EditorialClinical Review

Diagnosis and Management of Pectus Excavatum in Primary Care

Nour B Odeh, Ahmed E Khedr, Rawan M Zeineddine, Abdulrahman Senjab, Juan M Farina and Dawn E Jaroszewski
The Journal of the American Board of Family Medicine January 2026, 39 (1) 157903; DOI: https://doi.org/10.3122/jabfm.2025.250122R1

Article Figures & Data

Figures

  • Figure 1.
    Figure 1. A 24-year-old female dancer presented with worsening exertional dyspnea, anxiety, and chest pain, noting a progressive decline in her ability to exercise. On physical exam, a severe pectus excavatum deformity is obscured by breast tissue (A). Although echocardiography appeared “within normal limits,” an Electrocardiogram revealed an incomplete right bundle branch block with secondary ST-segment changes. Due to persistent symptoms, a cardiac MRI was obtained, demonstrating a severe deformity (Haller Index (HI) 26.7) with compression of the right ventricle, leftward displacement of the heart, and altered right ventricular morphology (B).
  • Figure 2.
    Figure 2. (A) MRI scan of a 20-year-old male with asymmetric pectus excavatum deformity with a Haller index >8, sternal torsion 38.1 degrees. (B) Corresponding pre-operative clinical photo showing anterior chest wall asymmetry and severe pectus excavatum deformity (C) post-operative clinical photo after pectus repair. (D) Post-operative chest roentgenogram after minimally invasive surgical repair with 3 bars and link bridges used for stabilization.
  • Figure 3.
    Figure 3. In wide, flat defects, pectus can appear less severe on physical exam despite underlying cardiac compression. (A) CT scan of a 27-year-old male patient with pectus excavatum Haller index of 3.6 and correction index of 12%. (B) Pre-operative image showing a relatively mild appearing deformity (C) post-operative image of the same patient. (D) Post-operative roentgenogram displaying three Nuss bars in place after minimally invasive surgical repair with a medial stabilizer on the lower bar. (E) Pre-operative transesophageal echocardiogram (TEE) of the same patient showing small right ventricular chamber volume due to the extrinsic compression by the pectus deformity. (F) Postoperative TEE showing resolution of right ventricle compression.

    Abbreviations: RV: right ventricle, LV: left ventricle, RA: right atrium, LA: left atrium.

  • Figure 4.
    Figure 4. (A) Axial computer tomography (CT) demonstrating a Haller Index (HI) of 2.7 and a Corrective Index (COI) of 35.7% in a patient with pectus excavatum. Although the HI is below the commonly cited threshold of 3.25, this deformity was associated with clinically significant symptoms secondary to underlying cardiac compression (red dashed lines and arrow). (B) Corresponding echocardiographic views demonstrate the sternal deformity compressing the right ventricular and show a reduced chamber size (blue area).
  • Figure 5.
    Figure 5. (A) Lateral X-ray highlighting the sternal concavity (orange arrow and dotted line) showing the minimum A/P distance between the anterior vertebral body and the posterior sternal body (green line) needed to calculate the Haller Index. (B) Anteroposterior x-ray view showing the maximum transverse thoracic diameter (blue line).
  • Figure 6.
    Figure 6. Computer tomography (CT) scan of a patient with severe pectus excavatum, Haller Index of 18 and correction index of 44% illustrating right asymmetry with the left side of the chest appearing incongruently larger than the right (orange lines) with sternal torsion of 31 degrees (red acute angle).
  • Figure 7.
    Figure 7. Effect of cardiac compression on electrocardiogram (ECG) findings. (A) Pre-operative CT scan of a pectus excavatum patient showing cardiac compression. (B) Preoperative ECG of the same patient showing normal sinus rhythm, ventricular conduction revealing incomplete right bundle branch block (RBBB). (C) Post-operative ECG showing resolved ECG changes in V1-V2 and V5-V6.
  • Figure 8.
    Figure 8. Pre-operative CT of a patient with severe pectus excavatum (Haller Index = 3.85) (A) and clinical photograph of patient preoperative and (B), (C) postoperative after minimally invasive repair of pectus excavatum (MIRPE). (D) Post-operative chest roentgenogram showing two Nuss bars after pectus repair with a medial stabilizer on the lower bar.

Tables

  • Table 1. Symptoms of Pectus Excavatum Noted by Patients.
    SymptomsPercentage Reported in the Literature
    Psychological Symptoms Avoidance of activities that expose the chest68%8
    Sad or depressed about the way their chest looks31%9 - 65%8
    Cardiopulmonary Symptoms Chest pain or pressure88%8
    Tachycardia76%8 - 94%29
    Palpitations25%27 - 72%4,8
    Exercise intolerance62%3 - 83%8
    Difficulty keeping up with peers67% - 86%4,8
    Dyspnea64%3 – 96%4,8
    Neurological Symptoms Headaches74%8
    Positional Dizziness67%8
    Exertional Dizziness59% - 61%8
    Gastrointestinal Symptoms Dysphagia2%30 - 48%8
    Post-prandial dyspnea52%8
    Early Satiety84%8
  • Table 2. Advantages and Disadvantages of the Imaging Techniques Assessing Pectus Excavatum.32
    ModalityAdvantagesDisadvantages
    Chest X-ray Can be used for diagnosis and calculating pectus indicesLess accurate
    Lower cost and less exposure to radiationCannot assess asymmetric chest defects and sternal torsion
    Computed Tomography (CT) Scan
    Low dose radiation imaging without contrast should be performed    		Excellent for diagnosing pectus excavatum, calculating indices, assessing cardiac compression, and evaluating calcification of the cartilageHigher cost and exposure to ionizing radiation
    Can assess asymmetric chest defects and sternal torsion
    Magnetic Resonance Imaging (MRI) (Chest/Cardiac) Excellent for diagnosing pectus excavatum, calculating pectus indices, and assessing cardiac compressionHigher cost and less commonly available due to insurance restrictions
    Cardiac MRI can be used to evaluate cardiac function as well as the degree of compressionsRequires sedation or other interventions to perform on claustrophobic individuals
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