The physical examination did not reveal any abnormal findings except for depression of the chest wall (Fig. 1). Fig. 1 On physical examination, depression of chest wall is apparent. Results of initial laboratory tests, including cardiac enzyme marker levels and thyroid hormone function, were within normal limits. However, B-type natriuretic peptide level was elevated at 314.11 pg/mL. Inhibitors,research,lifescience,medical Initial electrocardiography showed atrial fibrillation without ST-segment elevation or depression or T-wave inversion. Chest X-ray revealed cardiomegaly (Fig. 2). Fig. 2 Chest X-ray shows severe cardiomegaly, prominently of the right and left atria. Transthoracic echocardiography demonstrated a moderately

enlarged left atrium, a markedly dilated right atrium, and a ALK inhibitor moderately enlarged RV with dysfunction. RV ejection fraction by Simpson’s rule was 37%. Left ventricular size and function was within normal limits. Stroke volume was 62 mL. A modified 4-chamber

view showed a round-shaped RV Inhibitors,research,lifescience,medical apex, which was not well visualized in the standard apical 4-chamber view (Fig. 3). The color Doppler image showed the mild tricuspid regurgitation. The peak velocity of Inhibitors,research,lifescience,medical the tricuspid regurgitant jet was measured at 2.4 m/s. Tissue Doppler systolic velocity at the tricuspid annulus was 8.0 cm/s (Fig. 4). Fig. 3 Transthoracic echocardiography. Apical 4-chamber view in diastole (A) and systole (B) demonstrates reduced a fractional shortening area of right ventricular (RV). Modified 4-chamber view in diastole (C) and systole (D) shows an aneurysm-shaped RV apex Inhibitors,research,lifescience,medical … Fig. 4 The peak velocity of the tricuspid regurgitant jet is measured at 2.4 m/s (A) and tissue Doppler systolic velocity at the tricuspid annulus was 8.0 cm/s (B). Arrow indicates peak systolic velocity. Chest computed tomography with enhancement, which was used to evaluate

the precise cause of RV dysfunction, revealed no pulmonary thromboembolism. The RV was compressed by the anterior chest wall. Haller index was determined as 4.2 Inhibitors,research,lifescience,medical (Fig. 5). Cardiac magnetic resonance imaging Ketanserin was then obtained to exclude arrhythmogenic RV dysplasia and it failed to show high RV signal intensities, dilatation or myocardial thinning on a T1-weighted image. Fig. 5 Measurement of the Haller index. On chest computed tomography, Haller index is calculated by dividing the inner width of the chest at the widest point (A) by the distance between the posterior surface of the sternum and the anterior surface of the spine … We concluded that RV dysfunction in this patient was caused by pectus excavatum. He was treated with an angiotensin converting enzyme inhibitor, coumadin, aspirin, a beta-blocker, and he is followed up regularly at the outpatient department. Discussion Pectus excavatum is present in nearly 1 out of every 400 births, and it is more common in male and Down syndrome patients.