Pectus excavatum: the effect of tricuspid valve compression on cardiac function.

BACKGROUND: Pectus excavatum (PE) is a common congenital chest wall deformity with various associated health concerns, including psychosocial impacts, academic challenges, and potential cardiopulmonary effects. OBJECTIVE: This study aimed to investigate the cardiac consequences of right atrioventricular groove compression in PE using cardiac magnetic resonance imaging. MATERIALS AND METHODS: A retrospective analysis was conducted on 661 patients with PE referred for evaluation. Patients were categorized into three groups based on the degree of right atrioventricular groove compression (no compression (NC), partial compression (PC), and complete compression(CC)). Chest wall indices were measured: pectus index (PI), depression index (DI), correction index (CI), and sternal torsion. RESULTS: The study revealed significant differences in chest wall indices between the groups: PE, NC=4.15 ± 0.94, PC=4.93 ± 1.24, and CC=7.2 ± 4.01 (P<0.0001). Left ventricle ejection fraction (LVEF) showed no significant differences: LVEF, NC=58.72% ± 3.94, PC=58.49% ± 4.02, and CC=57.95% ± 3.92 (P=0.0984). Right ventricular ejection fraction (RVEF) demonstrated significant differences: RVEF, NC=55.2% ± 5.3, PC=53.8% ± 4.4, and CC=53.1% ± 4.8 (P≥0.0001). Notably, the tricuspid valve (TV) measurement on the four-chamber view decreased in patients with greater compression: NC=29.52 ± 4.6; PC=28.26 ± 4.8; and CC=24.74 ± 5.73 (P<0.0001). CONCLUSION: This study provides valuable insights into the cardiac consequences of right atrioventricular groove compression in PE and lends further evidence of mild cardiac changes due to PE.

Quantitative CT lung volumetry and densitometry in pediatric pectus excavatum.

The purpose of this study was to evaluate the quantitative computed tomography (CT) volumetry and densitometry and in pediatric patients with pectus excavatum (PE). We measured pectus index (PI) and separated inspiratory and expiratory lung volumes and densities. We obtained the total lung volume (TLV) and mean lung density (MLD) during inspiration and expiration, and the ratio of end expiratory to inspiratory volume (E/I volume) and MLD (E/I density) were calculated. The difference between inspiratory and end expiratory volume (I-E volume) and MLD (I-E density) were also calculated. A total of 199 patients, including 164 PE patients and 35 controls, were included in this study. The result shows that the PE group had lower inspiratory TLV (mean, 2670.76±1364.22 ml) than the control group (3219.57±1313.87 ml; p = 0.027). In the PE group, the inspiratory (-787.21±52.27 HU vs. -804.94±63.3 HU) and expiratory MLD (-704.51±55.41 HU vs. -675.83±64.62 HU) were significantly lower than the indices obtained from the control group (p = 0.006). In addition, significantly lower values of TLV and MLD difference and higher value of TLV and MLD ratio were found in the PE group (p <0.0001). PE patients were divided into severe vs. mild groups based on the PI cutoff value of 3.5. The inspiratory MLD and TLV ratio in the severe PE group were lower than those in the mild PE group, respectively (p <0.05). In conclusion, quantitative pulmonary evaluation through CT in pediatric PE patients may provide further information in assessing the functional changes in lung parenchyma as a result of chest wall deformity.

New Computerized Planning Algorithm and Clinical Testing of Optimized Nuss Bar Design for Patients with Pectus Excavatum.

BACKGROUND Computer-aided design (CAD) has been used in the Nuss procedure to determine the bar length and shape. Despite computer aid, the shape and design remain quite intuitive. We tested a new algorithm to determine the optimal bar shape. MATERIAL AND METHODS The normal sterno-vertebral distance was defined on computed tomography (CT) scans of patients without pectus excavatum (PEx) at the same level where the deepest depression was found on CT scans of 97 patients with PEx. Four points were marked on the CT scan of 60 patients with PEx at the deepest deformity: P1: edge of the vertebra; P2: edge of the deformity; P3: the expected contact point of the bar and the rib; and P4: the expected end of the bar. The algorithm generated 3 circles upon these points, and the fusion of the arcs drew the line of the ideal bar. Corrected and normal sterno-vertebral distance values were compared with the Mann-Whitney U test. Ten bars were bent manually guided by a 1: 1 printout of the designed bar and were implanted in 10 adolescents. RESULTS The shortest sterno-vertebral distance was 3 cm below the intermammillary line in PEx patients. The normal mean sterno-vertebral distance at this level was 10.16±1.35 cm in non-PEx patients. The mean virtually corrected sterno-vertebral distance was 10.28±1.27 cm. No significant difference was found (P=0.44). The bars were seamless and were successfully implanted. No bar needed adjustment, the operation time was shorter, and the patient satisfaction score was 9.4/10. CONCLUSIONS With our new algorithm, an optimal Nuss bar can be designed.

Utility of White Light Scanning as an Alternative to Computed Tomography to Evaluate Severity of Pectus Excavatum Deformity.

BACKGROUND: Pectus excavatum (PE) severity and surgical candidacy are determined by computed tomography (CT)-delineated Haller Index (HI) and Correction Index (CI). White light scanning (WLS) has been proposed as a non-ionizing alternative. The purpose of this retrospective study is to create models to determine PE severity using WLS as a non-ionizing alternative to CT. METHODS: Between November 2015 and February 2023, CT and WLS were performed for children ≤18 years undergoing evaluation at a high-volume, chest-wall deformity clinic. Separate quadratic discriminate analysis models were developed to predict CT HI ≥ 3.25 and CT CI ≥ 28% indicating surgical candidacy. Two bootstrap forest models were trained on WLS measurements and patient demographics to predict CT HI and CT CI values then compared to actual index values by intraclass correlation coefficient (ICC). RESULTS: In total, 242 patients were enrolled (86.4% male, mean [SD] age 15.2 [1.3] years). Quadratic discriminate analysis models predicted CT HI ≥ 3.25 with specificity = 91.7%, PPV = 97.7% (AUC = 0.91), and CT CI ≥ 28% with specificity = 92.3%, PPV = 93.5% (AUC = 0.84). Bootstrap forest model predicted CT HI with training dataset ICC (95% CI) = 0.91 (0.88-0.93, R2 = 0.85) and test dataset ICC (95% CI) = 0.86 (0.71-0.94, R2 = 0.77). For CT CI, training dataset ICC (95% CI) = 0.91 (0.81-0.93, R2 = 0.86) and test dataset ICC (95% CI) = 0.75 (0.50-0.88, R2 = 0.63). CONCLUSIONS: Using noninvasive and nonionizing WLS imaging, we can predict PE severity at surgical threshold with high specificity obviating the need for CT. Furthermore, we can predict actual CT HI and CI with moderate-excellent reliability. We anticipate this point-of-care tool to obviate the need for most cross-sectional imaging during surgical evaluation of PE. LEVEL OF EVIDENCE: Level III. STUDY TYPE: Study of Diagnostic Test.

A preliminary study on the normal values of the thoracic Haller index in children.

OBJECTIVES: The Haller index (HI) is widely utilized as a quantitative indicator to assess the extent of the pectus excavatum (PE) deformity, which is the most common chest wall abnormality in children. Both preoperative correction planning and postoperative follow-up need to be based on the standard of normal thoracic growth and development. However, there is currently no established reference range for the HI in children. Consequently, the goal of this study was to conduct a preliminary investigation of normal HI values among children to understand thoracic developmental characteristics. METHODS: Chest computed tomography images obtained from January 2012 to March 2022 were randomly selected from the imaging system of the Children's Hospital of Chongqing Medical University. We divided the images of children into a total of 19 groups: aged 0-3 months (1 group), 4-12 months (1 group) and 1 year to 17 years (17 groups), with 50 males and 50 females, totaling 100 children in each group. HI was measured in the plane where the lowest point of the anterior thoracic wall was located and statistically analysed using SPSS 26.0 software. RESULTS: A total of 1900 patients were included in the study. Our results showed that HI, transverse diameter and anterior-posterior diameter were positively correlated with age (P < 0.05). Using age as the independent variable and HI as the dependent variable, the best-fit regression equations were HI-male = 2.047 * Age0.054(R2 = 0.276, P<0.0001) and HI-female = 2.045 * Age0.067(R2 = 0.398, P<0.0001). Males had significantly larger thoracic diameters than females, and there was little difference in the HI between the 2 sexes. CONCLUSIONS: The HI rapidly increases during the neonatal period, slowly increases during infancy and stops increasing during puberty, with no significant differences between the sexes.

Sternal cleft and pectus excavatum: an overlooked congenital association?

BACKGROUND: Sternal cleft (SC), a rare thoracic malformation, is associated with pectus excavatum (PE) in 2.6-5% of cases. It remains unclear if these conditions are congenitally linked or if SC repair triggers PE. To investigate the potential higher frequency of PE in SC cases, we conducted a retrospective study of our SC patients. METHODS: We assessed PE incidence, progression, and management in SC patients treated at our institute from 2006 to 2022. When available, we collected pre-SC repair CT scan data, calculating the Haller Index (HI) and Correction Index (CI) and compared them to a selected control group. RESULTS: Among 8 SC patients, 7 had concomitant PE (87.5%), varying in severity. PE management ranged from observation to thoracoplasty, depending on its degree. We observed a significant pre-operative CI difference between SC and control group patients (p < 0.00001). In the last two SC repair cases, we attempted concurrent PE prevention or treatment. CONCLUSION: Our findings suggest an underestimated association between PE and SC in the existing literature. SC patients may exhibit a predisposition to PE from birth, which may become more apparent with growth after SC repair. Consequently, PE prevention or treatment should be considered during SC repair procedures.

The relationship between mitral valve prolapse and thoracic skeletal abnormalities in clinical practice: a systematic review.

BACKGROUND: Literature data suggest high inter-study variability in mitral valve prolapse (MVP) prevalence among individuals with thoracic skeletal abnormalities (TSA). This systematic review aimed at estimating the overall prevalence of MVP in individuals with the most common TSA, including not only the oldest studies (before the year 2000) but also the most recent ones (after the year 2000). METHODS: PubMed and EMBASE databases were systematically reviewed in November 2023. Studies assessing the relationship between MVP and TSA and estimating the MVP prevalence in pectus excavatum (PE), pectus carinatum (PC), scoliosis, straight back syndrome (SBS) and Marfan syndrome (MS) were included. There was no limitation on time periods. RESULTS: Twenty-five studies with a total of 2800 patients (27.9 ±â€Š13.9 years, 48.2% females) were analyzed. The highest prevalence of MVP was observed among MS patients (47.3%), while the lowest was detected in PC individuals (23%). Prevalence of MVP was similar among PE (30.8%), scoliosis (26.3%) and SBS (25.5%) patients. When dividing the studies on the basis of temporal period, the average MVP prevalence was approximately two-fold higher in all studies conducted before the year 2000 in comparison with the most recent ones, regardless of TSA type. This discrepancy might be primarily ascribed to relevant differences in the echocardiographic criteria employed for MVP diagnosis before (less specific) and after (more specific) the year 2000, respectively. CONCLUSIONS: The estimated MVP prevalence in TSA individuals is significantly higher than that observed in the general population. Individuals with TSA should be screened for MVP presence on transthoracic echocardiography.

Satisfacción de pacientes y profesionales con las nuevas tecnologías de imagen tridimensional aplicadas a la medicina / Patient and healthcare professional satisfaction with 3D imaging new technologies for medical purposes

ANTECEDENTES Y OBJETIVOS: Gracias a los avances en el campo del escaneado tridimensional (3D) existen instrumentos capaces de generar imágenes con utilidad en medicina. Por otra parte, los estudios de satisfacción ganan cada vez más importancia para evaluar la calidad en la asistencia. Nuestro objetivo es valorar la satisfacción de los pacientes con el uso de un escáner 3D aplicado a las malformaciones de la pared torácica, así como de los profesionales implicados en su uso. MATERIAL Y MÉTODOS: Se han desarrollado encuestas de satisfacción para pacientes y profesionales que han completado pacientes sometidos a escáner 3D en el contexto de un estudio para validar los resultados obtenidos con esta nueva tecnología. Se han obtenido los estadísticos descriptivos de los resultados obtenidos. RESULTADOS: Se han incluido 42 pacientes y 10 profesionales. Los pacientes evalúan de manera positiva la velocidad y la inocuidad. La media de satisfacción global es de 4,71 en una escala del 1 al 5. Entre los profesionales, la satisfacción es inferior, sobre todo en lo que respecta al tratamiento de la imagen. La media de satisfacción global es de 3,1. CONCLUSIONES: Los pacientes evaluados tienen una buena aceptación y satisfacción con la tecnología de escaneado 3D. No ocurre lo mismo con los profesionales, ya que debido a la dificultad de tratamiento de la imagen y a la falta de familiaridad con el sistema presentan una satisfacción menor. Son necesarios avances en la difusión y simplificación de esta tecnología para aprovechar al máximo su potencial

BACKGROUND AND OBJECTIVES: Advances in the field of three-dimensional scanning have enabled the development of instruments that can generate images that are useful in medicine. On the other hand, satisfaction studies are becoming increasingly important in the evaluation of quality in healthcare. We aimed to evaluate patients' and professionals' satisfaction with the use of a three-dimensional scanner applied to chest wall malformations. MATERIAL AND METHODS: In the framework of a study to validate the results of three-dimensional scanning technology, we developed questionnaires to measure satisfaction among patients and professionals. We analyzed the results with descriptive statistics. RESULTS: We included 42 patients and 10 professionals. Patients rated the speed and harmlessness positively; the mean overall level of satisfaction was 4.71 on a scale from 1 to 5. Among professionals, the level of satisfaction was lower, especially with regards to the treatment of the image; the mean overall level of satisfaction was 3.1. CONCLUSIONS: Patients rated 3D scanning technology highly, but professionals were less satisfied due to the difficulty of treating the images and lack of familiarity with the system. For this technology to reach its maximum potential, it must be simplified and more widely disseminated

Pectus excavatum, manejo mínimamente invasivo con técnica de Nuss: experiencia Instituto Nacional del Tórax / Pectus excavatum, minimally invasive management with Nuss technique

Resumen Objetivo Comunicar la experiencia en el tratamiento de pectus excavatum en el Instituto Nacional del Tórax. Material y Método: Estudio descriptivo con seguimiento. Se recolectaron datos de las variables de interés, mediante la revisión de fichas clínicas. Se incluyeron pacientes operados entre marzo de 2007 y abril de 2018. Resultados Se incluyeron 86 pacientes operados con técnica mínimamente invasiva en el período descrito. De ellos, 74 pacientes de sexo masculino. El promedio de edad al momento de la cirugía fue de 17,8 años. El principal motivo de consulta fue por desmedro estético que correspondió al 41,8% de los pacientes. Salvo en 1 paciente, en todo el resto se ocupó una sola barra. En nuestra serie hubo 12 pacientes que presentaron alguna complicación operatoria y 1 paciente fallecido. Hasta el cierre del seguimiento se retiraron 61 barras, 2 de ellas previo al período estipulado de tratamiento, por morbilidad. Hay 20 barras in situ y 4 pacientes de los cuales no se tiene registro por abandono de controles. Discusión El pectus excavatum es la más frecuente de las deformidades de la pared torácica, es 4 a 6 veces más frecuente en hombres que en mujeres. En general los pacientes son asintomáticos, aunque algunos pueden presentar síntomas cardiopulmonares. La reparación con cirugía mínimamente invasiva con técnica de Nuss aparece hoy en día como el gold standard de manejo. Conclusión El manejo de los pacientes con pectus excavatum en nuestra Institución se asemeja a lo reportado en la literatura internacional. Nuestros esfuerzos deben apuntar a disminuir la morbimortalidad asociada.

Aim To communicate the experience in the treatment of pectus excavatum in the National Institute of Thorax. Materials and Method: Descriptive study with follow-up. Data of variables of interest were collected through the review of clinical records. Patients operated between March 2007 and April 2018 were included. Results 86 patients operated with the Nuss technique were included in the period described. Of them, 74 male patients. The average age at the time of surgery was 17.8 years. The main reason for consultation was due to cosmetic detriment that corresponded to 41.8% of the patients. Except in 1 patient, in all the rest a single bar was occupied. In our series, there were 12 patients who presented some operative complication and 1 patient died. Up to the end of the follow-up, 61 bars were removed, 2 of them in non-scheduled surgery. There are 20 bars in situ and 4 patients of which there is no registration due to abandonment of controls. Discussion Pectus excavatum is the most frequent of the deformities of the chest wall, it is 4 to 6 times more frequent in men than in women. In general, patients are asymptomatic, although some may have cardiopulmonary symptoms. The repair with minimally invasive surgery with Nuss technique appears today as the goldstandard of management. Conclusion The management of patients with pectus excavatum in our Institution is similar to that reported in the international literature. Our efforts should aim to reduce the associated morbidity and mortality.

Viabilidad del desfibrilador automático implantable subcutáneo en un paciente con pectum excavatum / Feasibility of a subcutaneous implantable cardioverter-defibrillator in a patient with pectus excavatum

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Compresión de la vena cava inferior en niños con pectus excavatum / Inferior vena cava compression in children with pectus excavatum

Introducción: En casos graves de pectus excavatum (PE), el hundimiento esternal ocasiona distorsión del corazón y grandes vasos. Nuestro propósito fue determinar si existe compresión de la vena cava inferior (VCI) en estos pacientes. Métodos: Estudio retrospectivo de pacientes con PE grave valorados entre 2015 y 2017. Se efectuaron mediciones del diámetro anteroposterior (AP) y transverso de la VCI suprahepática a su paso por el hiato diafragmático en imágenes de RM-cardiaca. Estas se compararon con las medidas de pacientes a los que se les realizó una RM o TC por otro motivo, ajustando los datos para edad y sexo. Resultados: De los 81 pacientes, 28 casos y 53 controles, el 63% fueron varones con una edad media de 12,9±0,5 años. Se identificaron diferencias significativas entre los grupos, tanto del diámetro AP como del transverso: 13,3±0,75 mm vs. 15,8±0,76 mm (p=0,001) y 28,8±1,34 mm vs. 27,1±0,89 mm (p=0,045), respectivamente. Tras ajustar los datos para edad y sexo, estas diferencias solo fueron significativas para el diámetro AP de la VCI en hombres: 12,7±0,5 mm (IC95% 11,66-13,79 mm) vs. 16,6±0,5 mm (IC95% 15,69-17,56 mm) (p=0,000). El coeficiente de correlación de Pearson del diámetro transverso de la VCI con el índice de Haller fue r=0,471 (p=0,01). Conclusión: Los varones con un hundimiento esternal grave asocian alteraciones en el diámetro de la VCI que pueden indicar compresión de la misma. Estos cambios se correlacionan con la gravedad del PE y podrían justificar algunos síntomas y alteraciones cardiovasculares encontradas en estos pacientes

Introduction: In severe cases of pectus excavatum (PE) the sternal depression may cause distortion of the cardiac chambers and great vessels. The aim of our study was to determine if the sternal impingement causes significant inferior vena cava (IVC) compression. Methods: Retrospective study of patients with severe PE assessed between 2015-2017. The antero-posterior (AP) and transverse diameters of the suprahepatic IVC were measured on a cardiac-MRI at the level of the diaphragmatic hiatus. Results were compared with patients that had a thoracic image study performed for other causes, adjusting for age and sex. Results: Among the 81 patients, 28 cases and 53 controls, 63% were males and had a mean age of 12.9±0.5 yrs. Significant differences were found between groups in both AP and transverse diameter of the IVC: 13.3±0.75 mm vs. 15.8±0.76 mm (p=0.001) and 28.8±1.34 mm vs. 27.1±0.89mm (p=0.045) respectively. After adjusting for age and sex, these differences were only statistically significant for AP IVC diameter in males 12.7±0.5 mm (95% CI 11.66-13.79 mm) vs. 16.6±0.5 mm (95% CI 15.69-17.56 mm) (p=0.000). The Pearson correlation coefficient for the Haller index was r=0.471 (p=0.01). Conclusion: Male patients with severe sternal depression show changes in the IVC diameter that may correspond to compression. These changes are correlated with the severity of the deformity and can justify certain clinical symptoms and cardiac function abnormalities in patients with severe PE

Back to the future: a case series of minimally invasive repair of pectus excavatum with regular instruments / De volta para o futuro: série de casos de reparo minimamente invasivo do pectus excavatum com instrumentos comuns

ABSTRACT Objective: Minimally invasive repair of pectus excavatum (MIRPE) is a surgical treatment for PE. During the procedure, a specialized introducer is used to tunnel across the mediastinum for thoracoscopic insertion of a metal bar. There have been reported cases of cardiac perforation during this risky step. The large introducer can be a dangerous lever in unskilled hands. We set out to determine the safety and feasibility of using regular instruments (i.e., not relying on special devices or tools) to create the retrosternal tunnel during MIRPE. Methods: This was a preliminary study of MIRPE with regular instruments (MIRPERI), involving 28 patients with PE. We recorded basic patient demographics, chest measurements, and surgical details, as well as intraoperative and postoperative complications. Results: Patients undergoing MIRPERI had Haller index values ranging from 2.58 to 5.56. No intraoperative complications occurred. Postoperative complications included nausea/vomiting in 8 patients, pruritus in 2, and dizziness in 2, as well as atelectasis, pneumothorax with thoracic drainage, pleural effusion, and dyspnea in 1 patient each. Conclusions: In this preliminary study, the rate of complications associated with MIRPERI was comparable to that reported in the literature for MIRPE. The MIRPERI approach has the potential to improve the safety of PE repair, particularly for surgeons that do not have access to certain special instruments or have not been trained in their use.

RESUMO Objetivo: O minimally invasive repair of pectus excavatum (MIRPE, reparo minimamente invasivo do pectus excavatum) é um tratamento cirúrgico do PE. Durante o procedimento, utiliza-se um introdutor específico a fim de criar um túnel mediastinal para a colocação toracoscópica de uma barra metálica. Já houve casos relatados de perfuração cardíaca durante essa etapa arriscada. O introdutor grande pode ser uma perigosa alavanca em mãos inábeis. Propusemo-nos a determinar a segurança e viabilidade do uso de instrumentos comuns (isto é, sem contar com dispositivos ou ferramentas especiais) para criar o túnel retroesternal durante o MIRPE. Métodos: Estudo preliminar sobre o MIRPE with regular instruments (MIRPERI, MIRPE com instrumentos comuns), envolvendo 28 pacientes com PE. Foram registrados dados demográficos básicos dos pacientes, medições torácicas e detalhes cirúrgicos, bem como complicações intra e pós-operatórias. Resultados: Os pacientes submetidos ao MIRPERI apresentavam índice de Haller entre 2,58 e 5,56. Não ocorreram complicações intraoperatórias. As complicações pós-operatórias incluíram náusea/vômito em 8 pacientes, prurido em 2 e tontura em 2, bem como atelectasia, pneumotórax com drenagem torácica, derrame pleural e dispneia em 1 paciente cada. Conclusões: Neste estudo preliminar, a taxa de complicações associadas ao MIRPERI foi comparável à relatada na literatura para o MIRPE. A abordagem de MIRPERI tem o potencial de melhorar a segurança do reparo do PE, particularmente para cirurgiões que não têm acesso a certos instrumentos especiais ou não foram treinados para utilizá-los.

Development of New Cardiac Deformity Indexes for Pectus Excavatum on Computed Tomography: Feasibility for Pre- and Post-Operative Evaluation

PURPOSE: The aim of this study was to evaluate new cardiac deformity indexes (CDIs) for diagnosis of pectus excavatum as well as morphological assessment of heart on computed tomography (CT). MATERIALS AND METHODS: We retrospectively evaluated the CT images of the control group (n=200), and the pectus excavatum before and after correction groups (n=178), and calculated the CDIs; cardiac compression index (CCI), and cardiac asymmetry index (CAI). We also calculated chest wall compression index (CWCI) and asymmetry index (CWAI) on the axial images. We performed logistic regression analysis using each index and age as predictor variables. RESULTS: The CDIs (CCI and CAI) were significant (p < 0.05) in the diagnosis of pectus excavatum, regardless of age (p = 0.4033, p = 0.8113). The CWCI and CWAI were significant (p < 0.05) and significantly affected by age (p < 0.05). If we selected 1.82 as the cutoff of the CCI, the sensitivity and specificity were 99.4% and 98%, respectively. The following cutoffs and the sensitivity and specificity were obtained: 1.15 for the CAI gave 94.4% and 94.5%, 3.05 for the CWCI gave 92.1% and 92%, and 1 for the CWAI gave 62.4% and 65%, respectively. The CCI after repair improved from 2.83 +/- 0.84 to 1.84 +/- 0.33, while the CWCI improved from 4.49 +/- 1.61 to 2.57 +/- 0.44. CONCLUSION: CDIs such as the CCI and CAI may be potentially useful to detect and estimate repair for pectus excavatum.