Sternal Compression Research Articles

Sternal compression before bar placement: Enhancing cosmetic outcomes and facilitating minimally invasive correction of pectus carinatum

Sternal compression before bar placement: Enhancing cosmetic outcomes and facilitating minimally invasive correction of pectus carinatum

A proof-of-concept study evaluating cardiac compression techniques for cardiopulmonary resuscitation in laying hens (Gallus gallus).

To determine in adult chickens which of 3 CPR techniques, sternal compressions (SC), SC with interposed caudal coelomic compressions (ICCC), or lateral compressions (LC), results in the highest mean systolic (SAP), diastolic (DAP), and mean arterial pressure (MAP) as measured directly from the carotid artery. Prospective, nonblinded, experimental crossover study. University teaching hospital laboratory. Ten retired laying hens. Birds were sedated, anesthetized, and placed in dorsal recumbency. A carotid artery catheter was placed to directly measure arterial pressure. Ventricular fibrillation was induced with direct cardiac stimulation using a 9-Volt battery. Each bird then received 2minutes of the 3 different cardiac compression techniques in a random order by 3 different compressors, with the compressor order also randomized. Birds were subsequently administered IV epinephrine, and transthoracic defibrillation was attempted. At the end of experimentation, each bird was euthanized, and simple gross necropsies were performed. Linear mixed models followed by pairwise paired t-tests were performed to evaluate differences in pressures generated by each technique. The primary study outcomes were SAP, DAP, and MAP over 2minutes of compressions for each compression technique. Pressures from ICCC (SAP: 27.6±5.3mmHg, DAP: 18.7±5.2mmHg, MAP: 21.7±5.2mmHg) were significantly higher than those from LC (SAP: 18.9±5.4mmHg, DAP: 11.6±4.1mmHg, MAP: 14.1±4.5mmHg). Pressures from SC (SAP: 24.5±6.4mmHg, DAP: 15.2±4.3mmHg, MAP: 18.3±5.0mmHg) were not significantly different from ICCC or LC. External compressions can generate detectable increases in arterial pressure in chickens with ventricular fibrillation. SC with ICCC generated significantly higher arterial pressures than LC. SC alone generated blood pressures that were not significantly different from those generated by SC with ICCC or LC.

Abstract 415: Standard versus Early Abdominal Counter-Constriction During Circumferential CPR

Introduction: Circumferential constriction CPR (CC-CPR) applied by pneumatic vest may be superior to standard sternal compression, and the addition of alternative pumping modalities may further enhance efficacy. Interposed abdominal counterpulsation (IAC-CPR) CC-CPR is one such modality. Early canine studies of IAC reported greater efficacy when the abdominal counterpulsation was started 30% before the thoracic compression, rather than fully counterphase timing as is used clinically. This may be thought of as “Abdominal Preload” IAC (Pre-CPR). Hypothesis: Addition of IAC-CPR to CC-CPR may be associated with improved perfusion pressures, and Pre-CPR may be even more effective. Methods: We compared CC-CPR to IAC-CPR and Pre-IAC in a porcine model of VF (n=6). In IAC-CPR, the constrictions are fully counterphase. In Pre-IAC, abdominal constriction is initiated 30% before thoracic constriction. Alternating 30 second epochs of each treatment were applied via a circumferential abdominal vest. Aortic (Ao) and Right Atrial (RA) pressures were measured by micromanometer catheters. IAC-CPR and Pre-CPR end-epoch pressures were each compared to preceding CC-CPR end-epoch pressures. Results: Addition of IAC-CPR and Pre-IAC to CC-CPR were both associated with similar, significant increases in CPPs. However, the source of these improvements differed (See Table 1). For IAC-CPR, the increase appeared to result from an Ao increase greater than an associated increase in RA. For Pre-CPR, the increase appeared to be solely due to increased Ao. Limitations: Small sample. Surrogate biomarkers. Non-human model. Conclusions: The addition of pulsatile abdominal counter-constriction to vest CC-CPR may be a promising path to multimodality, regardless of the particulars of cycle timing. We do not confirm earlier observations that Pre-CPR may be superior to IAC-CPR.

Abstract 218: Effect of Airway Pressure and Localized Sternal Compression Upon Hemodynamics During Cardiopulmonary Resuscitation

Background: During cardiopulmonary resuscitation (CPR), chest compression (CC) and mechanical ventilation are cyclic in nature and each modulate the intrathoracic pressure (ITP). ITP is increased during the compression phase of CC, causing an increase in aortic pressure (AoP) and right atrial pressure (RAP) to drive forward blood flow. Similarly, positive pressure ventilation increases ITP during the inspiratory phase as pressure is transmitted through the lungs, which also has an impact on hemodynamics. The purpose of this analysis was to examine differences in hemodynamics during ventricular fibrillation (VF) arrest due to ventilation alone and during localized sternal CC of varying depths in a porcine model of cardiac arrest. Methods: Domestic swine (n = 8) underwent electrically induced VF with ten-minute downtime, followed by resuscitation with mechanical ventilation and CC with active lift to neutral chest position. Mechanical ventilation was delivered using pressure-controlled synchronized intermittent mandatory ventilation (SIMV) mode (Vt 10 mL/kg, 10 bpm, trigger -6 cmH 2 O, PEEP 5 cmH 2 O, FiO 2 100). CPR was initiated with three minutes of ventilation only, followed by one minute of break-in CC at 1.0 in and 1.5 in prior to increase to depth of 2.0 in. AoP, RAP, esophageal pressure (Pes), and airway pressure (Paw) were examined over the ventilation cycle to determine the effect of each treatment upon parameters. Results: Positive pressure ventilation caused similar changes to the Pes, RAP, and AoP values (3-5 mmHg). CC caused similar changes to Pes (3-5 mmHg), but much larger changes to the RAP and AoP (10-130 mmHg) depending on compression depth. Conclusions: The ITP is not uniform during CC, creating only modest changes to Pes. This suggests that CC generate blood pressures, and presumably flows, through mechanisms other than ITP modulation. Understanding this interaction could improve our understanding of blood flow during CPR.

Iatrogenic pectus excavatum in a giant breed dog following median sternotomy

AbstractA giant breed dog was presented to a university teaching hospital for restlessness and what its owners perceived to be vomiting. The patient was subsequently diagnosed with spontaneous pneumothorax secondary to a pulmonary mass and underwent median sternotomy for lung lobectomy. Post‐operatively, the patient developed iatrogenic pectus excavatum, which likely contributed to morbidity and prolonged hospitalisation. A Hoyer lift was employed to assist patient mobility and limit external sternal compression from prolonged recumbency. This case highlights the potential for iatrogenic pectus excavatum, which may affect recovery in giant breed dogs post‐median sternotomy.

Abstract 169: End Tidal CO2 In Multimodal Vest CPR

Introduction: Circumferential constriction vest CPR is more effective at creating forward blood flow than traditional sternal compression only CPR. Active compression-decompression plus the impedance threshold device CPR (ACD-ITD-CPR) incorporates multiple hemodynamic pump mechanisms and also appears more effective. We have developed a new multimodal CPR that combines vest CPR with additional pump mechanisms, one of which is abdominal counterpulsation. Traditional coronary perfusion pressure (CPP) has not been validated during CPR that incorporates compression modalities applied during the relaxation phase. End tidal carbon dioxide (ET-CO2), however, is an indicator of forward blood flow during CPR that is unaffected by relaxation phase compressions. Hypothesis: Multimodal vest CPR that incorporates multiple pump mechanisms may be more effective than standard alternatives as indicated by ET-CO2. Methods: Utilizing a porcine model of ventricular fibrillation, we measured ET-CO2 in: 1) traditional sternal compression CPR (S-CPR), 2) active compression-decompression plus the impedance threshold device CPR (ACD-ITD-CPR) and 3) a new multimodal CPR comprised of circumferential constriction plus abdominal counterpulsation and active sternal decompression (MM-CPR) . After onset of cardiac arrest, 1 min. epochs of each CPR were randomly performed. Results: Seven experiments were performed with a mean number of epochs per experiment of 7. The mean (M + SD) ET-CO2 for S-CPR was 9 + 3 mmHg, for ACD-ITD-CPR 12 + 6, and for MM-CPR 19+8 (P<.05). Conclusions: Multimodal CPR comprising circumferential constriction plus abdominal counterpulsation and active sternal decompression is a promising new type of non-invasive circulatory support.

Application of three-dimensional reconstruction technology combined with three-dimensional printing in the treatment of pectus excavatum.

OBJECTIVES:To explore the clinical value of three-dimensional (3D) reconstruction technology combined with 3D printing in the treatment of pectus excavatum (PE).METHODS:The clinical data of 10 patients with PE in our department from June 2018 to December 2020 were analyzed retrospectively. All patients underwent thin-layer computed tomography examination before the operation, and then 3D reconstruction was performed with Mimics 20.0 software. The radian and curvature of the pectus bar were designed according to the reconstructed images. Afterward, the images were imported into the light-curing 3D printer in STL format for slice printing. Hence that the personalized operation scheme, including the size of the pectus bar and the surgical approach, can be made according to the 3D printed model. The thoracoscopic-assisted Nuss operation was completed by bilateral incisions. The operation time, intraoperative blood loss, and postoperative hospitalization were counted and analyzed. The satisfaction of the surgery was evaluated according to the Haller index and the most posterior sternal compression sternovertebral distance.RESULTS:The surgeries were successfully completed in 10 patients without a transfer to open procedure. The average operation time was (56 ± 8.76) min, the intraoperative blood loss was (23.5 ± 11.07) mL, and the postoperative hospitalization was (7.2 ± 0.92) d. There were no serious complications or death during the perioperative period. Compared with the data before the operation, the most posterior sternal compression sternovertebral distance was larger, and the Haller index was lower, the differences were statistically significant (P < 0.05).CONCLUSIONS:3D reconstruction technology combined with 3D printing, which can be used before operation, contributes to the operator performing thoracoscopic-assisted Nuss operation safely and effectively, which has productive clinical application value for the treatment of pectus excavatum.

Biomechanical analysis of thorax-abdomen response of vehicle occupant under seat belt load considering different frontal crash pulses

Purpose: The purpose of this work was to understand the biomechanical response and injury risk of thorax and abdomen of vehicle front seat occupants caused by seat belt load under different frontal crash pulses. Methods: A vehicle-seat-occupant subsystem finite element (FE) model was developed using the a assembly of vehicle front seat and seat belt together with the THUMS (Total Human body Model for Safety) AM50 (50th% Adult Male) occupant model. Then the typical vehicle frontal crash pulses from different impact scenarios were applied to the vehicle-seat-occupant subsystem FE model, and the predictions from the occupant model were analyzed. Results: The modeling results indicate that the maximum sternal compression of the occupant caused by seat belt load is not sensitive to the peek of the crash pulse but sensitive to the energy contained by the crash pulse in the phrase before seat belt load reaching its limit. Injury risk analysis implies that seat belt load of the four crash scenarios considered in the current work could induce a high thorax AIS2+ injury risk (&gt;80%) to the occupants older than 70 years, and a potential injury risk to the spleen. Conclusions: The findings suggest that control of the energy in the first 75 ms of the crash pulse is crucial for vehicle safety design, and thorax tolerance of the older population and spleen injury prevention are the key considerations in developing of seat belt system.

Myocardial strain analysis in infants with pectus excavatum: A subtle method to detect myocardial impairment?

Myocardial strain analysis in infants with pectus excavatum: A subtle method to detect myocardial impairment?

Sternal Wound Reconstruction Made Simple

Summary:Sternal wounds and associated infections represent a complex reconstructive problem in a highly morbid patient population. Through strict adherence to excellent plastic surgical principles, this process can be simplified, allowing safe and effective wound closure. Emphasis is placed on thorough debridement, hardware removal, obtaining adequate tissue cultures, and finally, appropriate flap closure. In most cases, pectoralis major myocutaneous advancement flaps provide excellent coverage while eliminating dead space and providing sternal compression. Secondary flap options, such as the omental flap or rectus abdominis muscle, may occasionally be necessary. This article will provide an overview and simplified approach to sternal wound reconstruction.

The assessment of the kinematics of the rescuer in continuous chest compression during a 10-min simulation of cardiopulmonary resuscitation

BackgroundIn pursuit of improvement in cardiopulmonary resuscitation (CPR), new technologies for the measurement and assessment of CPR quality are implemented. In our study, we assessed the kinematics of the rescuer during continuous chest compression (CCC–CPR). The proper performance of the procedure is a survival predictor for patients with cardiac arrest (CA). The purpose of the study was a prospective assessment of the kinematics of the rescuer’s body with consideration given to the depth and rate of chest compression (CC) as the indicator of properly performed CC maneuver by professional and non-professional rescuers during a simulation of a 10-min CCC using a manikin.MethodsForty participants were enrolled in the study. CCC–CPR was performed in accordance with the 2015 AHA guidelines on a manikin positioned on the floor. Kinematic data on the movement were obtained from the measuring system (X-sens MVN Biomech) transmitting information from 17 inertial sensors. Measurement data were imported to the author’s program RKO-Kinemat written in the Matlab and C # environments. Two groups of results were distinguished: Group I—results of CC with the depth of ≥ 40 mm and Group 2—CC results with the depth of < 40 mm.ResultsThe multiple regression model demonstrated that the path length, left knee flexion angle, and left elbow flexion angle were the essential elements of the rescuer’s kinematics that facilitated achieving and maintaining the normal depth of CC.ConclusionsWe believe that raising the rescuer’s hips by moving the center of the rescuer’s body over the point of sternal compression increases the value of the CC force vector, thereby increasing the depth of CC. In addition, we observed that, during an effective CC, the rescuer was unable to maintain arms straight and, in consequence, a slight elbow flexion was observed. It, however, did not influence the quality of the maneuver.

Visualization of Acquisition Experience in Sternal Compression Maneuver Using Kinect Sensoring: For Co-Creation of Medical Technique Experiential Values

In this study, we compare and verify data that have been rendered visual by Kinect sensoring with data obtained by conventional devices. This is in order to promote the co-creation of experiential values in the acquisition of a sternal compression technique in basic life support in the context of the improvement of the clinical skills of physicians and healthcare professionals. We find that Kinect sensoring is sufficiently accurate to evaluate measurements of the rate and depth of sternal compression; it is comparable to accelerometers and sternal compression-dedicated sensoring devices. This provides a platform for the co-creation of experiential values for the improvement of clinical skills based on the acquisition of medical techniques using the Kinect sensor, which is low in cost and easy to use. It also provides a platform for the exchange of sensor-captured information between the instructor and trainee. It is hoped that this will lead to the co-creation of values useful for the development of educational services in life-saving medical techniques.

Late results of right ventricular outflow tract reconstruction with a bicuspid expanded polytetrafluoroethylene valved conduit.

We report the results of a bicuspid expanded polytetrafluoroethylene (ePTFE) valved conduit used for right ventricular outflow tract reconstruction (RVOTR). Between November 2005 and February 2009, 12 conduits were used for RVOTR. The mean age and weight of patients were 43.5 ± 46.4 months and 13.4 ± 8.6 kg. The main diagnosis was tetralogy of Fallot with pulmonary atresia in eight patients. The most common conduit size was 18 mm. The mean follow-up was 88.0 ± 35.9 months. There were no operative and late mortalities. At discharge, the mean peak systolic pressure gradient across the RVOT was 14.1 ± 11.3 mmHg. There was no conduit valve regurgitation in nine patients. At the latest echocardiography (mean follow-up: 84.3 ± 35.5 months), the mean peak systolic pressure gradient across the RVOT was 59.7 ± 20.2 mmHg, and there was no conduit valve regurgitation in six patients. Freedom from conduit malfunction was 100% and 83.3%, at 1 and 8 years, respectively. Two conduits were explanted due to sternal compression and four from conduit malfunction. Freedom from explantation was 83.3% and 74.2% at 2 and 8 years, respectively. ePTFE bicuspid valved conduit has good late function in terms of valve regurgitation, but the pressure gradient across the conduit increases with time, which is the main cause of conduit failure and explantation.

Differences in myocardial strain between pectus excavatum patients and healthy subjects assessed by cardiac MRI: a pilot study.

To evaluate differences in myocardial strain between pectus excavatum (PE) patients and healthy subjects (HS) assessed by cardiac MRI using the feature-tracking algorithm. Cardiac MRI was performed in 14 PE patients and 14 HS (9:5 male to female in each group; age 11-30 years) using a 3T scanner. Post-examination analysis included manual biventricular contouring with volumetry and ejection fraction measurement by two independent radiologists. Dedicated software was used for automated strain assessment. In five of the PE patients, the right ventricular ejection fraction was slightly impaired (40-44 %). PE patients had a significantly higher left ventricular longitudinal strain (P=0.004), mid (P=0.035) and apical (P=0.001) circumferential strain as well as apical circumferential strain rate (P=0.001), mid right ventricular circumferential strain (P=0.008) and strain rate (P=0.035), and apical right ventricular circumferential strain (P=0.012) and strain rate (P=0.044) than HS. The right ventricular longitudinal strain and strain rate did not differ significantly between PE patients and HS. Myocardial strain differs significantly between PE patients and HS. Higher myocardial strain in the mid and apical ventricles of PE patients indicates a compensation mechanism to enhance ventricular output against basal sternal compression. • The right ventricle is frequently affected by the pectus excavatum deformity. • Cardiac MRI revealed differences in myocardial strain in pectus excavatum patients. • Pectus excavatum patients exhibited higher strain in the mid/apical ventricles. • A compensation mechanism to enhance ventricular output against sternal compression is possible.

自動胸骨圧迫装置による心肺蘇生後に発症した外傷性肝損傷に対して開腹止血術を施行し救命しえた1例

自動胸骨圧迫装置による心肺蘇生後に発症した外傷性肝損傷に対して開腹止血術を施行し救命しえた1例

EComment. The thoracic configuration of patients with left ventricular assist devices likely determines whether cardiopulmonary resuscitation using sternal compressions is both safe and effective.

eComment. The thoracic configuration of patients with left ventricular assist devices likely determines whether cardiopulmonary resuscitation using sternal compressions is both safe and effective.

Role of Manual and Mechanical Chest Compressions During Resuscitation Efforts Throughout Cardiac Arrest

The previously published randomized trials of mechanical versus manual resuscitation of patients with cardiac arrest are inconclusive, but a recent systematic review concluded: "There is no evidence that mechanical cardiopulmonary resuscitation devices improve survival; to the contrary they may worsen neurological outcome." However, in our view, none of the randomized trials to date are definitive as the manual groups with primary cardiac arrest have not been treated optimally; that is, with minimally interrupted manual chest compressions, as advocated with cardiocerebral resuscitation. Since the mechanical chest compression devices work on different principles, it is possible that, while they may not be as effective and may even be worse in some subsets of patients, they may be preferable in others. Nevertheless, there are situations where manual chest compressions are not practical and, in these, mechanical devices may well be preferable. The Thumper® (Michigan Instruments, MI, USA) and the LUCAS™ (Jolife AB, Lund, Sweden) devices produce sternal compressions at 100 per min. By contrast, the AutoPulse® (ZOLL Circulation, CA, USA) produces chest compressions at a rate of only 80 per min. Since chest compression rate, as reviewed in this article, is important, one would guess that the devices that can produce a faster rate would be more effective. On the other hand, it could be that sternal compressions with manual or mechanical devices may be more or less effective depending on the arrested patient's chest configuration. We speculate that in the subset of patients with barrel chests, where sternal compressions are less likely to be operative, the AutoPulse might be more effective, but less effective in thin-chested individuals, where direct cardiac compression is the major mechanism of forward blood flow in the manual, Thumper and LUCAS methods. The original LUCAS device had the potential of active decompression as well as compression. To market in the USA, holes had to be placed in the 'suction cup'. It would be informative to know whether the original LUCAS device is more effective than the device in which the active decompression has been deactivated.

Association of arterial blood pressure and CPR quality in a child using three different compression techniques, a case report

A 2-year-old boy found in cardiac arrest secondary to drowning received standard CPR for 35 minutes and was transported to a tertiary hospital for rewarming from hypothermia.Chest compressions in hospital were started using two-thumb encircling hands technique. Subsequently two-thumbs direct sternal compression technique and after sternal force/depth sensor placement, chest compression with classic one-hand technique were done. By using CPR recording/feedback defibrillator, quantitative CPR quality data and invasive arterial pressures were available for analyses for 5 hours and 35 minutes.316 compressions with the two-thumb encircling hands technique provided a mean (SD) systolic arterial pressure (SAP) of 24 (4) mmHg, mean arterial pressure (MAP) 18 (3) and diastolic arterial pressure (DAP) of 15 (3) mmHg. ~6000 compressions with the two thumbs direct compression technique created a mean SAP of 45 (7) mmHg, MAP 35 (4) mmHg and DAP of 30 (3) mmHg. ~20,000 compressions with the sternal accelerometer in place produced SAP 50 (10) mmHg, MAP 32 (5) mmHg and DAP 24 (4) mmHg.Restoration of spontaneous circulation (ROSC) was achieved at the point when the child achieved normothermia by using peritoneal dialysis. Unfortunately, the child died ten hours after ROSC without any signs of neurological recovery.This case demonstrates improved hemodynamic parameters with classic one-handed technique with real-time quantitative quality of CPR feedback compared to either the two-thumbs encircling hands or two-thumbs direct sternal compression techniques. We speculate that the improved arterial pressures were related to improved chest compression depth when a real-time CPR recording/feedback device was deployed.Trial registrationClinicalTrials.gov: NCT00951704.

Mechanical versus manual chest compression CPR under ground ambulance transport conditions

Novel mechanical chest compression devices offer the possibility to transport cardiac arrest patients with ongoing CPR and might shorten significantly the time delay to post-resuscitation care. We simulated an eight-minute cardiac resuscitation situation during ambulance transport using CPR training manikins. We compared teams consisting of two experienced resuscitators with the performance of a mechanical chest compression device (LUCAS). CPR-performance by two experienced resuscitators demonstrated ambivalent results. Whereas mean compression rate was within the recommended range (103/min, 95% CI: 93-113/min), mean compression depth was closely below the actually recommended compression depth of >5 cm (49.7 mm, 95% CI: 46.1-53.3mm). Nevertheless, only a mean of two thirds (67%) of all compressions were classified as manually correct (defined as sternal compression depth >5 cm). In contrast, the LUCAS device showed a constant and reliable CPR performance (99.96% correctly applied chest compressions correctly applied within the device programmed parameters, P = 0.0162) with almost no variance between the different sequences. The LUCAS CPR device represents a reliable alternative to manual CPR in a moving ambulance vehicle during emergency evacuation. Furthermore, it needs less human resources and is safer for the EMS personnel.

Editorial Comment: The Nuss operation for pectus carinatum

The controversy regarding the wisdom of applying the Nuss operation for the repair of pectus excavatum (or PE, also known as ‘funnel chest’) is ongoing. The debate was further fuelled by Abramson, who also applied the method for the correction of carinatum deformities [2]. The article by Bostanci and co-workers ‘Quality of life of patients who have undergone the minimally-invasive repair of pectus carinatum’ joins the advocates of this approach [3]. To address the issue of Nuss repair of pectus carinatum (PC), one has to consider as a whole the state-of-the-art surgery available for anterior chest deformities. The introduction of the so-called ‘minimally-invasive repair’, developed by Donald Nuss in the mid-1990s, created turmoil in the seemingly quiet field of PE repair, not only by inserting the magic words ‘minimally-invasive’ into the field—thus tripling the number of patients requesting anterior chest wall repair—but also opened the door to other disciplines besides thoracic surgeons [4]. The fact that inserting up to three foot-long metal rods through double incisions, passing them through the narrow sternopericardial space and through both pleural cavities, leaving them in place for up to five years, then re-operating for removal apparently does not concern those who regard the operation as ‘minimally-invasive’. While the results of the Nuss procedure are comparable to modern, truly minimally-invasive modifications of the classic Ravitch operation, the potential for serious complications, including perforation of vital organs, is real and lasting postoperative pain and discomfort are common [5, 6]. The wisdom of applying the Nuss operation in patients with PC is even more dubious. These patients are different to those with excavatum deformity, not only because patients with PC of moderate-to-medium severity seldom, if ever, present themselves with cardiovascular impairment but also because, while severe cases of PE may benefit most from surgical correction, the physical status of far-advanced cases of carinatum—because of associated spinal deformities—can seldom be surgically alleviated. Thus, the open approach to correct PC is, for the majority of patients, purely cosmetic. To correct the anomaly with the minimally-invasive open method is simple. The surgeon has only to remove the protruding cartilages, perform a sternotomy, push the sternum down and close the pectoralis muscles over it [5]. The procedure may be performed through a 5–6 cm incision, the operative time is less than an hour and, if properly performed, it yields most satisfactory results. Considering this, one may rightly question why anybody would choose to apply a large metal bar and leave it place for up to five years to provide sternal compression, instead of performing a simple and low-risk open repair, discharging the patient from the hospital the next day and forgetting that he ever had a carinatum deformity. Bostanci and co-workers collected valuable information, coming from an institution with excellent and extensive experience with the Nuss procedure [3]. However, it must be emphasized that the information they provide is based on subjective data. It would also be of interest to know the ages of patients, as well as their anatomical and physiological parameters before and after the intervention, the number of peri-operative and late complications and, last, why only 30 out of their 40 operated patients were included in the study. Their conclusion that the patients’ quality of life improved after this largely cosmetic operation is certainly not surprising. The study did not intend to provide evidence of the superiority of the Nuss procedure over the minimally-invasive open approach; however, it does support the views of those who are, in general, in favour of interventional treatment of pectus carinatum.