Sudden Chest Pain Years After A Pectus Excavatum Repair

Submitted by Dr T on June 2, 2014 – 2:14pm

Question:

I am a 30 year old male who had severe Pectus Excavatum repaired via Ravitch procedure when I was 15. The surgery was mostly successful and my chest has even greatly improved. About 3 months ago I experienced sudden onset of chest pain (about a 3-4 on scale of 1-10) while watching a movie which caused me to have a panic attack/palpitations. After extensive cardiac investigations including many ECG’s, 24hr Holter, echo, stress echo and CTCA, all heart issues have been ruled out by my cardiologist. The only anomaly were 5 runs of SVES on the Holter, RBBB on all my ECG’s and abnormal wall motion at peak exercise after the stress echo. The CTCA was ordered because of the ‘rocking motion’ that was viewed during the stress echo. Because the CTCA was normal with calcium score of zero, the wall motion abnormality was put down to compressed RV wall due to residual Pectus Excavatum. I apparently don’t have any of the cardiac problems that can be associated with PE (eg MVP).
The pain has not improved in the last 3 months. It is mainly situated down the left hand side of my rib cage, under my arm pit and can sometimes also be felt in my back. Pain to the left of my sternum is also common. I do not feel pain when the area is touched or manipulated. Exercise does not appear to make the pain worse, though I have ceased going to the gym and lifting weights.
I’m still not confident in the diagnoses of non-cardiac chest pain but I am unsure of what other avenues I should be pursuing. Where to from here? Also, are wall motion abnormalities without the presence of heart disease of concern?

(From Mayo Clinic Medical Education Resources)

Hi Jamie,

All the tests have proven your heart to be OK. The “rocking motion” (the wall motion abnormality) is probably the result of a residual chest wall depression that is still pushing on your heart, however, w/o it causing any functional abnormality.

The Ravitch procedure includes removal of the deformed rib cartilages and a metal rod(s) to push the rib cage outwards and thus restore a normal chest wall configuration:

The rod(s) is (are) usually removed after a few years and you haven’t mentioned whether that was actually done. Therefore I’d look into a local chest wall injury, rather than continue to investigate your heart. For starters I’d recommend a chest CT or MRI to evaluate your rib cage and underlying lung, followed by a consultation with a thoracic surgeon with experience in this type of surgery. If the rod is stll there, it might have slipped, or another injury to your ribs may have occurred.

Some of your symptoms occur in patients with Marfan’s syndrome and if so, your aorta wouls (should have been checked as well, The echocardiogram would probably have excluded a problem with your aorta, although sometimes more extensive testing is needed.

Hope this helps,

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