|Correction of chest wall defects known as pectus excavatum (sternal
depression) and pectus carinatum (sternal protrusion) are now available
to patients. At the University of Minnesota, Pediatric Surgeons, Robert
Acton MD and Daniel
Saltzman MD Ph.D., perform both major techniques of pectus repair
(Ravitch and Nuss) as well as the Leonard Technique for the Pectus repair.
Dr. Arnold Leonard, now retired Adjunct Professor of Surgery from the University
of Minnesota, has performed more than 1500 of these procedures with
remarkable success. Upon his retirement, he has "passed the torch" to his
What is Pectus Excavatum and Pectus Carinatum?
The defect known as pectus excavatum, or funnel chest, and pectus carinatum, know as pigeon breast, are congenital anomalies of the anterior chest wall. The excavatum defect is characterized by a deep depression of the sternum, usually involving the lower half or two thirds of the sternum, with the most recessed or deepest area at the junction of the chest and the abdomen. The lower 4-6 costal or rib cartilages, dip backward abnormally to increase the deformity or depression and push the sternum posterior or backward toward the spine. Also, in many of these deformities, the sternum is asymmetric or it courses to the right or left in this depression. In most instances, the depression is on the right side. Also, because of the pressure of the sternum and cartilages, the abdomen looks like a "potbelly". The entire defect also pushes the midline structures so that the lungs are compressed from side to side and the heart (right ventricle) is compressed and displaced.
excavatum defect is found in somewhere between 1 in every 500-1000
children. It does occur in families and thus, is inherited in many
instances. Other problems, especially in the muscle and skeletal system,
also may accompany this defect. In approximately 1/5 of the patients,
scoliosis is present. The defect is seen shortly after birth and then
progresses to its maximum after the growth period in adolescence. The
regression or any improvement in this defect rarely occurs because of the
fixation of the cartilages and the ligaments. When one takes a deep breath
or inspires, the defect is usually accentuated.
|What are the symptoms related to pectus excavatum and pectus carinatum?|
The symptomatology of this defect many times is not really apparent until the child participates in athletic or high stress activities. As children, the individuals are shy and many times will not participate where their chest is exposed such as in swimming or athletic events. As the child progresses in age, the symptoms, easy fatigability, decreased stamina and decreased endurance become apparent especially during competitive athletics. Also, adults in the twenties and thirties year age groups and elderly adults, become very aware of this problem. If they have not participated in physical activities during high school, newer fitness programs bring out the easy fatigability; cardiac arrhythmias and tachycardia during these extensive physical and strenuous exercises have been reported. The moderately to very severe defects, where the heart is displaced to the left of the sternum or the midline, may cause a murmur and this murmur is really due to the pressure on the system causing rough instead of smooth flow. The electrocardiogram also can demonstrate strain on the right side of the heart. The expansion of the lungs during breathing or exercise which is important to maintaining normal respiratory function is confined because the chest wall cannot expand. Thus, more intensive and rapid respiratory rate is necessary. Also, the diaphragm is called upon to make larger movements to provide enough oxygen and carbon dioxide exchange to meet the demand of the body under exercise conditions. More energy is thus utilized for breathing and contributes to fatigue, in contrast to the normal individual.
It is interesting, also, that there has been an increased incidence in respiratory infections and asthma reported by several authors. Almost all of these individuals have a body configuration of rounded shoulders and a "potbelly". Front and lateral view chest x-rays demonstrate the defect and displacement of the heart to the left of the midline as well as compression of the right ventricle. How can one test this defect with pulmonary function test or cardiac output evaluation? In most instances, conventional pulmonary function tests or cardiac stress echocardiograms to measure cardiac output and function are normal with the patient at rest. If the patients, however, are subjected to upright intense exercise, the cardiac output is usually decreased when compared to normal individuals of the same age. Also, the respiratory function is reduced, and depending on the severity of the defect, this reduction can be from 10-30%.
correction of the defects, the function returns to near normal in the
majority of the patients. These studies have been corroborated by groups
at other institutions as well as our own. Studies using a bike-ergometer,
both before and after pectus excavatum chest deformity surgery, have shown
an increased ability to expand the lung and exchange oxygen and carbon
dioxide. Also, fatigue rarely occurred after expansion of the lung. Also,
the heart rate is slower and the ability to exercise at high levels of
energy output is improved. It is important, therefore, to realize that the
pectus excavatum deformity is not just a cosmetic problem. One only has to
ask the 30 and 40 year old or the athletic teenager whether he is having
difficulty with his strenuous exercise activities. A good history and
physical exam is important. This history combined with the x-rays should
be the indication for surgical intervention. Patients with moderately to
severe uncorrected deformity usually cannot be competitive in major
activities. The continuous beating of the heart against a firm bone may
also lead to arrhythmias. We have treated patients up to 70 years of age.
|What can be done to correct these conditions?|
|What are the average results of surgical corrective treatment?|
When our patients were specifically asked, the results of these operations have been rated excellent and very good. Most individuals have reported an increased ability to participate in normal strenuous activities and athletics.† Also, there is a marked improvement in the patient's self image. The operations are carried out for physiologic reasons, not for cosmesis, although the cosmesis is a benefit with the correction. Many of the small children are teased by their schoolmates and they become very inhibited and reclusive. They, many times, refuse to take showers with the other kids and during physical education, refuse to take their shirts off during these activities. We have found that this does not decrease with age. We have carried out a number of procedures in 30-40 year olds and even in 60 year olds who have marked limitation in physical and social activities. In the 60 year old age group, arrhythmias have been the most challenging problem and these have been referred in by cardiologists. Once pressure on the right ventricle is relieved, the symptoms disappear.
of the chest deformity, in almost all instances, should allow the
individuals the ability to participate in full activities. Because this
new procedure has a marked decrease in morbidity and cost, greater numbers
of patients are having this surgical correction performed (especially in
the 30-40 year old age group). This new corrective procedure is rarely
turned down by insurance companies due to the increased understanding of
it not being a cosmetic defect.
*There are health risks associated with all invasive
References: Wolf WM., Fischer MD, Saltzman DA, and Leonard AS:
Surgical Correction of Pectus Excavatum and Carinatum. Minnesota Medicine 70:447-453, 1987
Soto L, Kirzeder D, Larsen D, Saltzman D, Leonard A; The Leonard Modification of the Ravitch Procedure for Pectus Excavatum Repair, J Amer. Coll. Surgeons, 197(3suppl): S32, 2003.
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