Cardiovascular magnetic resonance in patients with pectus excavatum compared with normal controls

Pectus excavatum: the effect of tricuspid valve compression on cardiac function

BACKGROUND

Pectus excavatum (PE) is a common congenital chest wall deformity with various associated health concerns, including psychosocial impacts, academic challenges, and potential cardiopulmonary effects.

OBJECTIVE

This study aimed to investigate the cardiac consequences of right atrioventricular groove compression in PE using cardiac magnetic resonance imaging.

MATERIALS AND METHODS

A retrospective analysis was conducted on 661 patients with PE referred for evaluation. Patients were categorized into three groups based on the degree of right atrioventricular groove compression (no compression (NC), partial compression (PC), and complete compression(CC)). Chest wall indices were measured: pectus index (PI), depression index (DI), correction index (CI), and sternal torsion.

RESULTS

The study revealed significant differences in chest wall indices between the groups: PE, NC=4.15 ± 0.94, PC=4.93 ± 1.24, and CC=7.2 ± 4.01 (P<0.0001). Left ventricle ejection fraction (LVEF) showed no significant differences: LVEF, NC=58.72% ± 3.94, PC=58.49% ± 4.02, and CC=57.95% ± 3.92 (P=0.0984). Right ventricular ejection fraction (RVEF) demonstrated significant differences: RVEF, NC=55.2% ± 5.3, PC=53.8% ± 4.4, and CC=53.1% ± 4.8 (P≥0.0001). Notably, the tricuspid valve (TV) measurement on the four-chamber view decreased in patients with greater compression: NC=29.52 ± 4.6; PC=28.26 ± 4.8; and CC=24.74 ± 5.73 (P<0.0001).

CONCLUSION

This study provides valuable insights into the cardiac consequences of right atrioventricular groove compression in PE and lends further evidence of mild cardiac changes due to PE.

The relationship between mitral valve prolapse and thoracic skeletal abnormalities in clinical practice: a systematic review

BACKGROUND

Literature data suggest high inter-study variability in mitral valve prolapse (MVP) prevalence among individuals with thoracic skeletal abnormalities (TSA). This systematic review aimed at estimating the overall prevalence of MVP in individuals with the most common TSA, including not only the oldest studies (before the year 2000) but also the most recent ones (after the year 2000).

METHODS

PubMed and EMBASE databases were systematically reviewed in November 2023. Studies assessing the relationship between MVP and TSA and estimating the MVP prevalence in pectus excavatum (PE), pectus carinatum (PC), scoliosis, straight back syndrome (SBS) and Marfan syndrome (MS) were included. There was no limitation on time periods.

RESULTS

Twenty-five studies with a total of 2800 patients (27.9 ± 13.9 years, 48.2% females) were analyzed. The highest prevalence of MVP was observed among MS patients (47.3%), while the lowest was detected in PC individuals (23%). Prevalence of MVP was similar among PE (30.8%), scoliosis (26.3%) and SBS (25.5%) patients. When dividing the studies on the basis of temporal period, the average MVP prevalence was approximately two-fold higher in all studies conducted before the year 2000 in comparison with the most recent ones, regardless of TSA type. This discrepancy might be primarily ascribed to relevant differences in the echocardiographic criteria employed for MVP diagnosis before (less specific) and after (more specific) the year 2000, respectively.

CONCLUSIONS

The estimated MVP prevalence in TSA individuals is significantly higher than that observed in the general population. Individuals with TSA should be screened for MVP presence on transthoracic echocardiography.

Is there a relationship between Haller Index and cardiopulmonary function in children with pectus excavatum?

Background

This study aims to systematically examine the cardiopulmonary functions in children with pectus excavatum and to compare the obtained findings with the Haller Index.

Methods

Between September 2017 and June 2018, medical records of a total of 31 patients (27 males, 4 females; mean age: 14.8±2.0 years; range, 9 to 18 years) with pectus excavatum were retrospectively analyzed. The patients were divided into Group 1 (<2.5), Group 2 (2.5 to 3.19), and Group 3 (>3.2) according to the Haller Index. All groups were systematically evaluated based on pulmonary function tests and echocardiography. Forced vital capacity, forced expiratory volume in 1 second, and the forced expiratory volume in 1 second/ forced vital capacity ratio were calculated. Left ventricular enddiastolic diameter, ejection fraction, mitral valve prolapses, and right ventricular cavity in the apical four-chamber position were evaluated with echocardiography.

Results

Of the patients, 19.4% were in Group 1, 38.7% in Group 2, and 41.9% in Group 3. The mean Haller Index value was 3.09±0.64. According to pulmonary function test results, 16.1% of the patients had restrictive disease and 6.5% had obstructive disease. There was a negative correlation between the index and forced expiratory volume in 1 second and forced vital capacity, and there was a statistically significant decrease in these values, as the Haller Index increased (p<0.017). There was a significant difference in the ejection fraction among the groups (p<0.001) and, as the Haller Index increased, ejection fraction statistically significantly decreased.

Conclusion

Our study results show a negative correlation between the severity of pectus excavatum and pulmonary dysfunction and, as the severity increases, left ventricular function may be affected by the deformity. As a result, there seems to be a significant relationship between the severity of the deformity and cardiopulmonary functions.

The influence of pectus excavatum on cardiac kinetics and function in otherwise healthy individuals: A systematic review

BACKGROUND

A number of anterior chest wall deformities, most notably pectus excavatum (PE), may have a detrimental effect on cardiac motion and function. Interpretation of transthoracic echocardiography (TTE) and speckle-tracking echocardiography (STE) results may be hampered by the possible influence of PE on cardiac kinetics.

METHODS

A comprehensive search of all articles assessing cardiac function in PE individuals was carried out. Inclusion criteria were: 1) individuals aged >10 years; 2) studies providing objective assessment of chest deformity (Haller index). Studies that measured myocardial strain parameters in PE patients were also included.

RESULTS

The search (EMBASE and Medline) yielded a total of 392 studies, 36 (9.2%) of which removed as duplicates; a further 339 did not meet inclusion criteria. The full-texts of 17 studies were then analyzed. All studies concordantly reported impaired right ventricular volumes and function. With respect to left ventricle (LV), TTE studies uniformly demonstrated a significant impairment in conventional echoDoppler indices in PE individuals, whereas STE studies provided conflicting results. Importantly, LV functional alterations promptly reverted upon surgical correction of chest defect. In subjects with PE of mild-to-moderate severity, we observed that degree of anterior chest wall deformity, as noninvasively assessed by modified Haller index (MHI), was strongly associated with myocardial strain magnitude, in heterogenous cohorts of otherwise healthy PE individuals.

CONCLUSIONS

Clinicians should be aware that in PE individuals, TTE and STE results may not always be indicative of intrinsic myocardial dysfunction, but may be, at least in part, influenced by artifactual and/or external chest shape determinants.

Evaluating Cardiac Lateralization by MRI to Simplify Estimation of Cardiopulmonary Impairment in Pectus Excavatum

BACKGROUND

The severity of pectus excavatum is classified by the Haller Index (HI) and/or Correction Index (CI). These indices measure only the depth of the defect and, therefore, impede a precise estimation of the actual cardiopulmonary impairment. We aimed to evaluate the MRI-derived cardiac lateralization to improve the estimation of cardiopulmonary impairment in Pectus excavatum in connection with the Haller and Correction Indices.

METHODS

This retrospective cohort study included a total of 113 patients (mean age = 19.03 ± 7.8) with pectus excavatum, whose diagnosis was verified on cross-sectional MRI images using the HI and CI. For the development of an improved HI and CI index, the patients underwent cardiopulmonary exercise testing to assess the influence of the right ventricle's position on cardiopulmonary impairment. The indexed lateral position of the pulmonary valve was utilized as a surrogate parameter for right ventricle localization.

RESULTS

In patients with PE, the heart's lateralization significantly correlated with the severity of pectus excavatum (p ≤ 0.001). When modifying HI and CI for the individual's pulmonary valve position, those indices are present with greater sensitivity and specificity regarding the maximum oxygen-pulse as a pathophysiological correlate of reduced cardiac function (χ² 10.986 and 15.862, respectively).

CONCLUSION

The indexed lateral deviation of the pulmonary valve seems to be a valuable cofactor for HI and CI, allowing for an improved description of cardiopulmonary impairment in PE patients.

Association of Pectus Excavatum With Ventricular Remodelling and Mitral Valve Abnormalities in Marfan Syndrome

Background: Marfan syndrome (MFS) is an inherited connective tissue disorder. Pectus excavatum (PEX) is common in MFS. The purpose was to evaluate the association of PEX with cardiovascular manifestations of MFS, biventricular size and function. Methods: MFS adults undergoing cardiac MRI were retrospectively evaluated. Exclusion criteria were incomplete cardiac MRI, significant artifacts, co-existent ischaemic or congenital heart disease. Haller Index (HI) ≥3.25 classified patients as PEX positive (PEX+) and PEX negative (PEX-). Cardiac MRI analysis included assessment of mitral valve prolapse (MVP), mitral annular disjunction (MAD), biventricular volumetry and aortic dimensions. Results: 212 MFS patients were included, 76 PEX+ and 136 PEX- (HI 8.3 ± 15.2 vs 2.3 ± 0.5, P < .001). PEX+ were younger (33.4 ± 12.0 vs 38.1 ± 14.3 years, P = .02) and similar in sex distribution (55% vs 63% male, P = .26) compared to PEX-. MVP and MAD were more frequent in PEX+ vs PEX- (43/76 [57%] vs 37/136 [27%], P < .001; 44/76 [58%] vs 50/136[37%], P = .003, respectively). PEX+ had higher right ventricular end-diastolic and end-systolic volumes (RVEDVi 92 ± 17mL/m2 vs 84 ± 22mL/m2, P = .04; RVESVi 44 ± 10 mL/m2 vs 39 ± 14 mL/m2, P = .02), lower RV ejection fraction (RVEF 52 ± 5% vs 55 ± 6%, P = .01) compared to PEX-. Left ventricular (LV) volumes, LVEF and aortic dimensions were similar. Conclusion: MFS adults with PEX have higher frequency of cardiac manifestations including MV abnormalities, increased RV volumes and lower RVEF compared to those without PEX. Awareness of this association is important for all radiologists who interpret aortic CT or MRI, where HI can be easily measured. PEX in MFS may suggest more severe disease expression necessitating careful screening for MV abnormalities and outcomes surveillance.

Society for Cardiovascular Magnetic Resonance/European Society of Cardiovascular Imaging/American Society of Echocardiography/Society for Pediatric Radiology/North American Society for Cardiovascular Imaging Guidelines for the use of cardiovascular magnetic resonance in pediatric congenital and acquired heart disease : Endorsed by The American Heart Association

Cardiovascular magnetic resonance (CMR) has been utilized in the management and care of pediatric patients for nearly 40 years. It has evolved to become an invaluable tool in the assessment of the littlest of hearts for diagnosis, pre-interventional management and follow-up care. Although mentioned in a number of consensus and guidelines documents, an up-to-date, large, stand-alone guidance work for the use of CMR in pediatric congenital 36 and acquired 35 heart disease endorsed by numerous Societies involved in the care of these children is lacking. This guidelines document outlines the use of CMR in this patient population for a significant number of heart lesions in this age group and although admittedly, is not an exhaustive treatment, it does deal with an expansive list of many common clinical issues encountered in daily practice.

Society for Cardiovascular Magnetic Resonance/European Society of Cardiovascular Imaging/American Society of Echocardiography/Society for Pediatric Radiology/North American Society for Cardiovascular Imaging Guidelines for the Use of Cardiac Magnetic Resonance in Pediatric Congenital and Acquired Heart Disease: Endorsed by The American Heart Association

Cardiovascular magnetic resonance has been utilized in the management and care of pediatric patients for nearly 40 years. It has evolved to become an invaluable tool in the assessment of the littlest of hearts for diagnosis, pre-interventional management and follow-up care. Although mentioned in a number of consensus and guidelines documents, an up-to-date, large, stand-alone guidance work for the use of cardiovascular magnetic resonance in pediatric congenital 36 and acquired 35 heart disease endorsed by numerous Societies involved in the care of these children is lacking. This guidelines document outlines the use of cardiovascular magnetic resonance in this patient population for a significant number of heart lesions in this age group and although admittedly, is not an exhaustive treatment, it does deal with an expansive list of many common clinical issues encountered in daily practice.

A new tool for assessing Pectus Excavatum by a semi-automatic image processing pipeline calculating the classical severity indexes and a new marker: the Volumetric Correction Index

Background

In clinical assessment of Pectus Excavatum (PE), the indication to surgery is based not only on symptoms but also on quantitative markers calculated from Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) scans. According to clinical routine, these indexes are measured manually by radiologists with limited computer support. This process is time consuming and potentially subjected to inaccuracy and individual variability in measurements. Moreover, the existing indexes have limitations, since they are based on linear measurements performed on single slices rather than on volumetric data derived from all the thoracic scans.

Results

In this paper we present an image processing pipeline aimed at providing radiologists with a computer-aid tool in support of diagnosis of PE patients developed in MATLAB® and conceived for MRI images. This framework has a dual purpose: (i) to automatize computation of clinical indexes with a view to ease and standardize pre-operative evaluation; (ii) to propose a new marker of pathological severity based on volumetric analysis and overcoming the limitations of existing axial slice-based indexes. Final designed framework is semi-automatic, requiring some user interventions at crucial steps: this is realized through a Graphical User Interface (GUI) that simplifies the interaction between the user and the tools. We tested our pipeline on 50 pediatric patients from Gaslini Children’s Hospital and performed manual computation of indexes, comparing the results between the proposed tool and gold-standard clinical practice. Automatic indexes provided by our algorithm have shown good agreement with manual measurements by two independent readers. Moreover, the new proposed Volumetric Correction Index (VCI) has exhibited good correlation with standardized markers of pathological severity, proving to be a potential innovative tool for diagnosis, treatment, and follow-up.

Conclusions

Our pipeline represents an innovative image processing in PE evaluation, based on MRI images (radiation-free) and providing the clinician with a quick and accurate tool for automatically calculating the classical PE severity indexes and a new more comprehensive marker: the Volumetric Correction Index.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12880-022-00754-0.

Society for Cardiovascular Magnetic Resonance 2020 Case of the Week series

The Society for Cardiovascular Magnetic Resonance (SCMR) is an international society focused on the research, education, and clinical application of cardiovascular magnetic resonance (CMR). Case of the week is a case series hosted on the SCMR website ( https://www.scmr.org ) that demonstrates the utility and importance of CMR in the clinical diagnosis and management of cardiovascular disease. Each case consists of the clinical presentation and a discussion of the condition and the role of CMR in diagnosis and guiding clinical management. The cases are all instructive and helpful in the approach to patient management. We present a digital archive of the 2020 Case of the Week series of 11 cases as a means of further enhancing the education of those interested in CMR and as a means of more readily identifying these cases using a PubMed or similar search engine.

Cardiovascular MRI assessment of pectus excavatum in pediatric patients and postoperative simulation using vacuum bell

BACKGROUND

The sternal lift by Vacuum Bell (VB) is effective, as largely demonstrated by its intraoperative use during surgical procedure to elevate the sternum during the Nuss procedure routinely. Indeed, the thoracic remodelling during VB application is comparable to post-surgical scenario, and suitable to compare cardiovascular parameters of the two different thoracic configurations immediately.

OBJECTIVE

We would quantify and correlate preoperative parameters which determine the severity of the pectus excavatum (PE), and the cardiovascular effects at the baseline. Than we would assess the cardiovascular changes during VB positioning, mimicking the immediate, temporary effect of Pectus-correction.

MATERIALS AND METHODS

We included 26 consecutive patients (mean age is 13,3 +/- 2,2 years) symptomatic and non, with a previous clinical diagnosis of PE. CMR was performed before and during application of VB, using the same imaging protocol. In both conditions, we measured thoracic indexes, and cardiac function as well as flow through main vessels.

RESULTS

Mean expiratory Haller Index (HI) was 5,4 (+/-1,4 SD; normal <3). During VB application, all patients showed improvement in the main morphologic parameters of the thorax (mean expiratory HI = 4,7 (+/-1,6 SD, delta -13%, P = 0,01). During VB application, a minimal but not significant increase of Right Ventricle End Diastolic Volume (RVEDVi) (delta +4,6%, P = 0,12), and Right Ventricle Ejection Fraction (RVEF) (delta +1,2%, P = 0,2) was observed.

CONCLUSION

In adolescents affected by PE, cardiacMRI (CMR) demonstrates normal values of biventricular volume and systolic function. During VB application, beside significative improvements in chest wall anatomy, CMR shows a minimal positive variation in right ventricle volume and function. A minority of patients showed some degree of diastolic dysfunction at baseline, unchanged after VB application, with possible correlation between valve inflow and sternal impingement.

Can categorised values of maximal oxygen uptake discriminate patterns of exercise dysfunction in pectus excavatum: a prospective cohort study?

Cohort studies of patients with pectus excavatum have inadequately characterised exercise dysfunction experienced. Cardiopulmonary exercise test data were delineated by maximal oxygen uptake values >80%, which was tested to examine whether patterns of exercise physiology were distinguished.

METHODS

Seventy-two patients considered for surgical treatment underwent assessment of pulmonary function and exercise physiology with pulmonary function tests and cardiopulmonary exercise test between 2006 and 2019. Seventy who achieved a threshold respiratory gas exchange ratio of >1.1 were delineated by maximal oxygen uptake >80%, (group A, n=33) and <80% (group B, n=37) and comparison of constituent physiological parameters performed.

RESULTS

The cohort was 20.8 (±SD 6.6) years of age, 60 men, with a Haller's Index of 4.1 (±SD 1.4). Groups A and B exhibited similar demography, pulmonary function test results and Haller's index values. Exercise test parameters of group B were lower than group A; work 79.2% (±SD 11.3) versus 97.7 (±SD 10.1), anaerobic threshold 38.1% (±SD 7.8) versus 49.7% (±SD 9.1) and O2 pulse 77.4% (±SD 9.8) versus 101.8% (±SD 11.7), but breathing reserve was higher, 54.9% (±SD 13.1) versus 44.2% (±SD 10.8), p<0.001 for each. Both groups exhibited similar incidences of carbon dioxide retention at peak exercise. A total of 65 (93%) exhibited abnormal values of at least one of four exercise test measures.

CONCLUSION

This study showed that patients with pectus excavatum exhibited multiple physiological characteristics of compromised exercise function. It is the first study that defines differing patterns of exercise dysfunction and provides evidence that patients with symptomatic pectus excavatum should be considered for surgical treatment.

Pediatric Myocardial T1 and T2 Value Associations with Age and Heart Rate at 1.5 T

The objective of the study was to determine normal global left ventricular reference values for T1 and T2 in children. This is a retrospective study that included healthy subjects, age 5-19 years, who underwent CMR for the indication of pectus excavatum from 2018 to 2019. Linear regression models were used to determine associations of native T1 and T2 values to heart rate, age, and other CMR parameters. 102 patients with a mean age of 14.0 ± 2.4 years were included (range 5.4-18.8). 87 (85%) were males and 15 (15%) were females. The mean global T1 was 1018 ± 25 ms and the mean T2 was 53 ± 3 ms. T1 was negatively correlated with age (r = - 0.39, p < 0.001) and positively correlated with heart rate (r = 0.32, p < 0.001) by univariate analysis. Multivariable analysis showed that age and heart rate were independently associated with T1. T2 demonstrated a weak negative correlation with age (r = - 0.20, p = 0.047) and no correlation with heart rate. There was no difference in T1 (p = 0.23) or T2 (p = 0.52) between genders. This study reports normal pediatric T1 and T2 values at a 1.5 Tesla scanner. T1 was dependent on age and heart rate, while T2 was less dependent on age with no correlation with heart rate.

Impact of chest wall deformity on cardiac function by CMR and feature-tracking strain analysis in paediatric patients with Marfan syndrome

Objectives

To evaluate systolic cardiac dysfunction in paediatric MFS patients with chest wall deformity using cardiac magnetic resonance (CMR) imaging and feature-tracking strain analysis.

Methods

Forty paediatric MFS patients (16 ± 3 years, range 8−22 years) and 20 age-matched healthy controls (16 ± 4 years, range 11−24 years) were evaluated retrospectively. Biventricular function and volumes were determined using cine sequences. Feature-tracking CMR was used to assess global systolic longitudinal (GLS), circumferential (GCS) and radial strain (GRS). A dedicated balanced turbo field echo sequence was used to quantify chest wall deformity by measuring the Haller index (HI).

Results

LV volumes and ejection fraction (EF) were similar in MFS patients and controls. There was a trend for lower right ventricular (RV) volume (75 ± 17 vs. 81 ± 10 ml/m², p = 0.08), RV stroke volume (41 ± 12 vs. 50 ± 5 ml/m², p < 0.001) and RVEF (55 ± 10 vs. 62 ± 6%, p < 0.01) in MFS patients. A subgroup of MFS patients had an increased HI compared to controls (4.6 ± 1.7 vs. 2.6 ± 0.3, p < 0.001). They demonstrated a reduced RVEF compared to MFS patients without chest wall deformity (50 ± 11% vs. 58 ± 8%, p = 0.01) and controls (p < 0.001). LV GLS was attenuated when HI ≥ 3.25 (- 16 ± 2 vs. - 18 ± 3%, p = 0.03), but not GCS and GRS. LV GLS (p < 0.01) and GCS (p < 0.0001) were attenuated in MFS patients compared to controls, but not GRS (p = 0.31). RV GLS was attenuated in MFS patients compared to controls (- 21 ± 3 vs. - 23 ± 3%, p < 0.05).

Conclusion

Chest wall deformity in paediatric MFS patients is associated with reduced RV volume, ejection fraction and GLS. Feature-tracking CMR also indicates impairment of systolic LV function in paediatric MFS patients.

Key Points

• Paediatric Marfan patients demonstrate reduced RV volume and ejection fraction compared to healthy controls.

• A concordant attenuation in RV global longitudinal strain was observed in Marfan patients, while the RV global circumferential strain was increased, indicating a possible compensatory mechanism.

• Subgroup analyses demonstrated alterations in RV ejection fraction and RV/LV global strain parameters, indicating a possible association of severe chest wall deformity with biventricular dysfunction in paediatric Marfan patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-020-07616-9.

False-positive electrocardiographic changes during exercise test in a patient with pectus excavatum

Exercise-induced ST-segment changes simulating myocardial ischemia have been described in otherwise normal subjects during hyperventilation. We present the case of a 60-year-old man with pectus excavatum showing significant exercise-induced "pseudo-ischaemic" ST-segment changes with neither coronary artery disease nor anxiety-induced hyperventilation. We found no report of the possible causative role of a narrow antero-posterior chest diameter in inducing "pseudo-ischaemic" ST-segment changes during exercise stress test in the literature.

Research progress in the effects of pectus excavatum on cardiac functions

Background

Pectus excavatum, the most common chest wall deformity in children, accounts for nearly 90% of congenital malformations of chest wall. Initially, both parents and doctors paid more attention to the influence of this deformity on patient appearance and psychology. Following deeper studies of pectus excavatum, researchers found that it also affected cardiac functions. The purpose of this review aims to present recent research progress in the effects of pectus excavatum on cardiac functions.

Data sources

Based on aspects of CT, ultrasound cardiography (UCG) and MRI, all the recent literatures on the influence of pectus excavatum on cardiac function were searched and reviewed.

Results

Moderate and severe pectus excavatum did have a negative effect on cardiac function. Cardiac rotation angle, cardiac compression index, right atrial and tricuspid annulus size, septal motion and myocardial strain are relatively effective indexes to evaluate cardiac function.

Conclusions

Pectus excavatum did have a negative effect on cardiac function; so surgeons should actively diagnose and treat such patients in clinical work. However, further research is needed on to explore the measures and indicators that can reflect the changes of cardiac function in patients objectively, accurately, effectively and timely.

Cardiovascular magnetic resonance assessment of biventricular changes during vacuum bell correction of pectus excavatum

BACKGROUND

Evidence of cardiac dysfunction in patients with pectus excavatum (PE) remains controversial. A growing number of studies report increased exercise tolerance following surgery. Nevertheless, many consider the correction of PE a cosmetic intervention, with post-operative changes ascribed to the concurrent growth of the young patient population. No studies have investigated non-invasively the immediate cardiac changes following relief of the deformity. The aim of this study was to assess cardiac function before and during temporary sternal elevation using the non-invasive vacuum bell (VB) device on young adults with PE.

METHODS

Adult patients scheduled for surgical correction of PE underwent cardiac magnetic resonance imaging (CMRI) before and during the application of the VB. Steady-state free precession sequences were used for the evaluation of biventricular volume and function. Phase contrast sequences measured the aortic and pulmonary flow to calculate stroke index (SI). Scans were analyzed post hoc by the same investigator. A control group of healthy individuals was assessed in the same way.

RESULTS

In total, 20 patients with PE (mean age 23±10 years) and 10 healthy individuals (mean age 25±6 years) underwent CMR before and during VB application. Before intervention, baseline cardiac volumes and function were similar between the groups, with patient-values in the low-to-normal range. Following VB application, PE patients revealed a 10% increase in biventricular SI. Furthermore, left ventricular end-diastolic volume index (LV EDVI) improved by 8% and right ventricular ejection fraction (RV EF) increased by 7%. These findings were not mirrored in the healthy individuals. No correlations were found between improved cardiac parameters and the baseline Haller index (HI) of PE patients.

CONCLUSIONS

Non-invasive, momentary correction of PE is associated with an immediate improvement in SI, RV EF and LV EDVI, not observed in controls. The findings suggest that sternal depression in PE patients affects cardiac function.

A novel technique to measure severity of pediatric pectus excavatum using white light scanning

BACKGROUND/PURPOSE

Computed tomography (CT) derived Haller Index (HI) remains the standard for quantifying severity in patient with pectus excavatum (PE). Optical scanning described in literature reports optimistic results and new indices that correlate with HI. This study assessed the feasibility of a handheld White Light Scanner (WLS) to obtain 3D measurements and indices of PE deformity.

METHODS

From April 2015-April 2017, WLS scanning was conducted by orthotists during clinical visits. Included were children with PE up to 18 years. Analysis assessed correlation of a WLS-derived severity index, Hebal-Malas Index (HMI), with physician measured PE Depth (PED), and CT-derived HI.

RESULTS

Of 195 participants, 185(94%) patients with PE were scanned and 127(69%) had complete WLS data. For 88 patients undergoing monitoring, HMI correlated with PED (r = 0.42, p = 0.004). For 39 patients with pre-operative CT, HMI demonstrated strong correlation with HI (r = 0.87, p<0.0001).

CONCLUSIONS

WLS demonstrated high feasibility of scanning PE. WLS-derived HMI best correlates with HI for patients with severe pectus deformity. Our current data is suggestive that WLS is best applied for severe deformities and yet to be established for milder deformities. Future yearly WLS will provide data on deformity progression and surgical therapy.

LEVEL OF EVIDENCE

IV.

TYPE OF STUDY

Diagnostic Study.

Disorders of the Chest Wall: Clinical Manifestations

Chest wall disorders represent deformities and/or injuries that alter the rib cage geometry and result in pulmonary restriction, increased work of breathing, exercise limitations, and cosmotic concerns. These disorders are congenital or acquired and affect all ages. Disorders affecting the spine (kyphoscoliosis, ankylosing spondylitis), ribs (flail chest), and sternum (pectus excavatum) are discussed in this article, with emphasis on clinical presentations, pulmonary function abnormalities, diagnosis, and treatment.

Improvement of cardiopulmonary function after minimally invasive surgical repair of pectus excavatum (Nuss procedure) in children

Background:

Severe pectus excavatum in children may result in cardiorespiratory functional impairment; therefore, we evaluated cardiopulmonary response to exercise before and after the Nuss procedure.

Methods:

Twenty-four physically active pediatric patients aged 9–18 years with severe pectus excavatum (Haller index >3.25) were included in the study. Cardiopulmonary exercise testing using treadmill and modified Bruce protocol was performed before and after the Nuss procedure.

Results:

Maximal oxygen uptake and oxygen pulse improved by 40.6% (32 ± 13–45 ± 10 ml/kg/min; P = 0.0001) and 44.4% (9 ± 4–13 ± 5 ml/beat; P = 0.03), respectively, after surgical correction of pectus excavatum by Nuss procedure. Significant improvement in maximum voluntary ventilation and minute ventilation after Nuss procedure was also noted.

Conclusions:

We found that, after repair of pectus excavatum by Nuss procedure, the exercise capacity as measured by maximal oxygen consumption improved significantly primarily due to increase in oxygen pulse, an indirect measurement of stroke volume.

Incremental value of three-dimensional transthoracic echocardiography over the two-dimensional modality in the assessment of right heart compression and dysfunction produced by pectus excavatum

The usefulness of two-dimensional transthoracic echocardiography (2DTTE) in the assessment of right heart compression and dysfunction produced by pectus excavatum chest wall deformity has been well described in the literature by several investigators. However, there is a paucity of reports describing incremental value of live/real time three-dimensional transthoracic echocardiography (3DTTE) over the two-dimensional technique in the evaluation of right heart function in these patients. We present a severe case of pectus excavatum chest wall deformity in a young male, in whom 3DTTE provided incremental value over standard 2DTTE in assessing compression of the right heart before surgery and marked improvement in right heart function parameters following surgical repair. In addition, an updated summary of salient features of this deformity, including 2D and 3DTTE findings as well as right heart echocardiographic parameters by both 2D and 3DTTE in normal/healthy subjects summarized from the literature have been provided in a tabular form for comparison.

Relationship between cardiac MR compression classification and CT chest wall indexes in patients with pectus excavatum

BACKGROUND/PURPOSE

In pectus excavatum (PE) patients owing to the location of the heart in the chest cavity, the most affected site of compression by the depressed chest wall is the right heart, and surgical repair has shown to provide a significant relief in the RH cavities compression. Our aim was to explore the relationship between the site of right cardiac compression, chest wall indexes (CT-CWI) and the sternal torsion angle (STA) based on cardiac magnetic resonance (CMR) and computed tomography (CT) among PE patients.

METHODS

We included PE patients with no previous surgical correction referred to CMR and chest CT imaging as presurgical evaluations. The following CT-CWI were calculated: Haller Index (HI), correction index (CI) and STA. A CMR compression classification (CMR-CC) was implemented based on the analysis (in the horizontal long axis plane at end of diastole) of the right cardiac compression site, caused by the thoracic cage (sternum/ribs): Type 0 (T0): absence of cardiac compression; Type 1 (T1): compression of the lateral wall of the right ventricle (RV) without involvement of the atrioventricular (AV) groove; Type 2 (T2): compression of the RV involving the AV groove.

RESULTS

Sixty PE patients underwent CMR and chest CT. Fifty (81%) patients were male, and the median age was 17.5 (14.0; 23.0) years. T0, T1 and T2 were found in 14 (23%), 27 (45%) and 19 (32%) patients. There were significant differences between types with regard to the HI (T0 3.9 ± 1.1, T1 4.8 ± 2.0, T2 6.4 ± 3.1, p < 0.009) and to the CI (T0 22.1 ± 10.4%, T1 31.6 ± 16.1%, T2 46.9 ± 16.3% p < 0.0001) and STA (T0 9.1 ± 7.9°, T1 12.7 ± 10.3°, class T2 23.0 ± 13.6°p = 0.001) respectively.

CONCLUSION

In this study, we established a cardiac magnetic resonance compression classification of patients with pectus excavatum comprising a simple discrimination of cardiac compression sites, which were related to chest wall indexes.

TYPE OF STUDY

Study of Diagnostic Test.

LEVEL OF EVIDENCE

Level II.

A comparison between laryngeal mask airway and endotracheal intubation for anaesthesia in adult patients undergoing NUSS procedure

Background

This study evaluates and compares the feasibility and safety of application of laryngeal mask airway (LMA) and endotracheal intubation (ETT) for anaesthesia in adult patients undergoing thoracoscopic surgery.

Methods

Sixty adult patients with pectus excavatum (PE) undergoing video-assisted thoracoscopic surgery for the NUSS procedure (VATS-NUSS) between September 2016 and March 2017 were selected and randomly separated into two groups with different methods of airway management. In one group, LMA was applied for general anaesthesia, and in the other group, ETT was used. The clinical parameters before, during and after the surgery in patients from both groups were collected from multiple data resources in a hospital. SPSS software was used for the analysis.

Results

Of all the selected patients, the physiological parameters showed similarity between the LMA and ETT groups, indicating consistency in the clinical characteristics of the study sample. Additionally, no significant differences were discovered between the two groups in terms of the anaesthesia and surgical time, peak PetCO₂ during operation, anaesthetic satisfaction score, and amount of blood loss as well as inpatient time for recovery. However, with a similar level of anaesthesia effects and suitable parameters for mechanical ventilation, patients in the LMA group showed much more stability in the physiological indicators for inflammation and haemodynamics, including white blood cell count (ΔWBC) and percentage of neutrophil granulocytes (ΔNEU%) in the blood as well as heart rate (ΔHR) and mean arterial pressure (ΔMAP). Moreover, the LMA patients had a significantly shorter time for recovery of consciousness and food/water intake. Finally, compared to the ETT group, patients in the LMA group also had a significantly lower incidence of side effects induced by the anaesthesia procedure after surgery, such as gastrointestinal reactions, throat discomfort and hoarseness.

Conclusions

Compared with ETT, the application of LMA for general anaesthesia may demonstrate promising advantages in airway management for the VATS-NUSS procedure.

The physiologic impact of pectus excavatum repair

The adverse physiologic effects of pectus excavatum and subsequent resolution following correction have been a subject of controversy. There are numerous accounts of patients reporting subjective improvement in exercise tolerance after surgery, but studies showing clear and consistent objective data to corroborate this phenomenon physiologically have been elusive. This is partially due to a lack of consistent study methodologies but even more so due to a mere paucity of data. As experts in the repair of pectus excavatum, it is not uncommon for pediatric surgeons to operate on adult patients. For this reason, this review evaluates the contemporary literature to provide an understanding of the physiologic impact of repairing pectus excavatum on pediatric and adult patients separately.

Left atrial compression and right ventricular outflow tract diameter on echocardiography are independently associated with exercise capacity in patients with large hiatal hernia

INTRODUCTION

Large hiatal hernia (HH) is often associated with left atrial (LA) compression, anteroposterior cardiac compression (manifesting as reduced right ventricular outflow tract (RVOT) diameter), and left ventricular (LV) compression (manifesting as systolic paradoxical outward motion (LV-PM) of the posterobasal LV segment). Exercise impairment, also common in this population, improves following HH surgery. We aimed to identify echocardiographic parameters independently associated with exercise impairment due to HH-mediated cardiogenic compression.

METHODS

Patients with a large HH (>30% intra-thoracic stomach, n = 163) referred for cardiac evaluation were included. Echocardiographic parameters were retrospectively analyzed in relation to HH-related LA compression severity and the presence of LV-PM. Echocardiographic parameters independently associated with exercise capacity were identified by multivariable analysis.

RESULTS

Mean baseline metabolic equivalents were reduced (70 ± 28% predicted). Moderate-severe LA compression and LV-PM were present in 91 of 163 (56%) and 65 of 162 (40%) patients, respectively. Patients with moderate-severe LA compression and LV-PM had decreased LA and LV dimensions. Moderate-severe LA compression was also associated with reduced RVOT diameter while LV-PM predicted a greater reduction in LV volumes. LA compression and RVOT diameter were independently associated with baseline exercise capacity and increased following HH surgery performed in a subgroup (n = 72, LA diameter: 14 ± 5 vs 20 ± 4 mm/m² ; RVOT diameter: 17 ± 3 vs 19 ± 3 mm/m² , P < .001 for both). Conversely, LV-PM was not independently associated with exercise capacity.

CONCLUSION

Hiatal hernia-related cardiac compression reduces LA and RVOT dimensions. These parameters are independently associated with baseline exercise capacity and improve following HH surgery. LV-PM is associated with decreased LV volumes but not exercise capacity in this population.

Occult RV systolic dysfunction detected by CMR derived RV circumferential strain in patients with pectus excavatum

Aims

To investigate the right ventricular (RV) strain in pectus excavatum (PE) patients using cardiac magnetic resonance tissue tracking (CMR TT).

Materials and methods

Fifty consecutive pectus excavatum patients, 10 to 32 years of age (mean age 15 ± 4 years), underwent routine cardiac magnetic resonance imaging (CMR) including standard measures of chest geometry and cardiac size and function. The control group consisted of 20 healthy patients with a mean age of 17 ± 5 years. RV longitudinal and circumferential strain magnitude was assessed by a dedicated RV tissue tracking software.

Results

Fifty patients with images of sufficient quality were included in the analysis. The mean right and left ventricular ejection fractions were 55 ± 5% and 59 ± 4%. The RV global longitudinal strain was -21.88 ± 4.63%. The RV circumferential strain at base, mid-cavity and apex were -13.66 ± 3.09%, -11.31 ± 2.79%, -20.73 ± 3.45%, respectively. There was no statistically significant decrease in right ventricular or left ventricular ejection fraction between patients and controls (p > 0.05 for each). There was no significant difference in RV global longitudinal strain between two groups (-21.88 ± 4.63 versus -21.99 ± 3.58; p = 0.93). However, there was significant decrease in mid-cavity circumferential strain magnitude in pectus patients compared with controls (-11.31 ± 2.79 versus -16.19 ± 2.86; p < 0.001). PE patients had a significantly higher basal circumferential strain (-13.66 ± 3.09% versus -9.76 ± 1.79; p < 0.001) as well as apical circumferential strain (-20.73 ± 3.45% versus -12.07 ± 3.38) than control group.

Conclusion

Mid-cavity circumferential strain but not longitudinal strain is reduced in pectus excavatum patients. Basal circumferential strain as well as apical circumferential strain were increased as compensatory mechanism for reduced mid-cavity circumferential strain. Further studies are needed to establish clinical significance of this finding.

Pectus excavatum: Right ventricular compromise with orthostatic syndrome and Brugada phenocopy

Pectus excavatum (PEXT) consists of an overgrowth of the chondral region with posterior displacement of the inferior part of the sternum, resulting in a concave chest deformity. Characteristic clinical and imaging findings may occur, depending on the compression that right cardiac chambers suffer, when squeezed between the sternum and the column vertebrae.

Exaggerated Interventricular Dependence Among Patients With Pectus Excavatum: Combined Assessment With Cardiac MRI and Chest CT

OBJECTIVE

We sought to explore whether patients with pectus excavatum have exaggerated interventricular dependence and to evaluate the impact of the malformation severity (assessed on CT) on both anatomic and functional cardiac parameters (assessed on cardiac MRI).

SUBJECTS AND METHODS

The current study involved consecutive patients with a diagnosis of pectus excavatum who were referred to undergo cardiac MRI and chest CT to establish surgical candidacy or to define treatment strategies.

RESULTS

Sixty-two patients with pectus excavatum underwent cardiac MRI and chest CT. Fifty (81%) patients were male, and the median age was 17.5 years (range, 14.0-23.0 years). Forty-seven (76%) patients had evidence of right ventricular compression. The left ventricle showed a significantly decreased end-diastolic volume (inspiration vs expiration: 70.4 ± 11.6 vs 76.1 ± 13.7 mL/m², respectively; p = 0.01) and a significantly higher eccentricity index (1.52 ± 0.2 vs 1.20 ± 0.1, p < 0.0001) during inspiration than during expiration. The median respiratory-related septal excursion was 8.1% (interquartile range, 5.1-11.7%). Patients with pericardial effusion showed a significantly higher pectus excavatum severity index than patients without pericardial effusion (6.3 ± 3.4 vs 4.4 ± 1.3, respectively; p = 0.003). Patients with a relative septal excursion equal to or larger than 11.8% showed a significantly higher pectus excavatum severity index than patients with a relative septal excursion of less than 11.8% (6.3 ± 2.6 vs 4.7 ± 2.4, respectively; p = 0.05).

CONCLUSION

In this study, patients with pectus excavatum showed significant alterations of cardiac morphology and function that were related to the deformation severity and that manifest as an exaggerated interventricular dependence.

Effect of the Nuss Procedure on the Physical Development of Patients with Pectus Excavatum

PURPOSE

This study assessed physical development of patients with pectus excavatum and evaluated the effect of the Nuss procedure on physical development.

METHODS

A total of 146 patients underwent the Nuss procedure; of these, at the time of the study, the bar had been removed from 123 patients (84.9%; male 93, female 30) who were eligible for participation in this study. Heights and body weights of patients were measured prior to surgery and immediately before bar removal. Chest computed tomography (CT) was performed preoperatively and immediately before bar removal. The associations between physical development and chest CT indices were evaluated.

RESULTS

The height standard deviation score (SDS) was - 0.66 ± 2.23 preoperatively and 0.04 ± 1.34 immediately before bar removal (p <0.01). The weight SDS was - 0.02 ± 2.59 preoperatively; it increased significantly to 0.56 ± 1.56 immediately before bar removal (p <0.01). The Haller index (3.85 ± 1.18 to 2.99 ± 0.54; p <0.01) and asymmetric index (9.75 ± 6.63 to 7.01 ± 4.77; p <0.01) also showed improvements.

CONCLUSIONS

The Nuss procedure may contribute positively to the physical development of patients with pectus excavatum.

Cardiac and arterial elastance and myocardial wall stress in children with pectus excavatum

OBJECTIVES

Pectus excavatum (PE) is one of the most common skeletal deformities of childhood. The study was undertaken to assess cardiac functions in children with PE.

METHODS

Echocardiography was performed on 32 children with PE and 40 age-matched healthy controls. The following parameters were monitored: meridional left ventricular (LV) wall stress (WSM), arterial elastance (Ea), LV elastance at end-systole derived by single beat (Ees(sb)), LV circumferential end-systolic wall stress (ESWSc), midwall shortening fraction (SFmid), predicted midwall fiber shortening for a measured fiber stress (midwall VCFc), myocardial fiber stress (MFS), LV end-systolic dimension (LVES), LV end-diastolic dimension (LVED) and end-systolic blood pressure (Pes), LV wall thickness at end-systole (hes). To assess the severity of PE, Haller index (HI) was calculated by computed tomography of the thorax.

RESULTS

SFmid, ESWSc, midwall VCFc and MFS were lower in PE children than in controls. The degree to which the parameters SFmid, ESWSc, midwall VCFc and MFS were altered in PE children was 14.9, 27.5, 20.3 and 20.3%, respectively. The minimum HI value of children with PE was 2.00, the maximum value was 4.93 and the arithmetic mean was 2.62 ± 0.56. Of the 32 children, 14 (43.75%) demonstrated mild deformity, 15 (46.88%) showed moderate and only 3 (9.37%) had severe deformity. In children with PE, there was no statistically significant correlation between the cardiac data (ESWSc, midwall VCFc, MFS, Ea, Ees(sb), LVES, LVED, Pes, hes) and HI.

CONCLUSION

We found ESWSc, MFS, midwall VCFc and SFmid to be lower in children with PE than in controls. We concluded that the myocardial contractility and afterload is affected in children with PE.

Development of a minipig model for lung injury induced by a single high-dose radiation exposure and evaluation with thoracic computed tomography

Radiation-induced lung injury (RILI) due to nuclear or radiological exposure remains difficult to treat because of insufficient clinical data. The goal of this study was to establish an appropriate and efficient minipig model and introduce a thoracic computed tomography (CT)-based method to measure the progression of RILI. Göttingen minipigs were allocated to control and irradiation groups. The most obvious changes in the CT images after irradiation were peribronchial opacification, interlobular septal thickening, and lung volume loss. Hounsfield units (HU) in the irradiation group reached a maximum level at 6 weeks and decreased thereafter, but remained higher than those of the control group. Both lung area and cardiac right lateral shift showed significant changes at 22 weeks post irradiation. The white blood cell (WBC) count, a marker of pneumonitis, increased and reached a maximum at 6 weeks in both peripheral blood and bronchial alveolar lavage fluid. Microscopic findings at 22 weeks post irradiation were characterized by widening of the interlobular septum, with dense fibrosis and an increase in the radiation dose-dependent fibrotic score. Our results also showed that WBC counts and microscopic findings were positively correlated with the three CT parameters. In conclusion, the minipig model can provide useful clinical data regarding RILI caused by the adverse effects of high-dose radiotherapy. Peribronchial opacification, interlobular septal thickening, and lung volume loss are three quantifiable CT parameters that can be used as a simple method for monitoring the progression of RILI.

Impact of surgical correction of pectus excavatum on cardiac function: insights on the right ventricle. A cardiovascular magnetic resonance study†

OBJECTIVES

Pectus excavatum (PE) is often regarded as a cosmetic disease, while its effect on cardiac function is under debate. Data regarding cardiac function before and after surgical correction of PE are limited. We aimed to assess the impact of surgical correction of PE on cardiac function by cardiovascular magnetic resonance (CMR).

METHODS

CMR at 1.5 T was performed in 38 patients (mean age 21 ± 8.3; 31 men) before and after surgical correction to evaluate thoracic morphology, indices and its relation to three-dimensional left and right ventricular cardiac function.

RESULTS

Surgery was successful in all patients as shown by the Haller Index ratio of maximum transverse diameter of the chest wall and minimum sternovertebral distance [pre: 9.64 (95% CI 8.18-11.11) vs post: 3.0 (2.84-3.16), P < 0.0001]. Right ventricular ejection fraction (RVEF) was reduced before surgery and improved significantly at the 1-year follow-up [pre: 45.7% (43.9-47.4%) vs 48.3% (46.9-49.5%), P = 0.0004]. Left ventricular ejection fraction was normal before surgery, but showed a further improvement after 1 year [pre: 61.0% (59.3-62.7%) vs 62.7% (61.3-64.2%), P = 0.0165]. Cardiac compression and the asymmetry index changed directly after surgery and were stable at the 1-year follow-up [3.93 (3.53-4.33) vs 2.08 (1.98-2.19) and 2.36 (2.12-2.59) vs 1.38 (1.33-1.44), respectively; P < 0.0001 for both]. None of the obtained thoracic indices were predictors of the improvement of cardiac function. A reduced preoperative RVEF was predictive of RVEF improvement.

CONCLUSIONS

PE is associated with reduced RVEF, which improves after surgical correction. CMR has the capability of offering additional information prior to surgical correction.

Cardiovascular magnetic resonance in Marfan syndrome

This review provides an overview of Marfan syndrome with an emphasis on cardiovascular complications and cardiovascular imaging. Both pre- and post-operative imaging is addressed with an explanation of surgical management. All relevant imaging modalities are discussed with a particular focus on cardiovascular MR.

Review of Journal of Cardiovascular Magnetic Resonance 2011

There were 83 articles published in the Journal of Cardiovascular Magnetic Resonance (JCMR) in 2011, which is an 11% increase in the number of articles since 2010. The quality of the submissions continues to increase. The editors had been delighted with the 2010 JCMR Impact Factor of 4.33, although this fell modestly to 3.72 for 2011. The impact factor undergoes natural variation according to citation rates of papers in the 2 years following publication, and is significantly influenced by highly cited papers such as official reports. However, we remain very pleased with the progress of the journal's impact over the last 5 years. Our acceptance rate is approximately 25%, and has been falling as the number of articles being submitted has been increasing. In accordance with Open-Access publishing, the JCMR articles go on-line as they are accepted with no collating of the articles into sections or special thematic issues. For this reason, the Editors feel it is useful to summarize the papers for the readership into broad areas of interest or theme, which we feel would be useful, so that areas of interest from the previous year can be reviewed in a single article in relation to each other and other recent JCMR articles. The papers are presented in broad themes and set in context with related literature and previously published JCMR papers to guide continuity of thought in the journal. We hope that you find the open-access system increases wider reading and citation of your papers, and that you will continue to send your quality manuscripts to JCMR for publication.

Review of journal of cardiovascular magnetic resonance 2010

There were 75 articles published in the Journal of Cardiovascular Magnetic Resonance (JCMR) in 2010, which is a 34% increase in the number of articles since 2009. The quality of the submissions continues to increase, and the editors were delighted with the recent announcement of the JCMR Impact Factor of 4.33 which showed a 90% increase since last year. Our acceptance rate is approximately 30%, but has been falling as the number of articles being submitted has been increasing. In accordance with Open-Access publishing, the JCMR articles go on-line as they are accepted with no collating of the articles into sections or special thematic issues. Last year for the first time, the Editors summarized the papers for the readership into broad areas of interest or theme, which we felt would be useful to practitioners of cardiovascular magnetic resonance (CMR) so that you could review areas of interest from the previous year in a single article in relation to each other and other recent JCMR articles 1. This experiment proved very popular with a very high rate of downloading, and therefore we intend to continue this review annually. The papers are presented in themes and comparison is drawn with previously published JCMR papers to identify the continuity of thought and publication in the journal. We hope that you find the open-access system increases wider reading and citation of your papers, and that you will continue to send your quality manuscripts to JCMR for publication.

Indications and guidelines for pectus excavatum repair

PURPOSE OF REVIEW

The introduction of the Nuss procedure in 1997 for treatment of pectus excavatum, in conjunction with the ever-expanding body of medical information available on the internet, significantly raised the level of awareness for this deformity as both an anatomic and a functional problem. The subsequent increase in referrals for pectus excavatum repair provided large patient series for clinical analyses to better define underlying physiologic impairments and stimulated surgeons to develop technical improvements to enhance the safety and effectiveness of pectus excavatum repair.

RECENT FINDINGS

Clinical assessment, diagnostic imaging, and cardiorespiratory testing of patients with pectus excavatum have helped to characterize physiologic impairments associated with severe pectus excavatum and to define inclusion criteria for surgical repair. Appropriate timing of repair is important to minimize complications, especially recurrence. Evidence of improved cardiorespiratory function after pectus excavatum repair has been presented. As a result of numerous technical improvements, safe and effective operative correction of pectus excavatum has been reported for both the Nuss procedure and open repair.

SUMMARY

The findings presented in this review provide objective evidence of the cardiorespiratory impairment associated with severe pectus excavatum. Clinical identification of affected patients should prompt timely work-up and referral for pectus excavatum repair if inclusion criteria are met. Regular follow-up through pubertal growth is recommended.