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To assess the role of the mitral valve apparatus (leaflets, chordae and papillary muscles, (PM)) in left ventricle outflow tract (LVOT) obstruction, and results of the surgical treatment for hypertrophic obstructive cardiomyopathy (HOCM).Twenty-eight consecutive patients (58±11years, 53% female) undergoing HOCM surgery from 2007 to 2016 at our institute were retrospectively reviewed. Endpoints included the involvement of the mitral valve in LVOT obstruction, mortality, and changes in clinical and echocardiographic characteristics after HOCM surgery.Secondary chordae tendineae tractioning the anterior mitral leaflet to the interventricular septum, and systolic anterior motion were detected in 78% of the patients. Anomalous, hypertrophied, and fused PM with muscularis trabeculae hypertrophy were found in 50%, 25%, and 35% of the patients, respectively. Four patients had posterior leaflet redundancy. Secondary chordae (92%), PM, and muscularis trabeculae resection (71%), and PM splitting and elongation (28%) were added variably to septal myectomy (100%). Nine procedures (32%) on mitral valve leaflets were performed, involving six posterior and three anterior mitral leaflets. Long-term follow-up was 4±2.8years. There was no hospital mortality, and NYHA was reduced from 3±0.5 to 1±0.7 (p0.0001), the LVOT gradient from 88±35 to 20±18mmHg (p0.0001), mitral valve regurgitation from grade 3±1 to 1±0.7 (p0.0001), and septum thickness from 18±3 to 14±2mm (p0.0001).The mitral valve apparatus contributes with all its components variably to LVOT dynamic obstruction thus surgical correction in addition to extended myectomy is recommended to achieve the best outcome.

Aims The optimal surgical management of the aortic root phenotype Marfan patients with severe pectus excavatum is a subject of debate. All the available literature were reviewed according to preferred reporting items for systematic reviews and meta-analyses (PRISMA) principles in order to assess the early outcomes of both pectus excavatum and aortic repair techniques. Methods Searches were done in PubMed and MEDLINE electronic databases dating from July 1953 to December 2015. Results A total of 97 peer-reviewed publications were retrieved, and 27 relevant publications were identified with a total of 39 Marfan patients with pectus excavatum who underwent ascending aorta and aortic root surgery. Emergency acute Type-A aortic dissection repair was reported in five cases. Concomitant pectus excavatum and aortic root repair and composite graft implantation were the most commonly performed procedures. Complications after a staged or a combined approach were uncommon and no deaths occurred. Conclusion Aortic surgery in Marfan patients with pectus excavatum was carried out according to a variety of strategies, surgical techniques and accesses with low complications rate and no mortality. Many of these were well tolerated with minimal complications and no mortality.

Aim: To present a systematic review on efficacy and toxicity of modern concurrent chemoradiation (CCRT) in unresectable biliary tract cancers (BTC). Methods: A systematic review of literature published within the last ten years (1 January 2007-31 December 2017), based on PRISMA methodology and using PubMed electronic database was conducted. Only articles reporting patients’ outcome in terms of toxicity and/or overall survival (OS) or progression-free survival (PFS) after CCRT, with or without other treatments, were analyzed. Only studies of patients with diagnosis of unresectable BTC, including intrahepatic, extrahepatic, and gallbladder neoplasm were considered. Results: Six eligible studies were included reporting data on 195 patients. Median follow-up ranged between 9.4 and 27.7 months (median: 16 months). Four studies were prospective phase II trials and 2 had a retrospective design. Different external beam radiotherapy (EBRT) techniques and chemotherapy (CT) schedules were used while only in one study a brachytherapy boost was delivered. Grade ≥ 3 acute toxicity (hematological or gastrointestinal) ranged between 0.0 and 55.6% (median: 37.0%). One study reported 30.0% gastrointestinal grade ≥ 2 late toxicity. PFS ranged between 6.8 and 10.5 months (median: 7.5 months) in 5 studies. OS ranged between 9.6 and 13.5 months (median: 13 months) in 5 studies. Conclusion: CCRT remains a reasonable treatment option for locally advanced BTC, providing results comparable with the ones of standard CT, particularly in terms of OS. Considering the progressive advance of modern EBRT techniques, further improvement of these results can be expected. Therefore, clinical trials based on advanced radiotherapy techniques and new integrations of CCRT with systemic treatments are warranted.

Objective An increasing number of elderly patients are referred for pulmonary endarterectomy. The distinction between operable and inoperable lesions has been challenged over time. Hence, we developed alternative cardiopulmonary bypass management and cerebral protection strategies to obtain satisfactory surgical results according to the changing patient features. Methods From April 1994 to March 2011, 347 pulmonary endarterectomies were performed at our center. We began with the technique championed by the San Diego Group, adopting a single period of deep hypothermic circulatory arrest for each side (group A). Since 2003, we began to perform short periods of intermittent deep hypothermic circulatory arrest followed by periods of reperfusion (group B). We then adopted moderate, instead of deep, hypothermia (group C). Finally, we modified our technique further performing shorter (5–7-minute) periods of circulatory arrest (group D). Results The hemodynamic results after surgery were excellent in all 4 groups. The patients' age increased significantly. A trend toward an increase in the number of Jamieson type 3 lesions was observed. Associated with our protocol changes, we observed better postoperative respiratory function, a reduction in the length of mechanical ventilation and postoperative infections, and a remarkable improvement in uneventful postoperative courses. Despite the increased total circulatory arrest time, a trend toward a reduction in the incidence of transient neurologic events was observed, and operative mortality was not affected. Conclusions In our experience, our alternative strategy resulted in a better combination of surgical accuracy and cerebral protection and improved outcomes.

Aims Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension, but there are few data in the literature about the results of this procedure in the elderly. In this study, we aimed to assess whether this type of surgery is effective and well tolerated for the elderly. Methods A total of 264 consecutive patients who underwent PEA between January 2008 and December 2012 were reviewed. PEA was performed under cardiopulmonary bypass and hypothermic ventricular fibrillation, with the aorta left unclamped. The population was dichotomized according to age into the following two groups: below 70 years (n = 176, younger patients) and at least 70-year-olds (n = 88, elderly patients). Regression models were used to identify predictors of hospital mortality and postoperative adverse events, and their interaction with age was tested. Results Hospital mortality was slightly, but not significantly higher in elderly patients (9.1 vs. 5.1%; P = 0.22). Effect modification by history of smoking and preoperative O2 therapy was present. The cumulative survival at 1, 2, and 4 years was 93, 92, and 91% among younger patients; and 88, 86, and 86% among older patients (P = 0.19). Clinical and hemodynamic improvement was similar in the two groups. Conclusion Despite a slightly higher short-term mortality, PEA is feasible and well tolerated for the vast majority of the elderly patients. Clinical and hemodynamic improvements are outstanding, with satisfactory long-term survival rates.

within the chest. For example, patients who have undergone Fontan palliation have only 1 atrioventricular valve, and a capacitance chamber must be constructed to adequately connect the TAH-t. Virtual implantation offers the ability to test several surgical approaches for device placement before the patient even enters the operating room. This study was limited by a single-center experience in a small patient cohort. In addition, the assessment by virtual implantation was retrospective, and no 50cc TAH-t device was actually implanted to confirm the predicted results of the virtual implantation because it was not available during the study. However, two 70cc TAH-t devices were placed successfully as predicted by virtual implantation. In conclusion, virtual compatibility testing allows device consideration for fit to be individualized and represents a movement away from using generalized assumptions about heart size, chest wall anatomy, and spatial relationships of cardiothoracic structures to determine fit. Disclosure statement

Patients with chronic thromboembolic pulmonary hypertension (CTEPH), despite successful pulmonary endarterectomy (PEA), can continue to suffer from a limitation in exercise capacity. The objective of this study was to assess whether pulmonary arterial compliance is a predictor of exercise capacity after PEA. Right heart haemodynamics, treadmill incremental exercise test, spirometry, carbon monoxide transfer factor, arterial blood gas and echocardiographic examinations were retrospectively analysed in a population of CTEPH patients who underwent PEA at a single centre. Baseline and 3-month haemodynamic data were available in 296 patients; 5-year follow-up data were available in 68 patients. In a multivariable model the following parameters were found to be independent predictors of exercise capacity after surgery: age, sex, pulmonary arterial compliance, tricuspid annular plane excursion, arterial oxygen tension and carbon monoxide transfer factor (p

Introduction Stereotactic body radiotherapy in the treatment of pancreatic carcinoma is a recent technique. The aim of this analysis is to present a summary of techniques and clinical results. Material and Methods Stereotactic body radiotherapy allows to perform a local treatment of the tumour in shortened time (1–5 days) compared with traditional treatments (about 1 month) but requires complex planning and delivery techniques with specific accessories for imageguided radiotherapy. The studies published to date are characterised by small series and very different methods in terms of dose, fractionation, techniques and evaluation modalities. Results The preliminary published results are positive in terms of tumour response (ORR: 50%) and local control of the tumour (crude rate: 80%). However, gastrointestinal toxicity seems to be the main limitation of stereotactic body radiotherapy, especially at the duodenal level. Conclusion If stereotactic body radiotherapy of pancreatic carcinoma will be standardised and optimised, reducing the risk of bowel toxicity, in the future it may have an increasing role in the field of integrated treatments of this tumour. Introduction The prognosis of pancreatic cancer pancreas is very unfavourable. Even in patients with non-metastatic disease at diagnosis, recurrences after primary therapy are very common both as a local relapse/progression and as distant metastases. Local recurrence rate, even of patients operated on, reached percentages of 70%–80%1,2. In addition, local disease progression produces severe symptoms (pain, biliary and/or intestinal obstruction, malnutrition) capable of significantly worsening the patients’ quality of life. Radiotherapy (RT) was used to promote local control of the disease. RT, usually associated with concurrent and adjuvant chemotherapy, is potentially useful to improve the resection rate3 and control symptoms in locally advanced carcinomas4 and to reduce the risk of recurrence in resected patients5. The main limitation of RT is the presence of radiosensitive organs in the upper abdomen in close proximity with the pancreas. In fact, due to these anatomic relationships, RT can produce severe side effects especially at the level of the duodenum. Therefore, a strong interest in the use of innovative precision RT techniques has developed, with the aim to administer effective doses * Corresponding author Email: gmacchia@rm.unicatt.it 1 Department of Radiation Oncology, Fondazione Giovanni Paolo II, Campobasso, Italy 2 Department of Medical Phisics, Fondazione Giovanni Paolo II, Campobasso, Italy 3 Department of Radiation Oncology, Ospedale San Francesco, Nuoro, Italy 4 Department of Radiation Oncology, Campus Biomedico University, Roma, Italy 5 Department of Radiation Oncology, Ospedale San Filippo Neri, Roma, Italy 6 Department of Radiation Oncology, Universita Cattolica del Sacro Cuore, Roma, Italy 7 Department of Medical Phisics, Universita Cattolica del Sacro Cuore, Roma, Italy 8 Department of General Oncology, Fondazione Giovanni Paolo II, Campobasso, Italy BODY

Objectives Chronic thromboembolic pulmonary hypertension can be cured by pulmonary endarterectomy. Operability assessment remains a major concern, because there are no well-defined criteria to discriminate proximal from distal obstructions, and surgical candidacy depends mostly on the surgeon's experience. The intraoperative classification of chronic thromboembolic pulmonary hypertension describes 4 types of lesions, based on anatomy and location. We describe our recent experience with the more distal (type 3) disease. Methods More than 500 pulmonary endarterectomies were performed at Foundation I.R.C.C.S. Policlinico San Matteo (Pavia, Italy). Because of recent changes in the patient population, 331 endarterectomies performed from January 2008 to December 2013 were analyzed. Two groups of patients were identified according to the intraoperative classification: proximal (type 1 and type 2 lesions, 221 patients) and distal (type 3 lesions, 110 patients). Results The number of endarterectomies for distal chronic thromboembolic pulmonary hypertension increased significantly over time (currently ∼37%). Deep venous thrombosis was confirmed as a risk factor for proximal disease, whereas patients with distal obstruction had a higher prevalence of indwelling intravascular devices. Overall hospital mortality was 6.9%, with no difference in the 2 groups. Postoperative survival was excellent. In all patients, surgery was followed by a significant and sustained improvement in hemodynamic, echocardiographic, and functional parameters, with no difference between proximal and distal cases. Conclusions Although distal chronic thromboembolic pulmonary hypertension represents the most challenging situation, the postoperative outcomes of both proximal and distal cases are excellent. The diagnosis of inoperable chronic thromboembolic pulmonary hypertension should be achieved only in experienced centers, because many patients who have been deemed inoperable might benefit from favorable surgical outcomes.