Eur J Cardiothorac Surg 2006;29:630-631
© 2006 Elsevier Science NL
Heart failure following left-sided pneumonectomy in a patient with known pectus excavatum — successful treatment using the Ravitch procedure
Stefan Welter
*
,
Marc Hinterthaner,
Georgios Stamatis
Ruhrlandklinik Essen, Department of Thoracic Surgery, Tüschener Weg 40, G-45239 Essen, Germany
Received 20 October 2005;
accepted 25 November 2005.
* Corresponding author. Tel.: +49 201 433 01; fax: +49 201 433 1716. (Email: Stefan.We{at}t-online.de).
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Abstract
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A rare case of a patient with progressive dyspnoea due to atrial compression between ascending and descending aorta is demonstrated. After neoadjuvant chemoradiation for a locally advanced nonsmall cell lung cancer stage IIIb, he had a left-sided pneumonectomy. The underlying problem for cardiac compression was the extreme mediastinal shift reinforced by a congenital pectus excavatum. Our treatment was a Ravitch procedure with fair result.
Key Words: Heart failure • Pneumonectomy • Pectus excavatum
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1. Introduction
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Postoperative hyperinflation of the remaining lung with mediastinal shift is a known and normal effect of pneumonectomy resulting in a loss of pulmonary function of about 30–40% compared to preoperative function [1]. Heart failure is not to be expected postoperative if pulmonary hypertension or relevant cardiac dysfunction is ruled out before. There is a different situation, when physical conditions negatively affect the left-side rotation of the heart. Under these circumstances pectus excavatum can compress cardiac structures and cause progressive heart failure. Grillo et al. [2] described 11 cases with postpneumonectomy syndrome. The mechanism of mediastinal shift and hyperinflation of the remaining lung caused airway obstruction with progressive malacic changes. Mediastinal repositioning with the use of prostheses in some was the therapy of choice. We report a case with the underlying congenital disorder of pectus excavatum, where cardiac compression was the main pathomechanism following left-sided pneumonectomy.
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2. Case report
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A 63-year-old male patient with a known pectus excavatum was diagnosed in April 2002 with a left central squamous cell carcinoma involving the lower left lobe and the mediastinal nodes. According to the 1997 revision of the International System for Staging Lung Cancer, the clinical tumor stage was T4, N3, M0. Echocardiography was normal at this time. The treatment was initialized with four cycles of neoadjuvant chemotherapy (Cisplatin/Taxol) followed by sequential radiation with 30 Gy. Recording to the good response to the induction treatment operative resection was possible resulting in a left-sided pneumonectomy. Histopathologic examination showed a tumor stage ypT2, N0, R0, G2.
Readmission of the patient was necessary 7 months later because of increasing dyspnoea on exertion with immediate improvement on lying down. The echocardiography showed a moderate impression of the left atrium with otherwise normal situation of the chambers, valves, and pressure profiles. No pulmonary congestion was found in a right heart catheterization. At this time the symptoms could be improved by the puncture of a little pericardial effusion and antimicrobiotic treatment. Another admission followed 6 months later due to further deterioration of dyspnoea which evolved whenever the patient got up out of bed. In hospital, he needed a wheel chair to get to his investigations.
Along with the right lung hyperinflation, a mediastinal shift to the left as well as a shrinking of the left hemithorax was diagnosed. A CT scan revealed a left atrial impression caused by the descending aorta and pulmonary artery (Fig. 1a). Cardiac compression due to pectus excavatum was stated. The echocardiography showed an important impression of the left atrium with an opening area of the mitral valve of less than 1 cm2. An increasing mitral valve stenosis was found in the upright position due to a sinking down of the heart into the smallest sterno-vertebral distance.
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Fig. 1. CT scans before (a) and after (b) the Ravitch procedure showing correction of the shortest distance between sternum and vertebral column.
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The treatment was a Ravitch operation [3]. Intraoperative anchoring of the two wires was difficult due to the extremely weak and osteoporotic sternum and ribs. ICU treatment was of 3 days; mobilization on ground floor was successful at the 6th postoperative day. The transesophageal echocardiogram revealed a left atrial compression in-between the descending aorta and the pulmonary artery comparable to a medium-grade mitral valve stenosis. He was discharged home on the 13th day and could leave the hospital walking (Fig. 1b). The last outpatient visit was in January 2004 that showed markedly improved symptoms and condition.
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3. Discussion
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Pectus excavatum is a rare congenital deformity of the chest wall, usually noticed within the first year of life. Accepted indications for operative correction are dyspnoea on exertion, shortness of breath at rest, pain, and palpitations or other cardiac symptoms [4]. In moderate degree of pectus excavatum, there are normal pressures in the heart chambers but improvement of right and left ventricular volumes can be achieved by operative correction [5]. We presented a case where an asymptomatic pectus excavatum caused major problems after left-sided pneumonectomy. Due to the reduced space behind the deformed sternum all mediastinal structures were gradually rotated to the left. Finally, the left atrium was compressed causing a mechanical heart failure with dyspnoea at rest (NYHA IV). Postpneumonectomy mediastinal shift is a well-known problem. Some authors described mediastinal repositioning with various forms of plombage in the empty hemithorax. Results are varying with a high postoperative mortality [2]. In the majority of these cases, bronchial obstruction was the main indication and not atrial compression. There are no reports in the literature about correction of pectus excavatum after left-sided pneumonectomy jet, but one of the right side [6]. Our postoperative result was fair, improving the patient's main symptoms particularly the dyspnoea. We also observed a significant improvement of walking distance from 20 to 150 m in 6 min. The sternal correction did not change the distinct mediastinal shift but did reduce the atrial compression in the upright position. Lung function testing showed not markedly changes probably caused by postoperative pain, the wires and the long-term consequence of the shrinking left hemithorax.
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4. Conclusion
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The operative correction of pectus excavatum after left-sided pneumonectomy in a patient with heart failure due to atrial compression was the only possible way to relief symptoms. The patient improved without major complications. It is worth thinking about correcting the sternal deformity prior to pneumonectomy to prevent extreme mediastinal shift of serious consequence.
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References
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Abstract
1. Introduction
