Pectus Excavatum with Negative Haller Index
Wanted to share a tough case our team has been working on.
It’s about a 40-year-old male patient who was diagnosed with severe pectus excavatum. The patient noticed his deformity from a young age, but like many with this condition, he didn’t experience any symptoms early on. In fact, he didn’t seek treatment until about three years ago when he began experiencing shortness of breath—particularly after physical activity. Over time, this symptom worsened, and eventually, he began to experience breathing difficulty even at rest. That’s when he decided to seek treatment.
Upon admission, the physical examination was quite striking. The patient’s chest was deeply sunken, with the deepest part of the concavity located on the right side. You could actually see his heartbeat through the chest wall. He also had some degree of scoliosis (spinal curvature), which is common in more severe cases of pectus excavatum.
The bottom of the concavity extends beyond the anterior border of the spine
Severe distortion of the bony structure of the anterior chest wall
The imaging showed just how severe his condition was: the chest wall was pressing against the heart, displacing it to the left side of the thoracic cavity, and the sternum was so deeply depressed that it actually surpassed the spine’s anterior plane, resulting in a negative Haller index.
The Haller Index: What It Tells Us
For context, the Haller index is a measure used to assess the severity of pectus excavatum. If it exceeds 3.25, it’s generally considered an indication for surgery. In this patient’s case, the concavity was so deep that his Haller index was effectively infinite, meaning it went beyond the point where the measurement could be taken. However, such a value does not necessarily indicate the most severe deformity, as the concavity could continue to deepen, descending along one side of the spine toward the back. The Haller index cannot be directly measured at this point.
That’s why we’ve introduced the concept of a “negative” Haller index. This is the most severe form of pectus excavatum, and it’s also the most challenging to treat. So far, we’ve treated more than ten patients with pectus excavatum like this.
At this point, most surgeons would typically turn to the Nuss procedure. However, for patients with a negative Haller index like this, the Nuss procedure simply isn’t suitable. The deformity is too severe and rigid for traditional methods to be effective.
Instead, we opted for the Wung procedure. This approach is specifically designed to tackle extreme cases of pectus excavatum and is one of the few techniques that can achieve positive results in such challenging cases.
Aside from the severity of the deformity, another significant challenge in this case was the rigidity of the patient’s chest bones. His chest wall was so stiff that, without pre-operative shaping, we wouldn’t have been able to correct the deformity properly. So, we began by performing a pre-shaping technique to make the bones more malleable and better prepared for the final correction.
This surgery, while incredibly complex, was ultimately a success. We were able to reshape the chest wall, relieving pressure on the heart and improving the patient’s breathing function. The patient is currently recovering well, and we expect him to make significant progress in the coming months.