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Modified Nuss Procedure for Pectus Excavatum Repair After Prior Sternotomy and Cardiac Repair: A Review of the Chest Wall International Group’s Experience

Dawn E. Jaroszewski(1), Paul J. Gustin(1), F-M Haecker(2), Hans Pilegaard(3), HJ Park(4), Shao-tao Tang(5), Shuai Li(5), Sadashige Uemura(6), Jose R. De Campos(7), Robert Obermeyer(8), FW Frantz(8), Michele Torre(9), Lisa McMahon(10), Andre Hebra(11), Chih-Chun Chu(11), J. Duncan Phillips(12), Antonio Messineo(13), Robert Kelly(14), Donald Nuss(14)

(1)Division of Cardiothoracic Surgery, Mayo Clinic Arizona, USA

(2)University Children’s Hospital Basel, Basel, Switzerland

(3)Aarhus University Hospital, Skejby, Denmark

(4)Seoul St. Mary’s Hospital, Seoul, South Korea

(5)Wuhan Union Hospital, China

(6)Kawasaki Medical School, Kurashiki, Japan

(7)Hospital das Clinicas, Sao Paulo, Brazil

(8)Department of Pediatric Surgery, Children’s Hospital of the King’s Daughters, Norfolk, VA, USA

(9)Pediatric Surgery Instituto G. Gaslini, Genoa, Italy

(10)Department of Pediatric Surgery, Phoenix Children’s Hospital, Phoenix, AZ, USA

(11)Medical University of South Carolina, Charleston, SC, USA

(12)Country Hospital, Taipei Taiwan

(13)WakeMed Health & Hospitals, Raleigh, NC, USA

(14)Meyer Children’s Hospital, Florence, Italy


Background: Pectus excavatum (PE) can be associated with cardiac anomalies and some patients may have had prior sternotomy and cardiac procedures. Use of the Nuss procedure after sternotomy for PE repair is controversial.

Methods and patients: A survey of surgeons from the Chest Wall International Group was performed for data on patients for which they performed an attempted Nuss after prior sternotomy during November 2000–August 2015.  Patient clinical records, demographics, operative course, outcomes and surgeon experience were summarized.

Results: Thirteen surgeons reported on 72 patients with prior sternotomy for cardiac surgery a mean of 7.7 years (median 5.7, range 0.8-27.2) before pectus repair. Mean age at PE repair was 11.5 years (median of 8.8, range 1.7-48.7); Haller index 5.1 (median of 3.96, range 2.8-20.5); 54.2% males; 98.6 % were successfully repaired with a modified Nuss. However, in 15.3% a redo sternotomy was performed prior to placement of support bars. Assisted sternal elevation (45.8%) and subxiphoid dissection (12.5%) was also described. Three cases of cardiac perforation occurred with no mortalities reported. Nine of 13 centers (69%) had cardiopulmonary bypass on standby should cardiotomy be experienced.

Conclusions: A modified Nuss procedure can be used to successfully repair PE in the majority of patients after prior sternotomy. The risk of cardiac injury is greater in this population and technique modifications including forced sternal elevation and directly visualized subxiphoid dissection should be considered if significant mediastinal adhesions are present. Re-sternotomy may be necessary and cardiopulmonary bypass should be available.