Ana Gomes Almeida

BACKGROUND: Guidelines advocate the use of dobutamine stress echocardiography (DSE) in low-gradient aortic stenosis (aortic valve area [AVA] 2 with aortic valve mean gradient 2 and aortic valve mean gradient ≥40 mm Hg, moderate AS when AVA ≥1 cm ² , and indeterminate AS when AVA 2 and aortic valve mean gradient 2 at a flow rate ≥210 mL/s or projected AVA 2 ) were assessed. RESULTS: After DSE, 84 (29%) patients had severe AS, 81 (28%) had moderate AS, and 122 (43%) had indeterminate AS. Over the median follow-up of 12.0 (interquartile range, 5–33) months, more patients with severe AS (73%) underwent aortic valve intervention compared with those with moderate (40%) and indeterminate AS (44%; P P =0.03), whereas the benefit was uncertain in the remaining indeterminate AS group (HR, 0.77 [95% CI, 0.22–2.75]; P =0.69). After aortic valve intervention, patients with conventionally diagnosed severe AS had a better outcome compared with patients with reclassified severe AS (HR, 2.88 [95% CI, 1.34–6.21]; P =0.007). CONCLUSIONS: In this real-world study, the transvalvular flow–based criteria for severe AS markedly reduced the number of indeterminate DSE. Within the indeterminate AS group, patients with reclassified severe AS derived benefit from aortic valve intervention.

Aims: Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous group of clinical entities requiring further investigation to assess aetiology. The European Society of Cardiology guidelines recommend advanced tests to establish an underlying mechanism. We evaluated advanced diagnostic testing utilization and real-world adherence to the current guideline in an international MINOCA registry. Methods and results: DOMINO is a prospective, multicentre, non-commercial registry enrolling 365 patients with MINOCA across 17 centres in 13 countries. Advanced testing was defined as cardiac magnetic resonance (CMR), intracoronary imaging, and/or invasive coronary functional assessment. The association between advanced testing and diagnostic resolution was assessed by multivariable logistic regression, with standard, cluster-robust, and generalized estimating equation (GEE) approaches to account for clustering by centre. Guideline-directed testing was performed in 254/365 (69.6%) and varied markedly by country (0–100%, P < 0.0001). A specific etiologic diagnosis was reached in 337/365 patients (92.3%). Advanced testing was associated with diagnostic resolution in the standard and GEE models, with a directionally consistent but non-significant cluster-robust estimate [standard odds ratio (OR) 3.94, 95% confidence interval (CI) 1.59–10.06; cluster-robust OR 3.75, 95% CI 0.95–14.72, P = 0.058; GEE OR 3.69, 95% CI 1.04–13.11]. Diagnostic resolution increased progressively with the extent of testing performed, from 85.6% with no advanced testing to 97.1% with CMR plus invasive/functional assessment (trend P = 0.02). Discharge pharmacotherapy varied significantly by etiologic diagnosis (P = 0.0001). Conclusion: Advanced diagnostic testing was associated with a higher likelihood of a determined etiologic diagnosis in MINOCA, despite marked international variability in its use; however, this association is partly definitional, as advanced testing directly contributes to diagnostic ascertainment for several etiologic categories. These findings nonetheless support closing the guideline-practice gap in advanced testing, while underscoring the need to distinguish mechanistically confirmed diagnoses from presumptive ones.

Introduction: Accurate quantification of aortic valve area (AVA) is essential in the evaluation of aortic stenosis (AS) severity. While two-dimensional (2D) Transesophageal echocardiography (TEE) is widely used for AVA planimetry, three-dimensional (3D) TEE may offer superior accuracy due to improved anatomical visualization. We aimed to compare AVA measurements by 2D versus 3D TEE in patients with AS. Methods: We conducted a systematic review and meta-analysis of studies reporting AVA measurements using both 2D and 3D TEE in adult patients with AS. Paired measurements, means and standard deviations, or correlations between techniques were extracted. The primary outcome was the mean difference in AVA (cm²) between modalities. Secondary outcomes included pooled correlation coefficients and assessment of heterogeneity. Analyses were performed using random-effects models. Eight studies comprising 381 patients were included. The pooled mean absolute difference between 2D and 3D TEE was 0.16 cm² (95% CI 0.09–0.23; p < 0.001), indicating that 3D TEE yielded slightly smaller AVA measurements overall, with a tendency to lower interobserver variability. Heterogeneity was low, and sensitivity analyses excluding older equipment showed consistent findings. Most studies demonstrated low risk of bias in patient selection and flow/timing, with some concerns regarding index-test and reference-standard domains. Conclusions: 3D TEE provides slightly smaller AVA measurements than 2D TEE, with low heterogeneity and acceptable study quality. While both modalities may be clinically useful, 3D TEE may offer more reliable anatomical assessment. Standardized imaging protocols and multicenter validation are warranted to enhance reproducibility and ensure consistent evaluation of AS severity.

Introduction Cardiac organ damage (OD) is associated with increased risk of cardiovascular disease. However, limited knowledge exists on cardiac OD in young patients with cryptogenic ischaemic stroke (CIS). Aim To explore prevalence and covariates of cardiac OD in patients with CIS compared to controls participating in the SECRETO study. Methods We analysed data from 427 patients with CIS aged p < 0.01), while presence of LAE did not differ. In multivariable analyses, CIS was associated with presence of abnormal LV geometry (odds ratio 1.86 [95% confidence interval 1.09–3.20], p=0.024). In separate multivariable analyses in patients only, obesity was associated with both abnormal LV geometry and LAE (both p < 0.01), and higher systolic blood pressure only with presence of abnormal LV geometry (p < 0.001). No significant association with PFO was found. Conclusion In young patients with CIS participating in the SECRETO study, abnormal LV geometry was more prevalent compared to age- and sex-matched controls and associated with presence of higher blood pressure and obesity. The results point to the importance of blood pressure and weight control in CIS to prevent progression of cardiac OD and recurrent cardiovascular events. Graphical Abstract

We report a case of acute myocarditis in a 25‐year‐old man with refractory generalized pustular psoriasis (GPP) following treatment with spesolimab, an anti–IL‐36 receptor monoclonal antibody. Cardiac magnetic resonance fulfilled the Lake‐Louise criteria for myocarditis, and genetic testing revealed a heterozygous pathogenic/likely pathogenic MYH7 variant, suggesting a possible gene–environment–drug interaction. The patient was managed with supportive care and presented no complications. In outpatient evaluation, the patient has remained asymptomatic with no further hospital admissions. This case underscores the need for vigilance regarding cardiac adverse events during IL‐36 blockade and highlights the potential role of genetic predisposition in modulating susceptibility to myocardial injury.

Sex differences in valvular heart disease (VHD) represent an emerging focus in cardiovascular imaging, with implications spanning aetiology, pathophysiology, chamber remodelling, and prognosis. This review aims to illustrate how multimodality imaging can be applied to address sex-specific differences in VHD, with the goal of improving disease grading, staging of extra-valvular cardiac damage, and risk stratification across the whole VHD spectrum.

Aims: Valvular heart disease is a leading cause of cardiovascular morbidity and mortality globally, with women experiencing delayed referrals, difficulties recognizing atypical symptoms, and suboptimal adherence to guideline-based therapies, resulting in worse outcomes. However, the literature identifying these disparities remains limited, underscoring the need for a comprehensive registry to address these gaps. The Valvular Heart Disease in Women Registry (VHD-W) aims to provide real-world insights into gender differences by examining treatment patterns, guideline adherence, and clinical results. Methods and results: The VHD-W is an international, multicenter, non-commercial, investigator-initiated, multipurpose registry endorsed by the European Association of Cardiovascular Imaging. The VHD-W involves adult patients with moderate-to-severe valvular heart disease admitted, either urgently or electively, to the cardiology inpatient service. The study aims to enrol 800 patients, balanced between genders, across more than 70 centres worldwide, over a 6-month period from the registry inception in March 2024 until the end of December 2025. Data will be collected at inpatient admission, inpatient discharge, and 1-year follow-up, including demographics, medical history, physical examination, biomarkers, echocardiography, other imaging results, and management. Conclusion The VHD-W is the first registry to focus on gender disparities in valvular heart disease in a real-world setting, aiming to fill a significant management gap that will help develop gender-specific, evidence-based guidelines for valvular heart disease.