Cardiopulmonary resuscitation in patients with a Nuss bar--a case report and review of the literature

Biomechanical Effectivity Evaluation of Single- and Double-Metal-Bar Methods with Rotation and Equilibrium Displacements in Nuss Procedure Simulations

Surgical treatment of the pectus excavatum has led to the introduction of the Nuss procedure, a minimally invasive surgical procedure that involves inserting a metal bar under the sternum through a small lateral thoracic incision. An additional metal bar was inserted in patients with pectus excavatum to improve the retention of the restored chest wall after the Nuss procedure. However, a need still exists to analyze the mechanistic advantages and disadvantages of the double-bar method owing to the increased surgical time and proficiency. The purpose of this study is to compare and evaluate the efficiency of single- and double-bar methods using rotational and equilibrium displacement simulations of the Nuss procedure. A finite-element model was constructed for two types of metal bars inserted into the chest wall. Boundary conditions for the rotation and equilibrium displacements were set for the metal bar. The anterior sternal translation, Haller index and maximum equivalent stress and strain owing to the behavior of the metal bar were estimated and compared with the single-bar method and postoperatively acquired patient data. The simulation results showed that the influences of the intercostal muscle and equilibrium after rotation displacement were significant. The stresses and strains were distributed across the two metal bars, and the upper-metal bar was heavily loaded. The double-bar method was advantageous regarding the load distribution effects of the two metal bars on the chest wall. However, mechanical assessments are also important because an excessive load is typically applied to the upper-metal bar.

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.

Sternal lifting technique for patients with sternal depression during robotic mitral repair

INTRODUCTION

Traditional surgical methods have been difficult for patients with chest wall deformities, but the use of the Electrical Sternum Lifting System (ESLS) has made the surgery easier.

MATERIALS AND SURGICAL TECHNIQUE

Patients with a sternum-to-vertebral distance of less than 80 mm on preoperative computed tomography (CT) scan routinely underwent sternal lift using the ESLS. The ESLS was effective in securing the operative field while suspending the sternum, allowing adequate observation of the left atrium, left ventricle, and the mitral valve, and safe mitral valve plasty. The use of the lifting device did not interfere with the robot arms, and the space between the sternum and vertebrae was widened with only a 3 mm wound to move the mitral valve surface in the sagittal plane, making the repair easy and accurate under robotic assistance. The effort to attach the ESLS was not difficult, and the postoperative cosmetic outcomes were excellent. Sixty-three out of 1002 patients (6.3%) underwent sternal elevation using ESLS. There were 19 males and 44 females with a mean age of 50.9 ± 14.0 years. The average of sternum-to-vertebral (S/V) distance was 72.4 ± 8.9 cm. Two patients had S/V distance of more than 80 mm but ESLS was used because of scoliosis.

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.

Pectus bar removal - why, when, where and how

OBJECTIVE

Despite its less invasive nature, the widespread use of the minimally invasive repair of pectus excavatum (MIRPE) procedure has been associated with a significant number of serious complications. On the other hand, Pectus bar removal (PBR) is often considered a simple procedure and often scheduled in an outpatient setting. However, several studies report near-fatal complications not only during bar placement, but also during bar removal. The aim of our study was to clarify why a pectus bar should be removed, timing for removal, where PBR should be performed, and overall setup for safe removal.

METHODS

A comprehensive review was performed in accordance with PRISMA guidelines, searching for articles published since 1998 in English. "Pectus bar removal AND (near-fatal) complications" were the applied terms. Inclusion criteria were articles reporting on the focus of PBR after MIRPE. Eligible study designs included (retrospective) case study series, case report and reviews. Full-text articles in which the technique in general was described were omitted.

RESULTS

Recently published results of an online survey raised awareness about type and number of possible complications during PBR. Furthermore, our comprehensive literature review identified only a few, but serious complications during PBR.

CONCLUSIONS

PBR has a high safety profile but in rare cases may be associated with major complications such as life-threatening hemorrhage from various thoracic sources. This risk is higher in patients with a history of complex MIPRE. In an effort to decrease these complications we recommend bilateral opening of surgical incisions, unbending the bar and meticulous mobilization of the bar. To manage these complications if they occur, we recommend removal in a hospital setting with adequate resources and personal including cardiac surgeons. If the postoperative course is uneventful discharge on the same day is reasonable.

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.

Cardiopulmonary resuscitation in pediatric pectus excavatum patients-Where is the heart?

BACKGROUND

In children with pectus excavatum, the posteriorly depressed sternum compresses and displaces the heart. However, the currently recommended compression site and depth for cardiopulmonary resuscitation have not been studied in this population.

AIM

This retrospective study investigated the location of the center of ventricles with the largest cross-sectional area to determine the optimal site and depth for chest compressions in pediatric pectus excavatum patients.

METHODS

Chest computed tomography images of 94 pediatric pectus excavatum patients before and after correction surgery were compared with normal patients. The caudal displacement of the ventricles was calculated by dividing the length of sternum by the length from the suprasternal notch to the transverse level of the largest cross-sectional area of the ventricles. The proportional leftward deviation of the center of the ventricles from the midline versus transverse diameter of the thorax was calculated. The remaining internal thickness was calculated at the midline assuming the recommended compression depth of one-third of the anterior to posterior diameter.

RESULTS

Compared with the normal population (mean = 81% [SD = 10.3%]), pediatric pectus excavatum patients showed caudal displacement of ventricles before (98.2% [15.1%], 95% CI of mean difference; 13.7%-20.5%, P < .001) and after correction (100.4% [13.5%], 95% CI of mean difference; 16.2%-22.5%, P < .001). Compared with the normal population (6.9% [2.7%]), pediatric pectus excavatum patients showed leftward deviation of ventricles before (16.2% [5.5%], 95% CI of mean difference; 8.2%-10.4%, P < .001) and after correction (13.3% [4.8%], 95% CI of mean difference; 5.3%-7.3%, P < .001). The remaining internal thickness assuming the recommended chest compression was <10 mm in 54/94(57.4%) and 18/94 (19.1%) of pediatric pectus excavatum patients before and after correction, respectively.

CONCLUSIONS

Pediatric pectus excavatum patients showed significant caudal displacement and leftward deviation of the ventricles compared with the normal population despite correction surgery and the currently recommended compression site and depth might injure intrathoracic structures without effective cardiac compression during cardiopulmonary resuscitation.

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.

Elastic stable chest repair and its hybrid variants in 86 patients with pectus excavatum

Background

Complex and mature funnel chest deformities are traditionally managed with open surgical procedures. Elastic stable chest repair (ESCR) has been used successfully and safely for relapse corrections. Does pure plate osteosynthesis in ESCR allow comparable corrective potency and implant safety as hybrid methods with metal bars?

Methods

Data from 86 patients with open funnel chest correction between 2011 and 2015 were analyzed in this retrospective study. Exclusion criteria included being under 12 years of age, and having a history of septic wound healing disorder or other malignant diseases. Main groups consisted of ESCR and hybrid techniques, subgroups were primary and recurrence correction. Correction results and follow-up examinations at six and 12 weeks and at 1 year were statistically analyzed.

Results

A total of 38 ESCR and 48 hybrid methods were analyzed. Bar implantation was required in 77% (recurrence 34%) of patients. All patients received plates with different combinations e.g., longitudinal-sternal, costosternal and costo-sterno-costal. In all groups, follow-up uptake showed a funnel chest correction result at the anatomical level with healthy values according to the Haller index (ESCR 4.36-2.84, hybrid 6.99-2.74, P<0.001). No material dislocations were observed in any subgroup.

Conclusions

ESCR and hybrid techniques represent promising and safe therapeutic approaches.

Concomitant aortic root and pectus deformity repair in Marfan syndrome patients

The role of concomitant aortic and pectus repair in Marfan patients remains controversial. We present our surgical technique for concomitant aortic repair of aortic root pathology and pectus correction. The concomitant surgery can be safely achieved in Marfan patients, thus, avoiding the need for a risky second stage operation.

Simultaneous repair of congenital heart defects and pectus excavatum in young children

PURPOSE

The present study was undertaken to summarize our experience with the concurrent repair of pectus excavatum (PE) and congenital heart defects in young children over the past 15 years.

METHODS

A retrospective study was conducted that included patients who underwent combined repair of PE and a congenital heart defect in a large clinical center between 2002 and 2017. Intraoperative and postoperative patient characteristics, postoperative complications and surgical outcomes were recorded.

RESULTS

Twenty-one patients met the inclusion criteria. An open heart surgery and a modified sternal elevation with anterior sternal suspension were performed. No intraoperative complications occurred. Postoperatively, three patients developed pneumonia, two patients developed subcutaneous effusions, one patient sustained an asymptomatic pneumothorax, and one other patient had a transitory fever. In all cases, postoperative recovery was uneventful, and no perioperative mortality occurred. Bar removal was performed in 19 patients at an average of 2.55 years postoperatively: 18 of them achieved an excellent outcome, and 1 patient had a good final result.

CONCLUSION

A combined procedure of modified sternal elevation and cardiac repair may be performed safely in young children. Early repair of PE is feasible and effective in these patients.

Anesthesia for minimally invasive chest wall reconstructive surgeries: Our experience and review of literature

Minimal access procedures have revolutionized the field of surgery and opened newer challenges for the anesthesiologists. Pectus carinatum or pigeon chest is an uncommon chest wall deformity characterized by a protruding breast bone (sternum) and ribs caused by an overgrowth of the costal cartilages. It can cause a multitude of problems, including severe pain from an intercostal neuropathy, respiratory dysfunction, and psychologic issues from the cosmetic disfigurement. Pulmonary function indices, namely, forced expiratory volume over 1 s, forced vital capacity, vital capacity, and total lung capacity are markedly compromised in pectus excavatum. Earlier, open surgical correction in the form of the Ravitch procedure was followed. Currently, in the era of minimally invasive surgery, Nuss technique (pectus bar procedure) is a promising step in chest wall reconstructive surgery for pectus excavatum. Reverse Nuss is a corrective, minimally invasive surgery for pectus carinatum chest deformity. A tailor-made anesthetic technique for this new procedure has been described here based on the authors’ personal experience and thorough review of literature based on Medline, Embase, and Scopus databases search.

Cardiac surgery and repair of pectus deformities: When and how?

OBJECTIVES

There is currently a lack of recommendations about patients with pectus deformities requiring cardiac surgery. This study reports the results of our surgical strategy on this issue.

METHODS

Eleven patients, from three centers treated over a 9-year period were included in this study. Pectus deformities were operated with a modified Ravitch procedure. In the case of pectus excavatum repair and concomitant cardiac surgery, subperichondrial resection of abnormal rib cartilages was always performed before the sternotomy and an easily removable retrosternal metallic strut was inserted at the end of the procedure ensuring anterior chest wall stability. During follow-up patients had to estimate their current appearance with a numeric scale ranging from 0 to 100.

RESULTS

Mean age was 27 ± 9.4 years. Pectus excavatum was present in 8 patients and pectus arcuatum in 3. There were 6 Marfan syndrome patients. Nine patients had concomitant surgery and, 2 underwent pectus repair after a history of cardiac surgery. There was no operative mortality. In the case of concomitant surgery, heart exposure through median sternotomy was facilitated by abnormal rib cartilage resection. Median follow-up was 54 months (range 16.7-119.7). Mean cosmetic result evaluated by the patients was 97.3 (±2.5).

CONCLUSIONS

In adults, concomitant scheduled surgery is reliable and offers excellent long-term cosmetic results. Moreover, it allows a better thoracic exposition with no added perioperative risk. The modified Ravitch technique seems more adequate in these patients as it can be used in all types of pectus deformities.

Cardiopulmonary arrest during the Nuss procedure: case report and review

Case

The Nuss procedure is an established and widely approved minimally invasive technique for the correction of pectus excavatum. However, patients undergoing the procedure are at increased risk of cardiac arrest. It has not been established whether cardiopulmonary resuscitation is possible in patients who have received the Nuss procedure. We present here the case of a 14-year-old boy with pectus excavatum who underwent minimally invasive pectus repair but later had a fatal cardiac event before pectus bar removal.

Outcome

Bystander cardiopulmonary resuscitation was carried out immediately but resuscitation failed.

Conclusion

In patients who have undergone the Nuss procedure for pectus excavatum, it is important to manage perioperative events such as arrhythmia, develop measures for managing emergency situations in patients' areas of residence, and carry out continuing research and development of medical supply materials that can be used to manufacture Nuss bars.

Simplified open repair for anterior chest wall deformities. Analysis of results in 205 patients

INTRODUCTION

Pectus deformities are the most frequently seen congenital thoracic wall anomalies. The cause of these conditions is thought to be abnormal elongation of the rib cartilages. We here report our clinical experience and the results of a sternochondroplasty procedure based on the subperichondrial resection of the elongated cartilages.

HYPOTHESIS

This technique is a valuable surgical strategy to treat the wide variety of pectus deformities.

PATIENTS AND METHODS

During the period from October 2001 through September 2009, 205 adult patients (171 men and 34 women) underwent pectus excavatum (181), carinatum (19) or arcuatum (5) repair. The patients' pre and postoperative data were collected using a computerized database, and the results were assessed with a minimum 2-year follow-up.

RESULTS

The postoperative morbidity rate was minimal and the mortality was nil. The surgeon graded cosmetic results as excellent (72.5%), good (25%) or fair (2.5%), while patients reported better results. Patients with pectus excavatum were found to have much more patent foramen ovale (PFO) than the normal adult population, which occluded after the procedure in 61% of patients, and significant improvement was found in exercise cardiopulmonary function and exercise tolerance at the 1-year follow-up.

DISCUSSION

Our sternochondroplasty technique based on the subperichondrial resection of the elongated cartilages allows satisfactory repair of both pectus excavatum and sternal prominence. It is a safe procedure that might improve the effectiveness of surgical therapy in patients with pectus deformities.

Prosthesis-free repair of pectus chest deformity

Background

Modified Ravitch and Nuss procedures use a metal bar to repair pectus chest deformity; an additional procedure is required to remove the bar. The aim of this study was to examine mid-term results of a novel technique that uses the patient's own chest wall muscles to stabilize the pectus repair aided by a posture-maintaining exercise regimen.

Methods

Thirty-two consecutive patients with pectus deformity underwent pectus repair without prosthesis between 1999 and 2008. The median age of the group was 18 (95 per cent confidence interval (c.i.) 14 to 34) years. Median follow-up was 44 (7 to 108) months. Twenty patients had an excavatum and 12 a carinatum defect. Surgery was performed through a transverse incision raising pectoralis and rectus muscle flaps. The sternum was released to a neutral position and stabilized to the overlying muscle raphe closure. Patient satisfaction was assessed with a single-step questionnaire.

Results

Median length of stay was 6 (95 per cent c.i. 4 to 7) days. Two patients returned to theatre for bleeding, two had a superficial wound infection and four developed a seroma. No patient had recurrence. There was a significant improvement in self-esteem (P &lt; 0·001) and a high level of overall satisfaction (median score 72, 95 per cent c.i. 56 to 80).

Conclusion

This non-prosthetic pectus deformity repair was effective with low serious morbidity and high patient satisfaction without the inherent disadvantages of using a metal bar.

Indications and technique of Nuss procedure for pectus excavatum

Pectus excavatum most frequently involves the lower sternum and chest wall. Because the morphology varies, preoperative imaging for anatomic assessment and documentation of dimensions of the chest are important. Many modifications have been made to the minimally invasive procedure since it was first performed in 1987. As a result, there has been an increase in the number of patients seeking surgical correction. This article discusses the clinical features of pectus excavatum and reviews the preoperative considerations and the steps involved in the repair of the deformity.

Minimally invasive surgical repair of pectus excavatum

The minimally invasive repair of pectus excavatum has become widely accepted. The number of patients presenting for repair has increased dramatically. There have been many technical improvements over 20 years that have made the procedure much safer and more successful. The complications have been identified and preventative measures instituted. The long-term results have shown a 95% good to excellent outcome, and patient satisfaction studies have shown similar results.

Cardiac perforation by a pectus bar after surgical correction of pectus excavatum: case report and review of the literature

Pectus excavatum (PE) is a congenital sternal depression. The two most popular methods of correction are the highly modified Ravitch repair (HMRR) and the Nuss procedure. Presented here is a case of PE surgical correction in a 17.5-year-old male, beginning with the Nuss technique and converting to the HMRR during surgery, due to unsatisfying results. The procedure inadvertently culminated in perforation of the heart and lungs by the inserted pectus bar, with aggravation of the damage by resuscitation efforts. This article analyzes the chain of events leading to the patient's death and reviews the literature on the subject.

Miniature access pectus excavatum repair: Lessons we have learned

BACKGROUND

Pectus excavatum (PE) is the most common chest well deformity seen in children. In 1997, the Miniature Access Pectus Excavatum repair (MAPER) was presented by Nuss et al, adding a new option for PE repair. This operation entails placing a custom bent metal bar across the chest to mechanically raise the sternum and remodel the cartilage. The authors have added modifications to Nuss' original description of this operation in an attempt to optimize technique, minimize complications, and improve outcomes.

METHODS

The authors have performed 52 MAPERs with an average operating time of 106 minutes, average length of stay of 3.9 days, and return to normal activities of 2 to 6 weeks. Modifications to Nuss' original description include preoperative evaluation consisting of an echocardiogram and pulmonary function tests (PFTs; with and without exercise and with and without bronchodilators), abandoning the use of routine preoperative computed tomography (CT) scans, the use of unilateral positive pressure insufflation of the hemithorax to provide visualization, and anesthesia using an epidural pain catheter (intraoperative and postoperative for 3 days). Intraoperatively, we use a 70 degrees thoracoscope for optimal visualization, and we have modified their location for optimal visualization. Additionally, the bars are secured with surgical wire, not absorbable suture, to avoid bar slippage.

RESULTS

Postoperatively, we leave our bars in for 3 years and have had no recurrences. Furthermore, these patients require significant support during the time their bars are in place and occasionally require reoperation to fix symptomatic problems with their bar.

CONCLUSIONS

Since the first description of the MAPER was presented more than 5 years ago, the operative treatment of PE has changed dramatically. The authors feel that the MAPER is superior to the open technique, and with the modifications they have implemented, complications have been minimized, and long-term results have been improved.