The physiologic impact of pectus excavatum repair
Section snippets
Resting pulmonary function testing
The majority of pectus patients do not have pulmonary parenchymal or airway disease, therefore any improvement in pulmonary function after pectus excavatum correction is likely attributable to an improvement in respiratory mechanics.10 At rest the diaphragm initiates most of the inspiratory effort. During exercise, more thoracic excursion is required to generate higher lung volumes, at which time the sternum and costochondral cartilage become more important for efficient respiration.14 Although
Chest wall motion analysis
In 2011, Redlinger et al. employed Optoelectronic Plethysmography (OEP), a form of motion analysis, to demonstrate regional chest and abdominal wall motion dysfunction in pectus excavatum patients. During deep breathing, the movement of the upper and lower sternum was decreased by 28–51%, and the abdominal wall motion was increased by 147% in pectus patients compared to matched controls. The significant increase in abdominal wall motion was hypothesized to be a compensatory reaction to a
Right ventricle
Analogous to resting PFTs, cardiac studies performed during rest may not provide a clear physiologic cardiac explanation for improved exercise tolerance. Jeong et al. demonstrated a statistically significant resolution of cardiac compression, namely the right ventricle, on computed tomography after pectus excavatum repair. However, it is important to recognize that supine imaging may underestimate the severity of this compression when the patient is in the upright position during exercise.11
Background
Exercise tolerance is difficult to measure, but cardiopulmonary exercise testing (CPET) is generally accepted as one of the most reliable methods to measure functional aerobic exercise capacity.16, 25,26 During CPET exercise capacity is quantified using peak oxygen uptake (vO2max, mL/min/kg) calculated by applying Fick's equation: (SVmax = max stroke volume; HRmax = max heart rate; CaO2max = max arterial oxygen content; CvO2max = mixed venous oxygen content)
Adult patients
A number of pectus excavatum patients may not experience cardiopulmonary symptoms until their later adult years or note progression of symptoms with aging.35, 36 This is more likely secondary to the increasing rigidity of the anterior chest wall structures versus worsening of the defect37. Adult pectus repair is more difficult and has higher complication rates reported.38, 39, 40, 41, 42, 43 Although symptoms are subjectively improved with surgical correction, there are only a few studies on
Resting pulmonary function testing
Only one study has been published assessing post MIRPE pulmonary outcomes in adults.44 Acosta et al reported no significant changes in either FEV1 or FVC at 6 months post repair, but there is no long term data which would be the appropriate measure of outcomes as previously discussed.
Right and left ventricle
A number of studies utilizing cardiac MRI for assessment of right and left ventricular dimensions/function have included adult patients however the information is not separated out from the younger population to allow further analysis by age group.24,45, 46, 47, 48 The majority of information available for the adult population on right ventricular (RV) and left ventricular (LV) function and volumes has come from intraoperative transesophageal echocardiogram (TEE).39,49, 50, 51, 52, 53 All but
Cardiopulmonary exercise testing
Assessment of the effects of surgical repair in adults by CPET has been reported in only 3 major studies, and only one after MIRPE. Follow up has been limited to the first year after operation. Neviere et al. 2011 evaluated 70 adult patients before and after an open modified Ravitch procedure.52 The significant findings in this study were that the adult PE patients had a reduced peak VO2 (77% of predicted) which increased after surgery. PE patients were able to achieve a higher aerobic exercise
Summary
Pediatric and adult patients experience subjective clinical improvement in exercise tolerance after pectus excavatum repair in the majority of cases. The benefits are likely multifactorial as suggested by studies demonstrating improved respiratory mechanics and increased stroke volume due to relief of right ventricular compression. The culmination of these physiologic effects is difficult to assess objectively, but cardiopulmonary exercise testing (CPET) currently represents the best
Disclosure statement
Obermeyer and Jaroszewski are product development consultants for Zimmer-Biomet, Inc., manufacturers of the bar used in the Nuss procedure.
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Cited by (36)
Non-surgical approaches to the management of chest wall deformities
2024, Seminars in Pediatric SurgeryOutcomes After Pectus Excavatum Repair: Center Volume Matters
2024, Journal of Pediatric SurgeryChanges in Pulmonary Functions of Adolescents with Pectus Excavatum Throughout the Nuss Procedure
2023, Journal of Pediatric SurgeryPectus Excavatum in Cardiac Surgery Patients
2023, Annals of Thoracic SurgerySpecific electrocardiographic findings in patients with pectus excavatum
2023, Revista Espanola de CardiologiaThe utility of echocardiography and pulmonary function testing in the preoperative evaluation of pectus excavatum
2022, Journal of Pediatric SurgeryCitation Excerpt :As mentioned earlier, there is a significant body of literature pointing to cardiopulmonary deficiencies in many patients with PE, particularly those at the severe end of the spectrum [1–10]. Several studies have documented postoperative improvements [2–4]. In fact, the evidence continues to move in this direction.