Guerrier K; Le Bonheur Children’s Hospital, Memphis, USA.
Bejnood A; Shyam S; Hyde RA; et al

Medical Sciences. 14(3), 2026 Jul 08.

BACKGROUND: Pectus excavatum (PEX) is the most common congenital chest
wall deformity and may result in cardiac compression and arrhythmias. The
relationship between structural severity and exercise-induced
electrocardiographic (ECG) abnormalities in pediatric patients remains
unclear.

METHODS: We performed a retrospective study of patients aged 10-19 years
that underwent standardized preoperative evaluation for PEX between 2015
and 2021, including ECG, transthoracic echocardiography (TTE), computed
tomography (CT), and cardiopulmonary exercise testing (CPET). PEX severity
was assessed using the Haller index (HI), while right ventricular (RV)
compression was evaluated on CT. Tricuspid valve annular size (TVAS) on
TTE was used as a surrogate marker of RV compression. Exercise-induced ECG
abnormalities, including premature ventricular complexes (PVCs), were
analyzed and correlated with HI, RV compression, and TVAS.

RESULTS: Among 124 patients (85% male; median age 15 years), 33%
exhibited exercise-induced ECG abnormalities, most commonly PVCs (24%
overall). PVC occurrence was not associated with Haller index severity (p
= 0.35) but was significantly associated with RV compression on CT (92.6%
vs. 62.1%, OR 7.64, p = 0.02). Patients with ECG abnormalities had
significantly smaller TVAS compared to those without (1.98 +/- 0.31 cm vs.
2.09 +/- 0.33 cm, p = 0.04). Although PVCs were more frequent in patients
with TVAS z-score <= -2.0, this did not reach statistical significance.

CONCLUSIONS: Exercise-induced ventricular ectopy in pediatric PEX is
associated with right ventricular compression rather than structural
severity as defined by HI. Echocardiographic measures such as TVAS may
serve as noninvasive markers of clinically significant compression. These
findings highlight the importance of cardiac-thoracic relationships in
predicting arrhythmic risk and suggest a potential for reversibility with
surgical correction.