Life-Threatening Cardiovascular Complications Related to Pectus Excavatum Surgery

Objectives: To assess the life-threatening cardiovascular complications (LCC) related to pectus excavatum surgery.
Methods: In-depth literature review of LCCs related to open repair (Ravitch-type or other procedures) versus minimally invasive repair (Nuss).
Results: Of 1262 patients undergoing an open Willital-Hegemann repair, we identified 1 death caused by intraoperative cardiac arrest in a patient with unspecified “cardiac anomaly”. In patients undergoing a Ravitch-type repair, we identified 11 non-lethal LCCs: 2 per/postoperative cardiac injuries; 6 delayed intracardiac bar migration (overall, 8 successful cardiac procedures under CPB were performed); 3 intrapericardial migration of broken sternal wire and consecutive tamponade treated by wire removal and pericardial drainage. Finally, we identified 1 case of ascending aortic injury caused by delayed migration of a fractured sternal wire requiring prosthetic aortic replacement 28 years after sternal turnover.
In patients undergoing a Nuss procedure we identified: 24 procedural cardiac injuries and 3 during bar removal; 1 case of intracardiac migration of the Nuss-bar (overall, 11 patients underwent a cardiac procedure under CPB); 2 procedural vena cava injuries; 6 obstructions of the inferior vena cava (3) or right ventricular outflow tract (3); 3 episodes of major bleeding from the ascending aorta leading to death in 1 patient; 2 pericardectomies and 2 delayed cardiac tamponades. Eight patients sustained procedural (3) or delayed (5) cardiac arrest and consecutive mortality in the latter group, the Nuss-bar impeding cardiopulmonary resuscitation manoeuvres. Overall, we identified 51 cardiovascular LCCs leading to 10 deaths and 2 cases of hypoxic brain injury.
Conclusions: Our review demonstrates a significant cardiovascular morbidity/mortality related to the Nuss procedure in comparison with open repair.