What are the surgical indications for pectus excavatum?

Surgical Indications for Pectus Excavatum

Surgery is indicated for pectus excavatum when patients meet two or more of the following criteria: severe symptomatic deformity, Haller index >3.25 on CT scan, cardiac compression or displacement, restrictive pulmonary disease on pulmonary function testing, mitral valve prolapse or other cardiac pathology secondary to compression, or progressive deformity with paradoxical respiratory motion. 1

Primary Indications

Anatomic Severity

• Haller index (pectus index) greater than 3.25 on CT scan is a key objective measure indicating severe anatomic deformity requiring surgical correction 1
• Severe depression of the sternum and costal cartilages with documented progression over time warrants intervention 1
• Paradoxical respiratory chest wall motion during breathing indicates significant structural compromise 1

Cardiopulmonary Dysfunction

• Cardiac compression or displacement demonstrated on imaging (CT or echocardiography) is an indication for surgery 1
• Pulmonary compression with restrictive disease pattern on pulmonary function studies supports surgical intervention 1
• Mitral valve prolapse occurs in approximately 15% of pectus excavatum patients and when present secondary to cardiac compression, indicates need for repair 1, 2
• Bundle branch block or other cardiac conduction abnormalities caused by cardiac compression 1
• Diminished right ventricular volume on echocardiography 1

Symptomatic Presentation

• Lack of endurance, shortness of breath with exercise, or chest pain are frequent symptoms that, when present with anatomic severity, support surgical indication 1
• Exertional dyspnea and reduced exercise tolerance that improve after surgical correction 3

Special Populations Requiring Comprehensive Evaluation

Associated Genetic Syndromes

• Complete cardiac evaluation is mandatory when genetic syndromes are suspected, particularly in patients with connective tissue disorders such as Marfan syndrome or Noonan syndrome 4
• In Marfan syndrome patients, pectus excavatum scores 1 point in the systemic features scoring system, and these patients require thorough aortic assessment 5
• Noonan syndrome patients may have pectus excavatum along with cardiac alterations such as pulmonary stenosis 4

Patients with Skeletal Abnormalities

• Patients with kyphoscoliosis and pectus excavatum may have cardiac migration to the left hemithorax, which affects surgical planning 4
• Osteogenesis imperfecta patients with pectus excavatum may have more severe restrictive respiratory patterns 4

Optimal Timing of Surgery

Surgical repair should preferably be performed between ages 1 and 8 years when the chest wall is more malleable, though adults can undergo successful correction 6

• For adults (≥15 years), surgical correction demonstrates excellent outcomes with significant improvement in cosmetic satisfaction, pain, dyspnea, and exercise tolerance 3
• Patient satisfaction is excellent in 77.9% of adult cases at 12-month follow-up 3

Preoperative Evaluation Requirements

Essential Studies

• Photographs for anatomic documentation 1
• CT scan to measure Haller index and assess extent of cardiac compression or displacement 1
• Echocardiography to evaluate for mitral valve prolapse (present in 15% of cases) and right ventricular volume 1, 2
• Pulmonary function testing to document restrictive disease 1
• Chest radiography to demonstrate depth of depression 1

Selective Studies

• Electrocardiography, arterial blood gas analysis, and advanced pulmonary function tests should be reserved for patients with suspected coexisting conditions such as Marfan syndrome, skeletal abnormalities, or pulmonary disease 2

Common Pitfalls to Avoid

• Do not rely solely on cosmetic appearance—objective measurements (Haller index >3.25) and functional impairment must be documented 1
• Do not miss associated mitral valve prolapse—echocardiography is essential as this occurs in 15% of patients and influences surgical decision-making 1, 2
• Do not overlook genetic syndromes—failure to perform comprehensive cardiac evaluation in suspected connective tissue disorders can miss critical associated pathology 4
• Do not assume all patients need the same surgical approach—complex or recurrent cases may require combination techniques rather than minimally invasive approaches alone 7

Failed or Recurrent Deformity

• Failed previous repair(s) constitute an indication for revision surgery 1
• Complex recurrent cases require combination of multiple techniques and reconstruction materials to achieve adequate correction and reduce recurrence rates 7