Improved Right Ventricular Diastolic Function Assessed by Hepatic Vein Flow After Pectus Excavatum Repair

Abstract

Background: The cardiovascular benefits of surgical repair in pectus excavatum (PEx) continue to be debated, with limited data supporting repair in adult patients. Hepatic vein flow is used to identify right-sided diastolic dysfunction in cardiovascular disorders, including tricuspid stenosis, cardiac tamponade, and constrictive pericarditis. This study evaluates the effects of cardiac compression on diastolic function (as assessed by hepatic vein flow patterns and velocities) before and after repair of PEx.

Methods: A retrospective study was performed of intraoperative transesophageal echocardiograms including hepatic vein assessments of adult patients who underwent preoperative and postoperative evaluations during repair of PEx from 2018 to 2021.

Results: In total, 127 patients were included (median age, 29.0 [15.4] years; median Haller index, 4.2 [1.7]; 60.6% male). Statistically significant improvements were seen after pectus repair of right ventricular stroke volume and diastolic function as measured by increased postoperative velocities for hepatic vein waves (P < .001 for all comparisons). Preoperatively, 5.5% of patients had constrictive-like physiology with end-diastolic retrograde flow that normalized postoperatively (P = .016). Approximately 10% of patients changed their pattern of hepatic vein flow after surgical procedure. Patients with more proximal cardiac compression had greater improvements in hepatic vein velocities after repair.

Conclusions: Surgical relief of cardiac compression resulted in an immediate improvement in hepatic vein flow and right ventricle stroke volume in patients with PEx. These results support diastolic dysfunction in a large number of patients, with improvement in function and compliance after the surgical relief of cardiac compression.

Graphical abstract

Figure 1

Classification of the patients according to the site of maximal cardiac compression. (A) Transesophageal echocardiography (TEE) and computed tomography (CT) showing no significant compression of right-sided heart chambers. (B) TEE and chest CT with contrast enhancement showing that the site of maximal compression is located at the level of the tricuspid annulus (proximal compression). (C) TEE and CT demonstrating compression of the right ventricle free wall and apex by left costochondral junction (distal compression).

Figure 2

Abnormalities in hepatic vein flow in patients with pectus. (A) A 23-year-old woman with pectus excavatum. Hepatic vein flow analysis at preoperative transesophageal echocardiography showed diastolic predominance (D wave > S wave), with low anterograde systolic velocities. This abnormal pattern in hepatic vein flow has been described in patients with obstruction to the right ventricle inflow tract, such as cases of tricuspid stenosis. Postoperatively, hepatic vein flow changed to a normal pattern (S wave > D wave) with increased systolic forward velocities. (B) A 44-year-old woman with pectus excavatum. Preoperative evaluation of the hepatic vein flow revealed the presence of an end-diastolic retrograde wave before atrial contraction (pre-A wave, arrow) in a manner similar to that seen in constrictive pericarditis. After repair, the end-diastolic retrograde wave was no longer present.

Supplemental Figure 1