Heart surgery for immigrants in Italy

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CE: Tripti; JCM-D-14-00422; Total nos of Pages: 8;

JCM-D-14-00422

Original article

Heart surgery for immigrants in Italy: burden ofcardiovascular disease, adherence to treatmentand outcomesAntonio Grimaldi, Anna Chiara Vermi, Valeria Cammalleri,Alessandro Castiglioni, Federico Pappalardo, Maurizio Taramasso,Francesca Baratto and Ottavio Alfieri

Aim Italy is a country with high rates of immigration and the

knowledge of immigrant health is very fragmentary. We

provide a current picture of cardiovascular disease causes

and clinical outcomes following heart surgery.

Methods A clinical and echocardiographic survey was

conducted on 154 consecutive immigrants referred for

heart surgery to San Raffaele Hospital in Milan between

2003 and 2011.

Results Major causes of heart disease were rheumatic

heart disease (RHD) (n U 64, 41%), nonrheumatic

valvulopathies (n U 41, 27%), ischemic heart disease (IHD)

(n U 25, 16%), congenital heart disease (n U 13, 9%) and

miscellaneous (n U 11, 7%). Median age was 49 years

[interquartile range (IQR) 7–81]; 55% of patients were male.

Among valvulopathies, rheumatic mitral disease was

predominant (n U 56, 53%) as both single and multivalvular

disease (n U 46, 73%); myxomatous prolapse emerged as

the second main pattern of mitral disease (n U 30, 33%).

Among patients with IHD, 72% had a high cardiovascular

risk. Surgery was scheduled in 138 patients (90%).

Clinical follow-up was available in 96 patients (62%)

[median time 62 months (IQR 15–123)], among whom 92

opyright © Italian Federation of Cardiology. Una

1558-2027 � 2014 Italian Federation of Cardiology

(96%) were alive, four patients (4%) had died and 58 (38%)

were lost.

Conclusion Cardiovascular diseases represent a major

health topic among immigrants in developed countries.

RHD still is the predominant cause of hospitalization for

heart surgery, nonrheumatic valvulopathies and IHD

emerging as second and third causes, respectively. Data

underline the need of reinforcement of prevention and care

strategies in the matter of immigrant health and warrant the

urgent attention of the international public health and

research communities.

J Cardiovasc Med 2014, 15:000–000

Keywords: heart surgery, immigration and health, rheumatic heart disease,valvular heart disease

Cardiovascular and Thoracic Department, San Raffaele Scientific Institute andUniversita Vita-Salute, Milan, Italy

Correspondence to Antonio Grimaldi, Cardiovascular and Thoracic Department,San Raffaele Scientific Institute, via Olgettina 60, 20132 Milan, ItalyTel: +390226437124; e-mail: [email protected]

Received 24 July 2014 Revised 10 September 2014Accepted 16 September 2014

IntroductionMovement of people between countries has become an

essential part of contemporary society and approximately

175 million people, up to 2.9% of the world’s population,

currently live outside their countries of origin, spurred by

poverty, political and social conflicts (http://publication-

s.iom.int/bookstore/free/WMR_2003.pdf). The widening

economic gap between the European Union and other

regions continues to prompt people to move elsewhere

and the need for more data on immigrants’ health has

definitely been recognized by the WHO.1 Italy is no

exception to this and the movement in and around the

country is unlikely to diminish in the foreseeable future

(http://www.istat.it/en/archive/40658). Cardiovascular

diseases (CVDs) account for the largest proportion of

all-cause mortality and up to 48% of all deaths in Europe,2

but estimating CVDs in immigrants is complicated and

should take into consideration net migration, morbidity

and ethnic identity. Mass population movements fre-

quently produce a mishmash between the diseases

inherently linked to the native country [e.g. rheumatic

heart disease (RHD), and other communicable diseases]

and acquired risk factors (e.g. smoking, alcohol abuse,

obesity).3–5 The population-based study aimed to pro-

vide a current picture of major heart diseases in immi-

grants referred for heart surgery to a tertiary care centre.

Ethnic provenance, noncommunicable risk factors,

adherence to treatment and outcomes are the major

issues addressed in a community in epidemiologic transi-

tion.

Materials and methodsStudy cohortWe prospectively analysed the demographic and

clinical characteristics of 159 consecutive indivi-

duals [median age 48 years, interquartile range (IQR)

7–81 years; male/female ratio ¼ 1,1)] referred for heart

disease to the Department of Cardiac Surgery of San

Raphael Hospital (Milan, Italy) between 2003 and 2011.

Patients were systematically evaluated by clinical and

uthorized reproduction of this article is prohibited.

DOI:10.2459/JCM.0000000000000228

mailto:[email protected]

http://publications.iom.int/bookstore/free/WMR_2003.pdf

http://publications.iom.int/bookstore/free/WMR_2003.pdf

http://www.istat.it/en/archive/40658

http://dx.doi.org/10.2459/JCM.0000000000000228

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JCM-D-14-00422

2 Journal of Cardiovascular Medicine 2014, Vol 00 No 00

echocardiographic examination based on transthoracic

echocardiography (TTE) and transoesophageal echocar-

diography (TEE). Among the 159 individuals, 154 (97%)

presented with clinical symptoms related to structural

heart disease and constituted the study cohort (Fig. 1).

Clinical assessmentRHD was diagnosed on the basis of medical history of

acute rheumatic fever, clinical evaluation and echocar-

diographic features according to WHO/WHF guidelines

(http://whqlibdoc.who.int/trs/WHO_TRS_923.pdf).6

Single and multiple valve diseases were quantified

according to EAE/ASE criteria7; patients with trivial

mitral regurgitation and no structural valve changes were

excluded. TTE and TEE were performed in all patients

aimed to assess the degree of valvular regurgitations and

other associated valvulopathies; valve area planimetry;

left ventricular dimensions and ejection fraction and right

ventricular systolic function; suitability for repair surgery;

and to rule out embolic sources in patients with atrial

fibrillation.

Statistical analysisWe performed descriptive statistics for the more fre-

quently observed heart diseases and the results are

pyright © Italian Federation of Cardiology. Unau

Fig. 1

Patientsstructura

diseaN = 1

RHDN = 64

Nonrheumaticvalvulopathies

N = 41N

Surgery pe

YesN = 138

Lost to FUN = 50 (36%)

Mortality at FUN = 4 (5%)

Alive to FUN = 84 (100% NYHA 1/2)

Flow chart, surgical treatment and outcomes in the overall study population

reported as median and IQR, or as numbers and percen-

tages, as appropriate.

ResultsAll causes of heart disease in the whole studypopulationThe clinical and echocardiographic characteristics of

patients are depicted in Table 1. The study group con-

stitutes a cohort of 154 patients; the median age was

49 years (IQR 7–81) and 85 patients (55%) were male. All

patients were symptomatic [New York Heart Association

(NYHA)¼ 2.3� 0.7; class II¼ 60%; class III/IV¼ 40%]

under optimized medical treatment and 25 patients

(16%) were in permanent atrial fibrillation at the time

of admission. The ethnic provenance included 61

Eastern Europeans (40%), 51 black Africans (33%), 19

Asians (12%), 19 Latin Americans (12%) and four Middle

Easterners (3%); all immigrants lived in urban and sub-

urban areas of Milan in Lombardy and were regularly

registered with the Italian NHS. A previous heart surgery

was reported in 25 patients (16%) and included mitral

(n¼ 8, 32%) and aortic valve replacement (n¼ 4, 16%),

mitral commissurotomy (n¼ 6, 24%), atrial septal

defect(s) (ASD) closure (n¼ 4, 16%), tricuspid annulo-

plasty (n¼ 2, 8%) and surgery for ascending aortic disease

(n¼ 1, 4%).

thorized reproduction of this article is prohibited.

with l heartse54

IHD = 25

CHDN = 13

VariousN = 11

rformed

NoN = 16

Lost to FUN = 8 (50%)

Mortality at FUN = 0

Alive to FUN = 8 (88% NYHA 1/2)

.

http://whqlibdoc.who.int/trs/WHO_TRS_923.pdf

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JCM-D-14-00422

Heart surgery in immigrants Grimaldi et al. 3

Table 1 Clinical and echocardiographic characteristics of 154 patients with structural heart disease

Main cause of heart disease RHD Nonrheumatic valvulpathies IHD CHD Various Total

No. of cases (%) 64 (41) 41 (27) 25 (16) 13 (9) 11 (7) 154 (100)Age (years) median (IQR) 44 (7–68) 52 (10–81) 57 (36–77) 43 (8–63) 43 (30–69) 49 (7–81)Male sex, n (%) 26 (40) 23 (56) 23 (92) 6 (46) 7 (64) 85 (55)Ethnic provenance, n (%)

Eastern Europe 19 (30) 20 (49) 10 (40) 6 (46) 6 (54) 61 (40)Africa (north/sub-Saharian) 28 (44) 12 (29) 7 (28) 2 (15) 2 (18) 51 (33)Central/South America 11 (17) 2 (5) 2 (8) 3 (23) 1 (9) 19 (12)Asia 6 (9) 6 (15) 6 (24) 0 (0) 1 (9) 19 (12)Middle East 0 (0) 1 (2) 0 (0) 2 (15) 1 (9) 4 (3)

CVD risk factors, n (%)Hypertension 12 (19) 13 (32) 20 (80) 7 (54) 2 (18) 54 (35)Hypercholesterolaemia 10 (16) 11 (27) 20 (80) 3 (23) 3 (27) 47 (31)Type 2 diabetes 3 (5) 1 (2) 11 (44) 1 (8) 1 (9) 17 (11)Smoking 6 (9) 6 (15) 7 (28) 1 (8) 3 (27) 23 (15)Overweight 9 (14) 18 (44) 12 (48) 1 (8) 4 (36) 44 (29)

NYHA (mean�SD) 2.6�0.7 2.2�0.7 2.2�0.6 1.8�0.5 2.4�0.9 2.3�0.7LV systolic dysfunction, n (%) 17 (26) 10 (24) 12 (48) 1 (8) 6 (54) 46 (30)LVEF % median (IQR) 60 (25–66) 60 (20–70) 50 (20–64) 60 (55–70) 50 (25–70) 60 (20–70)LV dilatation

�, n (%) 28 (44) 21 (51) 12 (48) 1 (8) 3 (27) 65 (42)

LA dilatation��

, n (%) 62 (97) 38 (93) 23 (92) 11 (85) 11 (100) 145 (94)AF 22 (34) 0 (0) 1 (4) 0 (0) 2 (18) 25 (16)Moderate-to-severe MR, n (%) 33 (51) 32 (78) 8 (32) 1 (8) 4 (36) 78 (51)PH, n (%)

��52 (81) 22 (54) 11 (44) 4 (31) 5 (45) 94 (61)

Moderate-to-severe RV dysfunction, n (%) 11 (17) 4 (10) 2 (8) 2 (15) 5 (45) 23 (16)Coronary artery disease, n (%) 1 (1) 8 (20) 25 (100) 0 (0) 2 (18) 36 (23)Surgical treatment 54 (35) 39 (25) 24 (16) 12 (8) 9 (6) 138 (90)

Valve surgery 54 (100) 37 (95) 5 (21) 9 (75) 3 (33) 108 (70)CABG 1 (2) 6 (15) 21 (88) 0 (0) 1 (11) 29 (19)Complex aorta surgery 0 (0) 2 (5) 0 (0) 7 (58) 0 (0) 9 (6)Others 0 (0) 3 (8) 3 (13) 6 (50) 6 (67) 18 (12)

AF, atrial fibrillation; CABG, coronary artery bypass graft; CHD, congenital heart disease; CVD, cardiovascular disease; IHD, ischemic heart disease; IQR, interquartilerange; LA, left atrium; LV, left ventricular; LVEF, left ventricular ejection fraction; MR, mitral regurgitation; MVD, multivalvular disease; PH, pulmonary hypertension; RHD,rheumatic heart disease; RV, right ventricular; SVD, single-vessel disease.

�end-diastolic diameter >55 mm.

��volume >40 ml.

��systolic pulmonary artery pressure

>35mmHg.

The predominant heart disease was RHD (n¼ 64; 41%)

(Fig. 2), mainly related to mitral regurgitation, either

isolated or associated with multiple valve disease. Other

main causes were nonrheumatic valvulopathies (NRVs)

(n¼ 41; 27%), ischemic heart disease (IHD) (n¼ 25;

16%), congenital heart disease (CHD) (n¼ 13, 9%) and

other cardiac disease (n¼ 11; 7%) mostly represented by

cardiomyopathies. Regarding the prevalence of disease


Fig. 2

7%

9%

16%

27%

Main causes of heart disease in the study population.

according to the ethnic background, RHD was prevalent

in black Africans (n¼ 28, 44%), while NRV (n¼ 20, 49%)

and IHD (n¼ 10, 40%) mostly affected Eastern European

immigrants, respectively. Cardiovascular risk factors such

as systemic hypertension (n¼ 54, 35%), hypercholester-

olaemia (n¼ 47, 31%), obesity (n¼ 44, 29%), smoking

(n¼ 23, 15%) and type 2 diabetes (n¼ 17, 11%) were all

represented in the study population. The prevalence of


41%

RHD

Nonrheumatic valvulopathies

IHD

CHD

Various

All causes of heart disease(n = 154)

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JCM-D-14-00422


coronary artery disease (CAD) in the overall population

study (n¼ 36, 23%) was higher than that from the single

IHD group, as 11 additional patients (17%) had subcli-

nical CAD at preoperative angiography. Left ventricular

ejection fraction (LVEF) was reduced in 46 cases (30%);

moderate-to-severe right ventricular dysfunction was

found in 23 (15%) cases.

Rheumatic heart diseaseRHD (n¼ 64) was the main cause of hospitalization for

heart surgery. The median age of patients was 44 years

(IQR 7–68) with a female/male ratio of 1.5/1. The

distinctive valvular patterns of RHD are depicted in

Table 2. Multivalvular disease (MVD) was prevalent

(n¼ 46, 72%) and mitral involvement was preferably

associated with tricuspid and aortic valve disease

(n¼ 24/46, 52%); two patients were affected by rheumatic

involvement of four valves (n¼ 2, 4%). Single valve

disease (SVD) (n¼ 17, 26%) affected the mitral valve

(n¼ 10/17, 59%) and the aortic valve (n¼ 7/17, 41%) with

a higher prevalence in female in both groups (MVD

n¼ 26; 26/46¼ 57%, SVD n¼ 12; 12/17¼ 70%). The


Table 2 Clinical and echocardiographic characteristics of patientswith rheumatic and nonrheumatic valvulopathies

Main cause of heartdisease RHD

Nonrheumaticvalvulopathies

No. of cases (%) 64 (41) 41 (27)Age (years) median (IQR) 44 (7–68) 52 (10–81)Male sex (M), n (%) 26 (40) 23 (56)SVD, n (%) 18 (28) 24 (59)MVD, n (%) 46 (72) 17 (41)Mitral valve disease, n (%) 56 (88) 35 (85)

MS 8 (14) 0 (0)MR 15 (27) 35 (100)Combined 34 (61) 0 (0)Valve prolapse 7 (13) 30 (86)Ruptured cordae 3 (5) 12 (34)Infective endocarditis 2 (4) 4 (11)Prosthesis dysfunction 8 (14) 0 (0)

Aortic valve disease, n (%) 40 (63) 12 (29)AS 1 (3) 0 (0)AR 26 (67) 6 (50)Combined 13 (33) 6 (50)Infective endocarditis 0 (0) 1 (8)Prosthesis dysfunction 4 (10) 0 (0)Ascending aorta dilatation 4 (10) 6 (50)

Tricuspid valve disease, n (%) 37 (58) 13 (32)Annular dilatation 36 (97) 10 (77)Leaflet thickening/fibrosis 11 (30) 2 (15)Valve prolapse 0 (0) 3 (23)Infective endocarditis 0 (0) 2 (15)

LA dilatation�

(ml, mean�SD) 110�52 78�24Atrial thrombi, n (%) 8 (12,5) 1 (2)Coronary artery disease, n (%) 1 (1) 8 (20)sPAP (mean�SD) 52�16 38�7Surgical treatment 54 (35) 39 (25)

Valve replacement 49 (91) 12 (31)Valve repair 5 (9) 25 (64)AF ablation 15 (28) 0 (0)Redo operation 6 (11) 1 (3)CABG 1 (2) 6 (15)Ascending aorta surgery 0 (0) 2 (5)Others 0 (0) 3 (8)

AF, atrial fibrillation; AR, aortic regurgitation; AS, aortic stenosis; IHD, ischemicheart disease; IQR, interquartile range; MVD, multivalvular disease; RHD, rheu-matic heart disease; sPAP, systolic pulmonary artery pressure; SVD, single-vesseldisease.

�volume >40 ml.

mitral valve was affected in 57 patients (89%) and mitral

regurgitation was the most common lesion (49/64 cases,

77%). Mitral stenosis was severe in 21 patients (33%) and

combined disease (MS-MR) affected 34 patients (61%).

Interestingly, 13% of rheumatic mitral valves also showed

an associated myxomatous valve prolapse. We observed

different patterns of rheumatic mitral regurgitation: sym-

metrical leaflet restriction with annular dilatation;

posterior leaflet restriction and anterior leaflet pseudo-

prolapse; and leaflet restriction associated with commis-

sural fusion and valve stenosis. Calcified lesions were

deemed not suitable for surgical repair.

Pulmonary hypertension (i.e. pulmonary artery systolic

pressures >35 mmHg) was present in 58 patients [81%;

median 50 (30–100 mmHg)] and moderate-to-severe right

ventricular dysfunction in 11 patients (17%). Moderate-to-

severe tricuspid regurgitation, mostly due to functional

annular dilatation, was present in 28 patients (44%).

Nonrheumatic valvulopathiesNRV (n¼ 41) was the second referring cause for heart

surgery in the population study. The median age of

patients was 52 years (IQR 10–81) with a male/female

ratio of 1.3/1. Mitral regurgitation was the most common

lesion observed (n¼ 35/41, 85%) (Table 2) and the

degree of mitral regurgitation was often severe (n¼ 32/

41, 78%). Among mitral valve disease, mitral regurgita-

tion was mostly related to myxomatous prolapse (n¼ 30,

86%) with associated ruptured chordae tendinae in 12

individuals (34%). Overall, among all (rheumatic and

nonrheumatic) valvulopathies, myxomatous prolapse

emerged as the second main pattern of mitral disease

(n¼ 30/91, 33%) following rheumatic mitral regurgitation

(n¼ 49/91, 54%).

Aortic valve disease (n¼ 12, 29%) was prevalent as aortic

insufficiency (n¼ 6, 50%) or combined disease (n¼ 6,

50%). Isolated Aortic Regurgitation was related to

intrinsic valve disease (n¼ 3) or functional involvement

secondary to aortic root disease (two hypertensive indi-

viduals and one with Takayasu’s arteritis). One out the

patients affected by severe calcified aortic stenosis (AS)

(n 4/12, 33%) also had severe porcelain aorta deemed not

suitable for opern heart surgery. Infective endocarditis

affected 17% of nonrheumatic mitral valves.

Ischemic heart diseaseIHD presenting with coronary syndromes affected 16%

(n¼ 25) of patients in the survey. The clinical profile is

depicted in Table 3. The median age of patients was

57 years (IQR 36–77) with a male/female ratio of 11.5/1.

Chest pain (80%) and shortness of breath (20%) were the

main symptoms at the time of admission to hospital.

Overall, a high cardiovascular risk profile (more than

two risk factors) was observed in 72% of patients.

Cigarette smoking was reported in 28% of patients,

and high blood pressure, dyslipidemia, obesity and


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JCM-D-14-00422


Table 3 Cardiovascular risk factors and clinical profile ofimmigrants with ischemic heart disease

CVD risk factors IHD

No. of cases (%) 25 (16)Age (years) median (IQR) 57 (36–77)Male sex (M), n (%) 23 (92)Multiple risk factors (>2 of the following), n (%) 18 (72)

Hypertension 20 (80)Hypercholesterolaemia 16 (64)Type 2 diabetes 8 (32)Smoking 9 (36)Overweight/obesity 12 (48)

History of IHD, n (%) 10 (40)Previous coronary intervention, n (%) 4 (16)Reason for referral, n (%)

Chest pain 20 (80)SOB 5 (20)

Echocardiographic patterns, n (%)No WMA 8 (32)WMA (hypokinesis/akinesis) 17 (68)LV aneurysm 4 (16)

LA size (mean�SD) 65�15LV dimension (mean�SD) 55�7EF, n (mean�SD) 49�12sPAP (mmHg) (mean�SD) 36�6Angiographic patterns of CAD, n (%)

Single-vessel disease 3 (12)Double-vessel disease 5 (20)Multivessel disease (�3 coronary arteries) 17 (68)a

Valvular heart disease associated with coronary Sdrs 6 (24)Severe AS 4 (67)Severe MR 2 (33)

Treatment options, n (%) 24 (96)CABG alone 13 (54)CABG and LV aneurysmectomy 3 (13)CABG and valvular surgery 5 (21)PTCA 3 (13)TAVI 1 (4)

AS, aortic stenosis; CABG, coronary artery bypass graft (or grafting); CAD,coronary artery disease; CVD, cardiovascular disease; IHD, ischemic heart dis-ease; IQR, interquartile range; LA, left atrium; LV, left ventricular; MR, mitralregurgitation; PTCA, percutaneous transluminal coronary angioplasty; SOB, short-ness of breath; sPAP, systolic pulmonary artery pressure; TAVI, transcatheteraortic valve implanation; WMA, wall motion abnormality; a Included two patientswith 4-vessel coronary artery disease.

type 2 diabetes affected 80, 80, 48 and 44% of patients,

respectively. All patients suffered from CAD in the

following proportion: 68% with severe multivessel dis-

ease, 20% with double-vessel disease and 12% with

single-vessel disease. Six patients (24%) were found to

be also affected by severe valvular disease (four patients

with severe calcified AS and two with ischemic mitral

regurgitation). Subclinical CAD (n¼ 8, 20%) also affected

four patients (50%) with degenerative mitral disease, two

patients (25%) with aortic valve disease, one (13%) with

Takayasu’s arteritis and one (13%) with tricuspid valve

infective endocarditis. Regarding the angiographic

patterns of CAD in the overall population (including

patients with subclinical CAD), 56% of patients had

severe multivessel disease, 22% had double-vessel disease

and 22% had single-vessel disease.

Congenital heart diseaseCHD (n¼ 13) affected 9% of the study population

(Table 1). The median age of patients was 43 years

(IQR 8–63) with a female/male ratio of 1.2/1. Briefly,

six patients (46%) suffered from valvular heart disease


related to bicuspid aortic valve and associated ascen-

ding aorta aneurysm (n¼ 4/6, 67%) or aortic coartaction

(n¼ 2/6, 33%); five patients had type II ASDs (including

one patient with associated severe pulmonic stenosis),

one patient (8%) had a ventricular septal defect(s) with

associated aortic regurgitation and one patient (8%) had

aortic insufficiency in dysplastic valve and supravalvular

stenosis.

Other diseasesOther cardiac diseases (n¼ 11, 7%) were mostly

represented by eight cases of cardiomyopathies (73%),

one case of constrictive pericarditis (9%), one case of

pulmonary hypertension related to sarcoidosis (9%)

and one case of penetrating cardiac trauma caused by

stab (9%). Median age was 43 years (IQR 30–69) with a

male/female ratio of 1.7/1. Among cardiomyopathies,

four patients (36%) had obstructive hypertrophic cardio-

myopathy (including one patient with associated CAD),

two patients (18%) had secondary CMP related to CAD

and valvular heart disease, respectively, and two patients

(9%) had primary CMP (including one case of with

peripartum cardiomyopathy).

Treatment optionsAmong the study population, 138 patients (90%) with an

indication of heart surgery were deemed fit for interven-

tion and 16 patients (10%) underwent clinical follow-up

(including one patient with severe mitral valve disease

who refused the intervention) (Fig. 1). Surgery was

scheduled in 54 patients with RHD (n¼ 54/138, 39%),

in 39 patients with NRVs (n¼ 39/138, 28%), in 24 patients

with IHD (n¼ 24/138, 17%), in 12 patients with CHD

(n¼ 12/138, 9%) and in nine patients with various dis-

eases (n¼ 9/138, 6%). Treatment options included valv-

ular surgery in 108 patients (n¼ 108/138, 78%), Coronary

Artery Bypass Graft (CABG) in 29 patients (n¼ 29/138,

21%), surgery of ascending aortic disease in nine patients

(n¼ 9/138, 6%) and various interventions in 18 patients

(n¼ 18/138, 13%) (including septal miectomy in five

patients and surgical correction of congenital defects in

six patients).

Clinical follow-up and outcomesData concerning main outcomes measures and surgical

follow-up are depicted in Fig. 1. Clinical follow-up was

available in 96 patients (62%) [median time 62 months

(IQR 15–123)], among whom 92 patients (96%) survived

during the study period and four patients (4%) had died.

The mortality rate among patients who did undergo

surgery included one perioperative death during redo

operation for tetralogy of Fallot and three late postopera-

tive deaths (one mitral prosthesis thrombosis and two

patients with severe CAD and heart failure). Fifty-eight

patients (38%) were lost to follow-up due to logistical

difficulties (i.e. incorrect phone numbers, transfer to

other countries). All patients (n¼ 84) who had undergone

cardiac surgery reverted to NYHA class I/II; patients who


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JCM-D-14-00422


did not undergo surgery (n¼ 8) did not report significant

clinical deterioration during the study period.

DiscussionImmigration will be the driving force in accounting for

the future growth of the European Union countries where

there is a growing interest in improving the primary care

health systems and in assessing the burden of CVD.8

Recent studies on migrants to Europe4,5,9 have attempted

to define the cardiovascular profile by comparing indi-

vidual risk factors among different ethnic groups of

immigrants. Health disparities seem to be inherently

related to the primordial ethnic identities, but they also

reflect new environmental factors: stress, depression and

uptake of western lifestyle10 may rapidly reverse the

immigrants’ ‘coronary disease (CHD) advantage’. Italy

seems to follow the epidemiological transition (OECD

2011)11 witnessed in many European countries and CVD

accounts for 36.6% of the deaths among immigrants.12

Demographics of immigrants in ItalyItaly is one of the most important destination countries

for migrants to Europe accounting for up to 5 000 000

regular migrants (8% of the total population) living in the

country, and shares with Spain the highest annual growth

of the European Union (http://www.iom.int/cms/en/sites/


Fig. 3

Non-European Union citizens holding a residence permit, Italian provinces: 1place of issue/renewal of the permit. Source: Istat on data of Ministry of In

iom/home/where-we-work/europa/european-economic

area/italy.html). The phenomenon is progressively grow-

ing. In 2011, the burden of immigrants was 335 000 more

than the previous year (þ7.9%) and non-European Union

foreigners holding a residence permit in Italy were over

3 500 000;13 from 2008 to 2011, there was an increase of

35%. The most relevant citizenships are Morocco,

Albania, China, Ukraine and Moldova. The distribution

of resident foreigners in Italy continues to be uneven:

86.5% live in the North (64.5%) and Central Italy (22%),

with the remaining 13.5% in the South (Fig. 3); however,

in 2010, the largest increases were seen in the South

(þ11.5%) and the Islands (þ11.9%) (http://www.istat.it/

en/archive/40658). The foreigners account for up to 85%

of the global growth rate of population in northwest Italy

and Lombardy is the region that hosts the largest number

of regular foreigners (26.6%), followed by Emilia-

Romagna (12.6%), and by Veneto (12.1%) where the

highest percentage of long-term permits is registered.

Italy and Japan share the record for longevity of the

population, being the countries in which demographic

pressure is most perceived as a result of the increase life

expectancy. In Italy, the ‘Ageing Population’ would have

been even bigger without the migratory flow: in 2008,

there were 19 000 newborns from migrants vs. 79 000


Less than 9001

From 9001 to 18 500From 18 501 to 35 000From 35 001 to 70 000More than 70 000

January 2012. Data are expressed in absolute values and referred to theterior.

http://www.iom.int/cms/en/sites/iom/home/where-we-work/europa/european-economic%20area/italy.html





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JCM-D-14-00422


newborns from Italians recorded in Lombardy, whereas

in 2002, there were 9000 vs. 77 000, respectively (http://

www.ismu.org/ISMUnews-notizia.php?id_notizia=201).

Most immigration has been illegal, although a series of

regulation has granted many immigrants legal status.14

Clear legislation was enacted as of 1998 to regulate the

immigrant population’s access to services provided under

the Italian National Health System (NHS) on a par with

Italian citizens; regular immigrants register with the NHS

in the same way as Italian citizens, as they have access to

primary and hospital care, rehabilitation and emergency

care.15 Italy has currently declared a state of emergency

over the recent surge in illegal immigrants flooding into

the country: most of the displaced populations arrive from

the Maghreb area and sub-Saharan Africa. Currently,

Sicily is the hub for Mediterranean migrants, the majority

of whom arrive through Lampedusa (http://www.euro.

who.int/__data/assets/pdf_file/0010/184465/e96796.pdf).

Trends in heart diseaseWe report here the first hospital-based series of immi-

grants referred to one of the highest-volume national

cardiac surgery centres, which shows that RHD still

prevails among the adult population and that more

Western patterns of diseases such as IHD and NRVs

progressively emerge. RHD represents a major health

topic by affecting 15 million people and leading to

200 000 deaths per annum worldwide,16 and despite

the significant decline over the last century,17 the disease

also persists among industrialized countries, primarily

because health-related resources may be unbalanced

between immigrants and not enough to provide full

protection. Furthermore, some outbreaks of RHD have

been reported in middle-class children in the USA in the

1990s17,18 and more recently in Italy19,20 where a worri-

some resurgence of the disease is expected to increase

according to migratory flows. Data from our survey

emphasize the need for reinforcement of primordial,

primary and secondary prevention strategies in order to

tackle re-emerging RHD from immigrants. As in other

series, the rheumatic patterns are similar to those recur-

ring in the developing countries such as higher pre-

valence among women from the third decade of life,

predominant mitral disease and severity of MVD; how-

ever, where more expertise exists, echocardiography

focused on anatomic details before surgery also allows

the identification of mixed patterns of rheumatic valves

associated with degenerative prolapse (13%). NRVs, in

fact, emerged as the second main cause of heart failure,

and interestingly, mixomatous mitral prolapse affected

73% of patients. More than half patients (53%; 16/30)

affected by mitral prolapse were Eastern European immi-

grants, both European Union and non-European Union

citizens, possibly reflecting different socio-economic and

ethnic background and environmental exposure com-

pared with black Africans suffering from RHD.


According to the epidemiologic transition of their country

of origin, Eastern Europeans exhibit the most hetero-

geneous picture of heart disease in the survey: rheumatic

and nonrheumatic valvuopathies, IHD and hypertrophic

cardiomyopathies were all represented.

CAD played a central role in the study. The prevalence of

CAD in the whole population was even higher than that

observed in the IHD group, due to the subclinical CAD

detected at preoperative angiography in the other groups

(n¼ 11, 17%); furthermore, the extension of coronary

burden was significantly high, 68% of patients being

affected from severe multivessel disease and 72% of

them having more than two risk factors. The lower

prevalence of IHD among immigrants than the Italian

citizens previously reported21 seems to be related to an

initial ‘healthy immigrant effect’, whereas the higher

prevalence of type 2 diabetes is inherently related to

ethnic differences.22 Over the time, the decline of the

‘CHD advantage’ after the arrival2,23,24 can be attributed

to the adoption of unhealthy lifestyles: physical inactivity

and dietary changes can result in higher overweight

rates among migrants than in native residents. Obesity

is thought to be the fastest growing health problem

worldwide and a strong risk factor for CVD and other

illnesses.14 Although the time of stay and the duration of

exposure were not datable in our survey, the overall

burden of risk factors among immigrants was high:

systemic hypertension, dyslipidemia, tobacco smoking,

type 2 diabetes and obesity (29%) were all represented.

As a well recognized cause of heart failure,25 systemic

hypertension affected 35% (n¼ 54) of the overall popu-

lation and 80% (n¼ 20) of IHD patients and it was also

associated with target organ damage as witnessed by the

dilatation of ascending aorta affecting 11% of patients.

The use of simple algorithms aimed to assess the cardio-

vascular risk and promote salt intake reduction among

immigrants should therefore become a priority.

Adherence to treatment and outcomesImmigrants to Italy are heterogeneous and differences

among the subgroups may address health issues. Most

Latinos have a common ancestry in people speaking the

Italian or Spanish languages or emigrating from Latin

America; eastern Europeans formed the largest subgroup,

including Romanians, Albanians and Ukrainians; black

Africans mostly came from Maghreb and sub-Saharan

Africa; Asians were mainly from the Philippines, Pakistan

and Sri Lanka. Recent immigration, family-oriented

cultural values and poverty are common and shared

features among the various subgroups. There is a wide

range of socio-economic characteristics in communities,

including reluctance to seek care when symptoms occur-

red, and different explanations for delays. In addition,

most patients from Albania and Romania were not

familiar with the Italian language and unaware of the

underlying illness. All these factors might explain the


http://www.ismu.org/ISMUnews-notizia.php?id_notizia=201

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Co


JCM-D-14-00422


percentage of patients lost to follow-up (n¼ 58, 38%) due

to logistical difficulties (incorrect phone numbers, trans-

fer to other countries). Nevertheless, the adherence to

surgical treatment and clinical follow-up was acceptable

(Fig. 1) and the clinical predictors such as proper timing

for surgery, early recovery and lack of complications from

late presentation were all similar to the standards

reported among Italian citizens.

LimitationsOur study has some limitations. First of all, data were

insufficient to investigate the relative relevance of push–

pull factors behind the migration such as the presence of

relatives already here, the political circumstances sur-

rounding departure, the time of stay in Italy and the

overall exposure time to risk factors. Moreover, a drop-

out from the cohort follow-up was recorded for 58

patients, including those needing to stick to the second-

ary prevention programmes following heart surgery;

migrants might decide to leave the area without inform-

ing or giving incorrect personal information. More

effort is needed to guarantee adequate support for vulner-

able groups and improve their access to healthcare

services (http://www.who.int/hac/events/consultation_

report_health_migrants_colour_web.pdf). Finally, the

small cohort of study was limited to patients referred

for heart surgery, regardless of the burden of patients with

missed diagnoses and nonsurgical follow-up.

Conclusion and perspectivesMigration and health are two processes inherently related

to each other. Poverty, despair and lack of employment

opportunities will continue to trigger migration flows

allowing an increase in the burden of CVD among the

industrialized nations. In order to design appropriate

public health policies and health promotion interven-

tions, greater consideration of the cultural environment

should be warranted. Migrants will form an increasing

proportion of the workforce in many European countries

and the demographic trends suggest that the health status

of immigrants and their descendants will play a central

role in shaping health outcomes of the developed

countries’ people. The current survey confirms that they

represent a high-risk group for which targeted CVD risk

reduction is needed and that the outcomes from surgical

treatment can be satisfactory if health-related pro-

grammes are adequately strengthened. It is therefore

of great importance to address these issues.

AcknowledgementsThere were no external funding sources for this study.

There is no potential conflict of interest in this article.

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Heart surgery for immigrants in Italy