Osama A. Bawazir, Mark Montgomery, Joyce Harder, and David L. Sigalet Alberta Children's Hospital Alberta Children's Hospital Calgary, AB Midterm Evaluation of Cardiopulmonary Effects Of Closed Repair for Pectus Excavatum

 Etiology: arises from imbalanced or excessive growth of the lower costal cartilages, causing a posterior sternal depression  Causes: i. idiopathic (80%) ii. Associated MSK defect (20%) iii. Scoliosis (most common) iv. Poland’s syndrome v. Marfan’s, CP, CDH vi. Cardiac Defects (2%) Pectus Excavatum

Pectus Excavatum: Evaluation  History and Physical  CT Scan(Index: Transverse/AP)  Pulmonary Function Studies  Echocardiogram Treatment:  Mild: (CT index < 3) exercise and clavicle strap  Moderate/severe: (CT index > 3) operate IF: Patient Motivated Functional Impairment

Pectus Excavatum: Surgical Options Open Repair (Ravitch)  Repair of cartilaginous portion of ribs, preserving perichondrium Closed Repair (Nuss)  Insertion of corrective bar

Hypothesis From the initial study we hypothesized:  Pulmonary function will ↓ after surgery & will improve over time and after bar removal.  Improve the cardiac function and will not change after bar removal.  Exercise tolerance would ↓ post –op & improve over time and after bar removal.  Appearance & fitness will improve post-op and will not change after bar removal.

MATERIALS AND METHODS  Aim of this study is to see the long term cardiopulmonary effect of pectus repair.  48 patients had closed repair of pectus excavatum (Nuss technique).  limited CT scan, for evaluation of the “pectus index”.

pulmonary function, progressive exercise testing and echocardiography was done pre-Op, 3M, 24 M post-Op and 3M following bar removal

Pre and post operatively, patients and their parents were asked to evaluate their perception of appearance, and ability to exercise on a five point likkert scale Appearance Terriblenot satisfied satisfiedAlmost normal normal Ability to exercise SOB with minimal activity a bit better Daily activity without SBO Significantly better able to run the length of a soccer field without SBO

RESULTS  48 Pts have completed the initial pre op and then three-month post op  22 Pts evaluated at 21 month follow-up  11 Pts followed after bar removal  hospital stay being 5.0 ± 1.4 days  3 Pts had bars which moved or slipped  One Pts developed pericarditis which required anti-inflammatory therapy.

Pre OpPost Op (3 months) Post Op (21 months) After Bar removal n Age13.5 ± ± ± ± 1.0 CT Index3.9 ± 0.8 Appearance2.2 ± ± ± 1.0 Exercise Tolerance 2.0 ± ± ± ± 1.0 Data: mean ± SD Appearance: self-rating determined at post op interviews (1 unable to run → 5 able to run soccer field)

FVC  maximal amount of air breath out following maximal inspiration Data (as % expected norm for age/height) : mean ± SD *p<0.05 vs. preop by ANOVA, ‡ p<0.05 vs. post op at three months FVC &FEV 1 result were the same

 Fitness can be measured by VO2 max.  Anaerobic Threshold, also known as the lactate threshold, is the point where lactate (lactic acid) begins to accumulate in the bloodstream. Data (as % expected norm for age/height) : mean ± SD *p<0.05 vs. preop by ANOVA, ‡ p<0.05 vs. post op at three months

CO = HR x SVCI= CO/BSA Data (as % expected norm for age/height) : mean ± SD *p<0.05 vs. preop by ANOVA

DISCUSSION  There is an increase in cardiac function as measured by cardiac output.  Decrease in early pulmonary function, and progressive exercise testing in spite of subjective improvement in exercise tolerance.  Over the two-year follow-up after initial repair and following bar removal, the cardiac indices remain stable but pulmonary function and exercise tolerance improves significantly.  However these indices do not improve to measured norms of patients of similar age and size.

 with the increased cardiac and pulmonary function there is an improved overall exercise ability.  We suggest that repair results in a significant improvement in pulmonary and cardiac function over the longer term.  Longer studies with more Pts to determine the effect of repair on the global quality of life and the best timing of the repair.

Thank You