Emergent Conversion to Open Heart Surgery during Transcatheter Aortic Valve Implantation: The Presence of a Rescue Team Improves Outcomes.

OBJECTIVE: Transcatheter aortic valve implant (TAVI) is the gold standard for the high-surgical-risk group of patients with aortic valve disease and it is an alternative to surgery in patients at intermediate risk. Lethal complications can occur, and many of these are manageable only with emergent conversion to open heart surgery. We retrospectively evaluate the outcome of all patients undergoing TAVI in our departments and the impact of a complete cardiac rescue team to reduce 30-day mortality. METHODS: Data from all patients undergoing TAVI between January 2020 and August 2023 in our center were analyzed. An expert complete rescue was present in catheter laboratory. Primary outcomes were in-hospital and at 30-day mortality and evaluation of all cases needed for emergent conversion to open heart surgery. RESULTS: 825 patients were enrolled. The total mortality was 19/825 (2.3%). Eleven of the total patients (1.3%) required emergent conversion to open heart surgery. Among them, eight were alive (73%), with a theoretical decrease of 0.98% in overall mortality. CONCLUSIONS: surgical treatment is rare during TAVI. The presence of an expert complete rescue team as support means an increase in survival. Surgery must be used only to restore circulatory and to treat complication while percutaneous approaches should complete the procedure.

The influence of metabolic syndrome in heart valve intervention. A multi-centric study.

BACKGROUND: The effect of metabolic syndrome (MetS), defined as insulin resistance along with two or more of: obesity, atherogenic dyslipidaemia and elevated blood pressure, on postoperative complications after isolated heart valve intervention remains controversial. We hypothesized that MetS may negatively influence the postoperative course in these patients. METHODS: Patients from 10 cardiac units who underwent isolated valve intervention (mitral ± $\pm $ tricuspid repair/replacement (mitral valve surgery [MVS]) or surgical aortic valve replacement (SAVR), or transcatheter aortic valve replacement (TAVR) were included. MetS was defined according to the World Health Organization criteria. Primary outcome was in-hospital mortality and overall postoperative length of stay (LOS). Relevant postoperative complications were also recorded. RESULTS: From 2010 to 2019, 17,283 patients underwent valve intervention. The MVS, SVAR, and TAVR accounted for the 39.4%, 48.2%, and 12.3% respectively of the whole. MetS compared to no-MetS was associated to higher mortality in the MVS group (6.5% vs. 2%, p < .001), but not in the SAVR and TAVR group. In both surgical cohorts, MetS was associated with increased complications including red blood cells transfusion, renal failure, mechanical ventilation time, intensive care and overall postoperative LOS (11 (9) vs. 10 (6), p < .001 and 10 (6) versus 10 (5) days, p = .002, MVS and [SAVR]). No differences were found in the TAVR cohort, with similar mortality and complications. CONCLUSION: MetS was associated to more postoperative complications, with higher mortality in the MVS group. In the TAVR cohort, postoperative complications and mortality rate did not differ between patients with and without MetS, however LOS was longer in the MetS group.

Sutureless versus transcatheter aortic valve replacement: A multicenter analysis of "real-world" data.

BACKGROUND: Recent data suggested that transcatheter aortic valve replacement (TAVR) may be indicated also for low-risk patients. However, robust evidence is still lacking, particularly regarding valve performance at follow-up that confers a limitation to its use in young patients. Moreover, a literature gap exists in terms of 'real-world' data analysis. The aim of this study is to compare the cost-effectiveness of sutureless aortic valve replacement (SuAVR) versus transfemoral TAVR. METHODS: Prospectively collected data were retrieved from a centralized database of nine cardiac surgery centers between 2010 and 2018. Follow-up was completed in June 2019. A propensity score matching (PSM) analysis was performed. RESULTS: Patients in the TAVR group (n=1002) were older and with more comorbidities than SuAVR patients (n=443). The PSM analysis generated 172 pairs. No differences were recorded between groups in 30-day mortality [SuAVR vs TAVR: n=7 (4%) vs n=5 (2.9%); p=0.7] and need for pacemaker implant [n=10 (5.8%) vs n=20 (11.6%); p=0.1], but costs were lower in the SuAVR group (20486.6±4188€ vs 24181.5±3632€; p<0.01). Mean follow-up was 1304±660 days. SuAVR patients had a significantly higher probability of survival than TAVR patients (no. of fatal events: 22 vs 74; p<0.014). Median follow-up was 2231 days and 2394 days in the SuAVR and TAVR group, respectively. CONCLUSION: The treatment of aortic valve stenosis with surgical sutureless or transcatheter prostheses is safe and effective. By comparing the two approaches, patients who can undergo surgery after heart team evaluation show longer lasting results and a more favorable cost ratio.

[Single versus double antiplatelet therapy following coronary artery bypass grafting]. / Terapia antipiastrinica singola o doppia nei pazienti sottoposti a intervento di bypass aortocoronarico.

Coronary artery bypass grafting is the treatment of choice in complex obstructive coronary artery disease, particularly in diabetic patients. The long-term benefits of coronary artery bypass grafting depend on the successful execution of the anastomosis, on the appropriate choice of conduits (arterial rather than venous) but are also influenced, as for the coronary stent, by the pharmacological measures used to prevent occlusion both in the period immediately following the intervention and in the subsequent years. The use of aspirin at intermediate doses, before and after surgery, clearly improves the clinical prognosis and bypass patency but does not prevent occlusion of venous bypasses from occurring in 10-20% of cases at 1 year of follow-up and in about 50% at 10 years. The combination of aspirin with first or more recent generation thienopyridines (dual antiplatelet therapy, DAPT) has produced conflicting results in the various randomized controlled trials. However, based on the most recent meta-analyses, there seems to be reason for a wider use of DAPT for at least 6 months after surgery for patients undergoing saphenous vein revascularization with a slightly higher risk of bleeding. This strategy could serve to reduce the risk of graft thrombosis as a consequence of the pro-thrombotic and pro-inflammatory state characterizing the first postoperative weeks.

[GISE (Italian Society of Interventional Cardiology) Position paper: Short-term hospitalization for percutaneous coronary intervention; a helpful tool to manage post-COVID-19 backlogs]. / Position paper GISE (Società Italiana di Cardiologia Interventistica): Ricovero breve per la PCI in elezione, uno strumento per la "ripartenza".

Minimization of hospital lengths of stay has always been a key goal for healthcare systems. More so during the current COVID-19 pandemic. In fact, we have faced a reduction in no-COVID-19 admissions with the generation of huge backlogs. Low-risk patients undergoing elective percutaneous coronary intervention (PCI) can be candidate for short-term hospitalization, with consequent reduction of waiting lists. Several single-center and multicenter observational studies, multiple randomized trials and some meta-analyses have addressed this topic.In this position paper, we present a proposal for short hospitalization for elective PCI procedures in selected patients who present complications only exceptionally and exclusively immediately after the procedure, if the inclusion and exclusion criteria are met. Each Center can choose between admission in day surgery or one day surgery, extending hospital length of stay only for patients who present complications or who are candidate for urgent surgery. Short-term hospitalization considerably reduces costs even if, with the current model, it generally results in a parallel reduction in reimbursement. Hence, we present an actual model, already tested successfully in an Italian hospital, that warrants sustainability. This approach can then be tailored to single Centers.

Transcatheter aortic valve-in-valve post-dilatation as an overlooked risk factor of delayed coronary obstruction: a case report.

BACKGROUND: The risk of coronary obstruction during transcatheter aortic valve-in-valve replacement (VIV-TAVR) in patients deemed at high risk for surgical re-intervention is still a concerning issue. CASE SUMMARY: A 78-year-old woman with a past medical history of hypertension, chronic kidney disease, and rheumatoid arthritis was referred for a symptomatic and severely stenotic surgical Mitroflow n.21 bio-prosthesis and was subsequently recommended for a VIV procedure. Multiple anatomical risk factors for coronary occlusion required a pre-emptive coronary chimney stenting protection. The implantation of an Evolut-R 23 mm valve resulted in a gradient of 21 mmHg thus, a post-dilatation with an 18 mm balloon was performed. Both electrocardiographic and haemodynamic parameters remained excellent, however, a hazardous leaflet dislodgment became evident. Regardless, a prophylactic chimney stenting was performed because of the operator's perceived high risk of late coronary occlusion. DISCUSSION: The implantation of transcatheter valves inside failed surgically implanted aortic bio-prosthesis is broadly recognized as a safe and less-invasive alternative to repeated high-risk surgery. Although procedural success is achieved in the great majority of patients, this therapy may be jeopardized by rare but serious complications such as impending or established acute coronary occlusion. Several specific anatomical and procedural risk factors have been identified and primary coronary prevention strategies are often mandatory when they arise. Valve-in-valve post-dilation has been overlooked in its role as an additional risk factor of late coronary obstruction. Therefore, chimney stenting, performed after balloon post-dilation to prevent delayed coronary obstruction, even if the acute coronary event does not occur intra-procedurally, is strongly advisable.

Downstream or upstream administration of P2Y12 receptor blockers in non-ST elevated acute coronary syndromes: study protocol for a randomized controlled trial.

BACKGROUND: The optimal timing to administer a P2Y12 inhibitor in patients presenting with a non-ST elevation acute coronary syndrome remains a topic of debate. Pretreatment with ticagrelor before coronary anatomy is known as a widely adopted strategy. However, there is poor evidence on how this compares with administration of a P2Y12 inhibitor after defining coronary anatomy (i.e., downstream administration). Moreover, there are limited head-to-head comparisons of the two P2Y12 inhibitors-ticagrelor and prasugrel-currently recommended by the guidelines. STUDY DESIGN: DUBIUS is a phase 4, multicenter, parallel-group, double randomized study conducted in NSTE-ACS patients designed to compare a pretreatment strategy (including only ticagrelor) versus a downstream strategy (including prasugrel or ticagrelor) and to compare downstream prasugrel with downstream ticagrelor. A total of 2520 patients will be randomly assigned to pretreatment with ticagrelor or to no pretreatment. The PCI group of the downstream arm will be further randomized to receive prasugrel or ticagrelor. The two primary hypotheses are that the downstream strategy is superior to the upstream strategy and that downstream ticagrelor is non-inferior to downstream prasugrel, both measured by the incidence of a composite efficacy and safety endpoint of death from vascular causes, non-fatal MI, or non-fatal stroke, and Bleeding Academic Research Consortium (BARC) type 3, 4, and 5 bleedings. CONCLUSIONS: The DUBIUS study will provide important evidence related to the benefits and risks of pretreatment with ticagrelor compared with a strategy of no pretreatment. Moreover, the clinical impact of using downstream ticagrelor compared with downstream prasugrel will be assessed. TRIAL REGISTRATION: ClinicalTrials.gov NCT02618837 . Registered on 1 December 2015.

Timing of Oral P2Y12 Inhibitor Administration in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome.

BACKGROUND: Although oral P2Y12 inhibitors are key in the management of patients with non-ST-segment elevation acute coronary syndrome, the optimal timing of their administration is not well defined. OBJECTIVES: The purpose of this study was to compare downstream and upstream oral P2Y12 inhibitors administration strategies in patients with non-ST-segment elevation acute coronary syndrome undergoing invasive treatment. METHODS: We performed a randomized, adaptive, open-label, multicenter clinical trial. Patients were randomly assigned to receive pre-treatment with ticagrelor before angiography (upstream group) or no pre-treatment (downstream group). Patients in the downstream group undergoing percutaneous coronary intervention were further randomized to receive ticagrelor or prasugrel. The primary hypothesis was the superiority of the downstream versus the upstream strategy on the combination of efficacy and safety events (net clinical benefit). RESULTS: We randomized 1,449 patients to downstream or upstream oral P2Y12 inhibitor administration. A pre-specified stopping rule for futility at interim analysis led the trial to be stopped. The rate of the primary endpoint, a composite of death due to vascular causes; nonfatal myocardial infarction or nonfatal stroke; and Bleeding Academic Research Consortium type 3, 4, and 5 bleeding through day 30, did not differ significantly between the downstream and upstream groups (percent absolute risk reduction: -0.46; 95% repeated confidence interval: -2.90 to 1.90). These results were confirmed among patients undergoing percutaneous coronary intervention (72% of population) and regardless of the timing of coronary angiography (within or after 24 h from enrollment). CONCLUSIONS: Downstream and upstream oral P2Y12 inhibitor administration strategies were associated with low incidence of ischemic and bleeding events and minimal numeric difference of event rates between treatment groups. These findings led to premature interruption of the trial and suggest the unlikelihood of enhanced efficacy of 1 strategy over the other. (Downstream Versus Upstream Strategy for the Administration of P2Y12 Receptor Blockers In Non-ST Elevated Acute Coronary Syndromes With Initial Invasive Indication [DUBIUS]; NCT02618837).

Minimally invasive surgical versus transcatheter aortic valve replacement: A multicenter study.

OBJECTIVES: Treatment of aortic valve stenosis is evolving, indications for transcatheter approach (TAVI) have increased but also surgical valve replacement has changed with the use of minimally invasive approaches. Comparisons between TAVI and surgery have rarely been done with minimally invasive techniques (mini-SAVR) in the surgical arm. Aim of the present study is to compare mini-SAVR and TAVI in a multicenter recent cohort. METHODS: Evaluated were 2904 patients undergone mini-SAVR (2407) or TAVI (497) in 10 different centers in the period 2011-2016. The Heart Team approved treatment for complex cases. The primary outcome is the incidence of 30-day mortality following mini-SAVR and TAVI. Secondary outcomes are the occurrence of major complications following both procedures. Propensity matched comparisons was performed based on multivariable logistic regression model. RESULTS: In the overall population TAVI patients had increased surgical risk (median EuroSCORE II 3.3% vs. 1.7%, p ≤ 0.001) and 30-day mortality was higher (1.5% and 2.8% in mini-SAVR and TAVI respectively, p = 0.048). Propensity score identified 386 patients per group with similar baseline profile (median EuroSCORE II ~3.0%). There was no difference in 30-day mortality (3.4% in mini-SAVR and 2.3% in TAVI; p = 0.396) and stroke, surgical patients had more blood transfusion, kidney dysfunction and required longer ICU and hospital length of stay while TAVI patients had more permanent pace maker insertion. CONCLUSIONS: Mini-SAVR and TAVI are both safe and effective to treat aortic stenosis in elderly patients with comorbidities. A joint evaluation by the heart-team is essential to direct patients to the proper approach.

The effect of surgical versus transcatheter aortic valve replacement on endothelial function. An observational study.

BACKGROUND: The effects of surgical aortic valve replacement versus transcatheter aortic valve replacement on endothelial function are unknown. We investigated the effects of surgical and transcatheter aortic valve replacement on early and 90-day endothelial function measured by brachial flow mediated dilation and apoptotic rate in the human umbilical vein endothelial cells in patients with significant aortic stenosis, intermediate risk of surgery, and no coronary artery disease. METHODS: We conducted a prospective observational case control single-blind study at a single tertiary center. Endothelial function was measured at baseline, early post-procedure (4 days), and follow-up (90 days). A blood pressure cuff was used to elicit reactive hyperemia for measuring brachial wall shear stress and flow mediated dilation. The apoptosis rate was observed in the human umbilical vein endothelial cells after 48-h incubation with 20% serum from patients. The rate of apoptosis was assessed by determining the number of annexin V and propidium iodide positive cells by flow cytometry. RESULTS: Early post-procedure flow dilation was significant lower in the surgical group (p < 0.003). At follow-up, both groups showed incremental increases in flow mediated dilation. Surgical group apoptotic rate did not significantly change, while transcatheter apoptotic rate steadily decreased, suggesting a trend toward improved endothelial function. CONCLUSIONS: The data suggest that conventional surgical aortic valve replacement may be associated with an early and transient decrease in endothelial function, likely due to the use of cardio-pulmonary bypass.

[ANMCO/ANCE/ARCA/GICR-IACPR intersociety consensus document: long-term antiplatelet therapy in patients with coronary artery disease]. / Documento di consenso intersocietario ANMCO/ANCE/ARCA/GICR-IACPR/GISE/SICOA: La terapia antiaggregante a lungo termine nel paziente con malattia coronarica.

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor is the cornerstone of the pharmacologic management of patients with acute coronary syndrome (ACS) and/or receiving coronary stents. Long-term (>1 year) DAPT may further reduce the risk of stent thrombosis after percutaneous coronary intervention (PCI) and may decrease the occurrence of non-stent-related ischemic events in patients with ACS. Nevertheless, compared with aspirin alone, extended use of aspirin plus a P2Y12 receptor inhibitor may increase the risk of bleeding events that have been strongly linked to adverse outcomes including recurrent ischemia, repeat hospitalization, and death. Over the last years, multiple randomized clinical trials have been published comparing duration of DAPT after PCI and in ACS patients investigating either a shorter or prolonged DAPT regimen.Although current European Society of Cardiology guidelines provide backup to individualize treatment, it seems difficult to identify the ideal patient profile who could safely reduce or prolong DAPT duration in daily clinical practice. The aim of this consensus document is to review the contemporary literature on optimal DAPT duration and to guide clinicians in tailoring antiplatelet strategies in patients undergoing PCI or presenting with ACS.

Incidence and outcome of switching of oral platelet P2Y12 receptor inhibitors in patients with acute coronary syndromes undergoing percutaneous coronary intervention: the SCOPE registry.

AIMS: In patients with acute coronary syndromes (ACS) undergoing a percutaneous coronary intervention (PCI), switching of oral P2Y12 receptor inhibitors may frequently occur. We aimed to assess the current incidence of switching of oral P2Y12 receptor inhibitors and its safety in consecutive ACS patients undergoing PCI over a three-month period. METHODS AND RESULTS: The SCOPE registry was a multicentre, observational, prospective study. A total of 1,363 consecutive patients were enrolled in 39 PCI centres across Italy. Switching of oral antiplatelet therapies occurred in 2.3% in the cathlab, 3.3% at discharge and 5.1% at follow-up. The cumulative incidence of major adverse cerebrovascular events (MACE) and net adverse cerebrovascular events (NACE: a combination of MACE and bleeding events) was 1.6% and 5.6%, respectively. Among patients receiving an upgrade switching (change from old to novel P2Y12 receptor inhibitors), no ischaemic or bleeding events occurred during the whole study period. On the other hand, downgrade switching (from novel to old P2Y12 receptor inhibitors) was an independent predictor of NACE (OR 5.3; CI: 2.1-18.2; p=0.04). CONCLUSIONS: Switching of oral antiplatelet therapies is not uncommon among ACS patients undergoing PCI. Notably, switching from clopidogrel to novel P2Y12 receptor inhibitors appears safe, while a downgrade switching in early phases of ACS is associated with adverse clinical events.

[Transcatheter mitral valve repair for patients not amenable to surgical correction: epidemiology, diagnosis, equiti of access, and economic impact]. / Trattamento transcatetere dell'insufficienza mitralica per i pazienti non eleggibili all'intervento chirurgico: epidemiologia, diagnosi, equità di accesso ed impatto economico.

Mitral regurgitation is the most common valvular heart disease in western world, with moderate to severe mitral regurgitation having a deep impact on prognosis, mortality and rehospitalizations. Advanced congestive heart failure is frequently complicated by mitral regurgitation, a pathologic condition that is often under-diagnosed. A significant proportion of patients with severe mitral regurgitation is not eligible for surgery (mitral valve repair or replacement) because of contraindications or excessive surgical risk. Therefore, the need for a less invasive treatment has led to the development of endovascular techniques; among them the MitraClip system, which mimics Alfieri's edge-to-edge surgical technique introduced in 2003, has gained widespread acceptance. More than 35 000 patients have been treated using this technique. Evidence from clinical studies suggests that the MitraClip system is effective in improving survival and quality of life in patients with severe mitral regurgitation, also reducing rehospitalization rates with substantial social and economic advantages. At present, in Italy, undertreatment of patients with severe mitral regurgitation not amenable to surgical correction is still significantly high, and remarkable inhomogeneity among regions is observed in the availability of the MitraClip procedure.

[SICI-GISE Position paper: Use of Absorb BVS in clinical practice]. / Documento di posizione SICI-GISE: Utilizzo di Absorb BVS nella pratica clinica.

Drug-eluting stents (DES) are the current gold standard for percutaneous treatment of coronary artery disease. However, DES are associated with a non-negligible risk of long-term adverse events related to persistence of foreign material in the coronary artery wall. In addition, DES implantation causes permanent caging of the native vessel, thus impairing normal vasomotricity and the possibility of using non-invasive coronary imaging or preforming subsequent bypass surgery. On the contrary, coronary bioresorbable stents (BRS) may provide temporary mechanical support to coronary wall without compromising the subsequent recovery of normal vascular physiology, and have the potential to prevent late adverse events related to permanent elements. Several types of BRS have been introduced into clinical practice in Europe or are being tested. However, most of available clinical data relate to a single BRS, the Absorb bioresorbable Vascular Scaffold (Absorb BVS) (Abbott Vascular, Santa Clara, CA). Despite encouraging clinical results, no societal guidelines are available on the use of BRS in clinical practice.A panel of Italian expert cardiologists assembled under the auspices of the Italian Society of Interventional Cardiology (SICI-GISE) for comprehensive discussion and consensus development, with the aim to provide recommendations on the use of bioresorbable stents in terms of clinical indications, procedural aspects, post-percutaneous coronary angioplasty pharmacologic treatment and follow-up. Based on current evidence and BRS availability in Italian cath-labs, the panel decided unanimously to provide specific recommendations for the Absorb BVS device. These recommendations do not necessarily extend to other BRS, unless specified, although significant overlap may exist with Absorb BVS, particularly in terms of clinical rationale.

A randomized multicenter study comparing a paclitaxel drug-eluting balloon with a paclitaxel-eluting stent in small coronary vessels: the BELLO (Balloon Elution and Late Loss Optimization) study.

OBJECTIVES: The aim of this study was to evaluate the efficacy of drug-eluting balloons (DEB) compared with paclitaxel-eluting stents (PES) for the reduction of restenosis in small vessels. BACKGROUND: DEB have been shown to be effective in the treatment of coronary in-stent restenosis, but data are limited regarding their efficacy in de novo disease. METHODS: BELLO (Balloon Elution and Late Loss Optimization) is a prospective, multicenter trial that randomized 182 patients with lesions located in small vessels (reference diameter <2.8 mm) to treatment with paclitaxel DEB and provisional bare-metal stenting (n = 90) or PES implantation (n = 92). The primary endpoint was noninferiority of angiographic in-stent (in-balloon) late loss with a delta of 0.25 mm. Secondary endpoints were angiographic restenosis, target lesion revascularization, and major adverse cardiac events (MACE; death, myocardial infarction, target vessel revascularization) at 6 months. RESULTS: Baseline characteristics were well matched, except for a smaller vessel size in the DEB group (2.15 ± 0.27 mm vs. 2.25 ± 0.24 mm; p = 0.003). The majority (89%) of lesions involved vessels with a diameter <2.5 mm. Bailout stenting was required in 20% of lesions in the DEB group. The primary endpoint of in-stent (in-balloon) late loss was significantly less with DEB compared with PES (0.08 ± 0.38 mm vs. 0.29 ± 0.44 mm; difference -0.21; 95% CI: -0.34 to -0.09; p(noninferiority) < 0.001; p(superiority) = 0.001). At 6 months, DEB and PES were associated with similar rates of angiographic restenosis (10% vs. 14.6%; p = 0.35), [corrected] target lesion revascularization (4.4% vs. 7.6%; p = 0.37), and MACE (10% vs. 16.3%; p = 0.21). [corrected]. CONCLUSIONS: Treatment of small-vessel disease with a paclitaxel DEB was associated with less angiographic late loss and similar rates of restenosis and revascularization as a PES. (Balloon Elution and Late Loss Optimization [BELLO]; Study NCT01086579).

Short-term and long-term results of cardiac surgery in elderly and very elderly patients.

OBJECTIVE: Cardiac operations in elderly patients are increasingly frequent and imply major clinical, ethical, and economic issues. Operative and 5-year results of cardiac operations in patients aged 79 years or more are known in limited series, and a debate is ongoing on the appropriateness of selection of patients for surgery. METHODS: We retrospectively reviewed our experience in 6802 patients aged 79 years or more who had received a cardiac operation. Surgical candidates were selected according to functional status, crude operative risk, and social context and were managed according to a multimodality protocol. RESULTS: Mean age was 82 years and surgery was nonelective in 1613 cases (23.5%, 31 salvage). Procedures consisted of valve replacement (aortic, 2817; mitral, 532; and tricuspid, 2 cases), valve repair (aortic, 66; mitral, 532; and tricuspid, 232 cases), coronary bypass grafting (12,034 coronary vessels bypassed), and replacement of the thoracic aorta (ascending, 315; arch, 28 cases). Overall operative mortality was 3.4%. Nonelective presentation, need for aortic counterpulsation, cardiopulmonary bypass time, blood transfusion, depressed systolic function, and chronic lung disease predicted operative mortality. Five-year cumulative mortality was 7.5%. Poor systolic function, previous myocardial infarction, and combined coronary/mitral surgery predicted late mortality. The operative risk of nonagenarians operated on electively did not differ from that of risk-matched octogenarians. CONCLUSIONS: Cardiac surgery in elderly and very elderly patients can be performed with acceptable mortality provided that accurate selection and a multifactorial risk evaluation are adopted. Whenever possible, nonelective operations should be avoided and earlier surgery should be encouraged. Five-year survival and functional recovery are good.