Unexpected death of a middle-aged man with severe pectus excavatum in association with pulmonary emboli

On a mid-summer day, a middle-aged man with severe pectus excavatum died unexpectedly in his bed one to two weeks after the onset of dyspnea, which had been followed by bedrest and restricted drinking and eating. Computed tomography (CT) and autopsy demonstrated an eccentrically hypertrophied heart (weight 600 g), which was displaced, rotated, and occupied a large space in the left thoracic cavity due to a deeply depressed sternum. The pulmonary artery was bent and extended across the left thoracic cavity to the right hilum. Anatomical abnormalities in the heart and pulmonary artery obstructed the right ventricular outflow, dilated the right ventricle, and induced restrictive hemodynamics. The left lung was atelectatic due to compression by the heart, while the right lung was enlarged and partly expanded to the left upper thoracic cavity. Histology confirmed pulmonary infarctions at different stages in the upper and middle lobes of the right lung. Restrictive hemodynamics promoted right ventricular dilation, causing spatial limitation of the left thoracic cavity. It is presumed that diastolic right ventricular dysfunction would have rapidly progressed along with pericardial effusion (150 mL), and intra-cardiac thrombi were formed due to stagnation, arrhythmia, bedrest, and dehydration. Consequently, the thrombi would be repetitively embolized in the right lung, thereby aggravating respiratory dysfunction and right-sided heart failure. This is the first autopsy report on the unexpected death of an untreated adult patient of pectus excavatum, with systematic pathophysiological analyses on the basis of the postmortem CT, macroscopic, and microscopic findings.