Aims:The aortic valve (AV) and aortic root complex constitute a functional unit, and their integrated anatomical and dynamic assessment is essential for the management of AV disease. This review highlights the role of three-dimensional echocardiography (3DE) in the comprehensive evaluation of AV disease and its contribution to therapeutic decision-making. Methods and results:Owing to close collaboration with cardiac surgeons, 3DE has significantly expanded the diagnostic information provided by imaging cardiologists and has become a key tool for guiding therapeutic strategies. In patients with significant aortic regurgitation (AR), detailed anatomical assessment of the cusps enables characterization of valve morphology and tissue quality, while multiplanar reconstruction provides accurate measurements of the virtual basal ring, coronary ostial height, and other key anatomical structures. Quantitative assessment of cusp geometry, including effective, geometric, and coaptation heights, allows precise identification of AR mechanisms, thereby facilitating repair-oriented surgical planning. In aortic stenosis (AS), 3DE improves evaluation of discordant or borderline cases through enhanced assessment of the left ventricular outflow tract and direct planimetric measurement of AV area. In addition, 3DE provides complementary information for procedural planning of both transcatheter and surgical AV replacement, particularly in patients with contraindications to computed tomography. Conclusion:Three-dimensional echocardiography, particularly transoesophageal 3DE, has become an essential imaging modality for integrating anatomical and functional information. It improves diagnostic accuracy, supports individualized therapeutic planning, and plays a pivotal role in promoting a repair-oriented approach to the management of aortic valve disease.

Ischemic heart disease, the main clinical expression of atherosclerotic cardiovascular disease, remains a leading global health challenge. While coronary angiography is the gold standard for anatomical assessment, it has limitations in determining the functional relevance of coronary lesions. Invasive physiological techniques - such as Fractional Flow Reserve (FFR) and its resting equivalents (iFR, RFR) - enable an objective hemodynamic evaluation, particularly useful in intermediate or multivessel diseases. Emerging imaging-derived tools, including QFR and FFRCT, offer less invasive alternatives that may play an increasing role in the upstream decision-making process. This article provides a practical overview of the available modalities, their physiological rationale, and their integration into interventional practice.

Several glucagon-like peptide-1 receptor agonists (GLP-1RAs) have proven their ability to reduce major adverse cardiovascular events (MACEs) among at-risk patients living with type 2 diabetes (T2D). Tirzepatide, a dual GIP/GLP-1 receptor agonist, demonstrated a better control of hyperglycaemia, body weight and several cardiovascular risk factors than pure GLP-1RAs (including semaglutide) in dedicated studies of the SURPASS programme. SURPASS CVOT has the primary objective to demonstrate, in a population with T2D and atheromatous cardiovascular disease, the non-inferiority of tirzepatide regarding both efficacy and safety compared with dulaglutide, a selective GLP-RA that has already proven a significant reduction in MACEs versus placebo in the REWIND trial. Non-inferiority was met in SURPASS CVOT (p = 0.003), but not superiority of tirzepatide compared to dulaglutide (hazard ratio [HR] 0.92; 95 % confidence interval [IC] 0.83 to 1.01; P = 0.09) regarding the primary end point (reduction in MACEs). Several secondary end points tended to favour tirzepatide versus dulaglutide, among which a reduction in the incidence of all-cause deaths after four years of median follow-up (HR 0.84 ; 95 % CI 0.75 to 0.94; exploratory analysis). SURPASS CVOT, the first and unique study that used an active comparator rather than a placebo, confirms the efficacy and safety of the dual agonist tirzepatide in patients with T2D and atheromatous cardiovascular disease.

Objective:Post-implant thrombocytopenia and subclinical leaflet thrombosis (SLT) are two common phenomena, yet their potential interplay remains unexplored. This study aimed to determine whether early platelet dynamics differed in patients diagnosed with SLT on multidetector computed tomography (MDCT) compared with those without SLT. Methods and results:A total of 118 consecutive patients treated with self-expandable supra-annular and intra-annular prostheses were longitudinally analysed. Platelet count was assessed using the corrected platelet count (CPC) from baseline to day 7 (or hospital discharge) and at 30 days. Platelet-to-lymphocyte ratio (PLR) and lymphocyte-to-monocyte ratio (LMR) were also measured as inflammatory markers. Spleen volume was assessed at baseline. MDCT was performed at 6-month follow-up to evaluate SLT. SLT, ranging from mild to severe, was detected in 22 patients at the 6-month MDCT follow-up. The SLT group had a lower baseline platelet count compared to the No-SLT group, with persistently lower levels from day 1 to day 7 post-implant. Platelet count was significantly lower in the SLT group on days 5 and 6 (CPC: 170 (IQR: 50) × 10³/μL vs. 215 (IQR: 72) × 10³/μL, P = 0.048; and 175 (IQR: 55) × 10³/μL vs. 240 (IQR: 85) × 10³/μL, P = 0.038). No significant differences were observed in PLR or LMR. Spleen volume was also significantly lower in the SLT group. Conclusion:We demonstrated a reversible thrombocytopenia during the first week post-implant, which was more pronounced in the SLT group than in the No-SLT group. Additionally, spleen volume was smaller in the SLT group, suggesting a potential interplay between these factors.

This issue illustrates how diagnostic innovations are integrated into daily clinical practice, highlighting the central role of clinical reasoning.

BACKGROUND:Right ventricular-pulmonary arterial coupling is a known prognostic marker in patients with tricuspid regurgitation (TR). However, its assessment by cardiac magnetic resonance and its clinical implications have not been evaluated. We aimed to assess the prognostic role of a cardiac magnetic resonance surrogate of right ventricular-pulmonary arterial coupling in a large cohort of patients with a spectrum of TR severity. METHODS:Comprehensive data were collected from patients referred for cardiac magnetic resonance from 2019 to 2024 who had TR quantification. Right ventricular-pulmonary arterial coupling was calculated by dividing the forward right ventricular stroke volume (f-RVSV) by the right ventricular end-systolic volume (ESV). The outcome of interest was the composite of all-cause death and heart failure hospitalization, under medical management. RESULTS:In the 631 patients included, median age was 66 (interquartile range [IQR], 54-75) years, median tricuspid regurgitant volume was 18 (IQR, 12-30 mL), median left ventricular ejection fraction was 53 (IQR, 41-61)%, median RV ejection fraction was 53 (IQR, 45-58)%, and median f-RVSV/ESV ratio was 0.82 (IQR, 0.58-1.11). In restricted spline curve analysis, the f-RVSV/ESV ratio cutoff associated with a hazard >1 for the composite outcome was ≤0.57. At baseline, a low f-RVSV/ESV ratio was strongly associated with subjective and objective signs of right heart failure, higher TRI-SCORE, and worse right-sided chamber remodeling (all P<0.001). After a median follow-up of 1.8 years (IQR, 1.5-2.0), patients with a low f-RVSV/ESV ratio showed worse survival (P<0.001). After comprehensive adjustment for clinical and imaging confounders, f-RVSV/ESV ≤0.57 remained a powerful predictor of outcome (adjusted hazard ratio, 2.36 [95% CI, 1.27-4.37]; P=0.004). Finally, patients with low f-RVSV/ESV displayed a worse long-term prognosis across mild, moderate, and severe TR groups (P<0.001, P<0.001, and P=0.018, respectively). CONCLUSIONS:In this large cohort of patients with a wide spectrum of TR severity, right ventricular-pulmonary arterial coupling assessed by cardiac magnetic resonance was strongly associated with right-sided heart failure and worse long-term prognosis, even after comprehensive adjustment.

Rare cardiovascular diseases represent a heterogeneous group of conditions that are individually uncommon but collectively significant. They include inherited cardiomyopathies, infiltrative and metabolic disorders, channelopathies, aortopathies, as well as rare vascular syndromes and some congenital heart diseases. Over the last decade, major advances in multimodality imaging, genetic testing, and targeted therapies have substantially improved diagnostic accuracy and clinical outcomes. Patient-tailored management and disease‑modifying treatments, particularly for cardiomyopathies and selected metabolic disorders, illustrate the transition towards precision medicine in the field. Despite these scientific advances, important organisational challenges remain. In Belgium, eight centres are recognised as reference hospitals for rare diseases since 2014, but high‑level expertise and advanced technologies are available in more tertiary centres and care pathways for rare cardiovascular diseases remain fragmented. The recent Plan rare disease 2026-2030 with a development of a Central Rare Disease Registry and the extension of structured rare disease event registration to all medical services represent important steps towards improved epidemiological monitoring and coordination. However, formally organising a national network dedicated to rare cardiovascular diseases is a challenge to offer uniform access to specialised care. The framework for collaboration of the reference centres with the different partners over the lines of care, the establishment and support of multidisciplinary clinics, the development of generic and personalised care pathways and national registries are key steps towards more coordinated, equitable, and efficient management of patients with rare cardiovascular diseases in Belgium.

Exercise imaging, particularly exercise stress echocardiography (ESE), has become a pivotal non-invasive tool for evaluating cardiovascular function in athletes and for distinguishing physiological adaptations from pathological conditions. This Clinical Consensus Statement by the European Association of Preventive Cardiology and the European Association of Cardiovascular Imaging synthesizes current evidence and provides practical guidance on indications, protocols, and interpretation of exercise imaging modalities in both competitive and recreational athletes. The document emphasizes the role of ESE in assessing cardiac reserve, unmasking concealed cardiomyopathies, and stratifying risk in clinical scenarios such as T-wave inversion, exercise-induced repolarization abnormalities, and extreme ventricular remodelling. Special attention is given to imaging protocols tailored to the athletic population, including dynamic assessment of the right and left ventricles, atria, and valvular function during various exercise modalities, highlighting the importance of the functional evaluation in athletes and active individuals. Additionally, the consensus explores the integration of advanced techniques such as cardiopulmonary exercise testing and exercise cardiac magnetic resonance imaging, highlighting their complementary roles in comprehensive cardiovascular evaluation. The statement advocates for individualized testing strategies that consider sport-specific demands, demographic factors such as body size, sex, ethnicity, and the underlying pathology. It also underscores the importance of exercise imaging in guiding sports eligibility and in tailoring exercise prescription for competitive athletes, as well as for patients willing to participate in recreational sports or exercise programs.

Transcatheter aortic valve implants are increasingly performed in younger and lower-risk patients, shifting attention towards long-term prosthetic valve durability. Although transthoracic echocardiography remains the cornerstone of follow-up, it primarily reflects global haemodynamics and may not detect early structural or geometric abnormalities after the valve is implanted. Hypoattenuated leaflet thickening and reduced leaflet motion, collectively referred to as subclinical leaflet thrombosis, represent dynamic phenomena that may precede overt valve dysfunction. Growing evidence suggests that prosthesis geometry, including underexpansion, ellipticity, commissural misalignment, canting, and implant depth, may alter neo-sinus flow and promote thrombotic substrate formation. Multidetector computed tomography enables integrated assessment of leaflet morphology, perivalvular thrombus, and prosthetic geometry, providing insights into the mechanical determinants of thrombosis. In this state-of-the-art review, we examine the role of multimodality imaging in identifying thrombogenic valve phenotypes and propose a pragmatic imaging framework integrating echocardiography with selective multidetector computed tomography to support the surveillance and management of individualized post-transcatheter aortic valve implants.

Global warming and the accompanying environmental changes now represent a major determinant of cardiovascular morbidity and mortality. Data from the Global Burden of Disease rank air pollution among the leading causes of death worldwide, with a predominance of cardiovascular events. Chronic exposure to fine particulate matter promotes the development and progression of atherosclerosis, while pollution spikes and extreme temperature variations act as triggers for acute events such as acute coronary syndrome (ACS), strokes, and arrhythmias. It is important to emphasize that 18-20 % of ACS cases occur in the absence of traditional cardiovascular risk factors, suggesting the involvement of environmental factors.

This issue of the Revue Médicale de Liège addresses a wide range of clinical situations, from acute conditions to chronic and rare diseases. It highlights the importance of a structured clinical approach to integrate diagnostic and therapeutic data and support medical decision-making.

BACKGROUND:The role of transcatheter aortic valve implantation (TAVI) in bicuspid aortic valve stenosis requires further evaluation, particularly as its use has become comparable to surgical aortic valve replacement. We sought to compare midterm outcomes of TAVI and surgical aortic valve replacement in patients with bicuspid aortic valve stenosis. METHODS:Systematic searches of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials identified studies reporting TAVI and surgical aortic valve replacement outcomes in patients aged ≥60 years with bicuspid aortic valve stenosis. The primary analysis included only comparative studies with interpretable Kaplan-Meier curves. Individual patient data were reconstructed for time-to-event analysis. Sensitivity analyses incorporated noncomparative single-arm studies. Baseline differences and heterogeneity were addressed using landmark analysis, time-varying hazard ratios (HRs), frailty Cox models, and covariate-adjusted restricted mean survival time. The primary outcome was death with or without unplanned rehospitalization and stroke. RESULTS:Five comparative, risk-adjusted studies (TAVI, 5901; surgical aortic valve replacement, 12 427) were included. At 48-month follow-up, TAVI was associated with a higher hazard for adverse events (HR, 1.62 [95% CI, 1.46-1.79]; P<0.0001 for the composite end point of death, stroke, or rehospitalization at 48 months); landmark analysis showed an initial benefit with TAVI, followed by a reversal at 6 months that was maintained beyond 12 months (12-48 months; P<0.0001). Time-varying HRs confirmed this trend. Sensitivity analyses, including frailty Cox models on the full cohort and restricted mean survival time analysis, supported the robustness of the findings. CONCLUSIONS:This meta-analysis found limited midterm benefits (ie, 48 months) of TAVI in bicuspid aortic valve stenosis. These findings should be interpreted considering patient selection, as younger patients with bicuspid aortic valve stenosis are increasingly referred for TAVI.

Cardiovascular medicine continues to move towards precision-based, individualised patient care, supported by novel biomarkers, refined imaging protocols, and multidisciplinary risk assessment. The studies featured in this issue of Acta Cardiologica span cardio-oncology, structural heart disease, immune and proteomic biomarkers, sepsis-related cardiac dysfunction, arrhythmia management, and vascular disease. Collectively, they underscore the growing importance of individualised diagnostic and therapeutic strategies across the cardiovascular spectrum, from cancer-related heart failure to conduction system pacing and cardiac arrest prevention.