Eur J Cardiothorac Surg 2000;17:495-497
© 2000 Elsevier Science NL
Combined repair of pectus excavatum and coronary artery bypass grafting
Dmitry Pevni,
Oren Lev-Ran,
Itzhak Shapira,
Rephael Mohr
Department of Thoracic and Cardiovascular Surgery, Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizman Street, Tel-Aviv 64239, Israel
Corresponding author. Tel.: +972-3-697-3322; fax: +972-3-697-4439
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Abstract
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Coronary artery bypass grafting (CABG) in patients with severe pectus excavatum is a surgical challenge. A two-stage correction of sternal deformities and cardiac lesions has been described and myocardial revascularization through a left lateral thoracotomy is a valid alternative in urgent situations. We report a one-stage repair of severe pectus excavatum and CABG with the use of bilateral internal thoracic arteries in a young patient requiring urgent myocardial revascularization. The technical aspects and operative consideration are discussed.
Key Words: Skeletonized internal thoracic artery • Pectus excavatum • Coronary artery bypass grafting
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1. Introduction
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Severe pectus excavatum complicates cardiac operations through a midsternal approach. Concurrent correction of sternal deformity and cardiac lesions have been reported [1,2], however, in none of these cases myocardial revascularization was required. This report describes a one-stage repair of sternal deformity and coronary artery bypass grafting (CABG). The technical aspects and operative consideration are discussed.
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2. Case report
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A 55-year-old male patient with severe pectus excavatum was referred for urgent CABG after an extensive anterior wall myocardial infarction. Coronary catheterization demonstrated significant three-vessel disease, including severe stenosis of a dominant right coronary artery (RCA). Pulmonary function tests could not be obtained preoperatively, but the patient's history was suggestive of severe reduction in pulmonary functional capacity. The surgical approach consisted of a vertical midline incision performed directly over the sternal manubrium. The manubrium was divided at midline and its left half was separated from the sternum (Fig. 1A). Pectoralis and rectus muscle flaps were mobilized bilaterally, and a subperichondrial resection of all deformed cartilages (cartilages 3–7) was performed. Sternal ends of the malformed cartilages were disconnected and subperichondrial tissue was separated and mobilized. Excision of the malformed cartilages was completed and the intercostal muscles were dissected free of the sternum. This maneuver prevents internal thoracic artery (ITA) injury. A satisfactory exposure of the heart and ITAs was achieved by placing a sternal retractor between the disconnected ribs on the left and the rotated and displaced sternum on the right. Harvesting of the left and right ITA was performed as skeletonized vessels, (without the use of electrocautery). Standard cardiopulmonary bypass (CPB) was instituted and three anastomoses were constructed: the right ITA to left the anterior descending (LAD) artery, the left ITA to the first marginal branch of the circumflex artery (LCX), and a saphenous vein graft to the posterior descending artery (PDA). After termination of CPB and reversal of heparin, sternal repair was completed, using the technique described by Shamberger et al. [3]. Transverse sternal osteotomy was created at the level of sternomanubrial junction with resection of a triangular wedge. The posterior table was angulated anteriorly and the sternum was elevated to the desired position (Fig. 1A,B). Suture wires were placed to close the wedge osteotomy. Reattachment of the perichondrial sheaths to the sternum followed by approximation of the rectus and pectoralis muscles completed the repair.
Late outcome and cosmetic results were excellent (Fig. 2).
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3. Discussion
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To the best of our knowledge, this is the first report of concomitant repair of pectus excavatum and myocardial revascularization. Combined correction of sternal deformities and intra-cardiac lesions has been described [1,2]. A two-stage approach for pectus repair and myocardial revascularization has been applied to non-urgent cases [4]. Approach through a left lateral thoracotomy is a valid alternative in patients with pectus excavatum when urgent myocardial revascularizatioin is required [5]. However, despite its availability, this technique has several limitations (1) branches of the RCA system are inaccessible for grafting, (2) the right ITA is unapproachable for harvesting and (3) simultaneous repair of the pectus deformity can not be performed.
A one-stage correction of the sternal deformity confers several benefits. It is anticipated that correction of the restrictive chest deformity will reduce postoperative pulmonary complications. Furthermore, the risk for injury of patent coronary grafts at time of sternal repair is prevented.
Considerations with regard to repeat CABG may influence conduit selection. The use of bilateral ITAs is associated with a reduced incidence of repeat CABG [6]. We therefore preferred to use two ITAs in this case. Harvesting of bilateral ITAs is associated with increased risk of sternal complications. However, mobilizing the ITAs as skeletonized vessels preserve collateral blood flow to the sternum, hence, reduce this risk [7,8]. The reduced risk of sternal complications provided by skeletonized ITA, coupled with superior patency conferred by arterial grafting, may justify the use of bilateral skeletonized ITAs in a young patient.
Three features of the sternal repair described herein should be emphasized: (1) It is possible to preserve both ITAs during resection of the malformed cartilages. (2) The described repair achieves sufficient exposure for ITA harvesting and coronary grafting. (3) Concurrent sternal repair should not prevent bilateral ITA use if harvested as skletonized arteries.
In conclusion, a one-stage approach for the correction of pectus excavatum and urgent CABG is feasible and may be recommended. For young patients, bilateral skeletonized ITAs should be considered.
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References
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Received July 26, 1999;
received in revised form January 18, 2000;
accepted January 25, 2000.
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Abstract
1. Introduction
