Pectus Excavatum–Induced Preload Insufficiency Presenting as Long-Standing Sinus Tachycardia

BACKGROUND: Severe pectus excavatum is an uncommon cause of hemodynamic compromise in adults and may present with unexplained tachycardia when preload filling is impaired by cardiac compression. CASE SUMMARY: A 65-year-old woman with long-standing palpitations presented with sinus tachycardia despite high-dose beta-blockade. Electrocardiogram and ambulatory monitoring showed sinus rhythm with marked heart rate variability. Right heart catheterization revealed low filling pressures, with a mean right atrial pressure of 1 mm Hg and preserved cardiac output. Cardiovascular magnetic resonance showed severe pectus excavatum (Haller index: 8.1) with anterior cardiac compression. Pectus-induced preload insufficiency was deemed responsible for her symptoms. She underwent a modified Ravitch repair with complete resolution of palpitations and normalization of heart rate. DISCUSSION: Chest wall deformity can cause clinically significant cardiac compression, preload insufficiency, and compensatory sinus tachycardia, even in late adulthood. TAKE-HOME MESSAGE: Severe pectus excavatum should be recognized as a reversible cause of preload insufficiency and sinus tachycardia, and surgical correction may result in symptom resolution.