Combining Modified Ravitch Approach for Pectus Excavatum With Complex Cardiac Surgery

Pectus excavatum repair using a modified Ravitch technique can safely be combined with cardiac surgery in a single operation, with low bleeding risk and good long-term outcomes. That’s the conclusion of the authors of a series of 11 patients who underwent the complex surgery at Cleveland Clinic as reported in Seminars in Thoracic and Cardiovascular Surgery (2021 Mar 6; online ahead of print).

“We published our experience to let surgeons know that combining pectus repair with cardiac surgery is a viable option for patients with multiple indications for the operation,” says Cleveland Clinic thoracic surgeon Daniel P. Raymond, MD, senior author of the case series. “We also want to increase awareness that pectus excavatum has implications beyond cosmesis.”

Staged or combined approach?

Especially in patients with a connective tissue disorder, pectus excavatum and congenital or acquired heart disease are often found together. Whether a staged or combined strategy is best to address both problems has not been well established, and few reports of simultaneous repair exist in the literature.

Those who argue for a staged approach cite bleeding, sternal wound infections, complicated sternal reentry (if required) and chest wall instability as potential complications of a single procedure. On the other hand, simultaneous repair offers the opportunity to correct cardiac problems and relieve the compression of cardiac chambers and restrictive lung disease brought about by severe pectus excavatum in a single operation.

“Pectus excavatum can be an important source of pathology by causing distortions in cardiac anatomy,” says Cleveland Clinic cardiac surgeon Patrick Vargo, MD, a co-author of the case series. “Compression by the chest wall can make it difficult to determine the cause of symptoms, contribute to cardiac dysfunction and make surgical outcomes less predictable if left untreated.”

Case series in summary

The series consisted of patients who underwent a modified Ravitch procedure for severe pectus excavatum at the time of cardiac surgery at Cleveland Clinic between 2012 and 2020.

There were 11 patients with the following characteristics:

• 7 males/4 females, median age 35 years (range, 12-74)
• Confirmed connective tissue disorder in eight
• No prior chest operations in eight; prior Nuss procedures in two; patent ductus arteriosus ligation in infancy followed by valve-sparing root replacement at age 2 in one
• Mean Haller index of 7.3 ±2 (range, 3.8-13)

The patients’ concomitant cardiac procedures were valve-preserving aortic root replacement (n = 7) or mitral valve repair (n = 4). Surgical details and outcomes were as follows:

• Median total operative time, 400 minutes (range, 347-712)
• Median total cardiopulmonary bypass time, 168 minutes (range, 57-211)
• Mean (± SD) stay in the intensive care unit, 82 ± 56 hours
• Mean (± SD) hospital stay, 9.1 ± 4 days

There were no reoperations for bleeding, tamponade or other indications, and no deaths occurred in-hospital or during follow-up.

Special considerations for combined approach

Dr. Raymond emphasizes the importance of a multidisciplinary team when considering performing this combined surgery. He notes that pectus excavatum is rare enough that most cardiac surgeons do not have the experience to contemplate conducting both operations at once. He adds that patients managed by Cleveland Clinic’s Center for Chest Wall Disease are evaluated by cardiac surgery, cardiology and cardiothoracic anesthesiology teams preoperatively.

Drs. Raymond and Vargo highlight the following critical points from their experience:

• Combined pectus/cardiac repair offers several important advantages. In addition to needing only a single surgery, correcting the pectus alleviates compression of the heart and enhances mitral valve repair by allowing a more normal anatomic shape. Dr. Raymond adds that “pectus repair after sternotomy is problematic, and I do not recommend it.” He points out that cardiac surgery with sternotomy creates adhesions between the heart and posterior sternum, potentially causing traction injury to the heart during a subsequent pectus repair.
• Modified Ravitch approach and left parasternal incision are recommended. Unlike a standard median sternotomy, this strategy provides excellent exposure for a variety of cardiac procedures in patients with pectus excavatum (see figure). “This approach offers no limitations on cardiac surgery,” says Dr. Vargo.

Figure. (A) A Cooley sternal retractor is placed to visualize the mediastinum. As the retractor is opened, the sternum is rotated and retracted to the right for optimal exposure of the heart and aortic root aneurysm. (B) Axial illustration of the rotation and retraction of the sternum with the retractor opened. Reprinted from Zaki et al. Semin Thoracic Cardiovasc Surg (2021 Mar 6; online ahead of print). © 2020 The Cleveland Clinic Foundation.

• The combination strategy using the modified Ravitch is safe. No increased need for perioperative transfusions was observed. To minimize bleeding, the team recommends packing the dissection plane before systemic heparinization following weaning from cardiopulmonary bypass and administering protamine.
• Adequate analgesia should be provided postoperatively. Pain medication needs are increased from the combined surgery compared with cardiac surgery alone. Because of the need for bypass, an epidural block cannot be used before the surgery but may be used afterward. A variety of strategies were used to minimize narcotic use, including acetaminophen, lidocaine patch, intravenous ketolorac and ibuprofen. Thoracic epidural catheters, continuous erector spinae plane catheters and traditional chest wall nerve blocks can be used for additional pain control if needed.
• Patient education and input are critical. Patients should be prepared that the surgery and hospital stay will be longer and more pain control will be required. After discharge, drains must often be left in longer than standard heart surgery (usually one to two weeks), so patients who live far from the hospital will need to arrange to stay nearby for the duration.

In a commentary accompanying the article, two thoracic surgeons from Brigham and Women’s Hospital and Harvard Medical School wrote: “The addition of a Ravitch to open cardiac procedure, besides being ideal in the synchronous management of two pathologies that impact one another, allows the patient to recover from one procedure. When done with skill and expertise, the outcomes can be superb.”