Former Italian prime minister Silvio Berlusconi left hospital on Tuesday, three weeks after an open-heart operation, sending mixed signals about his willingness to continue engaging in frontline politics.

Berlusconi, who turns 80 in September, checked into the San Raffaele Hospital in Milan on June 7 with symptoms of heart failure. He had surgery a week later to replace a faulty aortic valve that was putting his life in danger.

"It was a very, very painful ordeal. I did not expect to experience so much pain. Anyway, I feel a bit better now, two months of rehabilitation await me, and after that I hope to still be useful to Italy and Italians, in some way," he said as he left the clinic.

Wearing a navy blue polo shirt and a black jumper over his shoulders, the normally ebullient Berlusconi spoke slowly and appeared to need support to stand up and walk, as he extended his right arm over the shoulder of an aide.

He said his main preoccupations while in hospital were "pain and not being able to sleep."

Asked if he still felt ready to lead the country, Berlusconi was non-committal. "I hope there will not be any need, but, if so, I hope to have the strength to be able to give some advice," he told reporters.

He displayed a willingness to comment on current affairs, expressing worries about terrorism, Europe's post-Brexit future, and promising to campaign against constitutional reforms proposed by the government and due for a referendum vote in October.

Berlusconi also confirmed that his AC Milan football team would be sold to Chinese buyers, but only on condition that they commit to invest "at least 400 million euros (445 million dollars) in the next two years" to revive the squad's fortunes.

The former premier led Italy in 1994, 2001-06 and 2008-11. He was expelled from parliament and given a six-year ban on holding public office in 2013 after a tax fraud conviction, but remains the head of conservative opposition party Forza Italia.

Health worries have increasingly weighed on his life.

Before the heart operation, he was admitted to the San Raffaele twice in recent months: in December to replace a heart pacemaker, which he has had since 2006, and in March for cataract surgery. His medical history also includes a 1997 operation to remove prostate cancer.

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