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\begin{document}

\title{Exceptional life threatening complication 19 years after Ravitch
correction of pectus excavatum.}



\author[1]{Krzysztof Greberski}%
\author[1]{Radoslaw Jarzabek}%
\author[2]{Bartłomiej Perek}%
\author[1]{Pawel Bugajski}%
\affil[1]{J Strus Multidisciplinary Hospital, Poznan, Poland }%
\affil[2]{Poznan University of Medical Sciences}%


\vspace{-1em}



  
  \date{May 17, 2024}


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\selectlanguage{english}
\begin{abstract}
Ravitch technique of chest correction has been considered, although
invasive, as safe and efficacious surgical method. We describe a case of
35-year-old woman with cardiac tamponade and in cardiogenic shock due to
exceptional late complication after pectus excavatum reconstruction by
means of classic Ravitch technique 19 years earlier. This very late
adverse event was caused by broken metal sternal wire that injured the
wall of the ascending aorta. Patient underwent salvage repair of this
segment of aorta in cardiopulmonary bypass. Postoperative course and
post-discharge 3-year follow-up have been uneventful.%
\end{abstract}%



\sloppy


Exceptional life threatening complication 19 years after Ravitch
correction of pectus excavatum

Krzysztof Greberski MD PhD\textsuperscript{1,2}, Rados\selectlanguage{polish}ł\selectlanguage{english}aw Jarz\selectlanguage{polish}ą\selectlanguage{english}bek MD
PhD\textsuperscript{1}, Bart\selectlanguage{polish}ł\selectlanguage{english}omiej Perek MD PhD\textsuperscript{3},
Pawe\selectlanguage{polish}ł \selectlanguage{english}Bugajski MD PhD \textsuperscript{1,2}

\textsuperscript{1} Department of Cardiac Surgery, J Strus
Multidisciplinary Hospital, Poznan, Poland

\textsuperscript{2} Faculty of Health Sciences, Poznan University of
Medical Sciences, Poland

\textsuperscript{3} Department of Cardiac Surgery and Transplantology,
Poznan University of Medical Sciences, Poland

Corresponding author:

Krzysztof Greberski M.D. PhD

\emph{kgreberski@gmail.com}

+48~728~470 460

Department of Cardiac Surgery,

J Strus Multidisciplinary Hospital,

Szwajcarska Str 3

61-285 Poznan, Poland

Abstract

Ravitch technique of chest correction has been considered, although
invasive, as safe and efficacious surgical method.

We describe a case of 35-year-old woman with cardiac tamponade and in
cardiogenic shock due to exceptional late complication after pectus
excavatum reconstruction by means of classic Ravitch technique 19 years
earlier. This very late adverse event was caused by broken metal sternal
wire that injured the wall of the ascending aorta. Patient underwent
salvage repair of this segment of aorta in cardiopulmonary bypass.
Postoperative course and post-discharge 3-year follow-up have been
uneventful.

Therefore, life-threatening cardiovascular complications may occur even
many years after reconstructive surgery for chest deformity.

Key words: pectus excavatum, Ravitch correction, late complication,
cardiac tamponade

1. INTRODUCTION

Pectus excavatum, although rather rare with estimated prevalence 0.1 to
0.8\% of life births, is the most common congenital chest deformity
{[}1{]}. It usually has minimal or no influence on the physiological
performance of the chest organs but rarely may lead to musculoskeletal
pain, respiratory disorders or even heart failure {[}2, 3{]}. Of note,
not uncommonly, the most troublesome symptoms are related to
psychological aspects of body image and the quality of life {[}4{]}.

Simplifying, there are two available methods of surgical corrections,
the open Ravitch (with many later modifications) and minimally invasive
Nuss. Generally, both mentioned above surgical techniques are considered
safe with good late outcomes, including significant improvement in life
quality {[}5{]}. Regarding late complications, they are relatively rare.
Up to now, only single life-threatening adverse events throughout
long-term follow-up period have been reported, although usually after
Nuss operation {[}6{]}.

In this report an exceptional but serious late complication requiring
salvage cardiac surgical intervention many years after Ravitch chest
correction for pectus excavatum is described.

2. CASE

A 35-year-old female patient was admitted to the regional hospital
because of loss of consciousness episodes preceded by transient
retrosternal pain after exercise. The only important issue of her
medical history was surgical correction of congenital chest defect
(pectus excavatum) that had been carried out 19 years earlier. It
consisted of surgical unveiling of parasternal cartilages, sections of
the ribs and their partial removal (that are usually too long),
sternotomy and its stabilization with steel wires. A computed
tomographic angiography (CTA) done on emergent basis revealed that a tip
of the broken wire loop faced backwards and touched aortic wall (see
Figure). Moreover, excessive accumulation of pericardial effusion was
noted. Due to rapid deterioration of her clinical status she was
transferred immediately by means of aircraft transportation to the
referential cardiac surgical department and then directly to the
operating room.

The salvage surgery was done from median sternotomy. Pericardial sac was
filled with blood and clots. Intraoperative findings confirmed
preliminary diagnosis of CTA. The anterior wall of ascending aorta was
injured by the sharp tip of broken metal sternal wire that was facing to
the mediastinum. Patient was connected to extracorporeal circulation and
after cardioplegic cardiac arrest a dacron patch was implanted to the
front wall of the ascending aorta and remnants of the metal wires were
removed from the sternum.

Following surgery her clinical status had been improving systematically
and eventually before she was discharged on day 16\textsuperscript{th}in
a good clinical shape. Both in-hospital stay and post-discharge
follow-up period (up to now more than 3 years) were uneventful.

DISCUSSION

Our case of the young lady showed that even many years after operations
for pectus excavatum applying the Ravitch method, life-threatening
complications may occur. Their prevalence is unknown. Even recent
meta-analysis comparing two methods of chest reconstruction failed to
assess long-term outcomes due to a scarce of reliable information
{[}5{]}. Of note, analyzing our patient, we are not able to explain
exact mechanism of this event. Abnormal stress put on the sternum during
exercise leading to the wire rupture and its backward distortion might
be one of them. Wire discontinuity was rather new because the tip was
sharp and uncovered by connective tissue (intraoperative finding) that
could have protect adjacent tissue, including the closest cardiovascular
structures.

Although, recurrence rate after open thoracic wall reconstruction is
low, the anterior-posterior chest dimension is usually small,
particularly in women. Therefore, in our opinion, in these patients the
risk of injury of any tissues and organs underneath the sternum is
higher than after standard cardiac surgical procedures performed from
median sternotomy. Consequently, we were taught that each symptoms
related to pain and subsequent low cardiac output syndrome must not be
ignored even many years after procedures on chest considered as
relatively safe.

Our report confirmed again how important diagnostic tool is CTA.
Currently it is considered as a method of choice in diagnostic process
of the vast majority of cardiovascular pathologies due to its common
availability and short examination time {[}7{]}.

CONCLUSION

Life-threatening cardiovascular complications may occur even many years
following reconstructive operations for chest deformity and in some of
them emergent cardiac surgical intervention is the only lifesaving
option.

References

1. Obermeyer RJ, Goretsky MJ. Chest wall deformities in pediatric
surgery. Surg Clin North Am 2012; 92: 669-684.
doi:10.1016/j.suc.2012.03.001

2. Brochhausen C, Turial S, M\selectlanguage{ngerman}üller F, Schmitt VH, Coerdt W, Wihlm J-M,
Schier F, and Kirkpatrick CJ. Pectus excavatum: history, hypotheses and
treatment options. Interact Cardiovasc Thorac Surg 2012; 14: 801--806.
10.1093/icvts/ivs045

3. Harris C, Croce B, Cao C. Pectus excavatum. Ann Cardiothorac Surg.
2016 Sep; 5(5): 528. doi: 10.21037/acs.2016.08.07.

4. Funk JF, Gross C, Placzek R. Patient satisfaction and clinical
results 10 years after modified open thoracoplasty for pectus
deformities. Langenbecks Arch Surg 2011; 396: 1213-1220.
doi:10.1007/s00423-011-0827-2

5. Kanagaratnam A, Phan S, Tchantchaleishvilli V, Phan K. Ravitch versus
Nuss procedure for pectus excavatum: systematic review and meta-analysis
Ann Cardiothorac Surg 2016; 5: 409--421. doi: 10.21037/acs.2016.08.06

6. Jemielity M, Pawlak K, Piwkowski C, Dyszkiewicz W. Life-Threatening
Aortic Hemorrhage During Pectus Bar Removal. Ann Thorac Surg 2011; 91:
593-595. doi: 10.1016/j.athoracsur.2010.07.041

7. Monica MP, Merkely B, Szilveszter B, Drobni ZD, Maurovich-Horvat P.
Computed Tomographic Angiography for Risk Stratification in Patients
with Acute Chest Pain - The Triple Rule-out Concept in the Emergency
Department. Curr Med Imaging Rev 2020; 16: 98-110. doi:
10.2174/1573405614666180604095120

Figure caption

Broken sternal wire tip facing backwards into mediastinum\selectlanguage{english}
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