Minimally invasive mitral valve surgery through right minithoracotomy for degenerative disease in asymptomatic patients: a thirteen-year experience at Ospedale del Cuore - Massa

The purpose of this thesis is to report and analyze early and long-term outcomes in asymptomatic patients who underwent minimally invasive mitral valve surgery through right minithoracotomy at Ospedale del Cuore - Fondazione Toscana Gabriele Monasterio in the setting of degenerative disease. A total of 374 patients satisfying these characteristics had benefited from minimally invasive mitral valve surgery, and thus avoided median sternotomy, from 2004 to 2016. Mitral regurgitation (MR), currently the most frequent valvular heart disease, is mostly degenerative, linked to aging, and of increasing prevalence. Mitral valve surgery is the only current approved treatment of MR. Cumulative evidence obtained worldwide show that early surgery in asymptomatic patients is the preferred approach. “Watchful waiting”, meaning closely observing the manifestation of symptoms such as dyspnea, heart palpitation and fatigue, or echocardiographic evidence of left ventricular dysfunction, is a failed strategy, because symptoms are insensitive markers of risk and often unrecognized in a timely manner and, even after successful surgery, associated with poor outcome. Furthermore, in patients with severe organic MR, surgery is almost unavoidable and early mitral repair before the appearance of symptoms or overt LV dysfunction and irreversible anatomical modifications may restore life expectancy. At Ospedale del Cuore, OPA minimally invasive mitral valve surgery has become the standard approach since 2005, it is safe, reproducible, associated with low mortality and morbidity, high rate of mitral valve repair and excellent long-term results. In this study, the mean age was 56 ± 13 years, 119 (31,8%) patients were female. Mean preoperative EF was 64 ± 4,9% and LVEDS 32,3 ± 4,6mm. MV repair was successfully performed in 358 patients, with a rate of success of 95,7%. Repair techniques included annuloplasty (93,6%), leaflet resection (65%), neochordae implantation (27,3%), and sliding plasty (17,1%). Overall in-hospital mortality was 0%. Incidence of stroke was 1,1%, and at discharge MR was trivial or none. At mean follow-up of 53 ± 13 months, overall survival was 98,7%, freedom from reoperation 98,4% and 362 (96,8%) patients denied symptoms or a reduction in quality of life. Our results are in line with recent literature: early surgery in asymptomatic patients may restore life expectancy to that of persons of similar age and sex who never had MR and never had cardiac surgery, as long as minimally invasive valve repair is performed in high-volume centers

Hybrid Approach in Acute and Chronic Aortic Disease

The management of patients with aortic disease that involves the ascending aorta, the aortic arch, and the descending aorta represent a surgical challenge. Open surgical repair remains the gold standard for aortic arch pathologies. However, this operation requires a cardiopulmonary bypass and a period of profound hypothermia and circulatory arrest, which carries a substantial rate of mortality and morbidity. For these reasons, hybrid arch repair that involves a combination of open surgery with endovascular aortic stent graft placement has been introduced as a therapeutic alternative for those patients deemed unfit for open surgical procedures. Hybrid repair requires varying degrees of invasiveness and can be performed as a single-stage procedure or as a two-stage procedure. The choice of the technique is multifactorial, depending on the characteristics of the diseased arch with regard to position of the stent graft proximal landing zone, patient fitness and comorbid status, as well as surgical expertise and hospital facilities. Among the evolving hybrid procedures is the so-called “frozen” or stented elephant trunk technique. Adapted from the classical elephant trunk technique, this approach facilitates the repair of a concomitant aortic arch and proximal descending aortic aneurysms in a single stage under circulatory arrest. This technique is increasingly being used to treat extensive thoracic aortic disease and has shown promising results

Anthracycline-Free Neoadjuvant Treatment in Patients with HER2-Positive Breast Cancer: Real-Life Use of Pertuzumab, Trastuzumab and Taxanes Association with an Exploratory Analysis of PIK3CA Mutational Status

HER2 is considered one of the most traditional prognostic and predictive biomarkers in breast cancer. Literature data confirmed that the addition of pertuzumab to a standard neoadjuvant chemotherapy backbone (either with or without anthracyclines), in patients with human epidermal growth factor receptor 2 (HER2)-positive early breast cancer (EBC), leads to a higher pathological complete response (pCR) rate, which is known to correlate with a better prognosis. In this retrospective analysis, 47 consecutive patients with HER2-positive EBC received sequential anthracyclines and taxanes plus trastuzumab (ATH) or pertuzumab, trastuzumab and docetaxel (THP). Despite the limited sample size, this monocentric experience highlights the efficacy (in terms of pCR) and safety of THP in the neoadjuvant setting of HER2-positive EBC as an anthracycline-free approach. Given the role of PIK3CA as a prognostic and therapeutic target in breast cancer, tumors were also analyzed to assess the PIK3CA mutational status. Thirty-eight out of forty-seven patients were evaluated, and PIK3CA variants were identified in 21% of tumor samples: overall, one mutation was detected in exon 4 (2.6%), two in exon 9 (5.3%) and four in exon 20 (10.5%). Of note, one sample showed concurrent mutations in exons 9 (codon 545) and 20 (codon 1047). Among patients reaching pCR (n = 13), 38.5% were PIK3CA mutants; on the other hand, among those lacking pCR (n = 25), just 12% showed PIK3CA variants. Regarding THP-treated mutant patients (n = 5), 80% reached pCR (three hormone-receptor-negative, one hormone-receptor-positive). Interestingly, the only patient not achieving pCR had a tumor with two co-occurring PIK3CA mutations. In conclusion, this study provides new evidence about the efficacy and good safety profile of THP, compared to the ATH regimen, as an anthracycline-free neoadjuvant treatment of HER2-positive EBC. Further studies on larger/multicentric cohorts are planned for more in-depth analysis to confirm our molecular and clinical results

Delayed colorectal cancer care during covid-19 pandemic (decor-19). Global perspective from an international survey

Background The widespread nature of coronavirus disease 2019 (COVID-19) has been unprecedented. We sought to analyze its global impact with a survey on colorectal cancer (CRC) care during the pandemic. Methods The impact of COVID-19 on preoperative assessment, elective surgery, and postoperative management of CRC patients was explored by a 35-item survey, which was distributed worldwide to members of surgical societies with an interest in CRC care. Respondents were divided into two comparator groups: 1) ‘delay’ group: CRC care affected by the pandemic; 2) ‘no delay’ group: unaltered CRC practice. Results A total of 1,051 respondents from 84 countries completed the survey. No substantial differences in demographics were found between the ‘delay’ (745, 70.9%) and ‘no delay’ (306, 29.1%) groups. Suspension of multidisciplinary team meetings, staff members quarantined or relocated to COVID-19 units, units fully dedicated to COVID-19 care, personal protective equipment not readily available were factors significantly associated to delays in endoscopy, radiology, surgery, histopathology and prolonged chemoradiation therapy-to-surgery intervals. In the ‘delay’ group, 48.9% of respondents reported a change in the initial surgical plan and 26.3% reported a shift from elective to urgent operations. Recovery of CRC care was associated with the status of the outbreak. Practicing in COVID-free units, no change in operative slots and staff members not relocated to COVID-19 units were statistically associated with unaltered CRC care in the ‘no delay’ group, while the geographical distribution was not. Conclusions Global changes in diagnostic and therapeutic CRC practices were evident. Changes were associated with differences in health-care delivery systems, hospital’s preparedness, resources availability, and local COVID-19 prevalence rather than geographical factors. Strategic planning is required to optimize CRC care