Abstract
BACKGROUND: The management of severe pectus excavatum (PEx) in patients with multiple prior sternal reconstructions presents unique challenges for safe median sternotomy for cardiac surgery and concomitant sternal reconstruction. Promising outcomes using various approaches have been reported; however, limited literature is available for urgent scenarios. CASE PRESENTATION: We report our surgical approach in a young female patient with Marfan syndrome and PEx status after multiple sternal reconstruction procedures who presented with acute congestive heart failure due to mitral valve insufficiency caused by chordae rupture. A thoracic surgeon first removed the previously implanted Nuss bars. Subsequently, the cardiac procedure was performed, including a standard midline incision with median sternotomy preceded by peripheral cannulation for cardiopulmonary bypass via the right common femoral artery and vein. Dense adhesions were expected, and adequate mitral valve exposure was achieved after meticulous dissection and usual left atriotomy. Valve analysis revealed a classic Barlow-type mitral valve prolapse with A1-A2 chordae rupture. Two sets of CV-4 sutures attached to both papillary muscles were used to restore chordal attachments, followed by secondary chordae transfer and 36 mm Physio-2 annuloplasty ring implantation. A piece of bovine pericardium was used to cover the heart. Postprocedural transesophageal echocardiography revealed trace mitral regurgitation without systolic anterior motion. The patient was weaned off the cardiopulmonary bypass, and hemostasis was achieved in preparation for sternal reconstruction and closure. The thoracic surgery team rejoined for Nuss bar re-implantation to complete the procedure. The patient's recovery was uneventful, and she was discharged on postoperative day 19. CONCLUSIONS: Our case report on complex mitral valve repair with concomitant Nuss bar reimplantation demonstrates the feasibility and safety of this procedure in challenging scenarios. The median sternotomy approach is safe for urgent open-heart surgery, even in patients with a previously corrected sternum due to PEx.