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. 2023 Mar;33(3):2128-2135.
doi: 10.1007/s00330-022-09197-1. Epub 2022 Oct 29.

Pectus excavatum in motion: dynamic evaluation using real-time MRI

Daniel Gräfe  1 , Martin Lacher  2 , Illya Martynov  2 , Franz Wolfgang Hirsch  3 , Dirk Voit  4 , Jens Frahm  4 , Harald Busse  5 , Sergio Bruno Sesia  6 , Sebastian Krämer  7 , Peter Zimmermann  2
Affiliations

Pectus excavatum in motion: dynamic evaluation using real-time MRI

Daniel Gräfe et al. Eur Radiol. 2023 Mar.

Abstract

Objectives: The breathing phase for the determination of thoracic indices in patients with pectus excavatum is not standardized. The aim of this study was to identify the best period for reliable assessments of morphologic indices by dynamic observations of the chest wall using real-time MRI.

Methods: In this prospective study, patients with pectus excavatum underwent morphologic evaluation by real-time MRI at 3 T between January 2020 and June 2021. The Haller index (HI), correction index (CI), modified asymmetry index (AI), and modified eccentricity index (EI) were determined during free, quiet, and forced breathing respectively. Breathing-related differences in the thoracic indices were analyzed with the Wilcoxon signed-rank test. Motion of the anterior chest wall was analyzed as well.

Results: A total of 56 patients (11 females and 45 males, median age 15.4 years, interquartile range 14.3-16.9) were included. In quiet expiration, the median HI in the cohort equaled 5.7 (4.5-7.2). The median absolute differences (Δ) in the thoracic indices between peak inspiration and peak expiration were ΔHI = 1.1 (0.7-1.6, p < .001), ΔCI = 4.8% (1.3-7.5%, p < .001), ΔAI = 3.0% (1.0-5.0%, p < .001), and ΔEI = 8.0% (3.0-14.0%, p < .05). The indices varied significantly during different inspiratory phases, but not during expiration (p > .05 each). Furthermore, the dynamic evaluation revealed three distinctive movement patterns of the funnel chest.

Conclusions: Real-time MRI reveals patterns of chest wall motion and indicate that thoracic indices of pectus excavatum should be assessed in the end-expiratory phase of quiet expiration.

Key points: • The thoracic indices in patients with pectus excavatum depend on the breathing phase. • Quiet expiration represents the best breathing phase for determining thoracic indices. • Real-time MRI can identify different chest wall motion patterns in pectus excavatum.

Keywords: Funnel chest; Magnetic resonance imaging; Thoracic wall.

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Conflict of interest statement

Jens Frahm and Dirk Voit are co-inventors of a patent and software describing the real-time MRI technique used here for real-time MR imaging. The other authors declare no competing interests

Figures

Fig. 1
Fig. 1
Schematic illustration of distances (solid lines) and definitions of (a) Haller index (HI), (b) correction index (CI), (c) modified asymmetry index (AI), and (d) modified eccentricity index (EI). Dashed lines are auxiliary contours
Fig. 2
Fig. 2
Ranges of HI and CI during maximum inspiration and expiration for all 56 participants. Four (7%) subjects crossed an HI of 3.25, which is considered a pathologic threshold. Fifteen (27%) subjects crossed the corresponding CI value of 28%
Fig. 3
Fig. 3
Absolute deviations between peak inspiration and expiration for HI, CI, AI, and EI. While HI increased in 98% of participants during expiration, CI decreased in 25%. AI tended to increase with expiration. The EI did not show a directional change
Fig. 4
Fig. 4
Correlation between HI and CI. Although there is a linear relationship, the dispersion is rather large (r2 = 0.48, p < .001)
Fig. 5
Fig. 5
Three distinct movement patterns characterized by selected frames of MRI videos and corresponding tracking curves in our cohort of patients with funnel chest. Please take note of the deactivated vacuum bell placed upon the funnel as part of our standard estimate of treatment response using real-time MRI. (Video 5a, Fig. 5b) Symmetric movement of both sides and funnel (Video 5c, Fig. 5d) pronounced movement of the lower side in asymmetric pectus excavatum, and (Video 5e, Fig. 5f) delayed movement of one side of the funnel
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