1. 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

2.  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

3. 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

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

5. 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.

6. 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”.

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

8. 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 12345 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

9. 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.

10. Pre OpPost Op (3 months) Post Op (21 months) After Bar removal n48 2211 Age13.5 ± 1.713.8 ± 1.815.7 ± 1.216.0 ± 1.0 CT Index3.9 ± 0.8 Appearance2.2 ± 1.84.1 ± 1.04.5 ± 1.0 Exercise Tolerance 2.0 ± 1.83.8 ± 1.24.5 ± 1.24.5 ± 1.0 Data: mean ± SD Appearance: self-rating determined at post op interviews (1 unable to run → 5 able to run soccer field)

11. 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

12.  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

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

14. 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.

15.  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.

16. Thank You