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.

Heart failure is the worst outcome of all cardiovascular diseases and still represents nowadays the leading cause of mortality with no effective clinical treatments, apart from organ transplantation with allogeneic or artificial substitutes. Although applied as the gold standard, allogeneic heart transplantation cannot be considered a permanent clinical answer because of several drawbacks, as the side effects of administered immunosuppressive therapies. For the increasing number of heart failure patients, a biological cardiac substitute based on a decellularized organ and autologous cells might be the lifelong, biocompatible solution free from the need for immunosuppression regimen. A novel decellularization method is here proposed and tested on rat hearts in order to reduce the concentration and incubation time with cytotoxic detergents needed to render acellular these organs. By protease inhibition, antioxidation, and excitation–contraction uncoupling in simultaneous perfusion/submersion modality, a strongly limited exposure to detergents was sufficient to generate very well-preserved acellular hearts with unaltered extracellular matrix macro- and microarchitecture, as well as bioactivity.

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Aim Transcatheter aortic valve implantation (TAVI) is a mainstay in the management of severe aortic valve stenosis in elderly patients, but there is uncertainty on their long-term effectiveness. We aimed to assess the long-term outcome of patients undergoing TAVI with the Portico valve. Methods We retrospectively collected the data on patients in whom TAVI with Portico was attempted from 7 high-volume centres. Only patients theoretically eligible for 3 or more years of follow-up were included. Clinical outcomes, including death, stroke, myocardial infarction, reintervention for valve degeneration and hemodynamic valve performance were systematically assessed. Results A total of 803 patients were included, with 504 (62.8%) women, mean age of 82 years, median EuroSCORE II of 3.1%, and 386 (48.1%) subjects at low/moderate risk. The median follow-up was 3.0 years (3.0; 4.0). The composite of death, stroke, myocardial infarction, and reintervention for valve degeneration occurred in 37.5% (95% confidence interval: 34.1–40.9%), with all-cause death in 35.1% (31.8–38.4%), stroke in 3.4% (1.3–3.4%), myocardial infarction in 1.0% (0.3–1.5%), and reintervention for valve degeneration in 1.1% (0.6–2.1%). The mean aortic valve gradient at follow-up was 8.1 ± 4.6 mmHg, and at least moderate aortic regurgitation was present in 9.1% (6.7–12.3%). Independent predictors of major adverse events or death were: peripheral artery disease, chronic obstructive pulmonary disease, estimated glomerular filtration rate, atrial fibrillation, prior pacemaker implantation, EuroSCORE II, and reduced left ventricular ejection fraction (all p < 0.05). Conclusions Portico use is associated with favorable long-term clinical outcomes. Clinical outcomes were largely impacted by baseline risk factors and surgical risk.

Introduction: Unlike secondary mitral regurgitation (MR) in the setting of left ventricular disease, results of surgical treatment of severe atrial functional MR has remained largely unspoken. The aim of this study is to analyze short to midterm results of isolated ring annuloplasty in patients with severe atrial functional MR, in comparison with a matched cohort of patients with secondary MR. Methods: A retrospective review of our Institutional database was carried out to find all patients fulfilling strict echocardiographic criteria to define atrial functional MR. A control group of patients with MR secondary to ventricular disease was selected. All patients underwent mitral repair by means of isolated ring annuloplasty. Mortality, reoperation for severe MR, and recurrence of MR were assessed by clinical and echocardiographic follow-up. Cumulative incidence function (CIF) of recurrence of MR using death and reoperation as the competitive risk was used. Results: Twenty patients were selected for the study group and 25 for the control group. There were no differences between the two groups in terms of mortality and reoperation rate. At 2 years, the CIF of recurrence of MR ≥ 3+ and ≥ 2+ was significantly higher in patients with secondary MR compared to patients with atrial functional MR (20.8 ± 8.29% vs 5.9 ± 5.71% and 45.8 ± 10.17% vs 5.9 ± 5.71%) Conclusion: In patients with severe atrial functional MR, mitral valve repair by means of isolated ring annuloplasty seems a more effective and durable treatment as compared to patients with MR secondary to ventricular disease. Larger cohorts with longer follow up are needed to confirm these results.

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 &lt; 0.001). Both intensive care unit and hospital stays were significantly longer in more advanced stages (P &lt; 0.001). Patients in stages 4 and 5 developed more postoperative complications, such as acute kidney injury (3.7–10% in stages 2 and 3 vs 44–100% in stages 4 and 5; P &lt; 0.001) and low cardiac output syndrome (15–50% in stages 2 and 3 vs 71–100% in stages 4 and 5; P &lt; 0.001). 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.

Background: Italy has been one of the countries most affected by the SARS-CoV-2 pandemic and the regional healthcare system has had to quickly adapt its organization to meet the needs of infected patients. This has led to a drastic change in the routine management of non-communicable diseases with a potential long-term impact on patient health care. We investigated the management of non-COVID-19 patients across all medical specialties during the pandemic in Italy. Methods: A PRISMA guideline-based systematic review of the available literature was performed using PubMed, Embase, and Scopus, restricting the search to the main outbreak period in Italy (from 20 February to 22 June, 2020). We selected articles in English or Italian that detailed changes in the Italian hospital care for non-COVID-19 patients due to the pandemic. Our keywords included all medical specialties in combination with our geographical focus (Italy) and COVID-19. Findings: Of the 4643 potentially eligible studies identified by the search, 247 studies were included in the systematic review. A decrease in the management of emergencies in non-COVID patients was found together with an increase in mortality. Similarly, non-deferrable conditions met a tendency toward decreased diagnosis. All specialties have been affected by the reorganization of healthcare provision in the hub-and-spoke system and have benefited from telemedicine during the pandemic. Interpretation: Our work highlights the changes taking place in the Italian public healthcare system in order to tackle the developing health crisis due to the COVID-19 pandemic. The findings of our review may be useful to analyze future directions for the healthcare system in the case of new pandemic scenarios.

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