Life-Threatening Complication after Pectus Excavatum Repair due to Malposition of the Metal Pectus Bar in the Pericardial Sac

Objectives: Pectus excavatum is occurring in approximately 1 to 2 out of 1,000 children. Currently the most common surgical procedure is a repair with a metal pectus bar. This bar is inserted horizontally over the rips and under the sternum to bend the sternum into a normal position. Complications are age-dependent with lower rates in children under 10 years. Most common are wound infections, pleural effusions, pneumothorax, and wound hematoma.

Methods: We report the case of a 15-year-old boy who underwent pectus excavatum repair by insertion of a metal bar in an external institution. Discharge happened after 1 week in stable condition. Fourteen days after surgery, a clinical deterioration took place which lead to rehospitalization. A left sided pleural effusion was detected and drained. Antibiotics were given for 1 week. Six weeks after surgery, the boy was evaluated again at the hospital with fever, dyspnea, and fatigue. Again a left-sided pleural effusion was drained. Antibiotics were restarted as fever continued for another week without detection of any microorganisms in the blood culture orpleural exudate.

Result: Seven weeks after surgery, a thoracic CT showed a malposition of the metal bar in the pericardium and the patient was transferred to our department for surgery. Patient was still in fever. Laboratory parameters showed a sterile periepicarditis. Preoperative echocardiac evaluation showed a nearly normal ejection fraction and a pericardial effusion mainly around the right ventricle. ECG T-waves were flat corresponding to a pericarditis stadium 2. Open-heart surgery by median sternotomy was performed. The left-sided end of the metal bar penetrated the pericardial sac and affected the complete anterior right ventricular wall. The metal bar was removed. Postoperatively echocardiographic strain deformation imaging showed a significant decrease in the lateral wall, while septal strain was nearly normal. Patient recovered and was discharged after 1 week.

Conclusion: The fever was caused by a mechanical induced sterile periepicarditis. Pectus bar dislocation is described in the literature as a less common complication with a rate of approximately 0.6%. Our case showed a life-threatening clinical course because of malposition in the pericardium and impairment of the right ventricle. Early cardiac diagnostic is recommended.