Background-Mitral valve (MV) repair is preferred over replacement in clinical guidelines and is an important determinant of the indication for surgery in degenerative mitral regurgitation (MR). Yet, the level of evidence supporting current recommendations is low, and recent data cast doubts on its validity in the current era. Accordingly, the aim of the present study was to analyze very long-term outcome after MV repair and replacement for degenerative MR with a flail leaflet. Methods-MIDA is a multicenter registry enrolling patients with degenerative MR with a flail leaflet in 6 tertiary European and US centers. We analyzed the outcome after MV repair (n=1,709) and replacement (n= 213), overall, by propensity score matching and by inverse probability-of-treatment weighting. Results-At baseline, patients undergoing MV repair were younger, had more comorbidities and were more likely to present with a posterior leaflet prolapse than those undergoing MV replacement. After propensity score matching as well as after inverse probability-of-treatment weighting, the 2 treatments groups were balanced and absolute standardized differences were usually below 10%, indicating adequate match. Operative mortality (defined as a death occurring within 30 days from surgery or during the same hospitalization) was lower after MV repair than after replacement, both in the entire (1.3 vs 4.7%; p<0.001) and in propensity-matched population (0.2% vs 4.4%; p<0.001). During a mean follow-up of 9.2 years, 552 deaths were observed, of which 207 were of cardiovascular origin. Twenty-year survival was better after MV repair than after MV replacement, both in the entire (46% vs 23%, p<0.001) and in matched population (41% vs 24%, p<0.001). Similar superiority of MV repair were obtained in patients' subsets based on age, sex or any stratification criteria (all p<0.001). MV repair was also associated with reduced incidence of reoperations and valve-related complications.Conclusions-Among patients with degenerative MR with a flail leaflet, referred to mitral surgery, MV repair was associated with lower operative mortality, better long-term survival and fewer valve-related complications compared to MV replacement.

AimsAlthough congestive heart failure (CHF) represents the most common cause of death in native valve infective endocarditis (IE), recent data on the outcome of IE complicated by CHF are lacking. We aimed to analyse the characteristics and prognosis of patients with left-sided native valve IE complicated by CHF and to evaluate the impact of early surgery on 1 year outcome. Methods and resultsTwo hundred and fifty-nine consecutive patients with definite left-sided native valve IE according to the Duke criteria were included in this analysis. When compared with patients without CHF (n ¼ 151), new heart murmur, high comorbidity index, aortic valve IE, and severe valve regurgitation were more frequently observed in CHF patients (n ¼ 108, 41.6%). Mitral valve IE, embolic events and neurological events were less frequent in CHF patients. Congestive heart failure was independently predictive of in-hospital [OR 3.8 (1.7 -9.0); P ¼ 0.0013] and 1 year mortality [HR 1.8 (1.1 -3.0); P ¼ 0.007]. Early surgery was performed in 46% of CHF patients with a peri-operative mortality of 10%. In the CHF group, comorbidity index, Staphylococcus aureus IE, uncontrolled infection, and major neurological events were univariate predictors of 1 year mortality. Early surgery was independently associated with improved 1 year survival ConclusionLeft-sided native valve IE complicated by CHF is more frequent in aortic IE and is associated with severe regurgitation. Congestive heart failure is an independent predictor of in-hospital and 1 year mortality. In CHF patients, early surgery is independently associated with reduced mortality and should be widely considered to improve outcome.--

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Objectives: To analyse clinical, echocardiographic, and prognostic characteristics of Staphylococcus aureus infective endocarditis (IE) compared with endocarditis caused by other pathogens. Design: Cohort study. Methods: 194 consecutive patients with definite IE according to the Duke criteria prospectively examined by transthoracic and transoesophageal echocardiography were enrolled. Patients without identified microorganisms were excluded. The S aureus IE group (n = 61) was compared with the group with IE caused by other pathogens (n = 133). Results: Compared with IE caused by other pathogens, S aureus IE was characterised by severe comorbidity, a shorter duration of symptoms before diagnosis, and a higher prevalence of right sided IE, cutaneous portal of entry, and history of renal failure. Severe sepsis, major neurological events, and multiple organ failure were more frequent during the acute phase in S aureus IE. In-hospital mortality (34% v 10%, p , 0.001) was higher in patients with S aureus IE and the 36 month actuarial survival rate was lower in S aureus IE than in IE caused by other pathogens (47% v 68%, p = 0.002). Multivariate analyses identified S aureus infection as a predictive factor for in-hospital mortality and for overall mortality. Conclusions: S aureus IE compared with IE caused by other pathogens occurs in a more debilitated clinical setting and is characterised by a higher prevalence of severe sepsis, major neurological events, and multiple organ failure leading to higher mortality.

Simple preoperative echocardiography measures allow the prediction of LV dysfunction after MVR in patients with leaflet prolapse. Patients with preoperative EF ≥ 64% and LVESD < 37 mm incur relatively low risk of post-operative LV dysfunction.