PMC9096201_01
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.
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Subsequently, as the scoliosis of the thoracic spine progressed (Figure 1(a)), it was decided to operate again. The maximum right ventricular inflow pressure gradient, which indicates the degree of anterior compression, increased from 12 to 15 mmHg (Figure 1(b)). The modified Haller index was severe but did not change (Figure 1(c)). The thoracic scoliosis was convex to the right side, and the sternal depression was located on the left side (Figure 1(a) and (c)).
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.
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Immediately after the patient was placed in the prone position, his blood pressure decreased to 74/51 mmHg and the heart rate increased to 134 beats per minute (Figure 2(a)). After the onset of the thoracic spine correction, the heart rate increased and blood pressure decreased gradually despite the autologous blood transfusion and vasopressor administration (Figure 2(b)). After placing the patient in the supine position, the hemodynamics rapidly stabilized (Figure 2(c)).
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.
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Postoperative imaging showed that the Cobb angle of the thoracic spine was corrected from 60  (T6-L4) to 32  (T7-L1), and the thoracic spine was moved to the left (Figure 3). The thoracic kyphosis changed from 39  to 27 , and the thoracic spine was moved forward (Figure 3). Consequently, the space in the mediastinum decreased, and the cardiac compression due to the corrected thoracic spine and depressed sternum became stronger (Figure 3).