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OBJECTIVES 3-Dimensional (3D)-shaped rings are largely adopted for tricuspid annuloplasty, but evidence about their long-term results is scanty. The goal of this study was to analyse the long-term results of tricuspid annuloplasty with 3D-shaped rings. MATERIALS AND METHODS A retrospective review of our prospectively maintained database was carried out to identify all patients who underwent tricuspid valve repair with 3D-shaped rings between January 2011 and December 2014. Kaplan–Meier methods were used to analyse long-term survival. Cumulative incidence function using death as the competitive outcome was used to estimate cardiac death. RESULTS A total of 168 patients were identified. The median age was 66 years. Eighty-two patients (49%) were in advanced New York Heart Association functional class III–IV. Atrial fibrillation (AF) was present in 101 (60%); the median ejection fraction was 60%. In 82 (49%) patients, a Medtronic 3D Contour annuloplasty ring was employed; in the remaining 86 (51%) patients, an Edwards MC3 ring was used. Cumulative incidence function of cardiac death, with non-cardiac death as a competing risk, was 1.9 ± 1.1%, 95% confidence interval (CI) (0.51–4.95) at 7 years. The cumulative incidence function of recurrence of tricuspid regurgitation (TR) ≥2+ at 7 years was 14 ± 3.17%, 95% CI (8.49–20.82). Recurrence of TR ≥2+ at 7 years was not significantly different between the Medtronic 3D Contour and the Edwards MC3 rings (P = 0.3). AF was identified as the only independent predictor of recurrence of TR ≥2+. CONCLUSIONS 3D-shaped rings are effective and durable. TR recurrence was relatively low at 7 years and usually moderate (2+/4+) without a significant difference between the 2 types of rings. The role of AF as a predictor of TR recurrence was confirmed.

OBJECTIVES The EuroSCORE II is widely used to predict 30-day mortality in patients undergoing open and transcatheter cardiac surgery. The aim of this study is to evaluate the discriminatory ability of the EuroSCORE II in predicting 30-day mortality in a large cohort of patients undergoing surgical mitral valve repair in a high-volume centre. METHODS A retrospective review of our institutional database was carried on to find all patients who underwent mitral valve repair in our department from January 2012 to December 2019. Discrimination of the EuroSCORE II was assessed using receiver operating characteristic curves. The maximum Youden’s Index was employed to define the optimal cut-point. Calibration was assessed by generating calibration plot that visually compares the predicted mortality with the observed mortality. Calibration was also tested with the Hosmer–Lemeshow goodness-of-fit test. Finally, the accuracy of the models was tested calculating the Brier score. RESULTS A total of 2645 patients were identified, and the median EuroSCORE II was 1.3% (0.6–2.0%). In patients with degenerative mitral regurgitation (MR), the EuroSCORE II showed low discrimination (area under the curve 0.68), low accuracy (Brier score 0.27) and low calibration with overestimation of the 30-day mortality. In patients with secondary MR, the EuroSCORE II showed a good overall performance estimating the 30-day mortality with good discrimination (area under the curve 0.88), good accuracy (Brier score 0.003) and good calibration. CONCLUSIONS In patients with degenerative MR operated on in a high-volume centre with a high level of expertise in mitral valve repair, the EuroSCORE II significantly overestimates the 30-day mortality.

OBJECTIVES The aim of this study is to evaluate the immediate and mid-term effects of omitting coronary artery bypass grafting in patients with moderate coronary artery stenosis who have a primary indication for valvular surgery. METHODS We included 77 consecutive patients admitted to our Institution for aortic or mitral valve surgery between June 2012 and June 2017 in whom a de novo diagnosis of ≥50%, but RESULTS There were no in-hospital deaths. In only 1 patient, acute myocardial infarction occurred postoperatively, which was immediately treated by percutaneous coronary intervention (PCI). The 6-year overall survival was 94.7 ± 2.59%. At 6 years, no cardiac deaths were recorded. At follow-up, 4 patients underwent elective PCI after a positive stress myocardial perfusion test. Only 1 patient underwent urgent PCI due to acute coronary syndrome. At 6 years, the cumulative incidence function of PCI, with death as competing risk, was 8 ± 3.9%. CONCLUSIONS In our experience, moderate coronary stenosis, occasionally discovered at the time of valvular heart surgery, can be safely overlooked and do not need any further treatment at follow-up in the majority of cases. Our results open up the opportunity to apply this ‘intentional omission strategy’ in different situations, such as minimally invasive heart surgery, percutaneous procedures and complex patients.

OBJECTIVES Mitral regurgitation (MR) due to commissural prolapse or flail represents a pattern of valve dysfunction that can be treated, among other techniques, by suturing the margins of the anterior and posterior leaflets in the commissural area (commissural closure). The very long-term results of this technique have not been reported so far and represent the objective of this study. METHODS A retrospective review of our institutional database was carried on querying for patients who underwent commissural closure and ring annuloplasty within the time frame 1997–2007 to provide a robust long-term assessment. Cumulative incidence function (CIF) using death as a competitive outcome was used to estimate cardiac death and reoperation for mitral valve replacement. To describe the time course of MR, we performed a longitudinal analysis using generalized estimating equations with a random intercept for correlated data. RESULTS A total of 125 patients were included. At 15 years, the CIF for cardiac death, with non-cardiac death as a competitive event, was 8.0 ± 2.57% (95% confidence interval [3.88–13.93]). At 15 years, the CIF for reintervention for a mitral valve replacement with death as a competitive event was 5.0 ± 1.98%, 95% confidence interval [2.04–9.89]. No significant predictors of reintervention for mitral valve replacement were identified. At 5 years, the predicted rate of MR ≥3+ recurrence was 2.53% while it was 8.22% at 15 years. In no case a more than mild mitral stenosis was detected. CONCLUSIONS Severe MR due to commissural prolapse/flail can be effectively treated with commissural closure and ring annuloplasty. In our series, the rate of reoperation in the very long term was extremely low. Similarly, longitudinal analysis demonstrated a very low rate of MR ≥3+ recurrence.

Objectives To evaluate whether the adoption of a right minithoracotomy operative approach had an impact on the long-term results of edge-to-edge (EE) repair compared to conventional sternotomy in patients with Barlow's disease and bileaflet prolapse. Methods We assessed the long-term results of 104 patients with Barlow's disease treated with a minimally invasive EE technique. An equal number of patients had a conventional median sternotomy EE repair for the same disease and were used as a control group. The inverse probability of treatment weighting was used to create comparable distributions of the covariates that were significantly different at baseline in the two groups. We performed a comparative analysis of the groups. Results No hospital deaths were observed. Follow-up was 99.5% complete (median 11.3 years). The cumulative incidence function (CIF) of cardiac death at 12 years, with noncardiac death as a competing risk, showed no difference between the two groups ( P = 0.87). At 12 years, the CIF of recurrent MR ≥ 3+, with death as the competing risk, was 7% in the sternotomy group and 5% in the minimally invasive group ( P = 0.30), and the CIF of recurrence of MR ≥ 2+ was 15 and 14%, respectively ( P = 0.63). The type of surgical approach was not a predictor of cardiac death, reoperation, recurrent MR ≥ 3+ or recurrent MR ≥ 2+. Conclusions A minimally invasive approach does not have a negative impact on the effectiveness and long-term durability of the EE repair for bileaflet prolapse in Barlow's disease. Long-term outcomes are excellent, and valvular performance remains stable over time with no evidence of mitral stenosis.

OBJECTIVES: Atrial fibrillation (AF) is common in patients with hypertrophic cardiomyopathy (HCM) and it is often poorly tolerated because of loss of atrial contraction and reduced filling time with rapid ventricular rates. Restoring sinus rhythm is of great clinical benefit to HCM patients. Very few data exist regarding surgical ablation of concomitant AF in this setting. The aim of this study was to evaluate the mid-term outcome of surgical AF ablation in patients who underwent cardiac surgery due to HCM. METHODS: Thirty-one consecutive patients with primary HCM and drug-refractory symptomatic AF underwent surgical ablation with concomitant septal myectomy (77%) and/or mitral valve repair/replacement (39%). Follow-up was 97% complete with a median of 6.4 years [3.8-9.1]. RESULTS: Hospital mortality was 6% and the overall survival at 7 years was 87 ± 6.1%. No stroke and thromboembolic events were documented at follow-up. The arrhythmia-free survival off antiarrhythmic drugs was 82 ± 7.3% at 1 year and 52 ± 10.2% at 6 years. The 1- and 6- year arrhythmia control (maintenance of sinus rhythm with or without antiarrhythmic drugs) was 96 ± 3.5 and 80 ± 8.1%, respectively. The recurrent arrhythmia was AF in all patients. No predictors of AF recurrence were detected. CONCLUSIONS: Concomitant surgical ablation of AF is a reasonable treatment option for drug refractory AF in patients with HCM undergoing surgical myectomy and/or mitral valve surgery. However, chronic antiarrhythmic drugs are needed to achieve a satisfactory mid-term arrhythmia control.

OBJECTIVES Recurrent mitral regurgitation (MR) is common after surgical and percutaneous (MitraClip) treatment of functional MR (FMR). However, the Everest II trial suggested that, in patients with secondary MR and initially successful MitraClip therapy, the results were sustained at 4 years and were comparable with surgery in terms of late efficacy. The aim of this study was to assess whether both those findings were confirmed by our own experience. METHODS We reviewed 143 patients who had an initial optimal result (residual MR ≤ 1+ at discharge) after MitraClip therapy (85 patients) or surgical edge-to-edge (EE) repair (58 patients) for severe secondary MR (mean ejection fraction 28 ± 8.5%). Patients with MR ≥ 2+ at hospital discharge were excluded. The two groups were comparable. Only age and logistic EuroSCORE were higher in the MitraClip group. RESULTS Follow-up was 100% complete (median 3.2 years; interquartile range 1.8;6.1). Freedom from cardiac death at 4 years (81 ± 5.2 vs 84 ± 4.6%, P = 0.5) was similar in the surgical and MitraClip group. The initial optimal MitraClip results did not remain stable. At 1 year, 32.5% of the patients had developed MR ≥ 2+ (P = 0.0001 compared with discharge). Afterwards, patients with an echocardiographic follow-up at 2 years (60 patients), 3 years (40 patients) and 4 years (21 patients) showed a significant increase in the severity of MR compared with the corresponding 1 year grade (all P < 0.01). Freedom from MR ≥ 3+ at 4 years was 75 ± 7.6% in the MitraClip group and 94 ± 3.3% in the surgical one (P = 0.04). Freedom from MR ≥ 2+ at 4 years was 37 ± 7.2 vs 82 ± 5.2%, respectively (P = 0.0001). Cox regression analysis identified the use of MitraClip as a predictor of recurrence of MR ≥ 2+ [hazard ratio (HR) 5.2, 95% confidence interval (CI) 2.5-10.8, P = 0.0001] as well as of MR ≥ 3 (HR 3.5, 95% CI 0.9-13.1, P = 0.05). CONCLUSIONS In patients with FMR and optimal mitral competence after MitraClip implantation, the recurrence of significant MR at 4 years is not uncommon. This study does not confirm previous observations reported in the Everest II randomized controlled trial indicating that, if the MitraClip therapy was initially successful, the results were sustained at 4 years. When compared with the surgical EE combined with annuloplasty, MitraClip therapy provides lower efficacy at 4 years.

OBJECTIVES To compare the surgical and percutaneous edge-to-edge (EE) repair in patients with severe left ventricular (LV) dysfunction and secondary mitral regurgitation (MR). METHODS We reviewed the prospectively collected data of the first 120 consecutive patients (age: 65 ± 9.8 years, EF: 28 ± 8.2%) treated with surgical (65 patients) or percutaneous (55 patients) EE repair for severe secondary MR in our institution. Age (P = 0.005) and logistic European System for Cardiac Operative Risk Evaluation (P < 0.0001) were significantly higher in the MitraClip group. LVEF (P = 0.37), end-diastolic (P = 0.83) and end-systolic (P = 0.68) volumes and systolic pulmonary artery pressure (SPAP) (P = 0.58) were similar. The follow-up was 100% complete [median: 4 years; interquartile range (IQR): 2.2-7.2]. RESULTS The length of hospital stay was 10 days (IQR: 8-13) for surgery and 5 days (IQR: 3.9-7.8) for MitraClip (P < 0.0001). Hospital mortality (3 vs 0%, P = 0.49) and freedom from cardiac death at 4 years (80.8 ± 4.9% vs 79.1 ± 5.9%, P = 0.9) were not significantly different in the surgical and MitraClip group, respectively. Residual MR ≥ 2+ at hospital discharge was 7.6% for surgery and 29% for MitraClip (P = 0.002). At 4 years, freedom from MR ≥ 2+ (74.9 ± 5.6% vs 51.4 ± 7.4%, P = 0.01) and freedom from MR ≥ 3+ (92.8 ± 3.4% vs 68.1 ± 7%, P = 0.002) were both significantly higher in the surgical group. Multivariate analysis identified the use of MitraClip as an independent predictor of recurrence of MR ≥ 2+ [Hazard ratio (HR): 2.1, 95% confidence interval (CI): 1.1-3.9, P = 0.02] as well as of MR ≥ 3 (HR: 6.1, 95% CI: 1.5-24.3, P = 0.01). In the surgical group, no predictors of cardiac mortality were identified. In the MitraClip group, left ventricular end-diastolic diameter (HR: 1.1, 95% CI: 1-1.2, P = 0.005) and SPAP (HR: 1, 95% CI: 1-1.1, P = 0.005) were independent predictors of cardiac death at the follow-up. CONCLUSIONS MitraClip therapy is a safe therapeutic option in selected high-risk patients with secondary MR and relevant comorbidities. The surgical EE provides higher efficacy both postoperatively and at the mid-term follow-up.

OBJECTIVES: While the results of mitral repair in ischaemic mitral regurgitation have been repeatedly reported, less data are available about the outcome of surgical repair of functional mitral regurgitation (FMR) in idiopathic dilated cardiomyopathy (iDCM) which represents the topic of this study. METHODS: Fifty-four iDCM patients (mean age 63 ± 10.5 years) underwent mitral valve repair for severe FMR. Coronary angiography confirmed the absence of coronary disease in all patients. Most of the patients (77.7%) were in New York Heart Association (NYHA) class III-IV. Pre-operative ejection fraction (EF) was 30.4 ± 8.5%, left ventricle end-diastolic diameter (LVEDD) 67.5 ± 7.8 mm, left ventricle end-systolic diameter (LVESD) diameter 53.9 ± 8.3 mm. Concomitant procedures were atrial fibrillation (AF) ablation (19 patients) and tricuspid repair (17 patients). Follow-up was 100% complete (mean 4.2 ± 2.5 years, median 4.2 years, range 3.3 months-11.1 years). RESULTS: In-hospital mortality was 5.6%. Actuarial survival at 6.5 years was 69 ± 8.8%. Patients submitted to successful AF ablation and/or cardiac resynchronization therapy (CRT) had a significantly better survival (91 ± 7.9 vs 67 ± 9.5%, P = 0.01). Freedom from MR≥3+/4+ was 89.1 ± 5.7% at 6.5 years. Follow-up echocardiography showed a reduction in LVEDD (P < 0.0001) and LVESD (P = 0.0003). Mean EF increased to 38.7 ± 12.4% (P < 0.0001). Multivariate analysis identified successful ablation of AF and/or CRT (P = 0.01) and higher preoperative EF (0.03) as predictors of overall survival. Successful ablation of AF and/or CRT (P = 0.02) and lower preoperative systolic pulmonary artery pressure (0.04) were identified as independent predictors of reverse LV remodelling at follow-up. At last follow-up, 86.2% of the patients were in NYHA II or less. CONCLUSIONS: Mitral repair for FMR in well-selected iDCM patients is associated with low hospital mortality and significant clinical benefit at late follow-up. Concomitant successful AF ablation and/or CRT provide a major symptomatic and prognostic advantage and should be associated to mitral surgery whenever indicated.

Mitral regurgitation (MR) is frequently found in patients scheduled for aortic valve replacement (AVR). The aetiology of concomitant MR can be organic or functional. Organic MR is the result of rheumatic or myxomatous degeneration or, particularly in the elderly, calcification of the mitral apparatus. Functional MR, on the other hand, is secondary to increased left ventricular (LV) afterload and/or variable degree of LV remodelling and is the most common form of mitral insufficiency in patients requiring AVR. The evidence is clear to not surgically intervene if associate functional MR is only mild. Similarly, there is a general agreement that mitral valve (MV) surgery, possibly repair, should be performed when severe functional MR exists. On the other hand, the question is often raised of whether additional MV surgery is required in patients submitted to AVR who do have concomitant less than severe functional MR [1–3]. Indeed, no randomized trials have been conducted in this setting and the scattered information available is the result of observational studies with small sample sizes, retrospective analyses, heterogeneous populations and different aetiologies of MR. In addition, the presence of concomitant procedures like myocardial revascularization and the use of different echocardiographic parameters in grading preoperative MR further limits direct comparison between studies. In this scenario, not surprisingly, even the last 2012 European Guidelines on the management of Valvular Heart Disease [4] do not specifically address this issue and simply suggest that, as long as there are no significant organic abnormalities of the mitral apparatus, surgical intervention on the MV is generally not necessary at the time of AVR because non-severe secondary MR usually improves after the aortic valve is treated. The prognostic significance of ‘less than severe’ functional MR in patients undergoing isolated AVR is still debated. Some studies have shown no difference in survival in patients with moderate or moderate-to-severe functional MR vs no (or mild MR) after isolated AVR [2, 5]. Other reports, on the other hand, have demonstrated significantly poorer survival in patients with at least moderate MR submitted to isolated AVR. Organic MV disease and severe degree of MR, however, were usually included in this second group of studies [6, 7]. Those controversial findings explain why some authors have recommended an aggressive approach in operating on the MV [7, 8], whereas others continue to support a more conservative strategy, believing that functional non-severe MR is likely to decrease after the surgical correction of aortic valve disease [2]. Most of the data available demonstrate a general trend towards an improvement of the grade of less-than-severe functional MR after isolated AVR. This is usually due to the postoperative reduction in LV systolic pressure (aortic stenosis) or to the decrease in LV dimensions (aortic regurgitation). Only in about one-third of the patients, preoperative functional MR remains unchanged and in a minority of them it further deteriorates [7]. Whether persistence or worsening in MR severity following AVR directly correlates with mortality remains unclear. The study by Coutinho et al. [9] provides some more light in this controversial field showing that, in the great majority of patients, secondary MR decreases early after isolated AVR and, in 67% of them, this improvement persists in the medium to long term. This finding confirms a relatively benign evolution of secondary MR in patients submitted to isolated AVR. The second important message emerging from this series is that functional MR, in the context of AVR, can be treated with a high rate of repair and with low mortality and morbidity if simple procedures are used. In the study by Coutinho, MV surgery mainly consisted of suture or ring annuloplasty, which required an extra aortic cross-clamp time of