Cardiopulmonary Manifestations of Pectus Excavatum

Michael K. Cheezum, MD; Christopher J. Lettieri, MD

Disclosures

April 10, 2008

In This Article

Corrective Surgical Procedures

Pectus excavatum is amenable to corrective surgical procedures, with a positive response to surgery seen in over 90% of cases. Surgery is best performed prior to adolescence as the chest wall is still malleable and stabilization is easily achieved. However, success rates remain high even among adults undergoing surgical repair. Restoration of a normal appearance of the chest can improve body image and self-esteem and is considered by many to be an acceptable cosmetic procedure. As stated, it is the most common reason for surgery.

Surgery should also be considered in those with exercise or physical activity limitations, especially with documented cardiopulmonary impairments. However, no conclusive evidence exists that surgical repair improves cardiac or pulmonary limitations, and indications for surgical repair remain controversial. Some reports have shown improvements in stroke volume, pulmonary function, and exercise capacity following surgery, while others have failed to show significant improvements or even further detriments postoperatively.

In a 2005 meta-analysis, Malek and colleagues[21] found that surgical repair produced a small but insignificant improvement in resting lung function. Other studies have suggested that pulmonary function declines in the early (3-month) postoperative period, which may improve over time and with bar removal.[22,23]

In another meta-analysis by Malek and associates,[24] surgery was associated with improvements in cardiovascular performance. Specifically, they found that exercise time, VO2 max, O2 pulse, maximal heart rate, and anaerobic threshold all improved. In addition, both cardiac output and index increased postoperatively. Contrary to these conclusions, a meta-analysis by Guntheroth and Spiers[25] demonstrated no improvement in cardiac function. As such, the effects of surgical repair on cardiopulmonary limitations remain controversial.

Although no consensus exists to demonstrate cardiac or pulmonary function improvements following surgical repair, experts tend to agree that patients exhibit subjective improvements in exercise tolerance and cardiopulmonary exercise testing following surgical repair.[12,13] Clearly, more data are needed to characterize the cardiopulmonary effects following surgery.

The majority of individuals can be managed conservatively, even those experiencing functional limitations. Orthotopic external braces may be a beneficial adjunctive strategy in the conservative, nonoperative management of pectus excavatum. However, there is no conclusive evidence that these devices improve outcomes. For those electing repair, surgical procedures aimed at correcting the thoracic defect appear to be the treatments of choice.

The Ravitch open procedure was first described in 1949.[26] Although often modified, it remained the most frequently used technique for correction of this deformity for 40 years. In this procedure, the fourth and fifth costal margins are resected with preservation of the growth plates (see Figure 2). A metal strut is placed for sternal support. Although largely successful, this procedure was complicated by significant blood loss, recurrence of the deformity, and the rare risk for asphyxiating osteodystrophy, a late complication resulting in a contracted, scarred anterior chest wall with a subsequent ventilatory restriction.[27]

Lateral radiograph demonstrating pectus deformity (a) prior to and (b) following surgical correction with the Ravitch procedure.

In 1987, the Nuss procedure was introduced. This minimally invasive procedure has excellent success rates, with over 90% of patients reporting satisfactory results.[28] During this procedure, a metal bar is placed to the underside of the sternum which applies pressure and facilitates remodeling. The bar is removed within 2-4 years. The Nuss procedure is less invasive than older procedures and recurrence is uncommon. However, one series reported a significant complication rate, with nearly 20% of individuals experiencing an adverse event postoperatively.[29] Displacement of the retrosternal bar occurred in 9.5% of patients. However, lateral stabilizers and additional fixation techniques have reduced this occurrence to less than 2.5%.[30] Given the less radical nature of this surgery and high success rates, it has become the procedure of choice for pectus excavatum repair.

The magnetic mini-mover procedure (3MP) recently gained investigational FDA approval, and clinical trials are ongoing.[31] In this procedure, patients wear an external brace that slowly attracts a magnet affixed to the sternum. The procedure is less invasive and can result in resolution of the deformity after several months to a year. Long-term outcomes and success rates have not yet been established.

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