Right ventricular compression observed in echocardiography from pectus excavatum deformity

Abstract

Pectus excavatum exists as varying anatomic deformities and compression of the right heart by the chest wall can lead to patient symptoms including dyspnea and chest pain with exertion. Echocardiography can be difficult but is critical to the evaluation and diagnosis of this patient population. Modifying standard views such as biplane transthoracic and 3-D transesophageal views may be necessary in some patients due to limitations from the abnormal anatomy of the deformed anterior chest wall. Apical four-chamber views when seen clearly can usually visualize any extrinsic compression to the right ventricle of the heart.

Keywords: Chest pain; Chest wall deformity; Echocardiography right heart; Pectus excavatum; Right ventricular compression.

Fig. 1

A: Patient clinical photograph at physical examination demonstrating physical abnormality of the post-operative chest. B: Preoperative chest roentgenogram shows abnormal bony projection of sternum posterior

Fig. 2

Computed tomography with contrast showing bony projection of the deformed chest wall compressing the right ventricle (arrow).

Fig. 3

Transthoracic echocardiography. Apical 4-chamber view demonstrates compression and deformation of the lower mid right ventricle by the chest wall in diastole which is more obvious during diastole (arrow) (A) than systole (B).

Fig. 4

A: Post surgical patient's chest was straightened and elevated 3-4 cm anterior to the heart and mediastinum with good cosmetic results and relief of cardiac compression. B: Lateral chest roentgenoram shows metal support bars and trabecular metal implant used to reconstruct patient's chest wall.

Fig. 5

Pre-operative transesophageal views showing extrinsic compassion of the RV during diastole (arrow) (A) and systole (arrow) (B). Tricuspid valve prolapse is evident during systole likely related to some distortion of the tricuspid annulus from extrinsic compression of the RV (square arrow) (B). Post-operative transesophageal image showing resolution of extrinsic RV compression (C). Note slight improvement in tricuspid valve prolapse as well following surgery. Pre-operative biplane images using three dimensional transesophageal probe from transgastric window showing extrinsic compression of the RV in the short axis (D) and long-axis views of the right ventricle simultaneously (arrows) (E). Note the acoustic shadowing behind the RV indentation due to bony structure. Improved visualization of the indentation of the right ventricle from live three dimensional image (arrow) (F). LV: left ventricle, LA: left atrium, RV: right ventricle, RA: right atrium.