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.

BACKGROUND:The natural history of mitral regurgitation (MR) in contemporary practice remains poorly defined. OBJECTIVES:The purpose of this study was to quantify clinical outcomes of patients with moderate and moderate-severe MR. METHODS:We conducted a retrospective cohort study of consecutive patients with moderate or moderate-severe MR who underwent echocardiography at Mayo Clinic between 2010 and 2023. MR was classified as degenerative or functional. The primary outcome was all-cause mortality. Secondary outcomes included heart failure (HF) hospitalization, MR progression to severe MR, and mitral valve intervention. RESULTS:Of 8,687 patients (mean age 70.7 ± 13.7 years; 45.1% female), 21.4% had degenerative MR and 78.6% had functional MR, and median follow-up was 4.1 years (Q1-Q3: 2.3-7.9). At 4 years, overall survival was 68.5% (95% CI: 67.4%-69.7%), with higher survival in patients with degenerative MR (84.1%; 95% CI: 81.9%-86.3%) compared to functional MR (65.0%; 95% CI: 63.7%-66.3%), and the cumulative incidence of HF hospitalization was higher in functional MR (36.8%; 95% CI: 35.6%-38.1%) than degenerative MR (17.9%; 95% CI: 15.7%-20%). However, the risk of death and HF hospitalization was similar after multivariable adjustments. MR progression occurred in 32.7% (95% CI: 31.0%-34.4%), less commonly in functional MR (adjusted HR: 0.65; 95% CI: 0.54-0.79; P < 0.001). Mitral valve intervention was infrequent (11.4%; 95% CI: 10.6%-12.1%) and significantly less common in functional MR (adjusted HR: 0.45; 95% CI: 0.37-0.56; P < 0.001). CONCLUSIONS:Patients with moderate or moderate-severe MR accrue significant mortality and morbidity over follow-up. Further trials are needed to ascertain the indication, optimal timing and method of procedural intervention.

Background Transcatheter edge‐to‐edge repair (TEER) and replacement (TTVR) have emerged as new modalities to treat patients with symptomatic significant tricuspid regurgitation. This study aimed to compare invasive hemodynamic and right ventricular (RV) changes and symptom improvement over 1 year. Methods Patients who underwent TEER/TTVR at Mayo Clinic (Rochester, MN, 2017–2024) were included. Hemodynamic profiles were described before and immediately after intervention, in addition to RV enlargement/dysfunction ≥moderate at 30 days and change in symptoms over time. Results Of 100 patients included (50 per group, median age 81 versus 80 years and female 62% versus 42%, in TTVR and TEER, respectively), all had ≥ moderate–severe symptomatic tricuspid regurgitation. Post intervention, mean right atrial pressure decreased in TEER (16 to 14 mm Hg, P<0.001), V wave decreased in both groups (to 16 mm Hg, P<0.001). RV enlargement was less prevalent in both cohorts at 30 days (60%–40% in TEER, P=0.01, and 72 to 58% in TTVR, P=0.07), yet prevalence of RV dysfunction decreased only in TEER (26 to 15%, P=0.17) as opposed to TTVR (31 to 44%, P=0.13). TTVR resulted in a higher stroke volume index and more complete tricuspid regurgitation elimination at 30 days. Both groups resulted in similar improvements in New York Heart Association class, with overall similar survival. Conclusions TEER was associated with a greater reduction in right atrial pressure and more favorable RV remodeling at 30 days, as opposed to TTVR, which achieved more complete and sustained elimination of tricuspid regurgitation with higher forward stroke volume.

Background Percutaneous management of high risk, percutaneous coronary intervention (PCI) needing mechanical support for complex coronary artery disease in patients needing transcatheter aortic valve replacement for severe aortic stenosis remains incompletely defined. We report on the feasibility and safety of a single-session strategy using Impella-assisted complex high-risk PCI (IA-CHIP) followed by transcatheter aortic valve replacement (TAVR). Methods We conducted a multicenter retrospective study of consecutive patients undergoing simultaneous IA-CHIP and TAVR at 3 tertiary centers between January 2015 and March 2026. All patients received mechanical circulatory support with percutaneous microaxial flow pump Impella CP (Abiomed) during PCI, followed by transfemoral TAVR in the same session. Baseline demographics, procedural characteristics, and clinical outcomes were collected. The primary endpoint was in-hospital complications, including death, stroke, major bleeding (Bleeding Academic Research Consortium types 2, 3, or 5), acute kidney injury, permanent pacemaker implantation, and vascular complications. Results A total of 12 patients were included (median age, 79.5 years [IQR, 77.0-81.2]; 91.7% male; median Charlson Comorbidity Index of 7 [IQR, 5.8-9]). Coronary lesions mainly involved left main disease in 66% of cases. Advanced calcium modification was required in 50% of cases. The median aortic valve area was 0.86 cm2, and median mean gradient was 38 mm Hg. Procedural success for IA-CHIP and TAVR was 100%. There were no in-hospital deaths, strokes, or major vascular complications. Conduction disturbances requiring permanent pacemaker implantation occurred in 25%. An acute kidney injury occurred in 16.7% of cases, with no requirement for dialysis. The majority of patients (91.7%) were discharged home. Conclusions A single-session strategy of IA-CHIP followed by TAVR is feasible and safe in selected patients with complex coronary artery disease and severe aortic stenosis.

Background Left atrial appendage occlusion (LAAO) has emerged as an effective stroke- prevention strategy for selected patients with nonvalvular atrial fibrillation (NVAF). However, LAAO outcomes data in patients with hypertrophic cardiomyopathy (HCM), rheumatic heart disease (RHD), or cardiac amyloidosis (CA), are limited. Objectives This study aimed to compare the safety and efficacy of LAAO in patients with NVAF, with and without comorbid HCM, RHD, or CA. Methods Using OptumLabs Data Warehouse, a retrospective cohort of adult patients undergoing LAAO (2015-2023) was analyzed. Outcomes included mortality, stroke/transient ischemic attack (TIA), and bleeding, with multivariable Cox models and subgroup analyses. Results A total of 14,755 patients (mean age 76.5 ± 7.0, 43.7% female, median follow-up 1.4 [0.8-2.4] years) were included. Compared with patients with AF, patients AF + RHD had high risk of nongastrointestinal/intracranial bleeding events (HR: 1.24; 95% CI: 1.04-1.49; P = 0.02), whereas AF + CA showed higher risk of composite endpoint (mortality, stroke/TIA, bleeding) (HR: 1.63; 95% CI: 1.17-2.27; P = 0.004), stroke/TIA (HR: 2.00; 95% CI; 1.13-3.54; P = 0.02), and gastrointestinal bleeding (HR: 2.50; 95% CI: 1.14-5.47; P = 0.02). There were no significant differences in clinical outcomes between patients with AF alone and those with AF + HCM. Conclusions Patients with AF and either RHD or CA experienced higher bleeding rates following LAAO compared with those without these conditions, despite similar stroke/TIA rates in AF + RHD, suggesting a higher inherent bleeding risk and possibly further supporting a role of LAAO. Importantly, there was no difference in outcomes between patients with AF and HCM vs those without. Because of the small sample size, the results in HCM and CA cohorts are mainly hypothesis generating.

BACKGROUND:Coronary obstruction during valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) is infrequent but catastrophic. Mechanical splitting of bioprosthetic leaflets may mitigate this risk, but real-world experience remains limited. OBJECTIVES:The aim of this is to evaluate procedural performance and in-hospital outcomes of a dedicated mechanical leaflet-splitting device in ViV TAVR. METHODS:Consecutive postapproval cases were performed at 28 centers from February to November 2025. Patients were selected for elevated risk based on preprocedural computed tomography criteria, including virtual valve-to-coronary distance ≤4 mm and/or virtual valve-to-sinotubular junction distance ≤3 mm. Procedural outcomes were assessed among patients in whom splitting was attempted; safety outcomes were assessed among all patients in whom the device was introduced. Events were adjudicated using Valve Academic Research Consortium-3 definitions. RESULTS:Among 150 patients (age 78.9 ± 8.5 years; 60.0% female), 95 of 150 (63.3%) underwent ViV TAVR for failed surgical and 55 of 150 (36.7%) for failed transcatheter valves. Computed tomography analysis showed predicted acute coronary obstruction risk in 131 of 150 (87.3%) patients, including combined sinus sequestration and direct ostial obstruction in 76 of 150 (50.7%). Leaflet splitting was attempted in 145 patients and was successful in 144 of 145 (99.3%); dual-leaflet splitting was performed in 83 of 145 (57.2%). Coronary obstruction occurred in 3 of 150 (2.0%; 95% CI: 0.7-5.7). All-cause mortality occurred in 3 of 150 (2.0%; 95% CI: 0.7-5.7), including 2 deaths from left ventricular perforation and 1 after stroke. Conversion to surgery occurred in 2 of 150 (1.3%; 95% CI: 0.4-4.7). CONCLUSIONS:In this early U.S. commercial experience, mechanical leaflet splitting demonstrated high procedural success in an anatomically high-risk ViV TAVR cohort. Serious complications occurred, and longer-term systematic follow-up remains important.

Introduction Angina with no obstructive coronary artery disease (ANOCA) affects millions and is frequently under-recognised because diagnostic pathways and risk tools predominantly target obstructive coronary artery disease (CAD). This protocol describes shared methods for two machine-learning (ML) studies: (1) differentiating ANOCA from stable angina with obstructive CAD and (2) predicting long-term mortality among patients with ANOCA and obstructive CAD.Methods and analysis We will develop and cross-site validate ML classification models using a multicentre retrospective cohort drawn from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry and institutional datasets from the University of Ottawa Heart Institute and the University Health Network. Eligible participants are adults (≥18 years) undergoing initial cardiac catheterisation for chest pain/anginal equivalents since 1995, excluding prior revascularisation, major structural heart disease and predefined non-anginal indications. Outcomes are (1) ANOCA (0% to <50% stenosis) versus obstructive CAD (≥50% stenosis) and (2) 1, 3 and 5-year mortality, modelled separately for ANOCA and obstructive CAD.Model development will use nested cross-validation with stratified k-fold inner-loop tuning and leave-one-site-out cross-validation for repeated external validation. Candidate predictors will be harmonised across sites, filtered for missingness and refined using expert/directed acyclic graph-guided selection plus Boruta and Least Absolute Shrinkage and Selection Operator. Preprocessing includes appropriate encoding, missing-data imputation (multivariate imputation by chained equations) and feature scaling. Algorithms will include elastic-net logistic regression, random forest, LightGBM and multilayer perceptron models; hyperparameters will be optimised via Bayesian optimisation. Performance and threshold tuning will be reported. Explainability and subgroup fairness will be assessed using SHapley Additive exPlanations. Final models will be deployed as a web-based clinical risk calculator.Ethics and dissemination Ethics approval has been obtained from the University of Calgary and the University Health Network (#24-5916). Analyses will use deidentified data in secure environments; only aggregate results will be reported. Findings will be disseminated via peer-reviewed publications, conferences and a web-based calculator.

Focused cardiac ultrasound (FoCUS) has become the standard of care for bedside assessments of cardiac function. With the integration of artificial intelligence (AI), there is limited evidence comparing it to bedside visual assessments by experienced users. In our prospective study conducted at Tufts Medical Center in Boston, Massachusetts from December 2020 to March 2022, patients ≥ 18 years requiring a TTE were recruited by convenience sampling. They each underwent FoCUS LVEF classification by AI and bedside visual assessment, with TTE as reference. LVEF was calculated by Simpson’s biplane method of disks in AI-FoCUS and TTE, and visual global assessment by the bedside sonographer. Data analysis was completed in October 2025. Our 215 participants had a median age of 63 (IQR 49–73) years with 83 (38.6

INTRODUCTION:Left atrial-to-coronary sinus (LA-to-CS) shunting through the APTURE transcatheter shunt system aims to unload the LA while preserving the interatrial septum. This article aims to examine the 3-year health status, functional capacity, and clinical outcomes of the ALT-FLOW Early Feasibility Study (EFS). METHODS:Device safety, patency, and echocardiographic parameters, but also symptoms, health status, and exercise capacity were assessed in patients with left ventricular ejection fraction (LVEF) > 40% (n & 95). Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) score predicted 3-year all-cause mortality was compared with observed mortality assessed by Kaplan-Meier analysis using adjudicated events. Predicted and observed HF hospitalization (HFH)-free survival rates were also compared. RESULTS:At 3 years, the safety profile remained stable with no new safety signals, and all implanted shunts remained patent. 76.3% of patients improved by at least one NYHA class, and mean KCCQ Overall Summary Scores increased by 25 points from baseline (P < .0001). The 6-min walk distance improved by an average of 39 m (P & .002). These benefits were consistent regardless of baseline pulmonary vascular resistance (PVR). Right heart echocardiographic parameters after 3 years were stable, though a reduction in TAPSE was observed, primarily in the high PVR subgroup. The observed 3-year survival was significantly higher than the MAGGIC-predicted survival (84.4% vs 70.2, respectively; P & .009), as well as the HFH-free survival (68.0% vs 24.0%, respectively; P < 0001). CONCLUSION:In patients with HF and LVEF >40%, the APTURE LA-to-CS shunting confirmed an acceptable safety profile with stable right heart parameters and sustained improvements in symptoms, quality of life, and functional capacity at 3 years. Observed survival and HFH were superior to MAGGIC predictions.

Background/Objectives: Atrial fibrillation is a frequent comorbidity amongst patients undergoing mitral valve transcatheter edge-to-edge repair (M-TEER) for mitral regurgitation. Left atrial appendage occlusion (LAAO) can be performed to reduce the risk of stroke in patients with atrial fibrillation. Both procedures require large-bore venous access, transseptal puncture, and real-time imaging of the left atrium. However, limited data exist evaluating the safety and feasibility of concomitant M-TEER and LAAO. Methods: We performed a retrospective review of all concomitant M-TEER and LAAO procedures at our institution between May 2019 and September 2024 to evaluate the safety and feasibility of this approach. Results: Concomitant left atrial appendage occlusion was successful in all 15 patients, requiring an additional 15 min (IQR 11-29) of procedural time. No patients died or had a major vascular complication. Routine transesophageal echocardiography performed within 90 days showed no device related thrombus, and no significant peri-device leak in any patients. Conclusions: Concomitant M-TEER and LAAO are feasible but additional prospective studies or randomized trials are needed to evaluate the potential clinical benefit.

Background We examined the potential influence of effective orifice area (EOA) and EOA index (EOAi) on survival between bioprosthetic and mechanical valves. Methods We analyzed 3265 patients aged 75 years or younger undergoing aortic valve replacement with or without coronary artery bypass grafting. EOA and EOAi were obtained from predischarge echocardiograms. Bootstrapped logistic regression and restricted cubic splines identified optimal survival cut points for EOA and EOAi. Multivariable Cox proportional hazards models were fitted, and adjusted Kaplan-Meier survival curves were generated using the identified EOA cut points. Results The mechanical aortic valve replacement group was younger (age 60 vs 69 years; P < .001). For mechanical and bioprosthetic aortic valve replacement groups, respectively, the median EOA was (2.0 cm2; range, 1.6-2.4 vs 2.1 cm2; range, 1.7-2.6 cm2; P < .001) and EOA index was (1.0 cm2/m2; range, 0.8-1.2 cm2/m2 vs 1.1 cm2/m2, range, 0.9-1.3 cm2/m2; P < .001) In patients with EOA ≥2 cm2, long-term adjusted risk of mortality was higher in the bioprosthesis group compared with the mechanical group (hazard ratio, 1.33; P = .010). However, no significant difference was observed for those with EOA <2 cm2 (hazard ratio, 1.01; 95% CI, 0.83-1.23; P = .932). Similarly, for EOA index ≥1.08 cm2/m2, the bioprosthesis group was associated with higher risk of long-term mortality (hazard ratio, 1.29; 95% CI, 1.01-1.64, P = .040), whereas no significant association was found for those with an EOA index <1.08 cm2/m2 (hazard ratio, 1.05; P = .621). Conclusions In this cohort, there was a survival advantage of mechanical valves over bioprostheses in larger valve sizes but not in patients with smaller EOA metrics.

BACKGROUND The ALT-FLOW trial EFS (Early Feasibility Study) evaluated safety, hemodynamics and outcomes for the APTURE system in patients with HF and mildly reduced or preserved ejection fraction. OBJECTIVES In this study, the authors sought to examine the 2-year health status, functional capacity, and outcomes of ALT-FLOW EFS. METHODS Device safety, performance, patency, hemodynamics, echocardiographic parameters, and outcomes were assessed in patients with LVEF >40% (n = 95); NYHA functional class, Kansas City Cardiomyopathy Questionnaire (KCCQ) Clinical Summary Score (CSS), Total Symptom Score (TSS), and Overall Summary Score (OSS), 6-minute walk distance, and the ratio of pulmonary capillary wedge pressure at peak exercise to workload normalized to body weight (PCWL) were evaluated. RESULTS Major adverse cardiac, cerebral, and renal events and reintervention through 30 days occurred in 2.8% of patients. All implanted shunts were patent for up to 5 years. The mean PCWL decreased from 131 f 74 mm Hg/W/kg at baseline to 76 f 57 mm Hg/W/kg after 6 months (P < 0.0001). After 2 years, NYHA functional class improvement was reported in 51/62 patients (82.3%). Mean KCCQ CSS, TSS, and OSS at baseline were 45 f 17, 46 f 19, and 38 f 18 points, respectively, and improved at 2 years by 25 f 20, 26 f 23, and 31 f 23 points, respectively. The reduction in PCWL and improvement in NYHA functional class and KCCQ scores were consistent in patients with or without pulmonary vascular disease. No detrimental changes in right or left ventricular function were observed. CONCLUSIONS In patients with HF and LVEF >40%, the APTURE shunt confirmed an acceptable safety profile with improvements in HF symptoms, quality of life, and functional capacity without negatively affecting right and left heart function after 2 years, regardless of pulmonary vascular disease. (Exploratory Study of the Edwards APTURE Transcatheter Shunt System [ALT-FLOW Canada]; NCT04000607; Early Feasibility Study-Edwards APTURE Transcatheter Shunt System [ALT-FLOW US]; NCT03523416) (c) 2025 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Spontaneous coronary artery dissection (SCAD) is a nonatherosclerotic cause of acute coronary syndrome that primarily affects young women. Although intravascular imaging, particularly optical coherence tomography (OCT), provides high-resolution visualization of intramural hematoma and dissection planes, its routine use in SCAD is not recommended. This is mainly due to the risk of false lumen propagation from high-pressure injection of a flushing medium, typically viscous contrast medium, to exclude intraluminal blood and enable OCT luminal visualization. We present a case series of 3 patients with SCAD who underwent flush-free OCT image acquisition, allowing for the identification of intramural hematoma without the need for high-pressure contrast injection. In all cases, findings were confirmed through conventional contrast OCT image acquisition. Our novel approach minimizes procedural risks associated with high-pressure contrast injection while preserving the diagnostic benefits of OCT. These findings suggest that the flush-free OCT technique is feasible and can be a safer initial intravascular modality in patients with suspected SCAD.