Journal and News Scan

Pectus defects are a group of congenital conditions found in approximately 1 in 250 people, where the sternum is depressed back toward the spine (excavatum), protrudes forward (carinatum) or, more rarely, is a mixture of both (arcuatum or mixed defects). For the majority of patients, it is well tolerated, but some patients are affected psychologically, physiologically or both. 

The deformity becomes apparent at a young age due to the growth of the ribs and the cartilage that links them to the sternum. The majority of defects are mild and are well tolerated, i.e. they do not affect activity and do not cause psychological harm. However, some young people develop lower self-esteem and depression, causing them to withdraw from activities, such as swimming and dancing, and from interactions that might “expose” them, such as sleepovers, dating, going to the beach, and wearing fashionable clothing. This psychological harm occurs at a crucial time during their physical and social development. A small number of patients have more extreme depression of their sternum that impedes their physiological reserve, which can occur when engaging in strenuous exercise, such as running, but can also limit moderate activity, such as walking and climbing stairs. The effects can be so extreme that symptoms occur at rest or cause life-threatening compression of the major blood vessels and organs. The group of patients with physiological impairment typically also suffer from low self-esteem and depression. 

This paper summarizes the current evidence for the different treatment strategies for this condition, including supportive care, psychological support and nonsurgical techniques including bracing and vacuum bell therapy. The authors also consider surgical techniques including the Ravitch procedure, the Nuss procedure (minimally invasive repair of pectus excavatum), pectus implants, and other rare procedures such as Pectus Up. 

For the majority of patients, supportive care is sufficient, but for a minority, a combination of the other techniques may be considered. 

This paper also outlines best practice guidance for the delivery of such therapies, including standardized assessment, consent to treatment, audit, quality assurance, and long-term support. 

All the interventions have risks and benefits that the patient, parents, and clinicians need to carefully consider and discuss when deciding on the most appropriate course. The authors hope this evidence review of “Best Practice for Pectus” will make a significant contribution to those considerations and help all involved—from patients to national policy makers—to deliver the best possible care. 

After enduring cardiopulmonary bypass, many patients experience an inflammatory response, which can lead to prolonged ventilation, bleeding, stroke, and renal dysfunction. The NewYork-Presbyterian and Weill Cornell Medicine trial center was chosen to further investigate RBT-1 to see if it can help the production of anti-inflammatory cytokines and reduce the occurrence of common post-surgical complications. Researchers found that patients who received RBT-1 had a 46 percent decrease in blood product transfusions, a lower likelihood of readmission to the hospital within 30 days, and spent less time in the ICU and on a ventilator.

The number of patients at intermediate and low surgical risk treated by transcatheter aortic valve implantation (TAVI) is rapidly increasing. Current guidelines recommend performing TAVI in heart valve centers with surgical backup. Nonetheless, there is an ongoing discussion about possibly abrogating on‐site surgical backup for TAVI procedures to increase accessibility. However, concerns and uncertainty exist about the safety of performing TAVI in nonsurgical centers.

This collaborative effort, using pooled data from 14 German centers, presents contemporary outcomes of patients undergoing emergency open-heart surgery (E-OHS) due to severe intraprocedural complications during elective transfemoral TAVI. 

The authors conclude that in the setting of a heart team approach with immediate surgical backup, E‐OHS due to potentially lethal TAVI complications is not a futile clinical situation, with acceptable short‐ and long‐term outcomes, especially in low and intermediate-risk patients.

In a single-center series of 502 patients who underwent thoracoscopic ablation and left atrial appendage closure, of whom 333 had preoperative and postoperative computed tomographic imaging, complete left atrial appendage closure (defined as residual stump <1 cm on computed tomography one year postoperatively) was lower with the stapled resection (83 percent) compared with a clip (96 percent), and the residual left atrial appendage stump depth was greater (5.3 vs 2.9 mm, respectively). Two patients with a residual stump experienced an ischemic stroke during follow-up.