Objective:To optimize the strategy of Nuss procedure with open approach via median sternotomy for pectus excavatum(PE) with congenital heart disease(CHD).Methods:25 PE patients with CHD treated in our center from January 2017 to November 2021 were reviewed and divided into two groups. The CHD surgery and open Nuss procedure with median sternotomy were performed concomitantly in 9 cases(group A), whose height of(121.7±28.0)cm, weight of(22.2±14.0)kg, age of(7.65±4.08) years old, and Haller index of 3.99±1.37. 16 cases underwent open Nuss procedure via median re-sternotomy after congenital heart surgery(group B), whose height of(130.9±27.2)cm, weight of(26.5±14.3)kg, age of(8.82±4.09) years old, and Haller index of 4.18 ± 0.97. The cardiac anatomy, cardiac function and the severity of PE of all patients were evaluated by echocardiography and computed tomography preoperatively. The preoperative gender, appearance of PE, types of associated CHD, retrosternal adhesion and the interval between open Nuss procedure and CHD surgery were collected. The details of operation, hospital stay, intraoperative adverse events, postoperative complications and follow-up were collected.Results:All the operations were accomplished successfully in 25 children. No intraoperative complications occurred. One had a postoperative wound infection in group A. The operation time of group A was significantly longer than that of group B[(3.78±1.54) h vs.(2.19±0.94) h, P<0.05]. There was no significant difference in the mechanical ventilation time between the two groups[(22.50±45.64) h vs.(4.18±1.41) h, P=0.263]. The ICU stay of group A was significantly longer than that of group B[(4.00±6.42) days vs.(1.13±0.34) days, P<0.05]. There was no significant difference in the length of hospital stay between the two groups[(16.00±15.18) days vs.(9.19±2.31) days, P=0.419]. The Nuss bar was removed in 14 cases of the two groups, with a interval of(27.9±11.25) months after open Nuss procedure, the postoperative Haller Index was 2.48±0.49. There was no difference of LVEF in postoperative and preoperative echocardiography(0.663±0.028 vs. 0.659±0.038, P=0.533). The FVC and FEV1 were significantly improved compared with before operation[(87.2±3.9)% vs.(84.1±8.2)%]. The outcome was good. Conclusion:For PE patients with CHD, one-stage or staged individualized Nuss procedure with open approach via median sternotomy can be performed after careful preoperative evaluation. A skillful median re-sternotomy and widely dissecting retrosternal adhesion between sternum and anterior wall of heart are necessary to avoid serious intraoperative complications such as massive heart bleeding and ensure good sternal elevation.