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Colección ReSed. Es un artículo de ReSed Nº 3, perteneciente al monográfico Crisis Social, Educación y Desarrollo Profesional. Coordinación del Monográfico: Dra. Montserrat Vargas Vergara Dirección de ReSed: Dra. A-Beatriz Pérez-González, Este ensayo analiza el fenómeno de la juventud NEET (Not in Education, Employment or Training) a través del análisis de teorías e investigaciones, que subrayan las diferentes representaciones del proceso de marginalización/exclusión, referido a la ausencia de trayectorias de instrucción/formación/trabajo, de importantes cuotas de la población juvenil. El ensayo pone en evidencia la multidimensionalidad del fenómeno que, en el escenario internacional, se caracteriza por una variedad de representaciones, generadas por una estrecha relación entre la dimensión histórica, social e institucional y por el multiplicarse de las definiciones y de los contenidos aquí representados. De este análisis emergen nuevas sugerencias que abren perspectivas de investigación insólitas y plantean interesantes puntos de reflexión, para todos los que se ocupan de este campo.

El ensayo analiza algunas de las cuestiones cruciales relacionadas con el tema del “cuidado”, emergidas en el interior de los más amplios procesos de cambios. Dichos cambios surgen por el progresivo envejecimiento de la población y por la crisis de una familia basada en el modelo varón sustentador (male beadwinner); cambios que hacen del “cuidado” la ‘nueva’ cuestión social. Utilizando un paradigma de género, el trabajo afronta el tema del envejecimiento, tema de gran actualidad no solo por las dificultades relacionadas con su sostenibilidad social, sino también por las imprevistas e inesperadas repercusiones que tiene sobre la familia en términos de distribución de las responsabilidades en el trabajo del cuidado o la atención., The paper analyzes some of the key issues related to the theme of “care” emerged within the wider processes of change generated by the progressive aging of the population and the crisis of the family based on the wrong model breadwinner, changes that make the “care” the ‘new’ social question. Using a paradigm of gender, work addresses the issue of aging, very topical issue not only for the difficulties associated with its social sustainability, exacerbated by the global economic crisis, but also for the unforeseen and unexpected effects that it has on the family in terms of the distribution of responsibilities in care work.

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 Previous series of minimally invasive mitral valve repairs showed excellent results at up to 10 years of follow-up. The goal of this study was to assess the long-term durability beyond 10 years of the edge-to-edge repair for myxomatous degeneration performed through a minimally invasive approach. METHODS Ninety-seven consecutive patients (mean age 35 ± 9 years; left ventricular ejection fraction 63 ± 6%) with severe myxomatous mitral regurgitation (MR) underwent mitral valve repair through a right minithoracotomy between 1999 and 2006. MR was due to lesions involving the posterior leaflet (7.2% of patients), anterior leaflet (12.4%) and both leaflets (80.4%). RESULTS No hospital deaths occurred. At hospital discharge all patients had no or trivial MR. Follow-up was 100% complete (median 15.5 years; interquartile range 13.6–17.0, max 19.3 years). The 16-year overall survival rate was 95.9 ± 2.02% [95% confidence interval (CI) 89.39–98.43]. At 16 years, the cumulative incidence function of cardiac death, with non-cardiac death as a competing risk, was 3.1 ± 1.75 (95% CI 0.83–8.02). Only 3 patients (4.1%) had redo operations for recurrent severe MR. At 16 years, the cumulative incidence functions of reoperation for and recurrence of MR ≥3+, with death as a competing risk, were 3.1 ± 1.76% (95% CI 0.83–8.02) and 5.6 ± 2.47% (95% CI 2.06–11.83), respectively. No predictors of recurrence of MR ≥3+ were identified. At the last follow-up, moderate MR (2+/4+) was detected in 17 patients (17.5%); most of the patients were in New York Heart Association functional class I–II (97%) and in sinus rhythm (90%). CONCLUSIONS Minimally invasive mitral valve edge-to-edge repair through a right minithoracotomy for myxomatous degeneration appears to be an effective and durable approach even in the long-term follow-up (up to 19 years).

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.

For cases of initial suboptimal mitral valve repair, the edge-to-edge (EE) technique has been used as a bailout procedure. However the long-term durability of those rescued mitral valves is currently unknown. With this study we aim to evaluate the long-term clinical and echocardiographic results of the EE technique used to rescue patients with initial suboptimal conventional mitral valve repair.A retrospective review of our institutional database was done to query for patients who had undergone mitral valve repair with the EE technique used as a bailout procedure. The cumulative incidence function using death as a competing event was used to estimate cardiac death and redo for mitral valve replacement. To describe the time course of mitral regurgitation, we performed a longitudinal analysis using generalized estimating equations with random intercept for correlated data.Eighty-one patients were selected. The median follow-up was 9.1 years (interquartile range, 6.7-12.1; maximum, 22.6 years). At 15 years the estimated Kaplan-Meier overall survival was 63.2% ± 8.69% (95% confidence interval, 43.76-77.46) and the predicted rate of moderate to severe mitral regurgitation recurrence was 16.67%. At 15 years the cumulative incidence function for redo for mitral valve replacement with death as a competing event was 2.5% (95% confidence interval, 0.48-7.84). No case of more than mild mitral stenosis was detected.The EE technique can be effectively used as a bailout procedure in patients with suboptimal conventional mitral valve repair with satisfactory long-term results.

OBJECTIVES This study aimed at assessing mid-term outcomes of patients undergoing isolated tricuspid valve (TV) surgery based on a preoperative baseline clinical and functional classification. METHODS All patients treated with isolated TV repair or replacement from March 1997 to May 2020 at a single institution were retrospectively reviewed and assessed for mid-term postoperative outcome according to a novel classification [stages 1–5 related to the absence or presence and extent of right heart failure (RHF)]. Kaplan–Meier survival curves were used to estimate mid-term survival. Competing risk analysis for time to cardiac death and hospitalizations for RHF were also carried out. RESULTS Among the 172 patients included, 129 (75%) underwent TV replacement and 43 (25%) TV repair. At follow-up (median 4.2 years [2.1–7.5]), there were 23 late deaths. At 5 years, overall survival was 100% in stage 2, 88 ± 4% in stage 3 and 60 ± 8% in stages 4–5 (P = 0.298 and P = 0.001, respectively). Cumulative incidence function of cardiac death at 5 years was 0%, 8.6 ± 3.76% and 13.2 ± 5% for stages 2, 3 and 4 and 5, respectively. At follow-up, cumulative incidence function of re-hospitalizations for RHF was 0% for stage 2, 20 ± 5% for stage 3 and 20 ± 6.7% for stages 4 and 5 (P = 0.118 and P = 0.039, respectively). CONCLUSIONS Both short- and mid-term outcomes support early referral for surgery in isolated TV disease, with excellent survival at 5 years and no further hospitalizations for RHF.

Background This study aims at better defining the profile of patients with a complicated versus noncomplicated postoperative course following isolated tricuspid valve (TV) surgery to identify predictors of a favorable/unfavorable hospital outcome.Methods All patients treated with isolated tricuspid surgery from March 1997 to January 2020 at our institution were retrospectively reviewed. Considering the complexity of most of these patients, a regular postoperative course was arbitrarily defined as a length-of-stay in intensive care unit less than 4 days and/or postoperative length-of-stay less than 10days. Patients were therefore divided accordingly in two groups.Results One hundred and seventy-two patients were considered, among whom 97 (56.3%) had a regular (REG) and 75 (43.6%) a non-regular (NEG) postoperative course. The latter had worse baseline clinical and echocardiographic characteristics, with higher rate of renal insufficiency, previous heart failure hospitalizations, cardiac operations, and right ventricular dysfunction. NEG patients more frequently needed tricuspid replacement and experienced a greater number of complications (p < .001) and higher in-hospital mortality (13% vs. 0%, p < .001). The majority of these complications were related to more advanced stage of the tricuspid disease. Among most important predictors of a negative outcome univariate analysis identified chronic kidney disease, ascites, previous right heart failure hospitalizations, right ventricular dysfunction, previous cardiac surgeries, TV replacement and higher MELD scores. At multivariate analysis, liver enzymes and diuretics' dose were predictors of complicated postoperative course.Conclusion In isolated TV surgery a complicated postoperative course is observed in patients with more advanced right heart failure and organ damage. Earlier surgical referral is associated to excellent outcomes and should be recommended.

OBJECTIVES The goal of this study was to assess the applicability of a novel classification of patients with tricuspid regurgitation based on 5 stages and to evaluate outcomes following isolated surgical treatment. METHODS All patients treated with isolated tricuspid valve repair or tricuspid valve replacement (TVR) from March 1997 to January 2020 at a single institution were retrospectively reviewed. Patients were divided according to a novel clinical-functional classification, based on the degree of regurgitation together with symptoms, right ventricular size and function and medical therapy. A total of 195 patients were treated; however, 23/195 were excluded due to lack of sufficient preoperative data. RESULTS A total of 172 patients were considered; of these, 129 (75%) underwent TVR and 43 (25%) had tricuspid valve repair. The distribution of patients showed that 46.5% of patients who underwent tricuspid valve repair were in stage 2, whereas 51.9% who underwent TVR were in stage 3. TVR patients were in more advanced stages of the disease, with dilated right ventricles, more pronounced symptoms and development of organ damage. Hospital mortality was 5.8%, in particular 0% in stages 2 and 3 and 15.3% in stages 4 and 5 (P CONCLUSIONS Patients in more advanced stages had higher hospital mortality and longer hospitalizations. Timely referral is associated with lower mortality, short postoperative course and mostly valve repair.

OBJECTIVES The aim of this study was to assess the long-term outcomes of different surgical strategies in patients with hypertrophic obstructive cardiomyopathy (HOCM) with septal thickness ≤18 mm and systolic anterior motion (SAM)-related moderate-to-severe mitral regurgitation (MR). METHODS Seventy-six HOCM patients with septal thickness 17 [16; 18] mm, resting left ventricle outflow tract gradient 60 [41; 85] mmHg and SAM-related MR ≥2+/4+, underwent septal myectomy alone (54%) or mitral valve (MV) surgery ± myectomy (46%). RESULTS No hospital death and no ventricular septal defect occurred. Patients undergoing MV surgery ± myectomy had longer cardiopulmonary bypass and X-clamp times (77 [60–106] vs 51 [44–62] min, P CONCLUSIONS In HOCM patients with moderate septal thickness and SAM-related MR, as the degree of septal hypertrophy decreases, addressing the abnormalities of the MV apparatus may become necessary to provide a durable resolution of left ventricle outflow tract obstruction and SAM-related MR. However, performing myectomy alone, whenever possible, seems to be associated to a better postoperative course and a trend towards lower cardiac mortality at follow-up, despite a higher rate of residual moderate MR.

Objectives: To report mid-term results after MitraClip repair, according to mitral regurgitation (MR) mechanism, in a real-world single-center experience. Background: Mid-term outcomes of percutaneous edge-to-edge mitral repair in the real world are still limited. Methods: We assessed the follow-up results of patients treated with MitraClip at a single high-volume mitral center from 2008 to 2016. All patients underwent Heart-Team discussion, prospective data collection and enrolment in a dedicated outpatient clinic. Functional (FMR, n = 242, 68.6%) and degenerative (DMR, n = 97, 27.5%) MR patients were separately analyzed. Results: 5-Year survival was 53.5 ± 4.5% in FMR vs 57.1 ± 7.5% in DMR (P = 0.18). Reduced survival was strongly associated with worse left ventricle remodeling (ESV HR 1.01, CI 1.01–1.02, P < 0.001) in FMR, and with worse symptoms (New York Heart Association IV HR 6.72, CI 1.78–25.45, P = 0.005) in DMR. 5-Year cumulative incidence function for MR ≥ 3 was 23.7 ± 3.4% in FMR vs 27.9 ± 5.9% in DMR (P = 0.39), being associated with residual MR = 2 both in FMR (HR 4.67, CI 2.49–8.74, P < 0.001) and DMR (HR 7.15, CI 2.72–18.75, P < 0.001). At 5-year, patients in NYHA class I-II increased from 17.9% to 45.3% in FMR (P < 0.001) and from 33.3% to 51.3% in DMR (P < 0.001). Conclusions: In this single-center real-world experience, 5-year after MitraClip, half of the patients were alive and 3/4 were free from MR, both in FMR and DMR. Symptoms benefit was sustained in both groups. Advanced ventricular remodeling, advanced symptoms, and suboptimal MR reduction were associated with worse results. Refined patient selection, improved efficacy and more data will be all required to improve long-term outcomes.

Background We report the long-term (19 years) clinical and echocardiographic results of the quadrangular resection with annular plication and annuloplasty. Methods Included were 145 consecutive patients (mean age, 58 ± 11.1 years; left ventricular ejection fraction, 0.59 ± 0.095) with severe degenerative mitral regurgitation due to posterior leaflet prolapse/flail who underwent quadrangular resection of the posterior leaflet combined with ring (127 patients [87.5%]) or pericardium (18 patients [12.5%]) annuloplasty. Results No hospital deaths occurred. At hospital discharge, all patients but 1 had none or trivial mitral regurgitation. Follow-up was 97% complete (median, 19 years; interquartile range, 18 to 20 years). At 20 years, the overall survival was 74% ± 3.7%. At 19 years, cumulative incidence function of cardiac death with noncardiac death as a competing risk was 9.9% ± 2.5% (95% confidence interval [CI], 5.7% to 15.5%). Age was the only significant predictor of cardiac death (hazard ratio, 1.1; 95% CI, 1.0 to 1.1; p = 0.01) at multivariate analysis. Only 6 patients (4%) were reoperated on for recurrent severe mitral regurgitation. At 19 years, cumulative incidence function of reoperation and recurrence of mitral regurgitation 3+ or higher with death as a competing risk was 4.3% ± 1.7% (95% CI, 1.7% to 8.8%) and 8.8% ± 2.8% (95% CI, 4.3% to 15.5%), respectively. Indeed, only 11 patients (8%) had recurrent mitral insufficiency 3+ or higher. No predictor of reoperation and recurrence of mitral regurgitation 3+ or higher was identified. At the last follow-up, moderate mitral regurgitation (2+/4+) was detected in 14 patients (10%). Conclusions Quadrangular resection with annular plication for posterior leaflet prolapse, combined with annuloplasty, is associated with a very low probability of reoperation and recurrent mitral regurgitation for up to 2 decades after the operation. These results provide reference values to which all of the other more recently introduced surgical and transcatheter options need to be compared.

OBJECTIVES After mitral repair for degenerative mitral regurgitation (MR), no or mild (≤1+/4+) residual MR should remain. Occasionally patients are left with more than mild residual MR (>1+/4+) for a number of reasons. The aim of this study was to assess the late implications of such a suboptimal repair in a matched cohort study. METHODS From 2006 to 2013, a total of 2158 patients underwent mitral repair for degenerative MR in our institution. Fifty patients (2.3%) with residual MR >1+ at hospital discharge (study group) were matched up to 1:2 with 91 patients operated on during the same period who were discharged with MR ≤1+ (control group). The median follow-up was 8 years (interquartile range 6.3–10.1, longest 12.7 years). A comparative analysis of the outcomes in the 2 groups was performed. RESULTS Overall survival at 8 years was 87 ± 8% in the study group and 92 ± 3% in the control group (P = 0.23). There were 3 late deaths (6.0%) in the study group and 6 deaths (6.6%) in the control group. Freedom from reoperation was similar (P = 1.0). At 8 years the prevalence of MR ≥3+ was significantly higher in the study group (15.6% vs 2.1%, P CONCLUSIONS Residual MR more than mild at hospital discharge is associated with lower durability of mitral repair and the need for more medical therapy in the long term. However, even an initial optimal result does not completely arrest the progression of the degenerative process.

Background The aim of the study was to evaluate whether the type of ring used had an impact on the long-term results of mitral repair for degenerative mitral regurgitation (MR), due to posterior leaflet prolapse, treated with quadrangular or triangular resection. Methods From January 2002 to December 2008, 1406 patients with severe MR due to posterior leaflet prolapse underwent mitral repair. Of these patients, we selected 452 consecutive patients treated with the same repair approach. Mitral annuloplasty to complete the repair was performed with a posterior flexible band (n = 260) or a complete semi-rigid ring (n = 192). The 2 groups were comparable at baseline, and their clinical and echocardiographic outcomes were compared at long-term follow-up. Results Overall survival at 14 years was similar (P = .29). The cumulative incidence function of cardiac death, with noncardiac death as competing risk, showed no difference (P = .71). At 14 years, probability of recurrence of MR greater than or equal to 3+ was 1.11% in the flexible band group and 3.25% in the semi-rigid ring group (P = .073). At 14 years, probability of recurrence of MR greater than or equal to 2 was 13.49% in the band group vs 10.78% in the semi-rigid ring group (P = .897). Conclusions In patients requiring mitral valve repair for posterior leaflet prolapse, treated with the same repair approach, the type of annuloplasty ring has no impact on the incidence of cardiac death and recurrence of MR at 14 years. Whether these findings remain stable at longer follow-up should be further investigated.

To compare the outcomes of MitraClip and surgical mitral repair in low-intermediate risk elderly patients affected by degenerative mitral regurgitation (DMR).We retrospectively selected patients aged ≥75 years, with Society of Thoracic Surgeons Predicted Risk Of Mortality (STS-PROM)8%, submitted to MitraClip (n = 100) or isolated surgical repair (n = 206) for DMR at 2 centers between January 2005 and May 2017. To adjust for baseline imbalances, we used a propensity score model for average treatment effect on survival.After weighting, MitraClip showed fewer postoperative complications (P .05) but increased residual mitral regurgitation (MR) ≥2 (27.0% vs 2.8%, P .001) compared with surgery. One-year survival was greater after MitraClip compared with surgery (97.6% vs 95.3%, hazard ratio [HR], 0.09; confidence interval [CI], 0.02-0.37, P = .001), whereas 5-year survival was lower (34.5% vs 82.2% respectively, HR, 4.12; CI, 2.31-7.34, P .001). Greater STS-PROM (HR, 1.18; CI, 1.12-1.24, P .001) and MR ≥3+ recurrence (HR, 2.18; CI, 1.07-4.48, P = .033) were associated with reduced survival. 5-year MR ≥3+ was more frequent after MitraClip compared with surgery: 36.9% versus 3.9%, odds ratio, 11.4; CI, 4.40-29.68, P .001.In elderly patients affected by DMR and STS-PROM8%, the average effect of MitraClip resulted in lower acute postoperative complications and improved 1-year survival compared with surgery. However, MitraClip was associated with greater MR recurrence and reduced survival beyond 1 year. Long-term survival was impaired by patients' greater risk profile and MR recurrence. Early results are promising, but in the setting of operable patients with life expectancy beyond 1 year, the quality bar for transcatheter mitral repair needs to be raised.