Secondary (or functional) mitral regurgitation (SMR) occurs frequently in chronic heart failure (HF) with reduced left ventricular (LV) ejection fraction, resulting from LV remodelling that prevents coaptation of the valve leaflets. Secondary mitral regurgitation contributes to progression of the symptoms and signs of HF and confers worse prognosis. The management of HF patients with SMR is complex and requires timely referral to a multidisciplinary Heart Team. Optimization of pharmacological and device therapy according to guideline recommendations is crucial. Further management requires careful clinical and imaging assessment, addressing the anatomical and functional features of the mitral valve and left ventricle, overall HF status, and relevant comorbidities. Evidence concerning surgical correction of SMR is sparse and it is doubtful whether this approach improves prognosis. Transcatheter repair has emerged as a promising alternative, but the conflicting results of current randomized trials require careful interpretation. This collaborative position statement, developed by four key associations of the European Society of Cardiology—the Heart Failure Association (HFA), European Association of Percutaneous Cardiovascular Interventions (EAPCI), European Association of Cardiovascular Imaging (EACVI), and European Heart Rhythm Association (EHRA)—presents an updated practical approach to the evaluation and management of patients with HF and SMR based upon a Heart Team approach.

The edge-to-edge (E-to-E) technique was introduced in the early 1990s and has provided a useful contribution to the surgical armamentarium of mitral valve repair. The free edges of the mitral leaflets have to be approximated in correspondence of the site of the regurgitant jet in such a way that mitral regurgitation is corrected without producing stenosis. A prosthetic ring is usually implanted to stabilize the repair. Middle- and long-term surgical results are now available. Appropriate indications and awareness of the important technical aspects of the procedure are prerequisites for a good outcome. In this review the present role of the E-to-E repair, the relevant technical aspects of the procedure, and some controversial issues will be outlined and discussed.

Systolic anterior motion (SAM) is a well-recognized complication of mitral reconstructive surgery [1]. SAM refers to the dynamic anterior movement of the mitral valve (MV) towards the interventricular septum during systole creating a left ventricular outflow tract (LVOT) obstruction almost invariably associated with residual mitral regurgitation (MR).

The elderly undergo cardiac surgery more and more frequently, often present multiple comorbidities, assume chronic therapies, and present a unique physiology. Aim of our study was to analyze the experience of a referral cardiac surgery center with all types of cardiac surgery interventions performed in patients ≥80 years old over a six years’ period. A retrospective observational study performed in a university hospital. 260 patients were included in the study (3.5% of the patients undergoing cardiac surgery in the study period). Mean age was 82 ± 1.8 years. Eighty-five percent of patients underwent elective surgery, 15% unplanned surgery and 4.2% redo surgery. Intervention for aortic valve pathology and coronary artery bypass grafting were performed in 51% and 46% of the patients, respectively. Interventions involving the mitral valve were the 26% of the total, those on the tricuspid valve were 13% and those on the ascending aortic arch the 9.6%. Postoperative low output syndrome was identified in 44 patients (17%). Mortality was 3.9% and most of the patients (91%) were discharged from hospital in good clinical conditions. Hospital mortality was lower in planned vs unplanned surgery: 3.8% vs 14% respectively. Chronic obstructive pulmonary disease (OR 9.106, CI 2.275 – 36.450) was the unique independent predictor of mortality. Clinicians should be aware that cardiac surgery can be safely performed at all ages, that risk stratification is mandatory and that hemodynamic treatment to avoid complications is expected.

The mitral valve was approached through a vertical transeptal incision extended into the roof of the left atrium in 111 patients. Good exposure was invariably provided even in unfavorable situations such as a small left atrium combined with right ventricular hypertrophy or a previously implanted aortic prosthesis. The only hospital death in the entire series was not related to this approach to the mitral valve. Due to breakage of the suture in the roof of the left atrium and to incomplete reconstruction of the atrial septum resulting in a large left-to-right shunt, 2 patients required reinstitution of cardiopulmonary bypass. Both had a smooth postoperative course. Other intra- or postoperative complications related to the incision did not occur. Duration of cardiopulmonary bypass and aortic occlusion was not significantly different from that of patients operated upon through the conventional left atrial approach in the year preceding the experience embraced by this study. Only 3 of 52 patients who were preoperatively in sinus rhythm were discharged in atrial fibrillation. Enhanced atrial vulnerability was demonstrated preoperatively in all 3. These data support a wide application of the extended vertical transeptal approach in mitral valve surgery.