Severe pectus excavatum and pericardial effusion - incidental finding with good prognosis

P. K. Bauerschmitz (Göttingen)¹, C. Dellas (Göttingen)², M. Steinmetz (Göttingen)¹, J. Lotz (Göttingen)³, C. Unterberg-Buchwald (Göttingen)⁴, U. Krause (Göttingen)^2
1Universitätsmedizin Göttingen Klinik für Pädiatrische Kardiologie und Intensivmedizin Göttingen, Deutschland; ²Universitätsmedizin Göttingen, Klinik für Kinder- und Jugendmedizin Pädiatrische Kardiologie und Intensivmedizin Göttingen, Deutschland; ³Universitätsmedizin Göttingen Institut Diagnostische und Interventionelle Radiologie Göttingen, Deutschland; ⁴Universitätsmedizin Göttingen Göttingen, Deutschland

Introduction:
Pectus excavatum (PEX) is a congenital abnormality with the sternum being displaced posteriorly. In PEX the right heart cavities are often impressed between the spine and the sternum. This morphological abnormality may lead to mechanical compression and distortion of the right atrium and the right ventricle and severe deformities can be associated with pericardial effusion.

Case Report: 
A 16 year old patient presented for cardiology consultation before his planned spinal spondylodesis. The asymptomatic patient presented with a severe funnel chest on clinical examination. The ECG showed an incomplete right bundle branch block. Cardiac magnetic resonance imaging (CMR) demonstrated cardiac displacement to the left, diminished right ventricular function (ejection fraction 48%) and dilated volume (RVEDVi 113ml/m²). The left ventricle was of normal size (LVEDVi 95ml/m²) with a reduced systolic function (LVEF 52%). There was pericardial effusion which was not of clinical relevance.

Conclusion: 
Severe pectus excavatum is often associated with hemodynamically insignificant pericardial effusion which usually does not need further evaluation. It is supposed to be caused by mechanical irritation of the pericardium and disturbed fluid absorption. CMR is the gold standard for imaging as it is totally independent from chest wall abnormalities.


Figure 1:            Cardiac magnetic resonance imaging presenting severe pectus excavatum.


Figure 2 and 3: Cardiac magnetic resonance imaging demonstrating a white layer of fluid around the heart which represents pericardial effusion. No signs of hemodynamic instability. 




Figure 4:           ECG with incomplete right bundle branch block.