Friday, August 22, 2014

Pectus Excavatum - Dr. Nasirov @ Sutter Memorial Hospital

Pectus Excavatum Article Recaps - Dr. Nasirov - Chief of Pediatric Cardiac Surgery, Sutter Medical Center
Teimour Nasirov
Identifying pectus excavatum in the primary care setting
The most common chest wall disorder treated at Sutter Children’s Center, Sacramento is pectus excavatum, a deformity that occurs in approximately one in 300 live births. Historically pectus excavatum has been viewed as a cosmetic concern but studies suggest that those who do not under-go surgery during childhood experience progressively worsening symptoms and cardiopulmonary function as they age. In the June 2014 The Nurse Practitioner, Kathryn Baker Lew, MSN, RN, FNP-C suggests it is the role of the primary care provider to offer an appropriate and timely diagnosis by using chest radiographs (chest X-ray and non-contrast CT scan), the Haller index and echocardiograms.
Conclusion: By screening for severe pectus excavatum cases, a primary care referral for surgery can improve cardiovascular function, exercise tolerance and body image.
Lew. Kathryn Baker. Identifying pectus excavatum in the primary care setting. The Nurse Practitioner. 2014 June. 39(6). 
Pectus excavatum causes limited cardiac function during exercise. A recent study published in The Society of Thoracic Surgeons tested a hypothesis that cardiopulmonary exercise function would improve after the Nuss procedure. Fourty-four teenage patients and 26 controls completed a 3-year study. When the 44 patients were tested preoperatively the forced expiratory volume (FEV1) and maximum cardiac index were lower in patients compared to the 26 controls.
Conclusion: Year one post-operatively both the parameters had increased, but only FEV1 had normalized. When tested 3 years post-operatively and after bar removal, cardiopulmonary function in patients during exercise had normalized.
Maagaard ET AL. Normalized Cardiopulmonary Exercise Function in Patients With Pectus Excavatum Three Years After Operation. The Society of Thoracic Surgeons. 2013; 96:272–8
While pectus excavatum is usually present at birth and through childhood, the severity of the depression worsens during the adolescent growth spurt. According to this article in Current Opinion in Pediatrics, 2011, Frazier W. Frantz suggests the introduction of the minimally-invasive Nuss procedure, along with the increased awareness for this deformity as both an anatomic and function problem has increased referrals for pectus excavatum repair and provided for better clinical analyses to define underlying physiologic impairments. While patients undergo evaluation for this condition at any age, the optimal timing for pectus excavatum repair is 10–14 years of age, while the chest wall is still malleable. Regular follow-up through pubertal growth is recommended.
Conclusion: Following the "Evaluation and Treatment Algorithm for Primary Repair of Pectus Excavatum" noted in the article provides clinical identification of patients and protocols for screening and treatment. While the Nuss procedure is most popular because of its less-invasive nature, open repair may still be used for patients with severe asymmetry of the chest wall or mixed pectus deformities.  
Frantz, Frazier W. Indications and guidelines for pectus excavatum repair. Current Opinion in Pediatrics. 2011. 23:486–491

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