Fabiola B. Sozzi

Aortic regurgitation (AR) in young adults (aged 18–44 years) is often under‐ or misdiagnosed and is not always benign. As in older populations, prognosis depends on the severity of regurgitation, the underlying cause, early left ventricular dysfunction, and the chosen intervention strategy. Prompt diagnosis and timely treatment improve outcomes, yet the optimal timing for surgery in asymptomatic chronic AR remains uncertain. Recent studies have proposed new thresholds for left ventricular structural and functional assessment to better evaluate the impact of AR on prognosis and guide intervention timing. Echocardiography remains the primary imaging modality, but a multimodality approach is essential to accurately assess AR severity and subtle left ventricular changes. Transesophageal echocardiography with 3‐dimensional imaging is crucial for evaluating valve repair feasibility, particularly when valve‐sparing root repair, reintervention, or transcatheter procedures are considered. Additional tools such as cardiac magnetic resonance, global longitudinal strain, and biomarkers may further enhance disease monitoring. Assessment can be challenging, especially with eccentric jets or complex valve anatomy, and current surgical cut‐offs remain debated. Aortic valve repair is preferred in young patients, including those with concomitant proximal aortic aneurysm, but it remains underutilized. Here, we propose a treatment algorithm for severe AR in young adults, integrating the underlying cause, valve anatomy, and left ventricular function, with a special focus on multimodality imaging to guide monitoring and therapeutic strategies.

Intermediate Care Units (ImCU) are worldwide considered as an intermediate setting of care between standard wards and intensive care units (ICU), specifically addressed to critically ill patients admitted from Emergency Departments, stepping down from ICUs or stepping up from general wards. ImCU formats vary considerably between institutions, missing univocal criteria of where they should be placed, how be formatted and staffed, what monitoring and treatments delivered, which patients admitted, and when discharged. Many published studies focused primarily on mortality as the main variable of interest, while the effects of ImCU implementations on healthcare costs, hospital governance and comprehensive inpatient outcomes remain controversial. A consensus on which measures should be most accurate and based on evidence is still lacking. Appropriate quality-of-care key indicators should concern structures, processes, outcomes and their relationships. The development of a multi-level framework to assess ImCU performance, tailored on resources and management of each specific reality, should consider their functional role on hospital macro-systems, warranting both by patient-level and system-level objectives to ensure effective benchmarking and to provide a substantial support to clinical practice.

Background: There have been 20.5 million deaths due to cardiovascular diseases (CVDs), including atherosclerotic coronary artery disease (CAD) and stroke, so far in 2025. Atherosclerosis, which begins in newborns, may be influenced by preconception factors and continues to develop in adults, requiring a proper assessment of the burden of atherosclerotic plaque, as it is the direct cause of CAD. This review aims to emphasize the role of a staging system proposed by the Lancet Commission for the quantification of atherosclerotic coronary artery disease (ACAD) with an emphasis on preconception risk factors and protective factors, based on coronary computed tomography angiography (CCTA). Methods: It is suggested that the use of CCTA scanning makes it possible to quantify the atherosclerotic plaque burden into four stages. Results: CCTA enables us to see how much plaque has built up, as well as the type of plaque, but not the biochemistry of the plaque, to determine its vulnerability. However, if the plaque is a non-calcified fatty plaque, it is considered to be a strong predictor of the risk of myocardial infarction (MI), whereas a more stable calcified plaque is known to be protective against MI. There are several risk factors and protective factors which may influence the process of the rupture or vulnerability of the plaque. A randomized trial revealed that, after a median follow-up of 10·0 years, deaths due to CAD or non-fatal MI were less frequent in the CCTA group compared with a control group. Conclusions: Despite a few gaps in knowledge about the value of a staging system of ACAD, the available evidence indicates that it is helpful in decreasing morbidity and mortality with available therapies.

Cardiac masses are complex clinical conditions that frequently pose diagnostic challenges in cardiology practice. These masses can form within heart chambers or near the pericardium and are generally categorized as either non-neoplastic or neoplastic. These latter are further classified into benign and malignant (primary and secondary or metastatic). Diagnosing these conditions often requires a multiparametric approach that includes both clinical features, such as the patient’s and associated clinical conditions, and multimodality imaging. However, histological examination of the resected specimen is often necessary to ascertain the nature of the mass. Given their heterogeneity and the rarity of many cardiac masses, there are no guidelines or consensus on the best diagnostic approach. Modern imaging protocols must be tailored to the specific clinical issues and patient characteristics, given the rapid advancements in technology. Thus, it is imperative to use a multimodality approach, combining different imaging techniques and multidisciplinary teamwork. Hereby, we propose a practical algorithm for evaluating cardiac lesions using a step-by-step implementation of multimodal imaging. Ultimately, the goal is to tailor the most suitable imaging technique to the patient’s needs.

Chronic heart failure (CHF) has different stages and they include pre-HF (PHF), a state of high risk of developing myocardial dysfunction and subsequently, advanced CHF (ACHF). Some major behavioral risk factors of PHF are Western diet, tobacco, alcoholism, sedentary life style and chronic mental disorders (anxiety, depression). These insults might predispose to biological risk factors such as obesity, diabetes mellitus dyslipidemia hypertension, myocardial infarction and cardiomyopathy. These risk factors damage the myocytes leading to fibrosis, apoptosis, cardiac hypertrophy, along with alterations in cardiomyocyte’ size and shape. A condition of physiological subcellular remodeling resulting into a pathological or deformation state might be developed conductiong to PHF. Both PHF and HF are associated with the activation of phospholipases and protease, mitochondrial dysfunction, oxidative stress and development of intracellular free Ca2+ [Ca2+]i overloading or an elevation in diastolic [Ca2+]i. Simultaneously, cardiac gene expression is activated leading to further molecular, structural and biochemical changes of the myocardium. The sub-cellular remodeling may be intimately involved in the transition of cardiac hypertrophy to heart failure. Two-dimensional (2D) and three-dimensional (3D) speckle tracking-echocardiography (STE) have been used to quantify regional alterations of longitudinal strain and area strain, through their polar projection, which permits a further assessment of both sites and degrees of myocardial damage. The examination of strain can identify sub-clinical cardiac dysfunction or cardiomyocyte remodeling. It is concluded that during remodeling of the myocardium, cardiac strain is attenuated which can be used for the assessment of disease progression and subsequently for therapeutic interventions.