Syncope in a Patient with Right Ventricular Compression from Severe Pectus Excavatum: A Case Report

INTRODUCTION: Pectus excavatum (PEX) is the most common congenital chest wall deformity, characterized by posterior depression of the sternum and lower costal margin. While often asymptomatic, severe PEX can lead to compression of the heart and great vessels, potentially causing right ventricular dysfunction, syncope, and other cardiovascular symptoms. Syncope due to right ventricle compression in PEX is rare but can significantly impact quality of life and may require surgical intervention. CASE REPORT: An 18-year-old female presented to the emergency department after an unwitnessed syncopal episode. The patient reported feeling lightheaded while showering, followed by collapse and brief loss of consciousness. Diagnostic testing revealed normal neurological and metabolic parameters including point-of-care glucose, electrocardiogram, serum troponin, electrolytes, and head computed tomography. Chest imaging showed severe PEX with concerns of right ventricular compression. Transthoracic echocardiography demonstrated normal cardiac function, and exercise stress testing showed no ischemic changes. Additional laboratory studies revealed iron deficiency anemia. CONCLUSION: This case underscores the potential for PEX to cause distorted cardiac morphology, including right ventricular compression, which can lead to syncope in severe cases. The absence of cardiac ischemia, arrhythmias, or metabolic derangement suggests postural changes compounded by undiagnosed anemia and underlying PEX as the most likely cause of this patient's syncope. Given the patient's symptoms and anatomical findings, referral for surgical evaluation was made to discuss definitive management options. This case highlights the importance of considering structural chest wall abnormalities in the differential diagnosis of syncopal events, particularly when standard causes are excluded.