Al‐Abcha, Abdullah

The ever-changing landscape of cardiology necessitates continuous education of healthcare providers. Case-based learning (CBL) provides an inquiry-based form of learning where learners apply knowledge to realistic clinical scenarios under instructor guidance. However, current case-based learning curricula are limited to representing 3-dimensional content in 2-dimensions with distinct modalities utilized for various data sources. Virtual reality (VR) shows promise for CBL given it provides an immersive and interactive 3-dimensional medium in which multi-source content can be incorporated into a unified learning experience, potentially translating to improved learning efficiency and lower cognitive load. With VR case-based learning, learners can view medical imaging in 3-dimensions or seamlessly interact with various 2-dimensional images within one unified medium. Further, additional content including simulated patients or procedures can be incorporated with a higher level of fidelity. Herein, we summarize the current literature exploring VR-CBL, demonstrate a proof-of-concept VR application, and review the implications for cardiology education. The proof-of-concept exemplifies many of the key advantages unique to VR-CBL, such as medical imaging rendered in 3-dimensions, integration of multiple imaging sources, and novel interaction methodologies. Given the importance and rapid evolution of ongoing medical education, VR-CBL, with its immersive and engaging nature, appears to be a promising form of instruction that may serve a larger role in continuing medical education initiatives.

Abstract Aims Coronary angiography might contain clinically relevant information, beyond its traditional role in delineating coronary artery disease. We sought to explore the role of deep learning (DL) in detecting right ventricular dysfunction from routinely acquired cine images during coronary angiography. Methods and results 3D-convolutional neural networks (CNN) were trained to identify right ventricle (RV) dysfunction from diagnostic angiography of the right coronary artery (RCA). The model’s input was two cine angiograms from LAO and RAO projections. The model’s output was normal vs. abnormal RV function. Ground truth on RV function was obtained from the nearest transthoracic echocardiogram to the coronary angiogram. Two analyses were performed to identify (i) any RV dysfunction (≥mild) and (ii) significant RV dysfunction (≥mild–moderate). A total of 10 336 coronary angiograms from 9849 patients (mean age 66, 36% women) were included. The cohort was split into training (70%), validation (15%), and testing (15%) sets. In the testing sets, the models attained an area under the ROC curve (AUC), sensitivity, and specificity of 0.82 (95% CI: 0.80–0.84), 0.75, and 0.74, for detecting any RV dysfunction, and 0.83 (95% CI: 0.80–0.86), 0.82, and 0.70 for detecting significant (≥mild–moderate) RV dysfunction. Combining an ECG-driven AI model with the angio-driven model improved the AUC values to 0.83 and 0.87 for detecting any or advanced RV dysfunction, respectively. Conclusion A novel deep learning algorithm yielded acceptable classification accuracy in detecting RV dysfunction from routine cine angiography of the RCA. The model’s performance improved further by adding ECG to its inputs.

Background The natural history of asymptomatic moderate or severe aortic regurgitation (AR) remains uncertain, with conflicting reports about its progression and surgical timing. We aimed to quantify adverse outcomes under conservative management and evaluate the association of aortic valve replacement/repair (AVR) with mortality. Methods Systematic searches (inception–July 2025) identified cohort studies of asymptomatic moderate/severe AR. Random-effects models estimated pooled incidence rates of adverse events; fixed-effects models were used for hazard ratios (HRs) of AVR vs conservative management. Results Twenty-seven studies (4720 patients; mean age 49 years; mean follow-up 3.9 years) were included. Pooled incidence rates per 100 person-years were 1.75 (95% CI 1.27 to 2.41) for all-cause mortality, 1.29 for cardiac death, 0.29 for sudden death, 4.30 for new symptoms and 7.01 for AVR. Asymptomatic low left ventricular ejection fraction occurred in only 0.9 per 100 person-years. Mortality rates were more than double those of the general population across age groups—2.45 (1.90 to 3.18) per 100 person-years for cohorts with mean age ≥50 years versus 0.59 (0.29 to 1.21) for younger cohorts. Early AVR was associated with lower mortality (pooled HR 0.33; 95% CI 0.30 to 0.37). Conclusion Asymptomatic moderate/severe AR carries significant excess mortality irrespective of age, contradicting its historically benign reputation. Given the rarity of asymptomatic LV dysfunction, earlier intervention guided by more sensitive markers of LV damage may improve outcomes, although heterogeneity and study quality warrant cautious interpretation. PROSPERO registration number CRD42024522683.

Introduction: Valvular heart disease (VHD) poses a growing global burden, particularly in aging populations. While transcatheter interventions have expanded rapidly over the past two decades, the extent to which trial populations reflect real-world demographics—especially age and sex—is unclear. Understanding enrollment trends and representation gaps is essential to ensure equitable, generalizable evidence for clinical decision-making. Methods: We systematically reviewed VHD interventional trials (2000–2024) indexed in PubMed. Surgical and percutaneous trials across aortic, mitral, tricuspid, and pulmonic valves were included. Trial characteristics, demographics, and interventions were analyzed using descriptive and nonparametric statistics. Results: We included 487 trials enrolling 87,412 participants (45% women). Median trial size increased over time (z = 4.98, p < 0.01), and the mean age of participants also rose significantly (z = 10.08, p < 0.01). Trials involving percutaneous (11% to 45%), bioprosthetic (22% to 53%), aortic valve (27% to 62%), and multinational (2% to 16%) interventions increased over time. Older participants were more commonly enrolled in percutaneous, industry-funded, multinational, bioprosthetic, and aortic valve trials. Female representation remained unchanged across time (median 47%, z = -0.48, p = 0.63), but trials enrolling older participants tended to include more women (ρ = 0.196, p < 0.01). Female representation was highest in mitral (59%) and tricuspid (59%) valve trials, and more common in percutaneous (52%) than surgical (42%) interventions. Conclusion: Over the past two decades, VHD trials have expanded in size and geographic scope, with increased enrollment of older adults, particularly in percutaneous and industry-sponsored studies. However, sex disparities and demographic variability persist. Future trials should prioritize inclusive designs to ensure equitable, generalizable evidence for evolving valve interventions.

ABSTRACTPlatelets are small, anucleate particles derived from bone marrow megakaryocytes that circulate in the blood and are central to hemostasis, atherothrombosis, and post‐angioplasty coronary restenosis. Initially thought to involve a simple process of platelet adhesion, activation, and aggregation, recent insights reveal an important interplay with genetics and other organ systems, especially in the setting of antiplatelet drug therapy. Interaction involving the hepatic cytochrome P450 enzymes, which regulate drug metabolism, and genetic variation in those enzymes affecting drug response, underscores the liver's role in modulating platelet function by attenuating circulating active drug metabolites with eventual cardiovascular implications. Circulating adhesive proteins such as von Willebrand Factor and fibronectin also significantly regulate platelet aggregation, a process that is further influenced by varying shear conditions within the vascular system. The efficacy of antiplatelet therapies can be attenuated by such individual genetic variation, which can affect multiple cellular pathways involved not only in drug metabolism and clearance but also the drug target itself. Identifying these genetic differences allows for tailored therapy, enhancing treatment outcomes and minimizing adverse effects. Genetic variation, particularly in the CYP2C19 gene, influences individual responses to the most commonly used antiplatelet drug other than aspirin, clopidogrel, with certain variants leading to reduced drug metabolism and antiplatelet effects. Therefore, genotype‐guided antiplatelet therapy has emerged as a promising approach to reduce ischemic events and minimize bleeding events. This personalized strategy requires an understanding of genetic variation, drug‐gene interaction, and the liver's role in impacting platelet function, the coagulation system, and cardiovascular systems.

ABSTRACT Background The assessment of aortic stenosis (AS) severity remains a challenge in some patients, and hemodynamic exercise testing has been proposed as a diagnostic tool in this population. However, the current understanding of exercise hemodynamics in AS is limited. Methods Retrospective review of 34 adults (aged ≥ 18 years) with ≥ moderate AS and preserved left ventricular ejection fraction (LVEF) undergoing exercise invasive hemodynamics (supine cycle protocol) with simultaneous measurement of aortic and left ventricular pressures. Results Age was 77.1 (IQR 68.6; 84.1) years, and 50% were female. LVEF was 62.1 ± 6.6%. All patients were symptomatic. Resting aortic valve area (AVA) was 1.0 ± 0.2 cm 2 and aortic valve (AV) systolic mean gradient 22.0 ± 7.3 mmHg. At peak exercise (40 [IQR 30; 60] W), AV systolic mean gradient (Δ3 [0.6; 7] mmHg, p < 0.001) and AVA (Δ0.2 [0; 0.6] cm 2 , p = 0.002) significantly increased, while stroke volume (SV) did not (Δ6.8 ± 19.4 ml; p = 0.07). Exercise‐induced changes in AV systolic mean gradient were directly related to changes in cardiac output ( r = 0.53, p = 0.003), being inversely related to exercise systemic vascular resistance ( r = −0.60, p = 0.002). Elevated pulmonary artery wedge pressure was present in 41.2% at rest (≥ 15 mmHg) and 69.7% during exercise (≥ 25 mmHg). Conclusions Symptomatic patients with ≥ moderate AS and preserved LVEF experience small increases in AV mean gradient with exercise, and unlike the normal physiological response to exercise, there was no significant increase in SV. In most patients, AVA rose during exercise. Exercise‐induced elevation in filling pressures was highly prevalent.

Background Acute ischemic stroke complicates 2% to 3% of transcatheter aortic valve replacements (TAVRs). This study aimed to identify the aortic anatomic correlates in patients after TAVR stroke. Methods and Results This is a single‐center, retrospective study of patients who underwent TAVR at the Mayo Clinic between 2012 and 2022. The aortic arch morphology was determined via a manual review of the pre‐TAVR computed tomography images. An “a priori” approach was used to select the covariates for the following: (1) the logistic regression model assessing the association between a bovine arch and periprocedural stroke (defined as stroke within 7 days after TAVR); and (2) the Cox proportional hazards regression model assessing the association between a bovine arch and long‐term stroke after TAVR. A total of 2775 patients were included (59.6% men; 97.8% White race; mean±SD age, 79.3±8.4 years), of whom 495 (17.8%) had a bovine arch morphology. Fifty‐seven patients (1.7%) experienced a periprocedural stroke. The incidence of acute stroke was significantly higher among patients with a bovine arch compared with those with a nonbovine arch (3.6% versus 1.7%; P =0.01). After adjustment, a bovine arch was independently associated with increased periprocedural strokes (adjusted odds ratio, 2.16 [95% CI, 1.22–3.83]). At a median follow‐up of 2.7 years, the overall incidence of post‐TAVR stroke was 6.0% and was significantly higher in patients with a bovine arch even after adjusting for potential confounders (10.5% versus 5.0%; adjusted hazard ratio, 2.11 [95% CI, 1.51–2.93]; P <0.001). Conclusions A bovine arch anatomy is associated with a significantly higher risk of periprocedural and long‐term stroke after TAVR.