Haemopericardium causing cardiac tamponade: a late complication of pectus excavatum repair

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.

Late complication of the Nuss procedure: recurrent cardiac tamponade

Pectus excavatum (PE) is known as one of the most common congenital deformities of the anterior chest wall. The Nuss procedure is an effective surgical therapy to correct PE. Here, we report a case of recurrent cardiac tamponade due to hemopericardium that occurred after 16 months following the Nuss procedure. The cause of recurrent hemopericardium was thought to be local, repetitive irritation of the pericardium by the Nuss steel bar. We should keep in mind that this serious complication can occur after the Nuss procedure, even in the late phase.

A runaway sternal wire: A rare case and outcome of sternal wire intravascular embolization

We present a case of a 56-year-old man with history of coronary artery disease and prior two coronary bypass surgeries, who presented with chronic chest pain and was found to have a fractured sternal wire that migrated through the right ventricle and embolized to the right lower pulmonary artery without evident hemodynamic consequences. The sternal wire migration process, in part due to patient's poor medical compliance, was captured on serial computed tomography scans over a period of several years. <Learning objective: Recognize potential sternotomy complications on imaging. Identify rare but potentially dangerous complications of sternal wire fractures. Review of the literature on sternal wire embolization.>.

Cardiac tamponade caused by broken sternal wire after pectus excavatum repair: a case report

Complications of pectus excavatum surgery include pneumothorax, pleuritis, hemothorax, pericardial effusion, displacement of bar, pericarditis and cardiac injury, etc. This is the case of a 15-year-old boy with cardiac tamponade caused by pericarditis who had taken the operation for a pectus excavatum repair one year previously. The cause was a sternal wire which was used for attachment of the bar to sternum that had fractured and migrated through the pericardium causing a pericardial injury and a pericarditis.

The vacuum bell for conservative treatment of pectus excavatum: the Basle experience

OBJECTIVE

Surgical repair of pectus excavatum (PE) in childhood is a well-established procedure. Previously used operative techniques to correct PE were largely based on the Ravitch technique. Since about 10 years, the minimally invasive repair (MIRPE) by Nuss is well established. Conservative treatment with the vacuum bell to elevate the funnel in patients with PE represents a potential alternative to surgery in selected patients.

METHODS

A suction cup is used to create a vacuum at the anterior chest wall. Three different sizes of vacuum bell exist which are selected according to the individual patients age. When creating the vacuum, the lift of the sternum is obvious and remains for a different time period. The device should be used for a minimum of 30 min (twice/day), and may be used up to a maximum of several hours daily.

RESULTS

One hundred and thirty-three patients (110 males, 23 females) aged from 3 to 61 years (median 16.21 years) used the vacuum bell for 1 to a maximum of 36 months. Computed tomographic scans showed that the device lifted the sternum and ribs immediately. In addition, this was confirmed thoracoscopically during the MIRPE procedure. One hundred and five patients showed a permanent lift of the sternum for more than 1 cm after 3 months of daily application. Thirteen patients stopped the application and underwent MIRPE. Relevant side effects were not noted.

CONCLUSION

The vacuum bell has proved to be an alternative therapeutic option in selected patients suffering from PE. The initial results proved to be dramatic, but long-term results are so far lacking, and further evaluation and follow-up studies are necessary.

Intrapericardial migration of dislodged sternal struts as late complication of open pectus excavatum repairs

Abstract

We present a case of sternal steel strut dislodgement and migration in a patient undergoing Ravitch repair for pectus excavatum (PE) 37 years ago. Broken struts perforated the right ventricle and right ventricular outflow tract (RVOT) and additionally migrated into the left upper lobar bronchus.

Dislodged sternal struts represent rare complications after surgical repair of patients suffering from pectus excavatum. Reviewing the literature, only five cases of intrapericardial migration of dislodged sternal struts or wires have been reported so far.

In our case, the first strut was removed from the airways through a left antero-lateral thoracotomy. Using cardiopulmonary bypass, a second strut was removed via ventriculotomy. These life-threatening sequelae underscore the importance of postoperative follow-up and early removal of osteosynthetic materials used in open PE repair. Accurate preoperative localization of migrated materials and availability of CPB support are crucial for successful surgical removal.

Introduction

The migration of dislodged sternal steel struts or wires into the pericardium and cardiac cavities is a rare but life-threatening complication of open pectus excavatum (PE) repair [1]. Removal of these materials poses a challenge for cardiothoracic surgeons. Herein, the authors report a case of migration of dislodged steel struts through the right ventricle and right ventricular outflow tract (RVOT) into the left upper lobar bronchus in a patient who underwent Ravitch repair 37 years ago.

Surgical correction of the funnel chest deformity in children

The aim of this study was to evaluate our results during and after the Nuss operation in children with pectus excavatum. We have performed the Nuss procedure in 128 patients with pectus excavatum since 2001, and 74 patients underwent bar removal. Of the 128 patients 96 were male and 32 were female; age ranged from eight to 21 years with an average of 13.8 years. In 46% of patients psychological reasons for operative treatment were dominant while in the other 54% of patients clinical signs were the indications. Complications in 128 patients included 36 pneumothorax, 28 of which resolved spontaneously. Postoperative pneumonia developed in six patients. In two patients we had infection of the implanted bar, and there were two patients with cellulitis. We had six patients with bar displacement and reoperation was needed. During the Nuss procedure we had one injury of the intercostal artery. We had pericardial tears in two patients without clinical significance. In two patients we had pericardial effusion six months after the Nuss procedure, requiring pericardiocentesis. In one patient we had fracture of the sternum. There were no complications following bar removal. After bar removal in 74 patients, 54 patients (72.9%) maintained excellent results with normal chest anatomy, good results were found in 16 patients (21.6%) with mild residual pectus and poor results in four patients (5.5%) with severe recurrence. Our experience with the Nuss procedure demonstrated excellent results with few minor complications.

Intra-abdominal pectus bar migration--a rare clinical entity: case report

We present the case of a 20-year-old male who underwent successful surgical correction of pectus excavatum with the Highly Modified Ravitch Repair (HMRR). At 29 months the attempted operative removal of the Ravitch bar was unsuccessful despite the impression of adequate bar location on chest x-ray. Subsequent imaging with computed tomography was unclear in determining whether the bar was supra or infra-diaphragmatic due to the tissue distortion subsequent to initial surgery. Video assisted thoracoscopic surgery (VATS) successfully retrieved the bar and revealed that it was not in the thorax, but had migrated to the intra-abdominal bare area of the liver, with no evidence of associated diaphragmatic defect or hernia. Intra-abdominal pectus bar migration is a rare clinical entity, and safe removal can be facilitated by the use of the VATS technique.

Migration of a Kirschner wire to the heart in a Yorkshire terrier

A 12-year-old, male Yorkshire terrier was presented for acute pulmonary oedema. Thoracic radiographs showed a linear metallic foreign body within the cardiac silhouette. Echocardiogram showed a hyperechoic line extending through the left ventricle, the mitral valve, leading into the left atrium. A 4 cm long Kirschner wire was surgically removed by left fourth thoracotomy. The dog died two days after surgery for acute pulmonary oedema. Necropsy showed thrombi on the mitral leaflets that impeded their movement.