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Table of Contents
Year : 2013  |  Volume : 16  |  Issue : 3  |  Page : 205-208
Emergent cardiopulmonary bypass during pectus excavatum repair

Department of Anesthesiology, Mayo Clinic Hospital, Phoenix, Arizona, USA

Click here for correspondence address and email

Date of Submission20-Feb-2013
Date of Acceptance29-Apr-2013
Date of Web Publication29-Jun-2013


Pectus excavatum is a chest wall deformity that produces significant cardiopulmonary disability and is typically seen in younger patients. Minimally invasive repair of pectus excavatum or Nuss procedure has become a widely accepted technique for adult and pediatric patients. Although it is carried out through a thoracoscopic approach, the procedure is associated with a number of potential intraoperative and post-operative complications. We present a case of cardiac perforation requiring emergent cardiopulmonary bypass in a 29-year-old male with Marfan syndrome and previous mitral valve repair undergoing a Nuss procedure for pectus excavatum. This case illustrates the importance of vigilance and preparation by the surgeons, anesthesia providers as well as the institution to be prepared with resources to handle the possible complications. This includes available cardiac surgical backup, perfusionist support and adequate blood product availability.

Keywords: Cardiac perforation, Cardiopulmonary bypass, Epidural anesthesia, Nuss procedure

How to cite this article:
Craner R, Weis R, Ramakrishna H. Emergent cardiopulmonary bypass during pectus excavatum repair. Ann Card Anaesth 2013;16:205-8

How to cite this URL:
Craner R, Weis R, Ramakrishna H. Emergent cardiopulmonary bypass during pectus excavatum repair. Ann Card Anaesth [serial online] 2013 [cited 2022 Oct 6];16:205-8. Available from:

   Introduction Top

Patients with pectus excavatum may suffer from effects on mental well-being, such as impaired body image [1] as well as significant cardiopulmonary limitations including exercise intolerance, shortness of breath, [2] and decreased cardiac index compared to healthy controls. [3] There is evidence that quality of life, [4] body self-image, [5] and cardiac function can all benefit from repair. [6],[7] Minimally invasive repair of pectus excavatum (MIRPE) or Nuss procedure initially published in 1998 [8] has become a widely accepted surgical technique for pectus excavatum repair. It involves inserting convex steel bars under the sternum often with thoracoscopic assistance through small lateral thoracic incisions across the mediastinum, with the convexity directed anteriorly to correct the abnormality. The procedure is associated with significant post-operative pain, far greater than that reported with sternotomy or thoracotomy, which is arguably best treated with thoracic epidural analgesia. [9] Although less invasive than a traditional open repair (Ravitch); the Nuss procedure also has a list of potential intraoperative and post-operative complications described almost exclusively in the surgical literature, including wound infection, pneumothorax, [10],[11] bar displacement, [12] thoracic outlet syndrome, [13] liver laceration or cardiac perforation. [14],[15],[16] We present a case of cardiac perforation in a 29-year-old male undergoing Nuss bar placement to emphasize the importance of appropriate and anticipatory anesthetic management for these procedures.

   Case Report Top

A 29-year-old male with Marfan syndrome presented to our institution for surgical correction of pectus excavatum. Approximately 6 years previously he had undergone mitral valve repair with a 34 mm annuloplasty band and excision of the middle scallop of the posterior leaflet for mitral valve prolapse. During the same operation, he also underwent Maze procedure and subsequently required permanent pacemaker placement for bradycardia. Upon interrogation of his pacemaker at admission, he was found "not pacemaker dependent". He was otherwise healthy without comorbidity; complaining only of dyspnea with exertion, and on no home medications. He was admitted to our facility for minimally invasive repair with a possible combination Ravitch procedure in the setting of severe, symptomatic pectus excavatum with a Haller index (H.I.) of 6.2. His perioperative echocardiogram demonstrated left ventricular ejection fraction of 60-65%, a mitral valve diastolic mean gradient of 4 mmHg post-repair, normal aortic valve and ascending aortic diameter of 4 cm, which was stable when compared to previous computed tomography scans. The cardiac surgical service requested placement of a thoracic epidural catheter for post-operative analgesia and it was placed without difficulty at the T6-T7 interspace in the pre-operative area. In the operating room general anesthesia was induced with fentanyl, propofol and rocuronium and maintained with sevoflurane. Lung isolation was obtained with a left sided double-lumen endobronchial tube to assist with thoracoscopic visualization. It is our practice at the Mayo Clinic to routinely perform intraoperative transesophageal echocardiography to gauge the severity of right ventricular compression [Figure 1] and evaluate biventricular function in these patients, and more importantly to monitor for post-implant bleeding. As a high volume adult pectus repair center, we do not routinely place central venous catheters for primary pectus repair, except in the setting of significant cardiac dysfunction, numerous or severe medical comorbidities or an extensive revision procedure. We routinely place large bore peripheral intravenous access 16 gauge or greater and invasive arterial monitoring. During the operative procedure, thoracoscopy revealed significant pericardial and pleural adhesions, which made dissection difficult. Continued surgical manipulation lead to a sudden tear of the right atrial wall with immediate hemorrhage and acute hemodynamic instability with systolic blood pressures in the 60-70 mmHg range associated with heart rates in the 120s. A central venous catheter was rapidly placed for volume resuscitation and central venous pressure monitoring. The decision was made to proceed with an open sternotomy to allow adequate surgical access to repair the atrial laceration. A dose of 24,000 units of heparin was administered approximately 182 min after the epidural catheter placement with a resultant activated clotting time of > 999 s. A second cardiothoracic surgeon was called into the operating room and the arterial and venous catheters were placed in the femoral vessels and fem-fem cardiopulmonary bypass was initiated. The atrium was repaired with pledgets and the pectus repair was completed with the placement of 2 bars and re-approximation of the sternum over the bars. There was significant blood loss intra-operatively and the patient received 14 units of packed cells, 10 units of fresh frozen plasma, 10 units of cryoprecipitate, and 2 units of platelets. Upon completion of the surgical procedure, the patient was taken to the intensive care unit intubated and sedated. He was successfully extubated on the post-operative day 1 and had no evidence of neurologic injury. His pain was well controlled with epidural infusion of 0.2% ropivacaine. Sequential compression of the lower limbs and early ambulation were initiated for deep venous thrombosis prophylaxis. His epidural catheter was removed on the post-operative day 4 after return of normal coagulation studies. He was subsequently discharged home on the post-operative day 9 in good condition.
Figure 1: Transesophageal echocardiograpy transgastric basal short axis view demonstrating left ventricular/right ventricular compression in presence of significant pectus excavatum

Click here to view

   Discussion Top

The reported incidence of cardiac perforation during a MIRPE is rare, ranging from 0% [17] to 0.4%. [18] In a review of case reports of cardiac perforation during Nuss bar placement, Bouchard et al. [19] suggest certain factors that place patients at a greater risk for cardiac injury. These include the severity of the chest wall deformity, a redo MIRPE after open procedure, and previous cardiac surgery. Although, the incidence of major complications is low, when it happens it can be catastrophic. Severity of a pectus deformity can be quantified using the H.I. [20] It is calculated by measuring the inner width of the chest (at the lowest level of the pectus defect) and dividing it by the distance between the posterior surface of the sternum (at the lowest part of the defect) and the anterior surface of the spine. A H.I. for a normal individual should be around 2.5, a H.I. greater than 3.1 is considered severe, [21] and the H.I. for our patient was 6.2.

The anesthetic implications of care for patients with significant pectus deformities range from hemodynamic instability at induction from altered right ventricular function (with the reduction in venous return from administered anesthetics and positive pressure ventilation) as well as restrictive lung physiology from the altered thoracic cavity. There are also many intraoperative perturbations that can occur including arrhythmias from manipulation of the heart, bleeding and cardiac compression during bar insertion and positioning. Once the bars are in place, the ability to perform cardiac compressions in the setting of cardiac arrest is also significantly limited. [22] Post-operatively, close hemodynamic monitoring and aggressive intervention for hemodynamic or pulmonary deterioration and providing adequate analgesia are the major anesthetic care issues.

The American Society of Regional Anesthesia guidelines (2010) for regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy state that the utility of placement of epidural catheters in patients undergoing cardiopulmonary bypass remains unclear. [23] Chaney, [24] suggests precautions for neuraxial blockade in cardiac surgery should include frank avoidance in the setting of coagulopathy, delaying the procedure in the event of a traumatic tap, 60 min between epidural catheter placement and systemic heparinization, tight control of heparin dosing and reversal and finally removal of the catheter only when normal coagulation is restored. Our case report supports these suggestions as our patient had a good outcome with atraumatic catheter placement, systemic heparinization and removal of the catheter after restoration of normal coagulation parameters. For those patients in whom epidural anesthesia is contraindicated, there are other modalities to assist in management of their acute post-operative pain including IV patient-controlled analgesia with opioids and other adjunctive agents including intravenous acetaminophen or N-Methyl-D-aspartic acid agonists such as ketamine. Continuous subcutaneous local anesthetic infusions, such as those delivered by the ON-Q Pain Relief System have had favorable results for post-sternotomy, [25],[26] and post-thoracotomy [27] pain and also have been used in our institution for analgesia post-MIRPE. When available, transitioning to oral opioids with non-steroidal anti-inflammatory drugs such as a cyclooxygenase-2 selective inhibitors [28] as well as a neuropathic pain agent such as gabapentin or pregabalin are also options prior to discharge.

MIRPE is becoming more common and is also being carried out in older patients. [29] A pre-operative discussion between attending surgeon and anesthesiologist is mandatory. This is especially important in any patient that had previous cardiac surgery, or previous pectus repairs, the aim is to assess the difficulty of the surgical exposure and if there is concern about mobilization of the heart or major vascular structures. The positive history of previous surgery and ensuing adhesions has serious implications for the anesthetic. Patients with severe pectus deformities can develop acute hemodynamic deterioration following induction of general anesthesia, especially those with significant right atrial and right ventricular compression. It is also important for a facility to be prepared with resources to handle the possible complications, including available cardiac surgical backup, perfusionist support and adequate blood product availability. In the post-operative setting, having a sound plan for post-surgical analgesia adds to patient recovery and satisfaction. Consultation with the hospital pain service may be indicated to assist in the care of these patients. In summary, surgical management of pectus deformity can pose significant challenges to the anesthesiologist. We must be vigilant and prepared to manage the most severe intraoperative complications as they occur.

   References Top

1.Steinmann C, Krille S, Mueller A, Weber P, Reingruber B, Martin A. Pectus excavatum and pectus carinatum patients suffer from lower quality of life and impaired body image: A control group comparison of psychological characteristics prior to surgical correction. Eur J Cardiothorac Surg 2011;40:1138-45.  Back to cited text no. 1
2.Kelly RE Jr, Shamberger RC, Mellins RB, Mitchell KK, Lawson ML, Oldham K, et al. Prospective multicenter study of surgical correction of pectus excavatum: Design, perioperative complications, pain, and baseline pulmonary function facilitated by internet-based data collection. J Am Coll Surg 2007;205:205-16.  Back to cited text no. 2
3.Lesbo M, Tang M, Nielsen HH, Frøkiær J, Lundorf E, Pilegaard HK, et al. Compromised cardiac function in exercising teenagers with pectus excavatum. Interact Cardiovasc Thorac Surg 2011;13:377-80.  Back to cited text no. 3
4.Lawson ML, Cash TF, Akers R, Vasser E, Burke B, Tabangin M, et al. A pilot study of the impact of surgical repair on disease-specific quality of life among patients with pectus excavatum. J Pediatr Surg 2003;38:916-8.  Back to cited text no. 4
5.Kelly RE Jr, Cash TF, Shamberger RC, Mitchell KK, Mellins RB, Lawson ML, et al. Surgical repair of pectus excavatum markedly improves body image and perceived ability for physical activity: Multicenter study. Pediatrics 2008;122:1218-22.  Back to cited text no. 5
6.Malek MH, Berger DE, Housh TJ, Marelich WD, Coburn JW, Beck TW. Cardiovascular function following surgical repair of pectus excavatum: A metaanalysis. Chest 2006;130:506-16.  Back to cited text no. 6
7.Huang PM, Liu CM, Cheng YJ, Kuo SW, Wu ET, Lee YC. Evaluation of intraoperative cardiovascular responses to closed repair for pectus excavatum. Thorac Cardiovasc Surg 2008;56:353-8.  Back to cited text no. 7
8.Nuss D, Kelly RE Jr, Croitoru DP, Katz ME. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg 1998;33:545-52.  Back to cited text no. 8
9.Densmore JC, Peterson DB, Stahovic LL, Czarnecki ML, Hainsworth KR, Davies HW, et al. Initial surgical and pain management outcomes after Nuss procedure. J Pediatr Surg 2010;45:1767-71.  Back to cited text no. 9
10.Redlinger RE Jr, Kelly RE Jr, Nuss D, Kuhn MA, Obermeyer RJ, Goretsky MJ. One hundred patients with recurrent pectus excavatum repaired via the minimally invasive Nuss technique: Effective in most regardless of initial operative approach. J Pediatr Surg 2011;46:1177-81.  Back to cited text no. 10
11.Schalamon J, Pokall S, Windhaber J, Hoellwarth ME. Minimally invasive correction of pectus excavatum in adult patients. J Thorac Cardiovasc Surg 2006;132:524-9.  Back to cited text no. 11
12.Miller KA, Woods RK, Sharp RJ, Gittes GK, Wade K, Ashcraft KW, et al. Minimally invasive repair of pectus excavatum: A single institution's experience. Surgery 2001;130:652-7.  Back to cited text no. 12
13.Moss RL, Albanese CT, Reynolds M. Major complications after minimally invasive repair of pectus excavatum: Case reports. J Pediatr Surg 2001;36:155-8.  Back to cited text no. 13
14.Becmeur F, Ferreira CG, Haecker FM, Schneider A, Lacreuse I. Pectus excavatum repair according to Nuss: Is it safe to place a retrosternal bar by a transpleural approach, under thoracoscopic vision? J Laparoendosc Adv Surg Tech A 2011;21:757-61.  Back to cited text no. 14
15.Castellani C, Schalamon J, Saxena AK, Höellwarth ME. Early complications of the Nuss procedure for pectus excavatum: A prospective study. Pediatr Surg Int 2008;24:659-66.  Back to cited text no. 15
16.Park HJ, Lee SY, Lee CS. Complications associated with the Nuss procedure: Analysis of risk factors and suggested measures for prevention of complications. J Pediatr Surg 2004;39:391-5.  Back to cited text no. 16
17.Nuss D. Minimally invasive surgical repair of pectus excavatum. Sem Pediatr Surg 2008;17:209-17.  Back to cited text no. 17
18.Hebra A, Swoveland, Egbert M, Outcome analysis of minimally invasive repair of pectus excavatum: Review of 251 cases. J Pediatr Surg 2000;35:252-8.  Back to cited text no. 18
19.Bouchard S, Hong AR, Gilchrist BF, Kuenzler KA. Catastrophic cardiac injuries encountered during the minimally invasive repair of pectus excavatum. Semin Pediatr Surg 2009;18:66-72.  Back to cited text no. 19
20.Haller JA Jr, Kramer SS, Lietman SA. Use of CT scans in selection of patients for pectus excavatum surgery: A preliminary report. J Pediatr Surg 1987;22:904-6.  Back to cited text no. 20
21.Jaroszewski D, Notrica D, McMahon L, Steidley DE, Deschamps C. Current management of pectus excavatum: A review and update of therapy and treatment recommendations. J Am Board Fam Med 2010;23:230-9.  Back to cited text no. 21
22.Zoeller GK, Zallen GS, Glick PL. Cardiopulmonary resuscitation in patients with a Nuss bar: A case report and review of the literature. J Pediatr Surg 2005;40:1788-91.  Back to cited text no. 22
23.Horlocker T, Wedel D, Rowlingson J, Enneking F, Kopp S, Benxon H, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American society of regional anesthesia and pain medicine evidence based guidelines. Reg Anesth Pain Med 2001;35:64-101.  Back to cited text no. 23
24.Chaney MA. Intrathecal and epidural anesthesia and analgesia for cardiac surgery. Anesth Analg 2006;102:45-64.  Back to cited text no. 24
25.White PF, Rawal S, Latham P, Markowitz S, Issioui T, Chi L, et al. Use of a continuous local anesthetic infusion for pain management after median sternotomy. Anesthesiology 2003;99:918-23.  Back to cited text no. 25
26.Dowling R, Thielmeier K, Ghaly A, Barber D, Boice T, Dine A. Improved pain control after cardiac surgery: Results of a randomized, double-blind, clinical trial. J Thorac Cardiovasc Surg 2003;126:1271-8.  Back to cited text no. 26
27.Wheatley GH 3 rd , Rosenbaum DH, Paul MC, Dine AP, Wait MA, Meyer DM, et al. Improved pain management outcomes with continuous infusion of a local anesthetic after thoracotomy. J Thorac Cardiovasc Surg 2005;130:464-8.  Back to cited text no. 27
28.Croitoru DP, Kelly RE Jr, Goretsky MJ, Lawson ML, Swoveland B, Nuss D. Experience and modification update for the minimally invasive Nuss technique for pectus excavatum repair in 303 patients. J Pediatr Surg 2002;37:437-45.  Back to cited text no. 28
29.Pilegaard HK. Extending the use of Nuss procedure in patients older than 30 years. Eur J Cardiothorac Surg 2011;40:334-7.  Back to cited text no. 29

Correspondence Address:
Ricardo Weis
5777 East Mayo Boulevard, Phoenix, Arizona 85054
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-9784.114249

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