,8 decreases the amount of dissection required and minimizes this bleeding risk when hemostasis is obtained after protamine is given. We used sternal plates not only to reinforce sternal wires for the osteopenic sternum but also to fill any gaps that the Nuss bar caused by pushing up the concave sternum.

Postoperative echocardiogram and 2-month follow-up echocardiogram showed minimal gradient through RVOT. Her symptoms have improved obviously, even though she experienced serious shortness of breath and worsening activity tolerance preoperatively. She has both excellent results in her cardiac repair and chest wall repair in a year without any complications.

If we perform more complicated cardiac surgery and patients show symptoms separately between pectus excavatum and cardiac issues, we could do two surgeries. However, we believe this simultaneous approach would be suitable for similar cases.

Conclusion

Simultaneous repair of pectus excavatum was beneficial for a 72-year-old female patient, even with adult congenital heart disease. Nuss procedure with cryoablation and sternal plate helped the postoperative course.

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