Chest Pain and Dyspnea After a Minimally Invasive Repair of Pectus Excavatum

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Right ventricular outflow tract compression by a displaced intrathoracic pectus bar following minimally invasive repair of pectus excavatum (n=1). Intervention: Surgical removal of displaced intrathoracic pectus bar with intraoperative transesophageal echocardiography. Primary outcome: Resolution of right ventricular outflow tract compression, symptoms, and continuous-wave Doppler velocity.

Q: What does this research mean for the field?

Surgical removal of a displaced intrathoracic pectus bar resolves right ventricular outflow tract compression and alleviates associated postoperative chest pain and dyspnea. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Juan Farina; Michael B. Gotway; Carolyn Larsen; Jesse J. Lackey; Kristen A. Sell‐Dottin; Steven T. Morozowich; Dawn E. Jaroszewski

doi:10.1016/j.jaccas.2021.11.011

April 1, 2022JACC Case ReportsOpen Access

Chest Pain and Dyspnea After a Minimally Invasive Repair of Pectus Excavatum

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Key result

Displaced pectus bar removal resolves RVOT compression and lowers Doppler velocity to ~1.2 m/s.

n=1

Why the study?

Damage to cardiovascular structures is an infrequent complication that can occur during or following a minimally invasive repair of pectus excavatum.

Key Points

To document a rare case of right ventricular outflow tract compression caused by a displaced intrathoracic bar following minimally invasive repair of pectus excavatum and describe its diagnostic and surgical management.
Evaluated an otherwise healthy 41-year-old male presenting with chest pain, exertional dyspnea, and palpitations 6 months after a minimally invasive repair of pectus excavatum with intrathoracic bars.
Assessed bar displacement and cardiac compromise using chest radiography, computed tomography, transthoracic echocardiography, and intraoperative transesophageal echocardiography.
Transesophageal echocardiography identified severe extrinsic right ventricular outflow tract compression with turbulent flow from the displaced bar, which was missed on transthoracic echocardiography due to limited acoustic windows.
Surgical removal of the bar relieved the outflow tract obstruction, reducing continuous-wave Doppler velocities from 1.89 m/s preoperatively to 1.18 m/s postoperatively with restored laminar flow.
The patient had resolution of chest pain, marked improvement in breathing capacity at 1-week follow-up, and was discharged on postoperative day one without complications.

Study Design

Type

Case Report (n=1)

Multicenter

No

Structured PICO

P

Population

1 otherwise healthy 41-year-old male with right ventricular outflow tract compression from a displaced intrathoracic pectus bar 6 months after minimally invasive repair of pectus excavatum, followed for 1 week post-removal.

I

Intervention

Immediate surgical removal of the displaced intrathoracic pectus bar under intraoperative transesophageal echocardiography (TEE) guidance with cardiovascular surgery and cardiopulmonary bypass standby.

O

Outcome

Relief of right ventricular outflow tract (RVOT) obstruction, improvement in continuous-wave Doppler velocity across the RVOT, and resolution of chest pain and dyspnea at 1-week postoperative follow-up.surrogate

Main Result

Absolute Event Rate: 1.18% vs 1.89%

Limitations

Single-patient case report
Limited transthoracic acoustic window on preoperative transthoracic echocardiography
Lack of clear consensus regarding echocardiographic criteria for assessing right ventricular outflow tract obstruction severity
Single-patient case report design
Transthoracic echocardiography had a limited acoustic window due to leftward heart displacement and metal bars
No clear consensus regarding echocardiographic criteria for assessing RVOT obstruction severity

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Implication

In patients with persistent cardiopulmonary symptoms after minimally invasive pectus excavatum repair, computed tomography and transesophageal echocardiography are critical to diagnose cardiac compression from bar displacement, which is reversible with prompt surgical bar removal.

Abstract

Although infrequent, damage to cardiovascular structures can occur during or following a minimally invasive repair of pectus excavatum. We present a case of right ventricular outflow tract compression caused by a displaced intrathoracic bar. Removal of the bar resulted in an improvement in symptoms and hemodynamics. ( Level of Difficulty: Advanced. ) Key Words: complication, computed tomography, echocardiography, right ventricle, thoracic Abbreviations and Acronyms: CT, computed tomography; MIRPE, minimally invasive repair of pectus excavatum; PEx, pectus excavatum; RVOT, right ventricular outflow tract; TEE, transesophageal echocardiography; TTE, transthoracic echocardiography

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Cite This Study

Farina et al. (2022) conducted a case report in Right ventricular outflow tract compression by a displaced intrathoracic pectus bar following minimally invasive repair of pectus excavatum (n=1). Surgical removal of displaced intrathoracic pectus bar with intraoperative transesophageal echocardiography was evaluated on Resolution of right ventricular outflow tract compression, symptoms, and continuous-wave Doppler velocity. Surgical removal of the displaced pectus bar resolved right ventricular outflow tract compression and chest pain, reducing continuous-wave Doppler velocity from 1.89 m/s to 1.18 m/s.

synapsesocial.com/papers/6aeb4b586c1f4ccb39c7802e https://doi.org/10.1016/j.jaccas.2021.11.011

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Chest Pain and Dyspnea After a Minimally Invasive Repair of Pectus Excavatum

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Chest Pain and Dyspnea After a Minimally Invasive Repair of Pectus Excavatum

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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