Pectus Excavatum Research Articles

Description of Case: A 14-year-old male with a Haller Index of 6.1 was referred to cardiology clinic for evaluation of severe pectus excavatum (PE). He was asymptomatic but was incidentally found to have incessant atrial tachycardia (AT) with a left atrial focus predicted based on p wave morphology analysis on electrocardiogram. On echocardiogram, he had evidence of left atrial compression and moderate left ventricular systolic dysfunction, consistent with tachycardia induced cardiomyopathy. Initial medical therapy with ivabradine, flecainide, and atenolol led to rate control and subsequent improvement in left ventricular function but failed to terminate the arrhythmia. He underwent surgical repair of the PE. Postoperatively, left ventricular function normalized, but AT persisted despite continued escalation to ivabradine, sotalol, and flecainide. An electrophysiology study performed 8 weeks from surgical repair identified a focal AT arising from the left atrial posterior wall. The focus was successfully eliminated with radiofrequency ablation. He has since remained in sinus rhythm and off antiarrhythmic therapy with full recovery of ventricular function. Discussion: Pectus excavatum is the most common anterior chest wall deformity. Though often a benign, asymptomatic, cosmetic anomaly, PE has been associated with several cardiac effects including hemodynamic compromise and arrhythmias secondary to cardiac compression. To our knowledge, this is the first pediatric case of persistent, drug refractory AT requiring catheter ablation, despite surgical correction of the PE. The p wave morphology on electrocardiogram, left atrial deformity on echocardiogram, and intracardiac activation map of the AT focus in this case, support cardiac compression as the mechanism for AT. These findings suggest the potential for sustained atrial remodeling with subsequent arrhythmia in the context of PE and underscores the importance of cardiac screening in asymptomatic adolescents with severe chest wall deformities.

This study aimed to implement and evaluate an enhanced recovery after surgery pathway for pediatric patients undergoing the Nuss procedure. The enhanced recovery after surgery pathway was implemented in 2024, and this protocol included preoperative education and counseling, a perioperative multimodal pain management protocol, a perioperative staged rehabilitation exercise program, and predischarge education. Data were collected prospectively for patients in the ERAS pathway and retrospectively for previous patients. Length of stay (LOS) and activity of daily living (the Barthel Index) were the main outcomes of this study, and the pain scores and time to first ambulation postoperatively were the secondary outcomes. A total of 86 patients were included in this study, with 43 patients in each group. There was no significant difference in age, sex, or the Haller index between the two groups. The average LOS decreased from 7.74 days to 6.84 days with ERAS. Patients in the ERAS group had improved Barthel indices, particularly on the day of discharge, and significantly lower pain scores from POD0 to POD3. The time to first ambulation was also shorter in the ERAS group. An enhanced recovery after surgery procedure implemented for the Nuss procedure can reduce the length of stay and early pain score. Alterations in the pathway may lead to the achievement of the desired goals of better self-care ability in daily living. Not applicable.

Time heals: The impact of waiting times on pediatric patients' decisions to decline pectus surgery.

Chest wall deformities are considered a risk factor for lung transplantation. A 5-year-old girl with protein surfactant C deficiency, interstitial lung disease, pulmonary hypertension, pectus excavatum (Haller 5.9) underwent lung transplantation and Nuss bar placement. Correction of her pectus was necessary to accommodate donor lungs. She was discharged after 18 days. We hope this youngest described child who underwent simultaneous transplant and pectus correction with excellent outcomes will lead others to consider concomitant surgeries.

Nonsurgical interventions typically emphasize patients safety, minimum complications, and cost effectiveness compared to surgical procedures. The aim of this study was to conduct a systematic review to evaluate the efficacy of vacuum bell therapy as a nonsurgical option for managing pectus excavatum in pediatric patients. Vacuum bell therapy. A systematic review adhering to PRISMA guidelines was conducted, we searched four electronic databases (PubMed, Scopus, and Web of Science) up to August 15, 2024. The search focused on PE and vacuum therapy. Inclusion criteria targeted pediatric patients, while unsuitable studies were excluded. The JBI Critical Appraisal Checklist, New Castle Ottawa scale assessment and Cochrane Risk-of-Bias Tool for Randomized Trials (RoB 2) were utilized to assess risk of bias. Twenty studies met the criteria. Risk of bias was low in two, moderate in thirteen, and high in five studies. VB therapy duration varied from 30min to several hours daily. Factors influencing outcomes included age, chest wall flexibility, PE severity, VB duration, and symmetry. The most common correction pattern was poor > fair > good > excellent, with good results observed as early as six months. Complications were mild and temporary, not requiring medication. VB therapy shows significant improvement in preteens with mild PE. Efficacy depends on age, chest flexibility, severity, and therapy duration. The lack of randomized controlled trials limits the strength of the evidence. The effectiveness of vacuum bell therapy in failed surgeries or in preventing injuries during procedures like the Nuss, needs further investigation, and if no visible results are seen after 6 to 12months, surgery should be considered.

Thoracic hyperkyphosis can occur idiopathically, in the context of Scheuermann's disease, or in association with neuromuscular or metabolic disorders. Treatment depends on the patient's age, severity of the deformity, and underlying conditions. Conservative measures such as physiotherapy and reclination bracing are used in mild cases, whereas surgical correction is indicated for kyphosis exceeding 60-70°. A known association exists between hyperkyphosis and pectus excavatum, the latter of which can cause cardiac symptoms. However, the impact of surgical kyphosis correction on cardiac symptoms in patients with concurrent pectus excavatum remains unclear. We present the case of a boy born in 2006 with progressive thoracic hyperkyphosis and pectus excavatum. Despite conservative therapy involving physiotherapy and bracing, the deformity progressed. In December 2023, a dorsal correction spondylodesis (Th6-L2) with Smith-Peterson osteotomies (Th8-L1) was performed. The kyphosis was corrected from 108° to 42°. Postoperatively, the patient developed tachycardia and dizziness. A pericardial effusion and a newly diagnosed right bundle branch block were detected. Radiological evaluation showed a reduction in the retrosternal space from 7.5cm to 5.2cm. Subsequently, surgical correction of the pectus excavatum was performed, leading to the resolution of symptoms and an increase in the retrosternal space to 8.7cm. This case study demonstrates that surgical correction of thoracic hyperkyphosis in the presence of pectus excavatum can lead to the clinical manifestation of previously asymptomatic cardiac issues. Due to the biomechanical interaction between the spine, ribs, and sternum, deformities in this region can influence each other. We recommend checking preoperatively whether pectus excavatum is present and then correcting it surgically as a priority to avoid cardiac complications.

To identify the risk factors associated with the development of post-Nuss procedure scoliosis in pectus excavatum patients and to establish a relevant predictive model. A retro-spective review was conducted on pectus excavatum patients who underwent Nuss procedure in Department of Thoracic Surgery at Beijing Jishuitan Hospital between January 2018 and February 2023. We gathered the patient demographic information (including age, sex, height, weight, and body mass index) and diagnostic imaging results (echocardiogram, chest CT scan, full-spine radiography, and PA/lateral chest X-rays), and measurements of Haller index, asymmetry index, sternal torsion angle (STA) index, and Cobb angle changes. The risk of post-Nuss procedure scoliosis was assessed. Cox regression analysis was performed to identify independent risk factors for scoliosis development in the pectus excavatum patients. Based on the results of the Cox regression analysis, a risk prediction model was established, and its specific predictive performance was assessed through internal cross-validation. A total of 59 pectus excavatum patients who underwent Nuss procedure were included after applying inclusion and exclusion criteria. The median follow-up duration was 6.84 months, and the follow-up results showed significant improvements in Haller index, STA index, and asymmetry index postoperatively. Twelve patients developed scoliosis 3 months after Nuss procedure, while 47 patients did not, the incidence of scoliosis was 20.3%. Cox regression analysis identified preoperative pulmonary artery hypertension and preoperative asymmetry index as independent risk factors for post-Nuss procedure scoliosis. A predictive model was constructed based on single-factor Cox regression analysis results, incorporating age, height, weight, body mass index, preoperative pulmonary artery hypertension, preoperative Haller index, STA index, asymmetry index, and Cobb angle. The receiver operating characteristic (ROC) curve was plotted, and the area under the curve (AUC) for the overall predictive model was calculated to be 0.995. A calibration curve demonstrated good alignment between predicted values and actual values. Nuss procedure achieved favorable clinical outcomes. However, postoperative scoliosis emerged as a significant complication with a high incidence rate. Pulmonary artery hypertension and asymmetry index were independent predictors of post-Nuss procedure scoliosis. The predictive model developed in this study demonstrated robust performance in estimating the risk of postoperative scoliosis.

Pectus excavatum (PE) is the most common deformity of the chest wall seen in children and adolescents. Besides its visible depression of the chest, this condition often causes functional impairments affecting the cardiovascular and respiratory systems, as well as postural issues. Additionally, the aesthetic aspect of the deformity can greatly impact the psychosocial well-being of those affected. This study aims to evaluate the effect of a tailored physiotherapy program on children and adolescents with PE, focusing on musculoskeletal, cardiopulmonary, postural, and balance measures. A total of 35 participants diagnosed with PE will be assessed using four complementary methods: myotonometry with MyotonPRO for the trapezius muscle involving all three fascicles and the pectoralis major muscle on both sides, cardiopulmonary exercise testing on a treadmill (including cardiopulmonary function), postural assessment with GaitOn, and static balance-stabilometry with PoData 2.0. These assessments will be performed before and three months after completing an individualized physiotherapy program, which participants will perform daily after proper instruction from a physical therapist. After three months, the initial and final results will be compared to determine how physical therapy influences treatment outcomes in patients with PE.

The treatment of pectus excavatum has historically been based on two main surgical techniques: the Ravitch procedure and the minimally invasive Nuss procedure. Both have demonstrated effectiveness over the years and have become well-established options in clinical practice. However, in recent years, a new approach known as the Pectus Up technique has emerged as an innovative and less invasive alternative for the correction of this congenital chest wall deformity. In this video tutorial, we present the case of a young male patient treated using the Pectus Up system, highlighting the surgical steps, clinical outcomes and potential advantages of this novel method compared to traditional techniques.

Potential role for immune cell signatures as predictors of acute and chronic pain in adolescents post major musculoskeletal surgery.

Nuss procedure is the standard technique for pectus excavatum repair. Despite its minimally invasive nature, this procedure is associated with significant postoperative pain and high opioid consumption. Intercostal nerve cryoablation (INC) has emerged as an adjunct to multimodal analgesia (MMA) to improve pain control, reduce opioid use, and shorten length of stay (LOS). This systematic review aims to assess INC outcomes following the Nuss procedure in pediatric patients.A systematic search was conducted in PubMed, Web of Science, Scopus, and Cochrane Library databases through December 2024. Studies comparing INC with standard MMA, with or without thoracic epidural, in pediatric patients undergoing the Nuss procedure were included. The primary outcome was LOS, and the secondary outcomes were opioid consumption, postoperative pain, complications, operative time, and hospitalization costs. Risk of bias was determined using the National Institutes of Health assessment tool. Meta-analysis was performed using R software.Eleven studies met the inclusion criteria, comprising 922 patients (476 INC and 446 control). INC significantly reduced LOS (-2.2 days; 95% CI: -2.8 to -1.8) at the expense of increased operating room time (+23 minutes; 95% CI: 10-39). Qualitative analysis showed reduced opioid use and comparable pain scores and complication rates with INC, while its impact on costs was conflicting.INC reduces LOS and opioid use in pediatric patients undergoing the Nuss procedure without increasing complications. Further studies are needed to assess long-term safety and cost-effectiveness.

Acute thoracic aortic dissection (ATAD) is a rare but life-threatening cardiovascular emergency, especially in patients with heritable thoracic aortic disease (HTAD). Early recognition and rapid intervention are essential to prevent fatal complications. A 42-year-old man with no prior diagnosis of cardiovascular disease presented with sudden severe tearing chest pain radiating to the back, accompanied by diaphoresis and nausea. Examination revealed elevated blood pressure in both arms, sinus tachycardia, and physical features suggestive of a connective tissue disorder, including mild pectus excavatum and disproportionately long extremities. Laboratory testing showed elevated D-dimer, while CTA confirmed a Stanford type A dissection extending from the ascending aorta to the proximal descending thoracic aorta. The diagnosis of acute type A dissection was established, and emergent surgery was performed. The patient underwent ascending aortic replacement with a Dacron graft and partial arch reconstruction. Intraoperative findings included a friable aortic wall consistent with connective tissue disease. Genetic testing later confirmed a pathogenic TGFBR2 mutation diagnostic of Loeys-Dietz syndrome. Written informed consent for publication was obtained. The patient underwent ascending aortic replacement (26-mm Dacron) with partial arch reconstruction under cardiopulmonary bypass; circulatory arrest duration was 28 minutes. At 12-month follow-up CTA and echocardiography showed durable repair and preserved ventricular function with only mild residual aortic regurgitation. This case highlights the need for rapid recognition, prompt surgery, genotype confirmation, and lifelong vascular surveillance in HTAD.

Reliability of External Caliper-Based Measurements for Identifying Severe Pectus Excavatum: Results from a Multi-Institutional Regional Consortium.

Osteopathic manipulative treatment improves mobility restrictions and statics in a patient with a pectus excavatum after a sternochondroplasty. A case report.

Preliminary study: Changes in systolic volume index during Nuss surgery.

Cosmetic repair after sternochondroplasty by modified Ravitch procedure for pectus excavatum in a thin patient: A novel mesh sandwich technique

Contemporary Management of Pectus Excavatum: A Survey of the Members of the American Pediatric Surgical Association

Pectus excavatum (PE) is the most common congenital chest wall deformity. While often perceived as a cosmetic issue, PE can impair cardiopulmonary function. Surgical correction has evolved from the Ravitch procedure to the minimally invasive Nuss technique, which offers reduced surgical risks and improved postoperative outcomes. However, diagnostic and therapeutic variability persists, highlighting the need for expert consensus. A 31-question web-based survey was distributed to CWIG members and PE specialists between November 2024 and January 2025. The survey explored five key domains: demographics, preoperative evaluation, surgical indications and timing, operative technique, and postoperative management. Responses from 100 international surgeons were analyzed. The most common indications for surgery were severe deformity (88.9%), Haller index > 3.25 (78.8%), psychosocial distress (77.8%), and symptoms (77.8%). Technique selection was influenced by prior surgery (48%) and surgeon experience (45.9%). For complex cases, 90.8% preferred the double-bar technique. Most surgeons removed the bar within 2-3years (86.6%). Postoperative pain was primarily managed with oral analgesics (64.6%) and IV pumps (47.5%). Early complications included pneumothorax (68.1%) and infections (62.8%); bar displacement (78%) was the most frequent late complication. Despite widespread adoption of the Nuss procedure, significant variation remains in PE management. These findings emphasize the need for standardized, evidence-based guidelines to optimize patient outcomes.

Minimally invasive repair of pectus excavatum (MIRPE) creates an iatrogenic communication between the pleural cavities, known as a "buffalo chest." Patients with pectus excavatum are also at increased risk of spontaneous pneumothorax due to congenital apical blebs. When these two conditions coexist, the risk of bilateral spontaneous pneumothorax becomes potentially life-threatening. This study aims to evaluate the incidence and characteristics of spontaneous pneumothorax following MIRPE, with particular attention to the presence and role of congenital blebs.We retrospectively reviewed patients who underwent MIRPE between 2005 and 2024 to identify cases of spontaneous pneumothorax. Only cases occurring at least 1 month postoperatively and unrelated to intraoperative thoracoscopy were included. Patients were followed for at least 10 months. We analyzed laterality, clinical presentation, presence of blebs, treatment, and outcomes. A systematic literature review was also conducted to explore the relationship between buffalo chest, pneumothorax, and pectus excavatum.Among 795 patients, 7 developed spontaneous pneumothorax: 4 unilateral, 3 bilateral. In six cases, blebs were identified and treated with thoracoscopic bullectomy and pleurodesis. Two patients with bilateral pneumothorax experienced cardiac arrest: one recovered after emergency drainage; the other died in a peripheral hospital, where blebs were suspected but not confirmed. The literature review identified nine similar cases in five reports.Bilateral spontaneous pneumothorax after MIRPE can be a life-threatening emergency due to the buffalo chest. Patients and families should be informed of this rare but serious risk to enable early recognition and prompt treatment. Preoperative detection of apical blebs may help reduce this risk.

Introduction: Chest wall deformities are congenital abnormalities of the sternum, ribs, and costal cartilage, most commonly presenting as pectus excavatum (sternal depression) or pectus carinatum (sternal protrusion). These conditions may cause cardiopulmonary dysfunction and psychosocial distress, particularly in adolescents. Radiology is essential for diagnosis, severity assessment, and treatment planning, utilizing indices such as the Haller Index and Pectus Correction Index (PCI). This report is unique as it describes diverse pediatric presentations, including a female adolescent with severe pectus excavatum, a case mimicking a chest wall tumor, and one combined with scoliosis. Case description: We report four pediatric cases with distinct chest wall deformities. Two adolescents presented with severe pectus excavatum (Haller Index >3.25), one with asymmetry and cardiac deviation, and another with symmetrical deformity. Two other patients demonstrated pectus carinatum, initially suspected to be chest wall tumors, confirmed by CT scan with Haller Index for Carinatum. Management varied from conservative bracing to surgical correction using the Nuss procedure, depending on severity and patient preference. Conclusion: This series highlights the critical role of imaging in differentiating deformities, quantifying severity, and guiding management. Radiology also enables monitoring of postoperative outcomes and complications. Early recognition and appropriate evaluation are vital to prevent cardiopulmonary compromise and long-term psychosocial impact. Radiology not only confirms the diagnosis but also prevents misdiagnosis and inappropriate interventions.