Correlation of anterior chest wall anomalies and spinal deformities: a comprehensive descriptive study.

PURPOSE: To investigate the association and evaluate the characteristics between different types of anterior chest wall and spinal deformities. METHODS: A total of 548 patients with anterior chest wall deformities were included in this study. Clinical and radiological examinations were performed to determine spinal deformities. The type and severity of the spinal deformities were evaluated and their relationships with chest wall deformity subtypes were statistically analyzed. RESULTS: Spinal deformities were identified in 93 (16.97%) patients. The patients were subdivided into 71 (76.3%) male and 22 (23.7%) female patients. A spinal deformity was detected in 57 (13%) of 418 pectus excavatum (PE) patients, in 23 (19%) of 117 pectus carinatum (PC) patients, and in all patients with mixed pectus deformity (PE + PC), syndromic deformity and rib anomalies. In the PE group, scoliosis, and kyphosis were observed at 57.9 and 31.6%, respectively. In the PC group, these rates were 43.5 and 47.8%, respectively. Idiopathic scoliosis was observed in 42 (77.7%) and constituted the most common scoliosis subgroup. The main thoracic curvature was the most common curve pattern, which was observed in 15 (35.7%) patients with idiopathic scoliosis. CONCLUSIONS: Idiopathic scoliosis with main thoracic curvature is the most common deformity in patients with anterior chest wall deformity. Spinal deformities are more common in male patients with chest deformities. Kyphosis is found in a significant number of PE and PC patients. Patients with mixed PE and PC, rib anomalies, and syndromic disease are more likely to have spinal deformities.

Evaluating the web as a source of information for patients with chest wall deformities: insights into engagement and disparities.

BACKGROUND: Recent data highlight the internet's pivotal role as the primary information source for patients. In this study, we emulate a patient's/caregiver's quest for online information concerning chest deformities and assess the quality of available information. METHODS: We conducted an internet search using combination of the terms "pectus excavatum," "pectus excavatum surgery," "funnel chest," "pectus excavatum repair" and identified the first 100 relevant websites from the three most popular search engines: Google, Yahoo, and Bing. These websites were evaluated using the modified Ensuring Quality Information for Patients (EQIP) instrument. RESULTS: Of the 300 websites generated, 140 (46.7%) were included in our evaluation after elimination of duplicates, non-English websites, and those targeting medical professionals. The EQIP scores in the final sample ranged from 8 to 32/36, with a median score of 22. Most of the evaluated websites (32.8%) originated from hospitals, yet none met all 36 EQIP criteria. DISCUSSION: None of the evaluated websites pertaining to pectus excavatum achieved a flawless "content quality" score. The diverse array of websites potentially complicates patients' efforts to navigate toward high-quality resources. Barriers in accessing high-quality online patient information may contribute to disparities in referral, patient engagement, treatment satisfaction, and overall quality of life. LEVEL OF EVIDENCE: IV.

Pectus excavatum and carinatum: a narrative review of epidemiology, etiopathogenesis, clinical features, and classification.

Background and Objective: A wide variety of congenital chest wall deformities that manifest in infants, children and adolescents exists, among which are pectus excavatum and pectus carinatum. Numerous studies have been conducted over the years aiming to better understand these deformities. This report provides a brief overview of what is currently known about the epidemiology, etiopathogenesis, clinical presentation, and classification of these deformities, and highlights the gaps in knowledge. Methods: A search was conducted for all the above-described domains in the PubMed and Embase databases. Key Content and Findings: A total of 147 articles were included in this narrative review. Estimation of the true incidence and prevalence of pectus excavatum and carinatum is challenging due to lacking consensus on a definition of both deformities. Nowadays, several theories for the development of pectus excavatum and carinatum have been suggested which focus on intrinsic or extrinsic pathogenic factors, with the leading hypothesis focusing on overgrowth or growth disturbance of costal cartilages. Furthermore, genetic predisposition to the deformities is likely to exist. Pectus excavatum is frequently associated with cardiopulmonary symptoms, while pectus carinatum patients mostly present with cosmetic complaints. Both deformities are classified based on the shape or severity of the deformity. However, each classification system has its limitations. Conclusions: Substantial progress has been made in the past few decades in understanding the development and symptomatology of pectus excavatum and carinatum. Current hypotheses on the etiology of the deformities should be confirmed by biomedical and genetic studies. For clinical purposes, the establishment of a clear definition and classification system for both deformities based on objective morphologic features is eagerly anticipated.

Advancements in preoperative imaging of pectus excavatum: a comprehensive review.

Pectus excavatum, the most common pectus deformity, varies in severity and has been associated with cardiopulmonary impairment and psychological distress. Since its initial documentation, a multitude of imaging techniques for preoperative evaluation (i.e., diagnosis, severity classification, functional assessment, and surgical planning) have been reported. Conventional imaging techniques encompass computed tomography (CT), chest radiography, magnetic resonance imaging (MRI), echocardiography and medical photography, while three dimensional (3D) optical surface imaging is a promising emerging technique in the preoperative assessment of pectus excavatum. This narrative review explores the current insights and advancements of these imaging modalities. CT imaging allows for the calculation of pectus indices and evaluation of cardiac compression and displacement. Recent developments focus on automated calculations, minimizing radiation exposure and improving surgical planning. Chest radiography offers a radiation-reducing alternative for pectus index measurement, but is unsuitable for disproportionally asymmetric chest deformations. MRI is a radiation-free imaging method, and allows for the calculation of pectus indices as well as the assessment of cardiac function. Real-time MRI provides dynamic insights, while exercise MRI shows promise for comprehensive evaluation of cardiac function but requires additional developments. Using echocardiography, structural cardiac changes can be identified, but its use in evaluating cardiac function in pectus excavatum patients is limited. Medical photography combined with caliper measurements complements other imaging methods for qualitative and quantitative documentation of pectus excavatum. Emerging as an innovative technique, 3D optical surface imaging offers a rapid, radiation-free assessment of the deformity which correlates with conventional pectus indices. Potential applications include quantifying other morphological features and predicting cardiac compression. However, standardization and validation are needed for its widespread use. This review provides an overview of preoperative imaging of pectus excavatum, highlighting the current developments in conventional methods and the potential of the emerging 3D optical surface imaging technique. These advancements hold promise for the future of the assessment and surgical planning of pectus excavatum.

Modification of the Nuss procedure: the crossed bar technique for new subtypes of pectus excavatum.

BACKGROUND: We aim to describe four new subtypes of PE in detail and represent modification of the Nuss procedure called crossed bar technique for their optimum correction with good results. METHODS: 101 patients who underwent crossed bar technique between August 2005 and February 2022 were included into the study. RESULTS: The mean age of the patient series was 21.1 (range 15-38 years) years. Mean Haller index was 3.87. Mean operation duration was 86.84 min. 2 bars were used in 74 (73.3%) of the patients whereas 3 bars were preferred in 27 (26.7%) of them. Mean hospital stay was 4.1 (2-8) days, and all the patients were seen routinely on postoperative follow-up at 1st, 6th, and 18th months. Quality of life questionnaires revealed satisfaction. CONCLUSIONS: Cross bar technique yields satisfactory results for these new subtypes and can be performed safely with good results in these selected group of patients.

Analysis of Psychological Assessments Affecting Patients Undergoing Treatment for Chest Wall Deformities.

AIM: This study aimed to review the literature with regard to the psychological aspects in patients with pectus excavatum (PE) and pectus carinatum (PC). METHODS: The literature was reviewed by analyzing articles on PubMed using the search terms "psychology" and "pectus." RESULTS: The literature search revealed 22 articles that offered a total of 2214 patients for analysis. Regarding chest wall deformities (CWD), there were 15 articles referring to PE, 4 articles on PC, and 3 pertaining to both PE and PC. Authors used various types of questionnaires and 14 studies which also included a parent questionnaire. There are 14 reports which analyzed both the preoperative and postoperative psychological status and 4 reports in which a control group was used. Treatment of CWD was shown to have consistently positive results. There is no consensus regarding the correlation between severity of CWD and psychological issues. Only 2 studies found no statistically significant results after treatment. CONCLUSIONS: The literature reveals a great concern for psychosocial issues in CWD patients. Most articles describe improvement in overall quality of life (QOL) after surgery. An increase in social and physical function, body image, and self-esteem was observed in CWD patients, which is supported by parent responses.

The Use of Acellular Dermal Matrix (Integra Single Layer) for the Correction of Malformative Chest Wall Deformities: First Case Series Reported.

Introduction Autologous tissue transfers have been used in chest wall reconstruction for decades, with high morbidity. Recently, acellular dermal matrices (ADMs) have emerged as an alternative. The aim of this article is to report our initial experience in the reconstruction of malformative chest wall deformities with ADM. Methods A prospective observational study was performed in patients with malformative chest wall deformities, who were reconstructed with ADM at our institution between 2018 and 2020. We analyzed demographic variables, surgical features, postoperative complications, and cosmetic results at 12 months' follow- up. Results Four male patients were included (median age: 16 years). Two patients had bilateral costal anomalies, one patient had a unilateral chest deformity, and one patient had Poland syndrome. In all patients, blunt dissection of the subcutaneous cellular tissue overlying the defect was performed through 2.5 to 3 cm skin incisions, creating a pouch. Afterwards, several sheets of Integra Single Layer were placed in the pouch, to replace the volume defect. All patients were discharged same-day. No postoperative infections, hematomas, or seromas were observed. Only one patient presented with a partial surgical wound dehiscence. Revisions were performed at 1, 3, 6, and 12 months. All 4 patients were satisfied with the cosmetic outcome (Nuss Questionnaire: median score: 16 points; Q1-Q3: 22-26). Conclusion The use of ADM in malformative chest wall deformities reconstruction has not been previously described in children. This study demonstrates that the use of ADM is a safe and reliable technique. However, more studies with long-term follow-up are warranted.

Clinical significance of concomitant pectus deformity and adolescent idiopathic scoliosis: systematic review with best evidence synthesis.

Background: A misbalance in forces is proposed for causing adolescent idiopathic scoliosis (AIS). AIS is therefore correlated to adjacent musculoskeletal pathologies. Its concomitance with idiopathic pectus deformities (PD) is underexposed. This systematic review analyzes the clinical significance and predictive factors of PD-associated AIS. Methods: A search was performed in PubMed, UpToDate, Embase, and Cochrane. A study was included if it: assessed the association between PD and scoliosis (category I), reported a prevalence of scoliosis in PD patients (category II), or addressed other topics about PD-associated AIS (category III). Studies in category I discussing predictive factors were appraised using the Quality in Prognosis Studies tool. Because of heterogeneity among the studies, predictive factors were analyzed according to a best evidence synthesis. A mean prevalence of scoliosis in PD patients was calculated using category I and II. Category III was narratively reviewed. Results: Forty-eight studies were included (I:19, II:21, III:8). Category I comprised 512 patients with PD-concomitant scoliosis. Thirteen studies reported predictive factors, of which 15 concerned the prevalence of scoliosis in PD patients and 12 Cobb Angle (CA) change after PD correction. Compared with AIS, PD seems to develop earlier in adolescence, and PD with concomitant AIS was more frequently reported in older patients. Evidence remained conflicting regarding the association between the severity of PD and that of scoliosis. As opposed to at a younger age, late PD correction is not associated with a postoperative increase of CA. Limited evidence showed that patients with a high CA undergoing PD correction do not experience an increase in CA, though, strong evidence indicated that it would not lead to a decrease in CA. The mean probable prevalence of AIS in PD patients was 13.1%. Conclusion: Current literature confirms the association between PD and AIS in patients with an indication for PD correction.Level of evidence: III.

Nuss Technique for Pectus Excavatum in Adult Patients: Cosmetic Satisfaction and Improvement of Quality of Life in a Single-Center Experience.

Objectives: Since its introduction, the Nuss minimally invasive procedure for pectus excavatum (PE) repair (MIRPE) has become the method of choice. The current study describes our experience of PE correction in adults, with particular focus on postoperative outcomes, pain, quality of life, and patients' satisfaction. Methods: We enrolled for this observational study n = 93 adult patients from 2011 to 2018. The Haller index was used to quantify PE severity. Pulmonary function tests and cardiac examinations were performed preoperatively; we developed a standardized surgical technique and postoperative treatment, including follow-up at 3, 12, and 24 months after surgery and 6 months after bar removal. We also evaluated the quality of life and the satisfaction with the cosmetic result after the procedure with standardized questionnaires. Results: No operative or perioperative deaths occurred nor life-treating complications. Thirteen complications occurred in 12 patients, with a total complication rate of 14% (n = 13/93). Pain intensity decreased in the follow-up [pain score visual analog scale at 3 months: median 1 (0-8); 12 months: median 1 (0-5); and 24 months: median 1 (0-4)]. Better or much better quality of life after the Nuss procedure was observed: n = 79 (84.1%) at 3 months, n = 80 (86%) at 12 months, and n = 85 (91.4%) at 24 months. After 2 years of observation, more than 90% of patients described improvement in their quality of life and satisfaction with the cosmetic results. Only a very small group of patients suffered from pain in the follow-up. Conclusion: Our results demonstrate that the MIRPE procedure is safe and can be performed with excellent results in adults both for improvement of quality of life and for satisfaction with cosmetic results.

Changes in self-image after pectus carinatum brace treatment.

BACKGROUND/PURPOSE: Pectus carinatum (PC) is a chest wall deformity resulting in anterior protrusion of the chest. PC does not typically result in significant physical or cardiopulmonary symptoms, but patients with this condition can experience a disturbed body image, lower self-esteem and reduced quality of life.  The purpose of this study was to investigate the relationship between self-image and non-surgical correction of PC using a brace. METHODS: This study was a descriptive, pre-post survey design. The sample included children ages 11 to <18 years undergoing PC treatment with the dynamic compressor system. Subjects completed the modified Pectus Excavatum Evaluation Questionnaire (mPEEQ) at the onset of bracing and again once PC correction was completed. RESULTS: Ninety-seven subjects were enrolled at the time of bracing, and 41 achieved correction and took the second survey. The mean age was 14 years and 80% were male. There was a statistically significant (p<0.001) improvement in body self-image between the first and second surveys. CONCLUSIONS: Non-surgical correction of PC with the dynamic compressor system resulted in an improvement in the self-image of children. PROGNOSIS STUDY: Level of Evidence II.

Remote treatment of pectus carinatum (Telepectus) during the COVID-19 pandemic.

BACKGROUND/PURPOSE: To report telemedicine's feasibility and satisfaction rates for treating patients with pectus carinatum using a dynamic compressor system. We analyzed treatment adherence in comparison with the previous, non-pandemic year. MATERIALS AND METHODS: Retrospective analysis including patients with pectus carinatum under treatment with a dynamic compressor system using telemedicine at the chest wall centers from two hospitals, private and public, between April and July 2020. A free video conference platform for teleconsultations was employed. We evaluated the incidence of pectus cases with telemedicine, the number of dynamic compressor system prescriptions, the number of patients in the correction phase, and the number who ended treatment. To assess adherence, we compared our cohort with an in-person cohort during the same time frame of the previous, non-pandemic year. In addition, we performed a patient satisfaction survey comprising questions related to socioeconomic status, the likeability of telemedicine, simplicity of modification of the system, and desire to continue with telepectus after the pandemic. RESULTS: One hundred and thirty-six telepectus consultations were performed in 76 patients. During this time frame, 15 patients started using the dynamic compressor system. Compared to the previous, non-pandemic year, the number of consultations per patient was similar (2019: 1.92 ± 1 .0 vs. 2020: 1.79 ± 0.8, p = 0.32), and there was a significant reduction in the number of dropouts with the use of telemedicine (9% vs. 1%, p = 0.025). Fifty-nine patients answered the satisfaction survey. All of them solved their doubts through telemedicine. Overall, 95% found telemedicine comfortable. Of note, those with a lower income evidenced the highest intention in continuing with telemedicine. CONCLUSIONS: We demonstrated the feasibility of remote care of patients with pectus carinatum using a dynamic compressor system with a similar frequency of consultations compared to in-person medical care. Telepectus patients revealed a high rate of satisfaction irrespective of their socioeconomic status. LEVEL OF EVIDENCE: IV. TYPE OF STUDY: Retrospective study.

Advancements in Methods and Camera-Based Sensors for the Quantification of Respiration.

Assessment of respiratory function allows early detection of potential disorders in the respiratory system and provides useful information for medical management. There is a wide range of applications for breathing assessment, from measurement systems in a clinical environment to applications involving athletes. Many studies on pulmonary function testing systems and breath monitoring have been conducted over the past few decades, and their results have the potential to broadly impact clinical practice. However, most of these works require physical contact with the patient to produce accurate and reliable measures of the respiratory function. There is still a significant shortcoming of non-contact measuring systems in their ability to fit into the clinical environment. The purpose of this paper is to provide a review of the current advances and systems in respiratory function assessment, particularly camera-based systems. A classification of the applicable research works is presented according to their techniques and recorded/quantified respiration parameters. In addition, the current solutions are discussed with regards to their direct applicability in different settings, such as clinical or home settings, highlighting their specific strengths and limitations in the different environments.

Pectus excavatum and scoliosis: a review about the patient's surgical management.

Although Nuss procedure is performed with satisfactory results, there has been a controversy in the literature regarding the effect of a Nuss procedure on the spine. This review article aims to perform an updated overview of the literature about the effect of pectus excavatum correction at the spine and the management of patients with both pectus excavatum and scoliosis. Although acquired scoliosis has been rarely reported after a Nuss procedure, studies show that the Nuss procedure can have a beneficial effect in mild coexisting scoliosis especially when it is performed during the adolescence. The management of cases presented with both pectus excavatum and scoliosis depends on the severity of pre-operative scoliosis and demands detailed evaluation of the spine pre and postoperatively. In the rare condition of post-operative scoliosis following a Nuss procedure, the removal of the metallic bar and conservative measures may have satisfactory results on the spine.

Mark M. Ravitch MD: Surgeon, author, teacher, soldier.

Mark M. Ravitch (1910-1989) was the most prolific surgeon-author of the 20th Century as well as an outstanding clinical surgeon, scholar, historian, and researcher. While today he would not be considered a "pure pediatric surgeon," he was a charter member of the American Pediatric Surgical Association and received the William E. Ladd medal from the Surgical Section of the American Academy of Pediatrics and the Denis Brown Medal from the British Association of Pediatric Surgeons. He contributed to the treatment of benign colon and rectal disease, intussusception, and chest wall deformities. His most enduring contribution was surgical stapling, a technology that he brought from Russia during the Cold War that opened the door to minimally invasive surgery.

Winged Ribs: An Underestimated Problem That May Compromise Breast Augmentation Outcomes.

Chest wall shape is an important aspect to consider when planning a breast augmentation. Minor chest wall deformities are usually underestimated by the patient and surgeon and may compromise postoperative outcomes. Lower costal cartilage dysmorphia or winged rib is one of these minor underestimated chest wall deformities characterized by a visible and palpable cartilaginous prominence under the inframammary fold and causes discomfort in patients decreasing the satisfaction with the breast augmentation surgery. For these patients, the author utilized an innovative surgical technique that allows resection of the protruding cartilages and placement of breast implants through the same surgical incision. Six patients with winged ribs underwent breast augmentation and costal cartilage resection via this method and there were no intraoperative or early postoperative complications, and all patients were satisfied with the aesthetical result after 6 months of follow-up. The presented surgical technique has a short learning curve with excellent postoperative results. Cases are presented to demonstrate the improved postoperative chest wall contour combined with breast augmentation outcome.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Simplified Method for Three-Dimensional Optical Imaging and Measurement of Patients with Chest Wall Deformities.

BACKGROUND: Pectus excavatum and carinatum are two of the most commonly observed chest wall deformities in pediatrics. The standard diagnostic evaluation for these conditions includes either chest radiograph (CXR) or computed tomography (CT). Our research aims to develop a novel and reliable way of quantifying chest wall deformities in the clinic setting without radiation exposure. METHODS: Using a handheld structured light scanner, we created three-dimensional (3D) models of patients with chest wall deformities through an IRB-approved protocol. Raters from a variety of backgrounds were then asked to take measurements based on the 3D model utilizing commercially available 3D graphical software. The standard deviation of the measurements and intraclass correlation coefficient (ICC) were then calculated to quantify inter-rater reliability. RESULTS: Sixty patients with pectus excavatum (Haller index range 2.0-6.38) and pectus carinatum were enrolled and imaged in our outpatient clinic using a structured light scanner. Five patients were used to verify interuser reliability. The standard deviation of all the measurements was 2.2 mm. The ICC for absolute agreement was 0.99139, with 1.0 being perfect correlation. CONCLUSION: Structured light scanners provide an alternative approach to quantifying chest wall deformities in pediatric patients without radiation exposure. Our method is highly reliable, even among users with minimal image processing or 3D modeling experience. Our protocol can potentially be used to track treatment progress in children with chest wall deformities.

A new technique in complex chest wall reconstruction: Open reduction and internal fixation.

BACKGROUND: Reconstruction of complex chest wall deformities is a surgical challenge. A new technique can improve long-term outcomes and result in high patient satisfaction. METHODS: A multicenter study was conducted on pediatric patients undergoing complex chest wall reconstruction between September 2015 and January 2018. The evolution of the technique using open reduction and internal fixation (ORIF) with SternaLock® and RibFix® to repair chest wall deformities is described. RESULTS: Seventeen patients underwent complex chest wall reconstruction with ORIF. Eight patients had severe or recurrent pectus excavatum, five patients had pectus carinatum, and four patients had complex chest wall fractures or other anomalies causing significant chronic pain. Up to three SternaLock® plates and four RibFix® plates were used for each procedure. Median length of hospital stay after surgery was four days. Median follow-up time was 12 months (range 2-30). There were no postsurgical complications. There was 100% patient satisfaction in postoperative recovery and cosmesis. CONCLUSION: ORIF using SternaLock® and RibFix® is an effective method of reconstructing complex chest wall deformities. This technique improves physical stability without the requirement of a subsequent surgery and enhances overall patient satisfaction. High volume centers should integrate this novel approach for challenging chest wall reconstruction. TYPE OF STUDY: Treatment study: case series. LEVEL OF EVIDENCE: Level IV.

Results of pectus excavatum correction using a minimally invasive approach with subxyphoid incision and three-point fixation.

OBJECTIVES: This study reviews the results of our previously described modification of the minimally invasive (Nuss) procedure for correction of pectus excavatum. It utilizes a subxyphoid incision with central fixation to maximize safe bar passage and minimize bar displacement. METHODS: Consecutive patients corrected with the modified Nuss procedure between 2010 and 2015 form the basis of this study. RESULTS: During the study period, 73 patients had correction of their pectus excavatum by the modified Nuss procedure, utilizing subxyphoid incision and central fixation. Average age was 14.3 (range 8-19). 54 patients were male, 19 female. The average Haller index was 4.3 (range 3.2-7.2). No episodes of cardiac perforation, hemothorax or significant pneumothorax were recorded. Bar displacement occurred in two patients (2.7%) with one late recurrence after bar removal. CONCLUSIONS: Our modification of the Nuss procedure is effective at preventing intrathoracic complications and cardiac perforation. Central fixation had a lower rate of bar displacement compared to published reports. Additional efforts are needed to further reduce bar displacement.

Determination of severity of deformity with rib length to costal cartilage length ratio in thorax deformities.

BACKGROUND: This study aims to investigate whether rib length to costal cartilage length ratio is effective in determining the severity of chest wall deformity. METHODS: The study included 72 patients (64 males, 8 females; mean age 18.5±6 years; range, 6 to 40 years) who were operated because of chest wall deformity and 38 control subjects (22 males, 16 females; mean age 14.6±4.2 years; range, 6 to 25 years). Of the patients, pectus excavatum was detected in 69 and pectus carinatum in three. All participants' rib length-costal cartilage length ratio index, Haller index, correction index and computed tomography depression index were measured and compared. RESULTS: In patient group, there was a mild-level significant negative relationship between computed tomography depression index and rib length-costal cartilage length ratio index (p<0.05). Except for the computed tomography depression index, there was no significant relationship between rib length-costal cartilage length ratio index and other indexes and control group indexes in patient group. Rib length was higher than costal cartilage length in patient group compared to control group. There was no statistically significant difference between patient and control groups in terms of costal cartilage length (p>0.05). CONCLUSION: Contrary to what would be expected, there was no significant difference between patient and control groups in terms of costal cartilage length. Therefore, studies with larger series are required to demonstrate if costal cartilage length is effective in determining the severity of chest wall deformities.

Endoscopic atrioventricular valve surgery in adults with difficult-to-access uncorrected congenital chest wall deformities.

OBJECTIVES: This study presents the first report on in-hospital and long-term outcomes of endoscopic port access atrioventricular valve surgery (EPAAVVS) in adult patients with uncorrected congenital chest wall deformities (CCWDs). METHODS: Our current surgical team performed EPAAVVS in 7 consecutive adult patients (mean age 51.3 ± 16.4 years, 14.3% female, 50% older than 60 years, mean EuroSCORE II 0.8 ± 0.1%) with uncorrected CCWDs between 1 November 2009 and 30 November 2015. The mean left ventricular ejection fraction was 66.0 ± 8.5%. Surgical indications included isolated or combined symptomatic mitral valve (MV) regurgitation (n = 7, 100%), left ventricular outflow tract (LVOT) obstruction (n = 1, 14.3%) and patent foramen ovale (n = 3, 42.9%). Fibro-elastic deficiency accounted for 57.1% of MV pathology and 5 patients (74.1%) presented with New York Heart Association (NYHA) Class III symptoms. CCWDs included isolated pectus excavatum (n = 5, 71.4%) and mixed pectus excavatum and carinatum (n = 2, 28.6%). The mean Haller-index and correction index scores were 2.7 ± 0.5 and 21.4 ± 10.2%, respectively. RESULTS: Procedures performed included MV repair (n = 7, 100%), tricuspid valve (TV) repair (n = 1, 14.3%) and left ventricular septal myomectomy (n = 1, 14.3%). There were no sternotomy conversions or complications with chest wall entry or atrioventricular valve exposure. The mean cardiopulmonary bypass and cross-clamp times were 162.1 ± 48.1 and 113.7 ± 33.5 min, respectively. No patient required mechanical ventilation or intensive care treatment longer than 24 h. There were no surgical revisions, in-hospital respiratory or chest wall morbidities. The mean length of hospital stay was 7.4 ± 1.0 days. A total of 208 patient-months (mean 29.7 ± 26.5) were available for long-term clinical and echocardiographic analysis. There were no 30-day or long-term mortalities and no patient required reintervention for residual atrioventricular valve pathology. All patients were classified as NYHA I during recent consultations, and echocardiographic follow-up confirmed no residual MV regurgitation greater than Grade 1 in any patient. CONCLUSIONS: EPAAVVS in adults with uncorrected CCWD is safe, feasible and durable and can successfully be performed by experienced teams to achieve Haller index and correction index scores of up to 3.3 and 38.3%, respectively, with favourable long-term clinical and echocardiographic outcomes. The mere presence of uncorrected CCWDs should not deter surgeons from offering these patients the full benefits of minimally invasive cardiac surgery.