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Case Reports
. 2022 May 10:10:2050313X221090848.
doi: 10.1177/2050313X221090848. eCollection 2022.

Hemodynamic deterioration due to increased anterior and posterior cardiac compression during posterior spinal fusion for scoliosis with pectus excavatum

Ryota Adachi  1 , Tasuku Nishihara  1 , Tadao Morino  2 , Keisuke Sekiya  1 , Sakiko Kitamura  1 , Amane Konishi  1 , Yasushi Takasaki  1 , Hiromasa Miura  2 , Naoki Abe  1 , Toshihiro Yorozuya  1
Affiliations
Case Reports

Hemodynamic deterioration due to increased anterior and posterior cardiac compression during posterior spinal fusion for scoliosis with pectus excavatum

Ryota Adachi et al. SAGE Open Med Case Rep. .

Abstract

Hemodynamics may deteriorate during the perioperative period when performing posterior spinal fusion in patients with pectus excavatum and scoliosis. A 13-year-old teenager diagnosed with Marfan syndrome had thoracic scoliosis and pectus excavatum. Thoracic scoliosis was convex to the right, and a right ventricular inflow tract stenosis was observed due to compression induced by the depressed sternum. The patient underwent T3-L4 posterior spinal fusion surgery for scoliosis. Deterioration of hemodynamics was observed when the patient was placed in the prone position or when the thoracic spine was corrected to the left front. Postoperative computed tomography examination showed that the mediastinal space was narrowed due to the corrected thoracic spine. Special attention should be paid in the following cases: (1) severe pectus excavatum, (2) right ventricular inflow tract compression due to depressed sternum on the left side, (3) correction of the thoracic spine on the left front, (4) long-term surgery, and (5) risk of massive bleeding. In some cases, pectus excavatum surgery should be prioritized.

Keywords: Haller index; Marfan syndrome; Pectus excavatum; posterior spinal fusion; right ventricular inflow stenosis; scoliosis.

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Conflict of interest statement

Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Figure 1.
Figure 1.
Preoperative examination. Chest X-ray photograph (Xp), transthoracic echocardiography, and chest computed tomography (CT) examination. Over a 2-year period, the Cobb angle deteriorated from 27° to 60° (a). The maximum right ventricular inflow pressure gradient was 15 mmHg (b). The preoperative modified Haller index was 9 (c). The modified Haller index was obtained as the ratio A/B. Values >3.5 are considered to be associated with severe pectus excavatum cases. LA: left atrium, LV: left ventricle, RA: right atrium, RV: right ventricle.
Figure 2.
Figure 2.
Intraoperative progress. Hypotension and tachycardia due to the patient’s prone position (a) and correction of the thoracic spine (b). Stabilization of hemodynamics due to the patient’s supine position (c). ART(SYS): systolic blood pressure, ART(DIA): diastolic blood pressure, bpm: beats per minutes, HR: heart rate.
Figure 3.
Figure 3.
Preoperative and postoperative chest X-ray photograph (Xp) and computed tomography (CT) examinations. Left movement of the thoracic spine (a). Narrowed mediastinum (b). In this case, the modified Haller index increased from 9 to 13.4 and the spinal penetration index increased from 10 to 16.
Figure 4.
Figure 4.
Mechanism of hemodynamic deterioration due to the prone position and spinal correction. Increased anterior cardiac compression due to prone position (a). Increased posterior cardiac compression attributed to the corrected spine (b). LA: left atrium, LV: left ventricle, RA: right atrium, RV: right ventricle.
See this image and copyright information in PMC

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