The influence of pectus excavatum on cardiac kinetics and function in otherwise healthy individuals: A systematic review.

A number of anterior chest wall deformities, most notably pectus excavatum (PE), may have a detrimental effect on cardiac motion and function. Interpretation of transthoracic echocardiography (TTE) and speckle-tracking echocardiography (STE) results may be hampered by the possible influence of PE on cardiac kinetics. A comprehensive search of all articles assessing cardiac function in PE individuals was carried out. Inclusion criteria were: 1) individuals aged >10 years; 2) studies providing objective assessment of chest deformity (Haller index). Studies that measured myocardial strain parameters in PE patients were also included. The search (EMBASE and Medline) yielded a total of 392 studies, 36 (9.2%) of which removed as duplicates; a further 339 did not meet inclusion criteria. The full-texts of 17 studies were then analyzed. All studies concordantly reported impaired right ventricular volumes and function. With respect to left ventricle (LV), TTE studies uniformly demonstrated a significant impairment in conventional echoDoppler indices in PE individuals, whereas STE studies provided conflicting results. Importantly, LV functional alterations promptly reverted upon surgical correction of chest defect. In subjects with PE of mild-to-moderate severity, we observed that degree of anterior chest wall deformity, as noninvasively assessed by modified Haller index (MHI), was strongly associated with myocardial strain magnitude, in heterogenous cohorts of otherwise healthy PE individuals. Clinicians should be aware that in PE individuals, TTE and STE results may not always be indicative of intrinsic myocardial dysfunction, but may be, at least in part, influenced by artifactual and/or external chest shape determinants. Multimodality imaging assessment of chest wall conformation. Panel A: Conventional radiological Haller index assessment by CT scan. The Haller index is measured as the ratio of the maximum internal transverse diameter of the chest divided by the minimum antero-posterior diameter, at the deepest point of the deformity, at end inspiration. CT, computed tomography. Panels B1 and B2: Conventional radiological Haller index assessment by CXR. Panel B1: The internal L-L major thoracic diameter is measured, on a P-A view, at the level of the distal third of the sternum and/or of the eighth thoracic vertebra, without including the soft tissues (red line). Panel B2: The internal A-P minor thoracic diameter measured, on a L-L view, at the level of the maximum sternal depression, from the internal anterior chest wall to the anterior surface of the eighth thoracic vertebral (red line). CXR, chest X-ray; A-P, antero-posterior; L-L, latero-lateral; P-A, postero-anterior. Panels C1 and C2: MHI assessment. Panel C1: The L-L thoracic diameter is measured with the subject in the standing position and with open arms, by using a rigid ruler in centimeters coupled to a level (the measuring device), placed at the distal third of the sternum, at level of the point of maximum depression of the sternum. Panel C2: The A-P thoracic diameter is obtained during conventional transthoracic echocardiography, from the parasternal long-axis view, by measuring the distance between the true apex of the sector and the posterior wall of the descending thoracic aorta, visualized behind the left atrium. A-P, antero-posterior; Asc ao, ascending aorta; Desc ao, descending aorta; LA, left atrium; L-L, latero-lateral; LV, left ventricle; MHI, modified Haller index; RV, right ventricle. [Display omitted] • Chest wall abnormalities may impair cardiac motion and function. • Modified Haller index (MHI) is a radiation-free technique for assessing chest shape. • The MHI method may identify subjects with concave-shaped chest wall (MHI >2.5). • Subjects with MHI >2.5 have small cardiac chambers and impaired strain indices. • Impairment in myocardial deformation indices is strongly correlated with MHI. [ABSTRACT FROM AUTHOR]