Evaluation of Pectus Abnormalities
Begin with chest radiography (PA and lateral views) combined with transthoracic echocardiography as your initial imaging approach, then proceed to CT for surgical planning and cardiac MRI when cardiac compression or functional impairment needs detailed assessment. 1, 2
Initial Clinical Assessment
Look specifically for these clinical features:
- Symptoms of exercise intolerance, dyspnea with mild exertion, decreased endurance, anterior chest pain, and tachycardia—these typically worsen during adolescence 3
- Signs of cardiac compression including right ventricular compression visible on physical examination 4
- Associated genetic syndromes, particularly Marfan syndrome, Noonan syndrome, or other connective tissue disorders that mandate complete cardiac evaluation 1
- Mitral valve prolapse, which commonly associates with pectus excavatum especially in connective tissue syndromes 1
Imaging Algorithm
First-Line Imaging (All Patients)
Obtain chest radiography (PA and lateral) immediately to assess cardiac size, position, and pulmonary vasculature patterns 2. This identifies clinically important findings including vascular rings and acute pathology while minimizing radiation exposure 5.
Perform transthoracic echocardiography concurrently to evaluate cardiac function, structural abnormalities, and compression effects 2. Modify standard views as needed—apical four-chamber views best visualize right ventricular compression from the deformed anterior chest wall 4.
Surgical Planning Imaging
Order chest CT with IV contrast when surgical repair is being considered to:
- Calculate the Haller index (pectus severity index) 5, 3
- Provide detailed anatomic measurements for surgical planning 1
- Assess the severity of chest wall deformity 6
Use limited CT technique focused on obtaining the Haller index rather than scanning the entire chest to reduce radiation exposure 5.
Advanced Cardiac Assessment
Obtain cardiac MRI without and with IV contrast when:
- Detailed cardiac function assessment is needed 2
- Evaluating interventricular dependence 2
- Determining the site of maximum cardiac compression 6
- Assessing for pericardial effusion 6
Consider stress echocardiography to evaluate exercise-related systolic/diastolic dysfunction, functional capacity effects, and tricuspid annulus compression 6.
Special Populations Requiring Enhanced Evaluation
Patients with suspected genetic syndromes (Marfan, Noonan, osteogenesis imperfecta):
- Mandatory complete cardiac evaluation including assessment for pulmonary stenosis, mitral valve prolapse, and aortic root dilation 1
- More severe restrictive respiratory patterns may occur, particularly with osteogenesis imperfecta 1
Patients with kyphoscoliosis and pectus excavatum:
- Anticipate cardiac migration to the left hemithorax, which affects surgical approach 1
Critical Pitfalls to Avoid
Do not order cardiac catheterization for diagnosis—reserve this only for interventional procedures, not diagnostic evaluation 2.
Do not routinely order stress imaging tests unless specific concerns about coronary artery disease exist 2.
Do not rely solely on appearance to determine severity—there is no direct correlation between deformity appearance and clinical symptoms or physiologic impact 7.
Do not perform extensive chest CT when limited imaging suffices—chest radiographs identify clinically important findings that would affect surgical decisions, and limited CT for Haller index calculation reduces radiation exposure substantially 5.
Physiologic Impact Documentation
Document these specific findings: