The "straight back" syndrome: current perspective more often associated with valvular heart disease than pseudoheart disease: a prospective clinical, electrocardiographic, roentgenographic, and echocardiographic study of 50 patients

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.

Related mechanisms and research progress in straight back syndrome

Despite the high prevalence of straight back syndrome (SBS), there is still limited research on this condition, posing challenges for effective diagnosis and treatment. The disease has been known for a long time, but there have been few related studies, which mostly consist of case reports. These studies have not been systematically summarized, making it difficult to meet the current needs of diagnosis and treatment. This article summarized the existing literature and comprehensively reviewed the diagnosis, pathogenesis, treatment, and research status of mitral valve prolapse related to SBS. We specifically emphasized the mechanisms and prognosis of SBS combined with mitral valve prolapse and discussed the latest research progress in this disease.

RASopathies and spinal deformities for screening of scoliosis

BACKGROUND

The RASopathies (Noonan syndrome [NS] and Costello syndrome [CS]) are rare disorders. Although these have been characterized, precise delineation of the differences in the spinal deformities associated with RASopathy has not been described. This study characterized the spinal deformities found in NS and CS and describes a strategy for the screening of scoliosis.

METHODS

The clinical records and spinal X-rays of 35 consecutive NS and CS patients were reviewed. Spinal X-rays were assessed to define the presence and progression of scoliosis. Clinical records were examined to identify the risk factors associated with scoliosis. In addition, we investigated the association between clinical records and scoliosis using logistic regression analysis.

RESULTS

Twenty-four patients with NS and 11 with CS were included. Nine patients with NS and five with CS showed scoliosis. The mean ± SD age at diagnosis was 12.6 ± 2.4 years in NS and 11.4 ± 2.5 years in CS (p = 0.55), and mean follow-up period was 4.8 ± 2.6 years and 6.3 ± 2.4 years (p = 0.42), respectively. The coronal angular deformity at final follow-up was 27.3 ± 8.5° in NS and 19.4 ± 6.9° in CS (p = 0.030) with a mean annual progression of 2.8 ± 1.1° in NS 1.0 ± 1.0° in CS (p = 0.030). Cardiac disease was present in eight out of nine patients with NS with concomitant scoliosis in NS, and significantly more than in CS (p = 0.007). PTPN11 significantly correlated with scoliosis (odds ratio 12.4 0.035, 95% confidence interval: 1.20-128.00).

CONCLUSIONS

Spinal deformity in NS is more severe than in CS. This study identified a relationship between PTPN11 and scoliosis. Therefore, PTPN11 can be used for the screening of scoliosis.

Straight Back Syndrome Presented with Chest and Back Pain: A Case Report

A 17-year-old female adolescent presented with her mother to our clinic with a two-month history of left-sided chest pain and a one-week history of middle back pain. We diagnosed straight back syndrome based on the chest and thoracic radiographic findings and symptoms of chest pain, palpitations, and dyspnea. We reassured the patient that the disease was benign and advised her to start and continue chiropractic therapy. All symptoms, including back pain, disappeared in three weeks. Straight back syndrome is under-diagnosed, and back pain is less recognized as a symptom of the disease.

A mechanism of a cardiac murmur with respiratory variation in a patient with straight back syndrome

A 20-year-old male without any symptoms was referred for heart murmur on a medical examination. A thrill was palpable at the upper left sternal border. His cardiac murmur showed respiratory variation. The systolic murmur was louder (Levine grade IV/VI) during expiration and diminished during inspiration (Levine grade I/VI). He was thin and had a narrow thoracic cage in the anteroposterior direction due to straight back syndrome (SBS). An echocardiogram and a right ventriculogram showed changes in the diameter of the right ventricular outflow tract (RVOT) on respiration. During expiration, the RVOT was compressed and narrow, while it was expanded during inspiration. Cardiac catheterization demonstrated a 10-mmHg of pressure gradient across the RVOT during expiration but no pressure gradient during inspiration. Thus, respiratory compression to the RVOT by a narrow thoracic cage due to SBS was the cause of the cardiac murmur with respiratory alterations. Our case highlights the importance of physical examination, including an inspection of the patient's physique. <Learning objective: When examining a patient with a cardiac murmur, respiratory alterations of cardiac murmurs should be auscultated. In these cases, straight back syndrome would be one of the differential diagnoses and should be considered. During a physical examination, inspection of the patient's physique is also important.>.

Straight Back Syndrome

Straight back syndrome is a rare condition usually associated with mitral valve prolapse and "pseudo-heart disease" caused by a very narrow anterior-posterior chest due to the loss of the normal dorsal curvature of the thoracic spine. More rarely, the narrowed upper chest may compress the trachea causing extrinsic tracheal obstruction. If severe enough, this requires operative repair by effectively opening up the upper chest by a variety of techniques to allow the trachea enough room to avoid compression.

An interesting case of straight back syndrome and review of the literature

Straight back syndrome is characterized by loss of the normal upper thoracic kyphosis, leading to a reduced anteroposterior diameter and squashing of the heart. Most patients are asymptomatic; if symptomatic, chest pain and palpitations are most common. On examination, the abnormal clinical findings simulate organic heart disease that needs to be ruled out by echocardiography and cardiac catheterization. A lateral chest radiograph is diagnostic. This condition is commonly associated with mitral valve prolapse and bicuspid aortic valve. We describe an interesting case of straight back syndrome with all the classic and rarely reported clinical findings.

Treatment of paroxysmal supraventricular tachycardia using instrument-assisted manipulation of the fourth rib: a 6-year case study

OBJECTIVE

The purpose of this case report was to describe the observation of the manipulation of the fourth rib followed by the reproducible, rapid return of heart rate to normal in a patient with paroxysmal supraventricular tachycardia.

CLINICAL FEATURES

A male patient had paroxysmal supraventricular tachycardia. He was evaluated using standard methods of palpation. He was followed over a 6-year period.

INTERVENTION AND OUTCOME

The patient was treated during episodes of supraventricular tachycardia (SVT) with instrument-assisted manipulation of the fourth rib without treatment of any other segments. Tachycardia was eliminated after rib manipulation within less than 2 minutes. Over a 6-year period, effective control of episodes of SVT was consistently achieved associated with manipulation of the fourth rib.

CONCLUSIONS

This case study is suggestive of a relationship between SVT and misalignment of the fourth rib. Controlled studies are necessary to validate this observation.

Supravalvular aortic stenosis and peripheral pulmonary stenosis coexisting with a straight thoracic spine

Supravalvular aortic stenosis (SVAS) is recognized in cases of Williams syndrome and in sporadic cases not associated with other features of the syndrome. It is also well recognized as associated with peripheral pulmonary stenosis (PPS). A male patient was diagnosed as having PPS at the age of 1 year and 8 months, and was found at the age of 18 years to have SVAS. Cardiac catheterization showed that he had a localized type of SVAS and regression of the PPS. Chest X-ray showed that he did not have the normal thoracic curvature. His 19-year-old sister had also been diagnosed with PPS, and his 43-year-old mother was known to have a harsh systolic cardiac murmur of unknown etiology. Cardiac magnetic resonance imaging showed a localized type of SVAS in his mother also, though not in his sister, both of whom had a somewhat straight thoracic spine, most noticeably in the mother, though not to the degree observed in the patient. This case appears to be familial, though it is not clear whether this skeletal abnormality is an unknown phenotypic feature of this cardiovascular disease.

Isolated pulmonary valvular regurgitation: current perspectives

IPVR is a rare clinical entity that was first diagnosed during life in 1955. In the past 35 years, only 69 patients have been reported. With increasing clinical awareness, as well as use of PDE, the confirmation of its clinical diagnosis has become easier and more accurate without having to take recourse to invasive cardiac studies as in the past. For this reason, it is becoming increasingly apparent that IPVR is not so rare as has been suggested in the past. IPVR is more common in men than in women, in whites than blacks, and in the young than the elderly. The mean age of IPVR patients is 27 years (range, 4 to 85). The majority of the patients are asymptomatic and the diagnosis is usually suspected upon the discovery of a crescendo-decrescendo, low-pitched, early to mid diastolic murmur in the second and third left intercostal space, which increases during inspiration, particularly in the presence of a hyperdynamic right ventricle and in the absence of peripheral circulatory phenomenon of aortic regurgitation. The ECG often shows right axis deviation, incomplete right bundle branch block, and rarely, right ventricular hypertrophy and strain. However, a normal ECG does not preclude its diagnosis. Approximately 30% of the IPVR patients have normal 12-lead ECGs. The diagnosis may be further suggested by the posteroanterior chest roentgenogram when dilated and large central pulmonary arteries are noted to pulsate vigorously (hilar dance) on chest fluoroscopy.(ABSTRACT TRUNCATED AT 250 WORDS)