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Dawn E. Jaroszewski, MD, David M. Notrica, MD, Lisa E

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1 Operative Management of Acquired Thoracic Dystrophy in Adults After Open Pectus Excavatum Repair 
Dawn E. Jaroszewski, MD, David M. Notrica, MD, Lisa E. McMahon, MD, Fayaz A. Hakim, MBBS, Jesse J. Lackey, CSFA, CST, James F. Gruden, MD, D. Eric Steidley, MD, Kevin N. Johnson, MD, Farouk Mookadam, MB, BCh  The Annals of Thoracic Surgery  Volume 97, Issue 5, Pages (May 2014) DOI: /j.athoracsur Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

2 Fig 1 (A) Three-dimensional computed tomographic image of a 42-year-old male patient with acquired thoracic dystrophy (ATD). (B) Chest roentgenogram and computed tomographic scan of same patient with ATD demonstrating restricted thoracic space and left-sided cardiac displacement. The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur ) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

3 Fig 2 (A) Intraoperative chest wall reconstruction using bridging spaces created between osteotomy sites to increase overall dimensions of anterior chest in both anteroposterior and lateral aspects. Titanium plating was then used to plate across, stabilize, and secure to adjacent chest wall and sternum. (B) Polyglactin 910 mesh was attached posteriorly to bridging gaps in a sling-type fashion and bone graft paste was injected into space. (C) Large bony defect was covered and filled with antibiotic-impregnated Palacos polymethyl methacrylate (PMMA). PMMA was fashioned to fit chest wall defect with overlap of chest wall borders and molded to fit within defect borders. Titanium plating was compressed into PMMA before hardening and screw placed to plate across, stabilize, and secure to ribs and peristernal attachments. This plating was also used across the PMMA implant to stabilize to chest wall. (D) Pectoral and rectus abdominis muscles were then brought back across chest and secured to midline and lower chest wall using nonabsorbable braided suture. The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur ) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

4 Fig 3 Patient with acquired thoracic dystrophy. Note thoracic hypoplasia and abnormal thoracic inlet with prominent clavicle and manubrium. The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur ) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

5 Fig 4 Intraoperative transesophageal echocardiography was performed both after induction of anesthesia and at completion of surgical correction with confirmation of relief of cardiac compression. (A) Preoperative midesophageal (ME) 4-chamber transesophageal echocardiographic view showing compression of right atrium (RA) (arrowhead) and right ventricle (RV) (arrow) caused by the pectus excavatum (PE) (asterisk). The dotted lines mark the PE angle. (B) Postoperative ME 4-chamber transesophageal echocardiographic view of the same patient showing considerable relief of right atrial and right ventricular compression. (C) Preoperative ME transesophageal echocardiographic view at level of interatrial septum (IAS) showing marked compression of RA (dotted arrow) caused by PE (asterisk). Swan-Ganz catheter can be seen in RA (arrowhead). (D) Postoperative ME 4-chamber transesophageal echocardiographic view at level of IAS showing relief of compression after surgical treatment of PE. Swan-Ganz catheter can be seen in RA (arrowhead). (E) Preoperative transesophageal echocardiographic ME view showing marked RA (arrow) and basal RV (arrowhead) compression by PE (asterisk). (F) Postoperative transesophageal echocardiographic ME view showing relief of RA and RV compression after surgical treatment of PE. (TV = tricuspid valve.) The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur ) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

6 Fig 5 Computed tomographic axial images of a patient with acquired thoracic dystrophy (ATD) (A) before and (B) after reconstructive surgical intervention. The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur ) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

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