Exercise Cardiac Output Limitation in Pectus Excavatum

Impact of pectus excavatum on pulmonary function and exercise capacity in patients treated with 3D custom-made silicone implants

BACKGROUND

Pectus excavatum (PE) is the most common congenital chest wall deformity, whose cardiopulmonary consequences are controversial. PE surgery is in our experience usually performed for aesthetic reasons.

OBJECTIVES

The aim of this study was to evaluate the impact of PE on respiratory function and exercise capacity in patients with PE before patient-specific silicone implant correction.

METHODS

This monocentric prospective study conducted at Toulouse University Hospital included sixty patients scheduled for custom-made silicone implants correction. Respiratory function (pulmonary function tests (FPTs)) and exercise capacity (VO2 max) were measured before surgery.

RESULTS

Before surgery, no (0/60) restrictive lung disease was detected, with a mean total lung capacity (TLC) of 98.5% of predicted value (IC 95%; 80.4-137). Median VO2 max (n=56) was normal (89% predicted), with no cardiac limitation.

CONCLUSION

In this cohort, PE had no impact on respiratory function nor exercise capacity. In patients without cardiac or respiratory effects of PE, silicone implants should be considered the preferred approach as it adequately addressed patients' main complaint of low self-esteem.

Ventilatory limitations are not associated with dyspnea on exertion or reduced aerobic fitness in pectus excavatum

Exercise intolerance and chest pain are common symptoms in patients with pectus excavatum. To assess if the anatomic extent of pectus deformities determined by the correction index (CI) is associated with a pulmonary impairment at rest and during exercise we performed a retrospective review on pectus patients in our center who completed a symptom questionnaire, cardiopulmonary exercise test (CPET), pulmonary function tests (PFT), and chest magnetic resonance imaging. Of 259 patients studied, dyspnea on exertion and chest pain was reported in 64% and 41%, respectively. Peak oxygen uptake (VO₂ ) was reduced in 30% and classified as mild in two-thirds. A pulmonary limitation during exercise was identified in less than 3%. Ventilatory limitations on PFT was found in 26% and classified as mild in 85%. Obstruction was the most common abnormal pattern (11%). There were no differences between patients with normal or abnormal PFT patterns for the CI, VO_2, or percentage reporting dyspnea or chest pain. Scatter plots demonstrated significant but weak inverse relationships between the CI and lung volumes at rest and during exercise. Multivariable linear regression modeling evaluating predictors of VO₂ demonstrated positive associations with the forced expiratory volume at one second and a negative association with the CI. We conclude that resting PFT patterns have poor correlation with the anatomic extent of the pectus defect, symptomatology or aerobic fitness. Pulmonary limitations on CPET are uncommon and lung volumes during exercise are only minimally associated with the CI.

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.

Pectus Excavatum: A Review of Diagnosis and Current Treatment Options

Osteopathic medicine places a special emphasis on the musculoskeletal system, and understanding how chest wall structure may influence function is critical. Pectus excavatum is a common congenital chest wall defect in which the sternum is depressed posteriorly. Patients may present with complaints of chest wall discomfort, exercise intolerance, and tachycardia. The medical implications, diagnosis, and treatment options for patients with pectus excavatum are reviewed.

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.