Pectus Excavatum Deformity in the Adult Patient

Pectus Excavatum Deformity in the Adult Patient

03/23/2015
Objectives
Pectus
Excavatum
Deformity in the
Adult Patient

Adult PE Presentation/Workup

MIRPE of the Primary Adult Patient
Techniques to facilitate repair of most Adult PE
Complex/Fixed Adult chest deformities
 Failed prior repairs in Adults
 Women and Implant Issues


Dawn Jaroszewski, MD, MBA, FACS
Associate Professor
Division of Cardiothoracic Surgery
Mayo Clinic Arizona
Adults Presenting with PE

Progressive loss of endurance/exercise intolerance



Chest pain with activity

Palpitations or Tachycardia (progressing at rest)

Awareness and Self Education
Non-contrast CT or
MRI gated axial/cine
Symptomatic Adult
Patient
18-40 years
>40
Physical Exam
Detailed chest Imaging
Non significant
findings
Refer back to
Primary Providers
Abnormal

Findings
Significant
Symptoms
ECG
Echocardiogram
CPET VO2
Findings
consistent with
PE physiology
Inspiration Views
Inspiratory
Index: 6.4

Expiration Views
Expiratory
Index: 10.6
Complete PFTs
Ischemic Stress Test
Heart Catheterization
Normal
Surgical
Correction
Dyspnea, tachycardia, chest discomfort with exercise
Inability to keep up with peers
Abnormal
Inspiratory
Index: 3.84
Expiratory
Index: 7.3
Refer back to
Primary Providers
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03/23/2015
Haller or Severity Index:
ratio of width/depth
(Significant>3.25)
Correction Index:
Difference between maximal and
minimum distance sternum to spine
divided by maximal prominence x 100
(Significant >10*-28**%)
Cardiac Compression Index (CCI)=
maximum transverse heart dimension (1)
divided by minimum transverse heart
dimension (2)
Albertal M. J of Ped Surg 2013;48:2011-6, Kim M. Yonsei Med J 2009;50:385
Haller Index: 220 wide/18 deep = 12.2
J.A. Haller Jr, J Ped Surg, 22 (1987)904–908
*St Peter J Ped Surg, 46 (2011) 2270-3
**Poston Ann Thorac Surg 97 (2014) 1176-80
25-year- old woman with PE

Noted worsening
dyspnea with exertion
past 4-5 years

CT scan inspiration
Index 3.06, mild
excavatum with no
significant
compression
Electrocardiogram
Right bundle-branch
block
CCI= 123.3/32.5= 3.79
CCI= 138.3/28.6= 4.8
MRI – on expiration, worsenign of deformity
with 32º sternal rotation; SI 6.34, decreased
RVEF @ 40%
Echo – What is the value of “normal”
in PE patients?
Low Voltage QRS
Ischemic Changes
WPW and other
conduction
abnormalities
• Right Sided heart compression is difficult to see with TTE
• Chest Wall compression best seen with transverse axis on TTE
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03/23/2015
Confirmation of Intraoperative
Release of Compression
Tricuspid annulus pre and post
(Diastole)
RA
RA
Preop Cardiac Compression
Post Op no residual Compression
Pre Operative Tricuspid Annulus
RVOT VTI Pre and Post
Pre Operative RVOT
LVOT VTI Pre and Post
Post Operative RVOT
Pre Operative LVOT
230 TEE images available for review before & after pectus repair
Males: 73.5%, mean age 33 (range 18-71), Mean preoperative HI was 5.6 (range 2.54-26.7),
correction index xx (xx) and cardiac compression index xx (xx).
Improvement was seen in right atrium, tricuspid annulus end systolic (ES), right ventricular
(RV) outflow tract end diastolic and ES dimensions (11.7%, 8.0%, 6.25% and 4.3%
respectively, all P<0.0001 vs. baseline). RV cardiac output increased by 24% post surgery
(3.7±1.9 L/min to 4.6±1.4, P<0.0001). (Figure 1)
Post Operative Tricuspid Annulus
Post Operative LVOT
Pulmonary Functions

Required for some insurance companies

Static pulmonary function tests are the least sensitive:
may show FVC & MVV (restrictive airway disease)

May have evidence of mild obstructive airway disease.
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03/23/2015
Case: 78-year old man with
longstanding PE
Cardiopulmonary Stress Testing
•Measures oxygen
delivered with exercise

Worsening dyspnea &
heart failure past 10
years

Echo EF 10-15% with
moderate-severely
decreased RV function
•Limitation generally
cardiovascular in PE
•VO2 is best non-invasive
surrogate for CO
•Statistically improved Index,
VO2 Max and EF after
excavatum repair*
*Tang M. Euro J CT Surg 2011; Krueger T. Ann Thorac Surg 2010; Neviere R.
Euro J CT Surg 2011; Jaroszewski D. Ann Thorac Surg 2009
Significantly improved Index, VO2 Max and
EF after PE repair
HR
VO2/HR
VO2/HR
30
135
27
120
24
105
21
90
18
90
18
15
75
15
12
60
12
9
45
9
6
30
6
75
60
45
30
15
0
Rec
0
1
2
Time
3
VO2 VCO2
150
30
135
27
120
24
105
21
15
3
0
0
4
Work
2 2
2
4
6
8
Time
10
12
Work
2 2
200
180
180
160
VO2/CO2
slope
160
140
140
120
120
1 1
100
1 1
100
80
80
60
60
40
40
20
20
0
Rec
0
0
0
1
2
Time
3
0
14

VO2 VCO2
200
4
Before PE Repair


3
Rec
0
Indications for Surgical Repair
VO2/HR
HR
150
0
Rec
0
0
2
4
6
8
10
12


0
14
Time

CT index > 3.2 (10-28%) correction
Cardiac compression or shift
Frequent respiratory symptoms or exercise
induced asthma
Symptomatic
Significant body image disturbance
Abnormal cardiopulmonary tests
After PE Repair
Issues Complicating Adult Pectus
Repair
Primary Adult
Minimally Invasive
Repair

Decreased flexibility & rigidity
of chest wall

Weight of chest wall overall

Prior implant placement
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03/23/2015
For majority of adult cases:
Nuss is an option
>90% of primary PE
adults can be corrected
with Nuss
Open Repair
with excision of abnormal cartilage
• Calcified fixed cartilage
or sternum
• Overlapping redundant
• Mixed carinatum/PE
deformities
Techniques I use to facilitate
repair:
 Forced
 At
sternal elevation
Forced Sternal Elevation:
Better visualization
Decreases force required to pass
bars & rotate into position
least 2 bars balancing pressure
(34% had 3 bars)
 FiberWire™
 FiberWire™
reinforce interspaces that strip
multipoint attachment b/l
Rultract® Retractor
Lewin Spinal Perforating Forceps (V.Mueller®NL6960, CareFusion, Inc)
Forced Sternal
Elevation
(Rultract Inc, Cleveland, OH)
Multiple bars are positioned to balance defect
Elevation
Defect with severe
cardiac compression
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03/23/2015
FiberWire™ Fixation
FiberWire™ Reinforcement of
Weaker Intercostal Spaces
Adult Minimally Invasive Repair of PE
Bilateral, Multi-point Fixation
The more complicated PE patient

Fixed, Deep Rigid
Defect with cartilage
calcifications

Rigid, Inflexible
and Tight…
Combined Defect with
Carinatum & PE
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03/23/2015
Forced Elevation
Combination Approach for Complex Repairs
Plating to secure sternum and sternal
costochondral attachments
• Calcified, fixed
• Overlapping redundant
cartilage
• Mixed carinatum/PE
deformities
Sternal osteotomy
Excision abnormal cartilage
Placement of support bars
36 y.o. male HI 9.8
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03/23/2015
Complex
Combined
Deformities
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03/23/2015
Revisions of prior
Minimally Invasive PE
(Nuss) repairs
1. Bar Dislocation or Lateral Stripping
2. Inadequate distribution of bars for
defect
Adult Revision Pectus
Repair
Chronic Pain
Failure to lift adequately
Residual Symptoms
Bar Rotation/Migration
Bars not supporting the defect:
-Inadequate distribution
-Lateral Striping
-Intrathoracic migration
Issues to consider with a failed repair

Why did it fail?



Chest wall rigidity or pressure too high
Bar rotation or movement
What to do differently to prevent from
happening again?
Additional bars
Different distribution
 Method of stabilization
 Reinforce intercostal space


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03/23/2015
28 yo male h/o Nuss 2 years
prior, chronic pain, residual
HI 4.6
Thoughts?
• Very stiff, tight chest wall
for age
• No elevation below single
bar
• Long bar with palpable
stabilizer
• Angle of rotation not
optimal
Forced Sternal elevation
20 y.o male h/o
nuss 1 bar then 2nd
surgery with 2nd bar
placed
Removal existing 17 in
bar/stabilizers,
2 @ 14 in bars placed
Thoughts?
Asymmetrical chest
elevation
Residual Defect
Overlapping bars, right side
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03/23/2015
2@ 15 in bars removed,
2 @ 12.5 bars placed,
lower cartilage secured
to bar
Issues to consider with a failed repair

Malunion of
costosternal
attachments
Why did it fail?



Recurrence/malunion after Open
Repair
Repair collapsed before healing
Malunion/necrosis
What to do differently to prevent from
happening again?
Support the chest wall
Prevent movement of costosternal reattachments
 Obliterate space
 Reinforce with bone graft


11
03/23/2015
Thoughts for
Reconstruction:
Stabilize
Reapproximate
Fill
Cover
28 y.o. male, Ravitch age 15, continue
chest pain, inability to exercise
Plating when necessary to secure sternum
and sternal costochondral attachments
Recurrence, Malunion, HI: 3.4
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03/23/2015
47 yo female h/o ravitch 1 year prior with BioBridge
plating, severe chronic pain, HI 4.2
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03/23/2015
50-year-old male: Ravitch age 36 with
malunion, revision 3 years ago

Exercise intolerance

Dyspnea

Chronic narcotic
dependent pain
HI 2.2, left costochondral defect
Intraoperative Findings
Procedure

PMMA to cover
chest wall defect

Osteotomy of
abnormal rib
attachments and
sternum

Titanium plating
Issues:
 Desire Implants
 Have implants Subcutaneous
or Subpectoral
 Different sized Implants
 Silicone block Implants
 Aged Implants
Implants
Existing Silicone Block & Breast Implants
and Simultaneous Augmentation
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03/23/2015
Take the implants
out before
attempting repair
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03/23/2015
Separate the Pectus Bar from the Implant with Biologic Mesh
(Strattice Reconstructive Tissue Matrix)
Ma IT, Rebecca AM, Notrica DM, McMahon LE, Jaroszewski DE. Pectus excavatum in adult
women: repair and the impact of prior or concurrent breast augmentation. Plast Reconstr Surg. 2015
Feb; 135(2):303e-12e.
Adult Pain Control Protocol
OnQ: anterior axilla subcutaneous
(.2% Ropivacaine)
Peri-Operative:








Gabapentin 600 mg PO
Celecoxib 400 mg PO
Clonidine Patch 0.1 mg
Dexamethasone 8 mg IV
Methadone 15-20 mg IV loading dose at case
start
Acetaminophen 1000 mg IV
Toradol 30 mg IV at completion
Intercostal block 1cc/kg/0.25 % Marcaine
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03/23/2015
Adult Pain Control Protocol
Post-Operative:






OnQ @ 7ml/hr bilateral anterior axilla subq
Gabapentin 600 mg PO TID
Toradol 30 mg IV q 6 hr then transition to
Ibuprofen 600 TID PO
Clonidine Patch 0.1 mg
IV Acetaminophen 1000 mg X 4 doses
PCA overnight then am POD 1 change to


OxyContin 20 mg BID scheduled
Oxycodone 5-10 mg q4 hrs PRN
POD 0-1:
•OnQ with Ropivicain 0.2%
•PCA Dilaudid (0.2 mg, Q8”, 4.8 mg 4 hr max)
•Ketorolac 30 mg IV Q 6 hours scheduled 72-96 hrs
•Gabapentin 300 mg PO TID
•IV acetaminophen 1000 mg Q 6 hours x 3 doses
•Protonix 40 mg daily
POD 1-discharge
•Start am POD 1: Oxycontin 10-20 mg PO BID or MS Contin 15 mg BID
•D/C PCA, Dilaudid 1-2 mg IV q 4 hours PRN
•Start Oxycodone 5-15 mg Q4 prn
•Continue gabapentin 300 mg PO TID
•Transition from ketorolac to Ibuprophen 600 mg TID scheduled
•Protonix 40 mg daily
•On-Q refill at 48 hours and d/c home will full Bulb
56 year-old male HI 4.6
A few before & after
examples
72 year old male HI 4.8
37 year old male HI 20.1
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03/23/2015
Summary

Adult PE patients present most commonly with
progressing physiologic symptoms

Adult repair may have additional issues to be addressed

Minimally invasive repair is an option for the majority
of patients however some cases require combined
procedures to adequately correct

Techniques such as use of Forced Sternal Elevation and
multiple bars may facilitate repair
Thank you!
Dawn Jaroszewski, MD, MBA, FACS
Associate Professor of Cardiothoracic Surgery
5777 East Mayo Boulevard
Phoenix, AZ 85255
[email protected]
480-342-2270 work
832-265-3177 cell
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