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ABSTRACT Background Pectus excavatum (PE), the most common congenital chest wall deformity, has known associations with connective tissue disorders and may lead to cardiopulmonary impairment; however, its relationship with atrial fibrillation (AF) remains underexplored. Objectives This study aimed to describe the frequency, clinical characteristics, and management of AF within an institutional cohort of patients with PE, and to determine whether the outcomes observed in clinically distinct subgroups persisted after adjustment for baseline risk. Methods This was a retrospective cohort study design. Patients with both PE and documented AF between January 1, 1990, and November 10, 2024, were included. Clinical, echocardiographic, and therapeutic data were collected. Bleeding and thromboembolic outcomes were evaluated using multivariable logistic regression adjusted for age, sex, CHA 2 DS 2 ‐VASc score, and anticoagulant class, and the surgically treated subgroup was additionally compared using propensity score matching. Results Among 11,578 patients with PE, 1309 (11.3%) had AF. Of those who had AF, mean age was 66.9 years; 54% were female, and 83% had paroxysmal AF. The mean CHA 2 DS 2 ‐VASc and HAS‐BLED scores were 2.8 and 1.9, respectively. Thromboembolic events occurred in 196 (15%) patients, most commonly stroke (11%), followed by pulmonary embolism (4%) and deep venous thrombosis (4%). Bleeding events occurred in 313 patients (24%), most commonly hematuria (12%), gastrointestinal bleed (11%), epistaxis (5%), and intracranial hemorrhage (1%). Seventy‐two patients (6%) underwent the Nuss procedure and were younger (45.3 vs. 68.2 years, p < 0.001), predominantly male (65%), and had lower risk scores compared to the non‐Nuss cohort. Patients who underwent the Nuss procedure had significantly fewer bleeding events (5.6% vs. 25%, p < 0.001) with similar thromboembolic rates. The pectus severity index, available in the 370 patients who underwent dedicated radiologic review, was not associated with bleeding (adjusted OR 0.89, 95% CI 0.75–1.05). The difference in bleeding by surgical status persisted after multivariable adjustment (adjusted OR 0.28, 95% CI 0.10–0.79) and after propensity score matching (5.6% vs. 16.7%, p = 0.030). Conclusions AF was identified in approximately one in nine patients within this single‐institution cohort of adults with PE, with paroxysmal AF representing the predominant subtype. Patients who had undergone surgical repair demonstrated a lower incidence of bleeding events than anticipated based on their baseline risk profile; however, given the limited number of events observed, this finding should be interpreted with caution and requires validation in larger studies. In the absence of a non–PE comparator group, these data are insufficient to determine whether PE independently confers an elevated risk of AF, and prospective, controlled investigations are necessary to elucidate this relationship.

BACKGROUND: Pectus deformities are common chest wall abnormalities, with surgical correction recommended for severe cases. Female patients undergoing repair may have a history of breast implants or seek concurrent augmentation. This retrospective study examines clinical implications of pectus repair in patients with breast implants and provides recommendations. STUDY DESIGN: A retrospective review of female patients undergoing pectus repair at Mayo Clinic Arizona (January 1, 2010 to February 1, 2025) was conducted. Outcomes and complications were analyzed in patients with and without breast implants. RESULTS: In total, 456 female patients were included (447 excavatum, 7 arcuatum, and 2 carinatum; median age 32.7). Most patients (78.5%) underwent primary minimally invasive repairs (MIRPE); 6.6% underwent primary hybrid MIRPE, 5.5% underwent redo MIRPE, and 9.4% underwent primary redo open and complex reconstructions. In total, 104 patients (22.8%) had a history of breast implants, with 68 patients having breast implant-related procedures at the time of pectus surgery. At 12 months, the cumulative incidence of infection was significantly higher in patients with implants present at the time of pectus repair than in those without (8.8% vs 1.8%; log rank, p = 0.0015). A 4.9-fold increase in overall infection was seen in patients with indwelling or placed implants during pectus surgery. Deep infections were significantly more common in patients with implants (4.4%) than without (1.0%; p = 0.035). Similarly, superficial infections were more frequent in patients with implants (4.4%) than without (0.8%; p = 0.016). At 30 days, patients with implants had higher rates of infection (p = 0.032), pneumothorax (p = 0.008), and hematoma (p = 0.027), with no significant differences in other complications. CONCLUSIONS: Breast implants at the time of pectus repair were associated with increased risk of postoperative infection, pneumothorax, and hematoma. Removal of implants before pectus repair is recommended with delayed replacement, if desired.

Objective: The objective of this study was to systematically review the literature-reported outcomes of CRYO compared to standard of care without CRYO (non-CRYO) after PEx repair. Summary Background Data: Surgical repair of pectus excavatum (PEx) via the Nuss or Ravitch procedures is associated with substantial postoperative pain. Intercostal nerve cryoablation (CRYO) performed during the primary surgical repair has been adopted as a non-opioid modality for pain management. Methods: A literature search was conducted in PubMed, Embase, and using additional online approaches to identify comparative studies of patients undergoing the Nuss or Ravitch procedure for PEx repair with CRYO versus non-CRYO between years 2014-24. Meta-analysis was performed to quantitatively evaluate primary outcomes of hospital length of stay (LOS) and opioid consumption. Secondary outcomes were hospital costs and complications, summarized qualitatively. Results: Of 178 studies, 32 comparative studies encompassing 13,103 patients were included; 28% (n=3,620) received CRYO. Random effects meta-analyses demonstrated a significantly shortened LOS by 1.8 days (95% confidence interval [CI]: -2.12, -1.42) and a significant reduction in inpatient and outpatient opioid consumption with CRYO by 186 morphine mg equivalents (MME) (95% CI: -262.26, -109.08) and 147 MME (95% CI: -255.72, -38.26), respectively. Complications with CRYO were either decreased or similar between groups and resolved over time. Hospital costs were similar. Conclusions: This systematic review suggests CRYO during PEx repair is associated with a significantly shorter hospital LOS, as well as decreased opioid consumption both in the hospital and after discharge. Complications were infrequent and time-limited.

Importance Pectus arcuatum is a rare anterior chest wall deformity that is often confused with excavatum, carinatum, or a mixed deformity. A complete understanding of its clinical and physiological basis will improve diagnostic accuracy and allow for standardized management. Objectives To gain a comprehensive understanding of pectus arcuatum, focusing on its nomenclatures, epidemiology, classification, pathophysiology, preoperative presentation and assessments, management options, and surgical outcomes. Evidence Review PubMed, Google Scholar, and subsequent reference searches were used to extract original studies addressing pectus arcuatum fully or partially. The searches were performed on February 2, 2025. Two independent reviewers screened articles based on preestablished inclusion and exclusion criteria. Quality assessment was performed, but given the rarity of arcuatum and the limited, heterogeneous nature of available literature, none of the studies were excluded based on the level of evidence or quality assessments. Using a standardized data extraction form, results were synthesized and presented as a review with recommendations to guide clinical decision-making. Findings A total of 65 studies were included in the final review. Of those, 37 (56.9%) were cohort studies, 18 (27.7%) were case reports, 8 (12.3%) were case series, and 2 (3.1%) were technical reports. A total of 455 cases of pectus arcuatum were represented. Heterogeneity was found in nomenclature, epidemiology, associated conditions, assessments, management, and outcomes. An open surgical approach and, more recently, hybrid open and minimally invasive technique are reported for surgical repair. Postoperative outcomes were good in most surgical series, with no significant difference when compared with the repair of other pectus deformities. Conclusions and Relevance Results of this systematic review reveal that pectus arcuatum is a rare variant of pectus deformities that is distinct from carinatum and excavatum. Unified terminology and standardized diagnostic criteria are important to facilitate proper management. Minimally invasive hybrid approaches continue to refine outcomes, balancing invasiveness with efficacy.

Summary Caustic esophageal injury can cause severe morbidity and mortality. Despite the need for emergent treatment, individual experience in diagnosis and management can be limited. Computed tomography (CT) has emerged as a promising non-invasive modality for assessing injury severity, but the clinical utility of both CT and endoscopy should be investigated. A systematic review was conducted following PRISMA guidelines. A comprehensive search of the PubMed database identified relevant articles published from January 1, 2000 to December 31, 2023. Inclusion criteria encompassed studies investigating the use of CT and/or endoscopy in diagnosing and managing caustic esophageal injury. Twelve articles were selected from a pool of 931 studies. Findings suggested that CT was superior in diagnostic capability to endoscopy in high-grade injury and stricture formation, but less so for low grade injuries. Diagnostic algorithms incorporating imaging with laboratory studies have emerged in the literature, which are promising pending additional validation. CT can serve as a valuable, non-invasive tool in the initial evaluation of caustic esophageal injury and is postulated to accurately predict both the need for emergent surgery and the risk of stricture formation. However, CT should not replace but rather complement the use of endoscopy to comprehensively evaluate these potentially highly morbid situations.

Background/Objectives: Pectus excavatum (PEx) is considered, at least partially, a familial disorder. A variety of inheritance patterns, associations with genetic syndromes, and pathogenic variants have been reported. However, the etiology of this condition is still not completely understood, and no known genes have been identified as definitive contributors. Methods: Family members with a confirmed PEx diagnosis (one proband and two first-degree relatives) and non-affected members were recruited into this study. Exome sequencing was performed on all affected familial PEx cases to systematically screen for candidate genes that are likely to be causative for PEx, and on non-affected family members for variant segregation analysis. Results: Ten families, with three affected members each, participated, providing thirty familial PEx cases. Different inheritance patterns were represented across the ten pedigrees, with possible incomplete penetrance. Genetic variants in REST (essential for neuronal development and associated with pectus deformities in prior studies), SMAD4 (variants can predispose individuals to thoracic aortic diseases), and COL5A (associated with Ehlers–Danlos syndrome and Fibromuscular dysplasia) were initially identified as potentially linked to the development of pectus deformities and segregated with the phenotype. No variants were shared across families in the studied population. Conclusions: Germline exome sequencing of families with multiple individuals affected by PEx in our study identified potential gene candidates linked to PEx. These candidates are private to individual families and no strong candidates shared across multiple families were identified. These findings suggest that the inheritance of PEx may not be strongly related to a shared single genetic variant in known genes. Given the accumulating evidence for the genetic basis of familial PEx, further studies, including polygenic analyses, as well as assessment of the non-coding genome and possible epigenetic markers are warranted.

Introduction: Pectus excavatum (PE) is the most common anterior chest wall deformity with dorsal deviation into the thoracic cavity. Depending on the severity, PE can cause minor cosmetic problem to significant cardiac compression in severe cases. This compression most frequently affects right heart chambers causing symptoms such as dyspnea, palpitations, fatigue, exercise intolerance, and difficulty with keeping up with peers. Previously, we reported the change in these symptoms with positon associated with change in right heart hemodynamics. Further, we are comparing the changes in right heart hemodynamics with position in pectus patients to normal healthy adults. Methods: A prospective cohort of 40 pectus excavatum patients (mean Haller index: 5.4±2) undergoing evaluation at Mayo clinic underwent 2-D transthoracic echo (TTE) with Doppler assessment of Right Ventricular Outflow Tract (RVOT) Velocity Time Integral (VTI). A cohort of 8 healthy adults without chest wall abnormality who had clinically indicated echocardiogram was used as control (Table). Additional assessment of the RVOT VTI was performed in sitting position in either group. A two-sample t-test was performed to assess significance between cohorts. Results: There is a significant difference in RVOT VTI between case and control cohorts in both supine and sitting positions (p=0.03 & p=0.001 respectively). Also, there is a significant decrease in RVOT VTI from supine to sitting position in PE patients compared to healthy adults (Table). Conclusion: This is the 1 st prospective cohort study in PE patients vs healthy adults showing the feasibility and utility of dynamic echocardiography in assessing the right ventricular hemodynamics. This study demonstrates a significant decrease in right sided hemodynamic changes with change in position in patients with PE which might explain their symptoms.

Introduction: The consequences of external cardiovascular compression and cardiac displacement from pectus excavatum (PEx) are debated. The complex geometry of the right (RV) and left ventricle (LV) along with distortion from the extrinsic chest deformity pose significant limitations to reliable assessment of LV and RV volumes and function using transthoracic 2D-echocardiography in this population. Hypothesis: A 3D-echocardiography approach can reliably assess the effects of external cardiac compression and the benefits of surgical correction on RV and LV function in PEx patients. Methods: Adult patients undergoing minimally invasive repair of PEx between Oct-2021 and Feb-2023 were included in this prospective study. Intraoperative transesophageal (TEE) 6 beat full volume video loops incorporating LV and RV were captured and compared before and after surgical correction of the PEx. TomTec Software® was used for offline 3D/4D reconstruction ( Figure 1 shows changes in 3D RV and LV shape pre- and post-surgery). Result: The study included 102 patients (mean age of 32.1 ±11.8 years; Haller index 4.9 ±2.5; 60.8% males). Post PEx repair, there was a significant (p<0.001) increase in the 3D RV volumes, RV ejection fraction (EF), RV stroke volume and RV strain ( Figure 1 ). Additionally, there was a significant improvement in 3D LVEF, 3D LV strain (longitudinal and circumferential), LV twist, and torsion ( Figure 1 ). Conclusion: In this PEx cohort, 3D/4D TEE imaging demonstrated significant increases in RV volumes and in RV and LV systolic function after surgical repair. These findings support the negative cardiovascular consequences of PEx compression and benefits of surgical repair.

AbstractBackgroundThere is a knowledge gap regarding lobar versus sublobar resection for atypical carcinoid (AC) of the lung. As such, the authors sought to understand and analyze the outcomes of sublobar resection versus lobectomy in this patient population.MethodsA retrospective analysis using the National Cancer Database was performed to compare overall survival (OS) between patients treated with lobectomy and patients treated with sublobar resection for AC of the lung between the years 2004 and 2016. Patient characteristics were compared with χ2 tests. The Kaplan–Meier method was used to estimate OS distributions, and the log‐rank test was used to compare distributions by treatment strategy. A multivariable Cox regression model was used to assess associations between the treatment strategy and OS. A propensity score matching method was also implemented to further eliminate treatment selection bias in the study sample.ResultsThe database identified 669 patients with T1–T4 and N0–N3 lung ACs that were surgically resected. Unadjusted Kaplan–Meier survival curves did not demonstrate an OS difference between lobectomy and sublobar resection (p = .094). After propensity score matching, curves demonstrated a numerical improvement in OS with lobectomy; however, it was not statistically significant (p = .5). In a subgroup analysis, lobectomy and node‐negative disease were associated with the best OS, whereas sublobar resection and node‐positive disease were associated with the worst OS (p < .0001). Nodal involvement was associated with worse survival, regardless of surgical treatment (p < .0001).ConclusionsIn patients with T1–T4 and N0–N3 ACs of the lung, lobectomy was not associated with an improvement in OS in comparison with sublobar resection.