Abstract
We report about a 37 year old male patient with a pectus excavatum. The patient was in NYHA functional class III. After performed computed tomography the symptoms were thought to be related to the severity of chest deformation. A Ravitch-procedure had been accomplished in a district hospital in 2009. The crack of a metal bar led to a reevaluation 2010, in which surprisingly the presence of an annuloaortic ectasia (root 73 × 74 mm) in direct neighborhood of the formerly implanted metal-bars was diagnosed. Echocardiography revealed a severe aortic valve regurgitation, the left ventricle was massively dilated presenting a reduced ejection fraction of 45%. A marfan syndrome was suspected and the patient underwent a valve sparing aortic root replacement (David procedure) in our institution with an uneventful postoperative course. A review of the literature in combination with discussion of our case suggests the application of stronger recommendations towards preoperative cardiovascular assessment in patients with pectus excavatum.
Highlights
There are no guidelines concerning the clinical evaluation of patients with isolated pectus excavatum prior surgical repair, but some recommendations do exist [1,2]
The following cardiological investigations revealed a tricuspid aortic valve with a severe aortic regurgitation due to an annuloaortic ectasia (73 × 74 mm root), a massively dilated left ventricle (LVEDD 85 mm) without hypertrophy and a slightly reduced ejection fraction of 45%
Historically, when underlying anatomical structures were not considerably affected by the pectus excavatum, a two-stage repair with a first intervention focused on the cardiovascular pathology followed by a second operation addressing the thoracic wall was recommended [3]
Summary
There are no guidelines concerning the clinical evaluation of patients with isolated pectus excavatum prior surgical repair, but some recommendations do exist [1,2]. A broken and dislocated lower metal bar with concomitant instability (Figure 2) led to a reevaluation in May 2010. After realization of a follow up computed tomography surprisingly and as a co-finding, a severely dilated ascending aorta >7 cm was found, located in direct neighborhood to the metal bars (Figure 3). After inspection of the aortic valve and almost complete resection of the ascending aorta, a valve sparing aortic root replacement (David procedure) using a straight 30 mm Hemashield prosthesis with lateral insertion of the coronary ostia was performed. Apart from a short period of atrial flutter and a spontaneously resolved paralytic ileus the patient’s postoperative course was uneventful and he was discharged at day 10 postoperatively
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