Thoracic Reconstruction Using a Poly-L-Lactic Acid Mesh Plate for an Infant with Pectus Excavatum and Complex Congenital Heart Disease Preventing Chest Closure.

Abstract

<h4>Introduction</h4>Pectus excavatum (PE) is the most common anterior chest wall deformity, but surgical intervention during infancy is rarely indicated. In patients with complex congenital heart disease (CHD), however, PE may severely compromise mediastinal capacity, particularly after repeated sternotomies. Although delayed sternal closure is a standard approach to address postoperative hemodynamic instability, in cases where chest wall deformity directly compresses the heart, definitive thoracic reconstruction may be required.<h4>Case presentation</h4>We report a 9-month-old boy with right atrial isomerism, single atrium, single ventricle, and total anomalous pulmonary venous connection (TAPVC). After initial TAPVC repair with pulmonary artery banding at 2 months of age, he developed progressive PE. At reoperation for pulmonary venous stenosis release and pulmonary artery re-banding, correction of mediastinal rotation returned the enlarged heart to the midline. Attempts at chest closure resulted in abrupt elevation of central venous pressure and systemic hypotension due to direct cardiac compression by the sternum and costal cartilages. Temporary skin-only closure was performed. Definitive thoracic reconstruction was undertaken 48 hours later using a modified Rehbein technique with a bioabsorbable poly-L-lactic acid (PLLA) mesh plate, molded into a convex shape and fixed anterior to the sternum. This approach increased mediastinal volume and allowed stable chest closure. Postoperatively, right phrenic nerve palsy required noninvasive ventilatory support for 3 weeks. The patient recovered and was discharged 2 months later in good condition.<h4>Conclusions</h4>This case demonstrates that in infants with complex CHD, severe PE may render chest closure impossible, leading to life-threatening hemodynamic compromise. Thoracic reconstruction using an absorbable PLLA mesh plate provided temporary but effective external fixation, securing mediastinal space without impairing growth. This growth-sparing strategy may represent a valuable salvage option when conventional closure fails in pediatric cardiac surgery.