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Intrapericardial migration of dislodged sternal struts as late complication of open pectus excavatum repairs
© Zhang et al; licensee BioMed Central Ltd. 2011
Received: 12 January 2011
Accepted: 30 March 2011
Published: 30 March 2011
We present a case of sternal steel strut dislodgement and migration in a patient undergoing Ravitch repair for pectus excavatum (PE) 37 years ago. Broken struts perforated the right ventricle and right ventricular outflow tract (RVOT) and additionally migrated into the left upper lobar bronchus.
Dislodged sternal struts represent rare complications after surgical repair of patients suffering from pectus excavatum. Reviewing the literature, only five cases of intrapericardial migration of dislodged sternal struts or wires have been reported so far.
In our case, the first strut was removed from the airways through a left antero-lateral thoracotomy. Using cardiopulmonary bypass, a second strut was removed via ventriculotomy. These life-threatening sequelae underscore the importance of postoperative follow-up and early removal of osteosynthetic materials used in open PE repair. Accurate preoperative localization of migrated materials and availability of CPB support are crucial for successful surgical removal.
The migration of dislodged sternal steel struts or wires into the pericardium and cardiac cavities is a rare but life-threatening complication of open pectus excavatum (PE) repair . Removal of these materials poses a challenge for cardiothoracic surgeons. Herein, the authors report a case of migration of dislodged steel struts through the right ventricle and right ventricular outflow tract (RVOT) into the left upper lobar bronchus in a patient who underwent Ravitch repair 37 years ago.
A 53-year-old male with known persistent atrial fibrillation was admitted with progressive dyspnea and malaise, aggravated in sitting and stooping position. He had undergone surgical Ravitch repair for PE deformity 37 years ago.
As internal stabilization, metal struts or wires have been widely used in open PE repair. The struts are used to stabilize the sternum at the desired level, reduce the incidence of recurrent sternal depression and prevent paradoxical respiration . Strut removal is recommended 6 to 12 months after repair [1–8]. Beside migration into pleural and peritoneal cavity, intrapericardial migration of dislodged metal struts or wires has been reported as an uncommon, but life-threatening sequela.
Summary of the reported cases on intrapericardial migration of sternal wires or struts following open PE repair.
Migrated metal material
Time of complication after repair (yrs)
Elami et al. 19918
Sudden chest pain and dyspnoea
Removal of parts of the metal plate and suture of the right atrium
Dalrymple-Hay et al. 19971
Right and left ventricular cavities
Progressive lower limb ischemia
Removal of the struts via aortotomy and atriotomy
Onursal et al. 19993
Stabbing chest pain
Removal of the steel struts followed by pledgeted sutures
Right anterior thoracotomy
Barakat et al. 20047
Removal of some wires
Mieno et al. 20106
Sudden chest pain
Resection and replacement of ascending aorta
Present case report
Right ventricle, RVOT and left upper lobe bronchus
Progressive dyspnoea and malaise
Removal of the struts via ventriculotomy
Left anterior thoracotomy
The previously reported intrapericardial migration of sternal struts or wires occurred between nine months and 28 years after initial open PE repair. In the present case, intracardiac migration of steel struts was found even 37 years after initial surgery. It underscores again the importance for early removal of sternal struts or wires, if chest wall stability is sustained. Distinguished from sternal wires, steel struts seemed to be able to migrate deeper and result in perforation into the cardiac cavities, probably due to their size and inflexible character. The presenting symptoms of intrapericardial injury are variable and could be unspecific. However, in three out of six cases, patients were admitted due to sudden chest pain. The intrapericardial injury was mostly described at the right ventricle. Dalrymple-Hay et al. reported a patient with multiple embolic events nine months after Ravitch repair. The used steel strut migrated through the pericardium into the right ventricle, across the interventricular septum into the left ventricular cavity. Comparatively, migrations of metal material into the right ventricle were associated with less severe symptoms and could remain undiscovered for a long time, as described in the presented case.
Surgical approaches for removal of migrated materials in pericardium depend on the location of the struts and the injured structures. CPB support or steady state was required in most reported cases and the present case as well. The migrated material could be removed through directional pull followed by defect closure via running sutures. However, aortotomy and atriotomy were required for removal of the thrombus in the left ventricular cavity in the case reported by Dalrymple-Hay et al.  In the present case, ventriculotomy at RVOT was necessary for removal of the second strut. This emphasizes again the necessity to treat such life-threatening sequelae in a center of cardiothoracic surgery.
In summary, intrapericardial migration of sternal struts or wires is a rare, but severe complication of open PE repair. Accurate localization of migrated materials by means of 3-D reconstruction of CT scan images and steady state of CPB are crucial for a successful surgical removal.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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