Sternal advancement surgery for pectus excavatum: a systematic review and meta-analysis of cardiac and respiratory function outcomes

Introduction

Pectus excavatum (PE) is the most common congenital anterior chest wall deformity, affecting approximately 1 in 400 births, with a male predominance (5:1) (1). The functional implications of PE and its optimal management strategies remain widely debated (2-4). While its etiology remains largely unknown, most cases are idiopathic (5), though 30–40% show familial patterns, suggesting a genetic component (6). The prevailing theory attributes the condition to abnormal cartilaginous rib growth causing posterior sternal displacement (5). Though associated with syndromes like Marfan and Ehlers-Danlos, most cases are isolated and not linked to connective tissue disorders (7).

PE is often noted in infancy but typically diagnosed in pre-adolescence. The deformity worsens during puberty, often leading to symptoms such as chest pain, dyspnea, reduced exercise tolerance, and palpitations (5-8).

Emerging evidence supports a link between PE and functional impairment, particularly due to right heart compression (9-11). While the extent of cardiorespiratory dysfunction and surgical benefit has been debated, growing data support improvement post-correction (12,13).

Standardized guidelines recommend surgery for PE when the Haller index (HI) exceeds 3.2, indicating a severe deformity. The ongoing debate (14) centers not on redefining treatment methods, but on refining their indications. Management should account for anatomical severity, functional impact, and psychological factors. Treatments fall into two categories: structural and non-structural. Structural approaches aim to remodel the chest wall, including surgical techniques like the minimally invasive repair of PE (MIRPE) (15), Ravitch procedure (16), or non-surgical vacuum bell therapy (17). These may improve cardiopulmonary function (18). Non-structural options, such as prosthesis placement, lipofilling, or flaps, address appearance but not physiology (19).

To guide treatment decisions, this study aimed to evaluate whether sternal advancement surgery improves cardiorespiratory function at rest and during exercise. We conducted a systematic review and meta-analysis, with a secondary objective of developing a personalized decision-making algorithm. We present this article in accordance with the PRISMA reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-347/rc).

Methods

Study design

A preliminary search of the PROSPERO registry (International Prospective Register of Systematic Reviews) confirmed no similar ongoing or published studies.

A comprehensive literature search was conducted in PubMed, Embase, and Cochrane databases from January to December 2024 using the keywords: “pectus excavatum” OR “funnel chest” AND “cardiac function” OR “cardiopulmonary function”. Two independent reviewers screened titles and abstracts using Rayyan software, followed by full-text review. Discrepancies were resolved by consensus.

Inclusion criteria were prospective or retrospective observational cohort studies, case-control studies, and randomized or non-randomized controlled trials evaluating cardiac and/or respiratory function before and after surgical correction of PE, at rest or during exercise. Only studies involving MIRPE or modified Ravitch procedures were included.

Exclusion criteria were non-corrective surgical techniques, acquired PE, complex deformities, pre-existing cardiopulmonary conditions, or associated musculoskeletal disorders. No age restrictions were applied.

Data extraction

Relevant data were extracted from text, tables, and figures of included studies. Extracted variables included:

• Study details: authors, country, publication year, journal, title, and study design.
• Patient demographics: number of patients, age, sex, weight, height, and follow-up duration.
• Surgical information: type of procedure (MIRPE or sternochondroplasty).
• Follow-up data: time to surgery, total follow-up period, and presence of a retrosternal bar during assessment.
• PE characteristics: symmetry, severity (e.g., HI or correction index), and cardiac compression.
• Paraclinical assessments: computed tomography (CT), magnetic resonance imaging (MRI), transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), forced expiratory flow rate (EFR), and exercise/stress testing.

Outcomes

Mean differences between pre- and post-operative data were analyzed across three main domains:

• Cardiac function at rest: cardiac output (Qc, L/min), cardiac index (L/min/m²), left ventricular systolic ejection volume (LVSEV, mL), and left ventricular ejection fraction (LVEF, %).
• Respiratory function at rest: forced expiratory volume in 1 second (FEV1, L/s), forced vital capacity (FVC, L), vital capacity (VC, L), and total lung volume (TLV, L), reported in absolute terms and as percentages of predicted values based on age and height.
• Exercise capacity: VO₂max (mL/kg/min and mL/min), VO₂max at anaerobic threshold (mL/kg/min), and O₂pulse (mL/beat), each expressed in absolute terms and as percentages of predicted values based on age and body size.

Statistical analysis

All analyses were performed using Stata 11^®, with a significance level set at P<0.05. The primary analysis calculated pooled standardized mean differences between pre- and post-operative values for each outcome. Due to study heterogeneity, a random-effects model was used, with weighting based on sample size.

An outcome was considered significantly improved if the mean difference (pre- minus post-operative) was negative, the 95% confidence interval excluded zero, and the P value was <0.05.

The main analysis pooled data from all sternal advancement techniques (MIRPE and Ravitch), including variations. Subgroup analyses were performed by age (<18 vs. ≥18 years) and surgical technique (MIRPE with/without bar in place at follow-up, and Ravitch) to assess heterogeneity.

A decision-making algorithm was developed, integrating factors such as preoperative functional impairment, deformity severity and progression, patient age and growth potential, and individual treatment goals—functional, aesthetic, or both.

Results

Bibliography

A total of 401 references were identified through database searches (Figure 1). After removing duplicates, 389 articles remained. Following title and abstract screening, 348 were excluded. Twenty-one studies (12,20-39) met the inclusion criteria and were retained for analysis (Table 1).

Figure 1 Flowchart detailing the study selection process.

Two studies presented distinct subgroup data. Al-Assiri et al. (26) reported outcomes for classic and modified MIRPE, which were analyzed separately. Liu et al. (33) divided patients into two age groups (3–12 and >12 years), which were also analyzed independently.

In total, 23 datasets from 21 articles were included, representing 1,087 patients with a mean age of 18.93 years [standard deviation (SD): ±7.7 years].

Cardiac function at rest

The meta-analysis, irrespective of surgical technique or age group, showed significant post-operative improvements across all cardiac function parameters (Table 2):

• Cardiac output: assessed exclusively in MIRPE studies, with a significant increase post-operatively (P=0.04). Subgroup analysis (Table 3) showed the improvement remained significant with the retrosternal bar in place (P=0.03), but was not enhanced by bar removal.
• Cardiac index: also measured only in MIRPE studies, with a significant post-operative rise (P=0.03) (Table 2).
• LVSEV: evaluated in both MIRPE and sternochondroplasty studies, showing a significant post-operative improvement (P=0.001) (Table 2).
• LVEF: demonstrated a significant improvement following surgery (P=0.03).

Respiratory function at rest

No significant post-operative improvement was found in any of the respiratory function parameters, including FEV1. Subgroup analysis confirmed the absence of significant changes (Table 3).

Exercise function

The combined analysis of MIRPE and Ravitch techniques showed a significant increase in absolute VO₂max values post-operatively (P<0.001, Figure 2). However, no improvement was observed when VO₂max was expressed as a percentage of predicted values (Table 2).

Figure 2 Summary of VO₂max outcomes from studies on MIRPE and sternochondroplasty techniques. CI, confident interval; MIRPE, minimally invasive repair of pectus excavatum; SMD, standard mean deviation.

Subgroup analyses revealed (Table 2):

• Significant VO₂max improvement in the MIRPE group, both with and without the bar in place (P<0.001, Figure 3), as well as in the Ravitch group (P<0.001, Figure 4).
• No significant VO₂max improvement when analyzing MIRPE subgroups separately (with bar: P=0.07; without bar: P=0.057, Figure 4).
• Significant improvement in VO₂max for both patients under 18 years (P=0.03) and over 18 years (P<0.001, Table 2).
• O₂pulse also improved significantly post-operatively, both in absolute terms (P<0.001) and as a percentage of predicted values (P<0.001, Table 2).

Figure 3 Subgroup analysis of VO₂max in patients undergoing MIRPE. CI, confident interval; MIRPE, minimally invasive repair of pectus excavatum; SMD, standard mean deviation.

Figure 4 Comparison of VO₂max outcomes in patients treated with MIRPE with or without a retrosternal bar, and the Ravitch procedure. CI, confident interval; MIRPE, minimally invasive repair of pectus excavatum; SMD, standard mean deviation.

Discussion

This meta-analysis shows that sternal advancement surgery significantly improves cardiac function at rest and during exercise in patients with congenital PE, but has no significant effect on respiratory function. A key limitation of this study is the heterogeneity in how cardiac and respiratory functions were reported across the included studies.

A major finding is the critical role of the retrosternal bar in the MIRPE technique. We observed significant improvements in cardiac output, cardiac index, SEV, and LVEF. These improvements are likely due to reduced cardiac chamber compression after sternal advancement, leading to enhanced cardiac filling (40). This is reflected in increased SEV and ejection fraction. As SEV increases, so does cardiac output (Qc = heart rate × SEV). Notably, only studies using MIRPE assessed these improvements. Subgroup analyses revealed that when the retrosternal bar remained in place during post-operative follow-up, the improvements were sustained. When it was removed, the improvements were lost. A possible explanation could be the recurrence of cardiac compression if sternal correction is lost, although definitive conclusions are limited by the lack of detailed chest and heart imaging in the studies. Notably, only one study (36) specifically assessed post-operative cardiac output with the Nuss bar still in place.

In contrast, respiratory function at rest showed no significant post-operative improvement across key parameters (FEV1, VC, FVC, TLV), with a trend toward deterioration. This is consistent with previous research, and there is limited evidence supporting a direct impact of PE on pulmonary function (41-43). For instance, the meta-analysis by Chen et al. (4) found no significant improvement in CV of TLV, or FEV1, although they did report a trend toward improved FEV1 3 years after Nuss bar removal compared to one year post-surgery. The presence of a MIRPE bar or Ravitch stabilization material may reduce thoracic compliance and alter respiratory biomechanics. The Nuss bar may restrict the ribs’ “bucket-handle” movement, while cartilage resections in the Ravitch technique could impair intercostal muscle function—both essential for normal breathing (44).

Selecting appropriate parameters for managing PE is essential. Although patients often report symptoms like palpitations, fatigue, and dyspnea, functional assessments at rest are frequently normal or only mildly impaired (8). This is likely due to the gradual onset of the deformity, which allows physiological adaptation. As a result, reduced endurance or exercise intolerance is usually the primary complaint (8,45,46), making stress testing more informative than resting evaluations. Metrics such as VO₂max and O₂pulse are particularly relevant, as they reflect the cardiovascular system’s response to increased metabolic demand—VO₂max indicating aerobic capacity, and O₂pulse representing oxygen use per heartbeat.

Our study found significant post-operative improvements in both VO₂max and O₂pulse, suggesting enhanced cardiorespiratory performance during exertion. Although VO₂max is affected by factors like genetics, age, and training, its improvement following surgery supports the idea that anatomical correction of PE improves physiological capacity for exercise. However, VO₂max can also be influenced by increased physical activity (47), and unfortunately, our dataset lacked information on patients’ activity levels before and after surgery. Still, the observed improvements in cardiac function at rest likely support better exercise adaptation.

Subgroup analysis showed VO₂max and O₂pulse increased post-operatively with both Ravitch and MIRPE techniques. However, this gain disappeared when the retrosternal bar remained in place during MIRPE follow-up, suggesting the bar may limit full physiological benefit. Despite limitations—such as small sample sizes, methodological heterogeneity, and inconsistent measurement techniques—our findings indicate that sternal advancement improves resting cardiac function and, by extension, exercise capacity.

Though the mean improvement in VO₂max may seem modest (e.g., 0.35 mL/kg/min), even small changes in exercise capacity are known to affect mortality risk (48). We therefore recommend sternal advancement surgery in cases showing impaired cardiorespiratory function.

Building on our findings and recent literature (49), advocate for comprehensive cardiopulmonary evaluation—both at rest and during exercise—prior to surgery, with systematic re-evaluation after the intervention, especially post-bar removal (18). A major challenge remains the lack of standardization in non-invasive cardiac output measurement, which limits comparability and confidence in outcomes.

To address these issues, we propose a clinical decision-making algorithm (Figure 5) to guide PE management. This tool is intended to support future prospective studies and promote standardized practice. Ideally, future research should be international, multicenter, and prospective, using unified evaluation protocols at baseline and follow-up. It should also establish clear criteria for selecting surgical techniques, considering functional outcomes, patient history, growth potential, and personal preferences.

Figure 5 Proposed management algorithm for PE, tailored to individual patient characteristics. CPET, cardiopulmonary exercise testing; CT, computed tomography; ECG, electrocardiogram; MIRPE, minimal invasive repair of pectus excavatum; MOVARPE, minor open videoendoscopically assisted repair of pectus excavatum; MRI, magnetic resonance imaging; PE, pectus excavatum; PFT, pulmonary function test; TUS, transthoracic ultrasonography; VB, vacuum bell.

Conclusions

This study evaluated the impact of sternal advancement surgery—via MIRPE and modified Ravitch techniques—in patients with PE. While respiratory function remained unchanged, significant improvements in cardiac performance at rest and during exercise were observed, underscoring the functional burden of cardiac compression in PE. These results support the systematic assessment of cardiopulmonary function and the pursuit of functional improvement as a surgical objective, particularly with MIRPE. By decompressing the heart, sternal advancement not only restores cardiac function but also contributes to a more comprehensive management of PE, including esthetic and psychosocial aspects. The proposed decision-making algorithm offers a basis for future multicenter studies aimed at standardizing care and improving outcomes.

Acknowledgments

The authors thank Sophie Domingues-Montanari, PhD, for reviewing the manuscript for English language and style.

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-347/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-347/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-347/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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