Cardiopulmonary arrest during the Nuss procedure: case report and review

Post-operative arrest following pectus excavatum repair: A case report with a systematic review of the published case reports

Key Clinical Message

Common complications after PE surgery include ventricular tachycardia, cardiac arrest, pneumothorax, and bar displacement. These can lead to severe outcomes, emphasizing the need for caution and meticulous post-operative monitoring. Patients and their families should be well-informed about potential risks during the consent process.

Abstract

The objective of this study was to raise awareness among medical staff and surgeons about potential complications, particularly rare and life-threatening ones, associated with pectus excavatum (PE) surgery. PE is the most common chest wall deformity, characterized by sternal depression. Patients primarily seek treatment for cosmetic concerns, but some also report exercise intolerance and shortness of breath. Although surgical repair is the standard treatment, the incidence and nature of severe complications remain unclear and underreported. This study presents a case of a lethal cardiac event following PE surgery and conducts a systematic review of published case reports. This study describes a case of a lethal complication of ventricular fibrillation and cardiac arrest following the Ravitch procedure for correction of PE in a 10-year-old boy. A systematic review of relevant cases of PE surgery complications was conducted. Of the 506 initial records retrieved, 93 case reports from 83 articles were identified over the 23 years. Among them, 72 patients were male, and 20 cases were female. The average age of patients was 19.2 ± 7.7 years (range: 5-53). Complications had occurred up to 37 years from the time of surgery, with most of the cases (22.5%) occurring during the operation. The most frequent complications included cardiothoracic issues and displacement of the implanted steel bar. In nine patients, complications led to fatal outcomes. Due to the possible risks of PE surgery, particularly in cosmetically motivated cases, surgeons must exercise extreme caution and remain vigilant for rare and potentially life-threatening complications.

Cardiorespiratory arrest during and after nuss procedure: case report

BACKGROUND

Pectum excavatum is a congenital thoracic alteration that can present important physiological alterations depending on the severity of the case. The Nuss procedure is a minimally invasive technique for managing chest wall deformity, in which there is a risk of perioperative complications.

CASE PRESENTATION

This article presents the case of a 16-year-old patient who underwent placement of a Nuss bar and suffered intraoperative and postoperative cardiorespiratory arrest.

CONCLUSIONS

it is important to consider the possible early and late complications scenarios as well as their treatment in patients with pectum excavatum scheduled for a Nuss procedure.

Combined robot-assisted mitral valve plasty and Nuss procedure via small ports

Pectus excavatum (PE) can be associated with cardiac disorders that also require surgical repair. Totally endoscopic robot-assisted mitral valve plasty for mitral valve regurgitation was performed while elevating the sternum with the aid of our original electrical sternum lifting system. Then, the Nuss procedure was performed successfully via small incision. Simultaneous robot-assisted cardiac surgery and the Nuss procedure is effective. Sternal elevation during cardiac surgery is very important for a safe procedure. The Nuss technique prevents perioperative cardiac compression and allows for correction of the pectus deformity with good cosmetic and functional results.

Efficacy of standard chest compressions in patients with Nuss bars

Background

The Nuss procedure temporarily places intrathoracic bars for repair of pectus excavatum (PE). The bars may impact excursion and compliance of the anterior chest wall while in place. Effective chest compressions during cardiopulmonary resuscitation (CPR) require depressing the anterior chest wall enough to compress the heart between sternum and spine. We assessed the force required to perform the American Heart Association’s recommended chest compression depth after Nuss repair.

Methods

A lumped element elastic model was developed to simulate the relationship between chest compression forces and displacement with focus on the amount of force required to achieve a depth of 5 cm in the presence of 1–3 Nuss bars. Literature review was conducted for evidence supporting potential use of active abdominal compressions and decompression (AACD) as an alternative method of CPR.

Results

The presence of bars notably lowered compression depth by a minimum of 69% compared to a chest without bar(s). The model also demonstrated a dramatic increase (minimum of 226%) in compressive forces required to achieve recommended 5 cm depth. Literature review suggests AACD could be an alternative CPR in patients with Nuss bar(s).

Conclusions

In our model, Nuss bars limited the ability to perform chest compressions due to increased force required to achieve a 5 cm compression. The greater the number of Nuss bars present the greater the force required. This may prevent effective CPR. Use of active abdominal compressions and decompressions should be studied further as an alternative resuscitation modality for patients after the Nuss procedure.

Successful cardiopulmonary resuscitation following minimally invasive pectus excavatum repair: A case report

INTRODUCTION

Pectus excavatum is the most common congenital chest wall deformity. The minimally invasive repair of pectus excavatum (MIRPE) is the most commonly practiced method of surgical treatment and there is concern that the pectus bar will prevent effective CPR. There are no recorded cases of successful cardiopulmonary resuscitation with pectus bars in place.

PRESENTATION OF CASE

A 17-year-old male with pectus excavatum underwent MIRPE. Two years later, he experienced out-of-hospital cardiac arrest and underwent successful cardiopulmonary resuscitation (CPR) in the field with a pectus bar in place.

DISCUSSION

Successful CPR is possible after MIRPE. Clear identification of patients who have undergone MIRPE and education of CPR providers in providing effective chest compressions and defibrillation for this patient population is necessary.

CONCLUSION

This is the first documented case of successful CPR in a patient with a pectus bar in place who experienced out-of-hospital cardiac arrest.

Life-threatening complications and mortality of minimally invasive pectus surgery

The prevalence and type of life-threatening complications related to the minimally invasive repair of pectus excavatum (MIRPE) and bar removal are unknown and underreported. The purpose of this communication is to make surgeons aware of the risk of these life threatening complications as well as the modifications which have been developed to prevent them.

METHODS

Data related to life-threatening complications of Pectus Excavatum (PE) patients was obtained from four sources: 1. A survey of Chest Wall International Group (CWIG) surgeons who specialize in repairing congenital chest wall malformations, 2. Papers and case reports presented at CWIG meetings, 3. Review of medico-legal cases from the USA and 4. A systematic review of the literature related to major complications post MIRPE.

RESULTS

From 1998 to 2016, we identified 27 published cases and 32 unreported life-threatening complications including: cardiac perforation, hemothorax, major vessel injury, lung injury, liver injury, gastrointestinal problems, and diaphragm injury. There were seven cases of major complications with bar removal (reported and non-reported) with two lethal outcomes. Mortality data with bar placement surgery: Four published death cases and seven unpublished death cases. The overall incidence of minor & major complications post MIRPE has been reported in the literature to be 2-20%. The true incidence of life-threatening complications and mortality is not known as we do not know the overall number of procedures performed worldwide. However, based on data extrapolated from survey information, the pectus bar manufacturer in the USA, literature reports, and data presented at CWIG meetings as to the number of cases performed we estimated that approximately fifty thousand cases have been performed and that the incidence of life-threatening complications is less than 0.1% with many occurring during the learning curve. Analysis of the cases identified in our survey revealed that previous chest surgery, pectus severity and inexperience were noted to be significant risk factors for mortality.

CONCLUSIONS

Published reports support the safety and efficacy of MIRPE; however major adverse outcomes are underreported. Although major complications with MIRPE and pectus bar removal surgery are very rare, awareness of the risk and mortality of life-threatening complications is essential to ensure optimal safety. Factors such as operative technique, patient age, pectus severity and asymmetry, previous chest surgery, and the surgeon's experience play a role in the overall incidence of such events. These preventable events can be avoided with proper training, mentoring, and the use of sternal elevation techniques.

TYPE OF STUDY

Treatment Study.

LEVEL OF EVIDENCE

Level IV.