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Concept: Pectus excavatum

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BACKGROUND: This study investigated the incidence, imaging characteristics and mechanical factors in scoliotic patients with pectus excavatum. METHODS: A total of 142 scoliostic patients with pectus excavatum were evaluated prior to operation. The evaluation included a complete physical exam, phenotype and severity of the pectus excavatum, incidence and severity of scoliosis, and analysis of radiological images, including calculation of the Haller index. RESULTS: Twenty five out of 142 patients (17.61%) with pectus excavatum had scoliosis with a Cobb angle >10 degrees, and in 80.00% of the cases the spinal column was bent to the right. Seventeen patients had bent-to-the-right spines that involved the 6th to 10 th thoracic vertebrae. We found that 23 out of 25 patients with a Cobb angle more than 10 [degree sign] were teenagers and adults. The incidence of scoliosis was only 6.06% in the children under 11 years whereas it was 21.79% in the teenage group. CONCLUSIONS: Mechanical forces appear to play a role in the coexistence of pectus excavatum and scoliosis. There is a relationship between age, severity (Haller index), asymmetry and scoliosis. The heart and mediastinum play a role in providing an outward force to the left of the sternum which may be an important reason for the coexistence of pectus excavatum and scoliosis, but the correlation needs further proof.

Concepts: Vertebral column, Pectus excavatum, Haller index, Chest, Degree, Sternum, Scoliosis

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INTRODUCTION: Blunt cardiac rupture is an exceedingly rare injury. CASE PRESENTATION: We report a case of blunt cardiac trauma in a 43-year-old Caucasian German mother with pectus excavatum who presented after a car accident in which she had been sitting in the front seat holding her two-year-old boy in her arms. The mother was awake and alert during the initial two hours after the accident but then proceeded to hemodynamically collapse. The child did not sustain any severe injuries. Intraoperatively, a combined one-cm laceration of the left atrium and right ventricle was found. CONCLUSION: Patients with pectus excavatum have an increased risk for cardiac rupture after blunt chest trauma because of compression between the sternum and spine. Therefore, patients with pectus excavatum and blunt chest trauma should be admitted to a Level I Trauma Center with a high degree of suspicion.

Concepts: Heart, Pectus excavatum, Chest, Sternum, Ventricle, Left ventricle, Physical trauma, Chest trauma

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The Nuss procedure, which is a minimally invasive approach for treating pectus excavatum, has better functional and cosmetic outcomes than other invasive procedures. Cardiac perforation is the most serious complication and several methods for the prevention of intraoperative events has been developed. Although most cardiac injuries are detected in the operating room, in the case described herein the patient experienced sudden hypovolemic shock during the postoperative recovery period. This indicates that special caution is mandatory even after successful execution of the Nuss procedure.

Concepts: Blood, Surgery, Pectus excavatum, Chest, Sternum, Shock, Minimally invasive, Hypovolemia

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Several techniques exist for the repair of complex pectus excavatum. The placement of retrosternal metal bars improves the results by reducing the recurrence rate, but entails several possible risks, complications and disadvantages. A new method, specifically conceived for the repair of severe, asymmetric forms in adult patients, is reported. The corrected bone is fixed in the proper position by two, patient-customized, titanium struts, externally screwed to the manubrium and sternal body. Any retrosternal bar is thus avoided, reducing possible complications, without hampering the chest wall dynamic. In this particularly difficult issue, this technique provides long-term good functional, mechanical and cosmetic results and does not entail a second surgery for struts removal.

Concepts: Heart, Pectus excavatum, Chest, Sternum, Pectus carinatum, Adult, Moral hazard, Fee tail

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BACKGROUND: Pectus excavatum is a skeletal abnormality which may have cardiac manifestations. OBJECTIVE: To determine if pectus excavatum is associated with lone atrial fibrillation. METHODS: The Pectus Severity Index (PSI) is the ratio of the lateral diameter of the chest to thedistance between sternum and spine on CT scan. A normal PSI is ≤ 2.5 whereas patients withsevere pectus excavatum have a PSI >3.25. We calculated the PSI of 220 consecutive patients withAF who underwent radiofrequency catheter ablation from September 2008 to 2012 and compared this to the PSI of 225 controls without a history of AF undergoing chest CT. RESULTS:: Mean PSI was higher in patients with lone AF (2.72 =/- 0.07) compared to non-lone AF(2.25 +/- 0.03) or controls (2.26 +/- 0.03) (p<0.001). The likelihood of mild, moderate, or severepectus excavatum was higher in lone AF compared to non-lone AF and controls (p<0.001). Patientswith lone AF were over 5 times as likely to have severe pectus excavatum compared to non-lone AF or controls (p<0.001) even after adjustment for potential confounders. CONCLUSIONS:: Nearly 2/3 of patients with lone AF have at least mild pectus excavatum and 17%have severe pectus, which is significantly higher than in patients with non-lone AF or controls. Thisassociation suggests a potential genetic or mechanical abnormality may be common to the twodisorders. Our study may provide insight into the pathogenesis of lone AF.3 ABBREVIATIONS: atrial fibrillation (AF), lone atrial fibrillation (lone AF), Pectus Severity Index (PSI),computed tomography (CT), Symptom Mitigation in Atrial Fibrillation Study (SMART Study),University of North Carolina (UNC), hypertension (HTN), coronary artery disease (CAD), heartfailure (CHF), percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG).

Concepts: Myocardial infarction, Atherosclerosis, Angina pectoris, Coronary artery disease, Heart, Atrial fibrillation, Pectus excavatum, Coronary artery bypass surgery

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: This article reviews pectus excavatum and the role of the primary care provider in correct identification. Historically, pectus excavatum was viewed as a cosmetic concern. Research indicates that severe cases result in cardiopulmonary impairment and physiologic limitations. Evidence demonstrates that surgical repair improves cardiovascular function, exercise tolerance, and body image.

Concepts: The Canon of Medicine, Pectus excavatum, Social sciences, Identification, Pectus carinatum, Primary care physician, Human appearance

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Nowadays the Nuss operation has been widely adopted as a minimally invasive procedure and standard surgical choice in pectus excavatum. However, much debate and concern have been raised regarding its applicability in adults with pectus excavatum flail chest and other thoratic wall deformities, as compared with younger patients, in terms of complications after surgery. To stabilize the segment of paradoxical chest wall movement we performed the Nuss operation on a patient with multiple myeloma who sustained blunt thoracic trauma. The patient presented with paradoxical movement of the thoracic wall and sternum instability due to multiple myeloma, which led to severe dyspnea, hypoxemia, hypercapnea, and bedridden state. His condition progressed to acute respiratory distress syndrome and did not respond to conservative treatment. We performed the Nuss operation on the patient, and his clinical symptoms were relieved after surgery. The patient regained the ability to walk unassisted and was discharged from the hospital without any specific events.

Concepts: Hospital, Surgery, Pectus excavatum, Chest, Acute respiratory distress syndrome, Sternum, Pulmonary contusion, Thoracic cavity

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Surgical correction of pectus excavatum (PE) has shifted to the modern minimally invasive Nuss procedure, which proved to be safe and effective. In order to restore the dented deformity, custom-curved metal bars provide continuous retrosternal pressure but cross the habitat of the internal mammary arteries (IMAs) directly affecting their patency. In this initial report, we sought to assess the patency of the IMAs in the first 6 patients who underwent Nuss bar removal in our department.

Concepts: Pectus excavatum, Minimally invasive, Pressure, Pectus carinatum, Internal thoracic artery, Human appearance

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The Haller index, derived from a chest computed tomography scan, remains the standard for determining candidacy for pectus excavatum repair (Haller index ≥3.25). However, it has been suggested that this index may not accurately reflect pectus severity in patients with abnormal chest wall morphologies. This study explores a new, more appropriate criteria for recommending repair based on a correction index, while still incorporating the standard set by the Haller index.

Concepts: Pectus excavatum, Haller index

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The technique of choice for surgical correction of pectus excavatum is the Nuss procedure, a minimally invasive technique in which rigid metal bars are placed transthoracically beneath the sternum and costal cartilages until permanent remodeling of the chest wall has occurred. Intraoperatively, anesthesia focuses on three areas: the potential for catastrophic blood loss caused by perforation of large capacitance vessels and the heart, the potential for malignant arrhythmias, and the consequences of bilateral iatrogenic pneumothoraces. Postoperatively, analgesia is institutionally dependent and controversial, based on usage and type of regional anesthesia. The necessity of multimodal analgesic techniques creates a common ground across different hospital systems.

Concepts: Heart, Surgery, Pectus excavatum, Chest, Sternum, Anesthesia, Minimally invasive, Thorax