Bruno Bezerra Lima

Multimodal cardiac imaging has fundamentally reshaped the evaluation of anomalous aortic origin of the coronary artery, yet risk stratification remains challenging because anatomy, symptoms, and physiological demands vary widely across patients. This review summarizes contemporary anomalous aortic origin of the coronary artery classification and emphasizes anatomic features associated with higher risk, including interarterial and intramural courses, adverse ostial morphology, and compression related to the intercoronary pillar or myocardial bridges, which contribute to both fixed and dynamic ischemia. The complementary roles of echocardiography, coronary CT angiography with CT-derived fractional flow reserve, nuclear myocardial perfusion imaging, cardiac magnetic resonance, and hybrid anatomic–functional imaging are discussed, with attention to the specific clinical contexts in which each modality is most informative. Finally, we discuss the Vanderbilt management approach that integrates age, symptoms, detailed anatomic assessment, and functional testing to guide observation, exercise recommendations, invasive evaluation, and surgical intervention, with particular focus on individualized counseling and safe return-to-play decisions in young and athletic patients.

Heart transplantation significantly enhances survival and quality of life for patients with end‐stage heart failure. Despite advances in surgical and postoperative care, immune‐mediated complications, acute graft rejection and cardiac allograft vasculopathy (CAV), remain major barriers to long‐term success. Acute rejection predominantly affects early posttransplant survival, whereas CAV becomes a leading cause of mortality in later years. The gold standards for diagnosis, endomyocardial biopsy for rejection and coronary angiography for CAV, are invasive and imperfect. Noninvasive multimodality imaging is increasingly used to complement or, in selected scenarios, defer invasive testing. Echocardiography with strain detects early myocardial dysfunction when ejection fraction is preserved; stress echocardiography provides prognostic information for CAV. Quantitative techniques, positron emission tomography myocardial blood flow/myocardial flow reserve and quantitative cardiac magnetic resonance perfusion, improve detection of diffuse, stage‐dependent CAV compared with qualitative assessments. Cardiac magnetic resonance tissue mapping characterizes edema and fibrosis relevant to rejection surveillance; fluorodeoxyglucose‐positron emission tomography for inflammation is emerging but remains investigational in most centers. Cardiac computed tomography angiography defines coronary anatomy and plaque with excellent negative predictive value and offers physiologic assessment with computed tomography‐myocardial perfusion imaging/computed tomography‐derived fractional flow reserve; it is best used strategically rather than as an annually repeated test. This contemporary review synthesizes the strengths, limitations, and practical roles of echocardiography, nuclear imaging, cardiac magnetic resonance, and cardiac computed tomography angiography across adult and pediatric populations; highlights areas where quantitative methods add incremental value; and provides pragmatic, stage‐aware surveillance frameworks. Integrating modalities can reduce reliance on invasive procedures, lower procedural risk, and refine therapeutic decision‐making benefits that are particularly relevant for children and other patients for whom repeated invasive testing is undesirable.

Background: Left ventricular (LV) thrombus is a complication of myocardial infarction and dilated cardiomyopathy and is associated with a high thromboembolic risk. Although warfarin has traditionally been used, direct oral anticoagulants (DOACs) offer a more convenient alternative. With the addition of the RIVAWAR trial, we conducted an updated systematic review and meta-analysis to assess the efficacy and safety of DOACs compared with warfarin in patients with LV thrombus. Methods: A systematic search of electronic databases (PubMed, EMBASE, Cochrane and clinicaltrials.gov) from inception to April 2025 identified randomised clinical trials (RCTs) comparing DOACs with warfarin for the treatment of LV thrombus. The main outcome of interest was thrombus resolution at 3 months. Risk ratios (RRs) with 95% CIs were calculated using random-effects models. Results: Seven RCTs comprising 554 patients were included. Non-contrast transthoracic echocardiography was used for LV thrombus assessment in all RCTs. There was no difference between DOACs and warfarin in thrombus resolution at 3 months (RR 1.02; 95% CI 0.95 to 1.09), major adverse cardiovascular events (RR 0.50; 95% CI 0.16 to 1.54), all-cause mortality (RR 0.92; 95% CI 0.36 to 2.31), stroke/systemic embolism (RR 0.76; 95% CI 0.12 to 4.68), rehospitalisation (RR 1.36; 95% CI 0.47 to 3.94) or major bleeding (RR 0.54; 95% CI 0.20 to 1.48). Subgroup and sensitivity analyses confirmed the robustness of these results. Conclusions: DOACs demonstrated similar efficacy and safety to warfarin for LV thrombus management in this meta-analysis, supporting their use for the treatment of LV thrombus. However, large-scale RCTs with longer follow-up periods and using diagnostic modalities with higher sensitivity and specificity for detecting LV thrombus resolution are warranted to confirm these findings and clarify long-term outcomes. PROSPERO registration number: CRD420251023513.