Cardiology, Peripheral Vasculature, Rhythm Disorders,

Background Insomnia symptoms are prevalent in older adults and linked to cardiovascular disease (CVD), but the role of long-term symptom trajectories remains unclear. We investigated associations between insomnia symptoms, their trajectories over time and incident CVD in a population-based cohort. Methods This longitudinal study included 12 102 participants aged ≥50 years without baseline CVD from the US Health and Retirement Study (2002–2018). Insomnia symptoms (non-restorative sleep, difficulty initiating/maintaining sleep, early awakening) were assessed at baseline; trajectories were modelled over 4 years (2002–2006) using latent class analysis. Cox models estimated HRs for incident CVD (heart disease or stroke), adjusted for sociodemographics, lifestyle and comorbidities. Results During a median of 10.2-year follow-up, 3962 incident CVD events occurred. Compared with no symptoms, participants with one, two, or three to four symptoms had higher CVD risk (HR 1.16, 95% CI 1.05 to 1.27; HR 1.16, 95% CI 1.05 to 1.28; HR 1.26, 95% CI 1.15 to 1.38, respectively). Four trajectories were identified: persistent low (56.3%), decreasing (27.1%), increasing (7.2%) and persistent high (9.5%). Compared with persistent low, increasing (HR 1.28, 95% CI 1.10 to 1.50) and persistent high (HR 1.32, 95% CI 1.15 to 1.50) trajectories were associated with elevated CVD risk. Conclusions Greater burden of insomnia symptoms at baseline and trajectories over time were associated with higher CVD incidence in older adults.

Background Non-dilated left ventricular cardiomyopathy (NDLVC), characterised by non-ischaemic scar/fatty replacement or isolated systolic dysfunction without dilatation, lacks validated risk stratification tools. We aimed to define cardiac magnetic resonance (CMR)-based phenotypes and evaluate their association with clinical outcomes. Methods In 515 patients with NDLVC (mean age 45 (16) years), three phenotypes were classified by CMR: late gadolinium enhancement (LGE+)/H– (LGE with preserved left ventricular ejection fraction (LVEF), n=130), LGE–/H+ (hypokinesia without LGE, n=226) and LGE+/H+ (LGE with reduced LVEF, n=159). The primary endpoint was all-cause death/heart transplantation; secondary endpoints included heart failure (HF) events and malignant ventricular arrhythmia (MVA). Results Over a mean follow-up of 6.5 (1.9) years, 29 patients (5.6%) reached the primary endpoint, while 81 (15.7%) and 19 (3.7%) experienced HF and MVA, respectively. The LGE+/H+ subgroup demonstrated the highest risk for composite clinical endpoints compared with other phenotypic groups (p<0.001). Multivariable analysis identified New York Heart Association class >II (HR 3.42, 95% CI 1.58 to 7.39, p=0.002), LVEF (HR 0.91 per 1% increase, 95% CI 0.88 to 0.95, p<0.001) and LGE extent (HR 1.14 per 3% increase, 95% CI 1.07 to 1.21, p<0.001) as independent predictors of the primary endpoint, with excellent discriminative power (C-statistic 0.862). In the adjusted model, LGE extent also independently predicted HF (HR 1.11 per 3%, 95% CI 1.06 to 1.17, p<0.001). The univariable Cox regression analysis indicated LGE extent was significantly associated with MVA (HR 1.12 per 3%, 95% CI 1.02 to 1.23, p=0.021). Conclusion CMR phenotyping enables risk stratification in NDLVC. LGE extent provides an objective marker to identify high-risk patients—even with preserved ejection fraction—supporting its integration into routine evaluation.

Background Bicuspid aortic regurgitation (AR) is common in younger patients who often do not meet guideline-based criteria for aortic valve (AV) surgery at diagnosis. However, identifying early predictors of disease progression may aid in risk stratification and surgical timing. Methods From a single-centre registry of 1927 patients with bicuspid AV, we identified 335 patients with moderate or severe AR, excluding those with severe aortic stenosis (AS), endocarditis or other major valvular diseases. Among them, 199 patients (mean age 52±14.0 years; 80% male) did not initially meet the surgical criteria and were included in the final analysis. Clinical data and echocardiographic parameters, including speckle-tracking-derived strain measurements, were analysed. The primary outcome was progression to AV surgery during follow-up. Results Over a mean follow-up of 4.9 years, 41 patients (21%) underwent AV surgery, primarily for symptom onset or left ventricular (LV) enlargement. In multivariable Cox regression, three independent predictors of future surgery were identified: LV mass index ≥113 g/m² (HR 4.49, 95% CI 1.74 to 11.6, p=0.002), left atrial (LA) reservoir strain <28% (HR 3.07, 95% CI 1.40 to 6.74, p=0.005) and concomitant moderate AS (HR 3.19, 95% CI 1.40 to 7.28, p=0.006). Conclusion In patients with significant bicuspid AR who do not initially meet indications for AV surgery, increased LV mass index, impaired LA reservoir strain and concomitant moderate AS are early predictors of surgical progression. These parameters may enhance surveillance strategies and inform earlier surgical referral in selected patients.

Clinical introduction A 52-year-old was referred by his general practitioner with new atrial fibrillation. The patient reported 6 weeks of mild dyspnoea which was non-limiting, New York Heart Association (NYHA) class II. He had no chest pain, syncope, fevers or palpitations. Background was notable for Bentall procedure with Dacron graft and Medtronic-Hall mechanical aortic valve replacement at age 20 for severe aortic regurgitation (AR), aortic root dilatation and left ventricular (LV) dilatation. Prior echocardiography images were not available but reports indicated ‘free’ AR, severely dilated LV and normal LV ejection fraction (LVEF). He had been lost to cardiology follow-up after discharge from cardiothoracic clinic and had no subsequent imaging. He had good adherence to warfarin with International Normalised Ratio (INR) consistently within therapeutic range. He also took levetiracetam for epilepsy, though he had been seizure-free for over 10 years. Admission troponin was elevated at 3718 ng/L, NT-proBNP 12 852 pg/mL, C-reactive protein...

Outflow tract ventricular arrhythmias (OT-VAs) are the most common type of idiopathic VAs.1 Despite their often benign clinical presentation, patients may experience symptoms that may severely impact quality of life, and, in case of high ectopic burden, OT-VA may also lead to VA–induced cardiomyopathy.2 Radiofrequency catheter ablation (RFCA) has emerged as a valuable therapeutic option for OT-VA, particularly given its high success rates and minimal complication risk. Accurate localisation of the ectopic foci—whether arising from the right ventricular outflow tract (RVOT) or left ventricular outflow tract (LVOT)—is a critical step for procedure planning and optimisation, determining essential aspects such as vascular access, anticoagulation strategy and potential procedural challenges and complications.3 4 In this regard, ECG morphology analysis serves as a simple, widely accessible and non-invasive method for estimating the site of origin. However, the close anatomical relationship between RVOT and LVOT...

Johnson LS, Economou Lundeberg J, Wuopio J, et al. Response to: Correspondence on ‘Estimated sodium intake and premature ventricular complexes: data from the population-based Swedish CArdioPulmonary bioImage study’ by Campbell. Heart 2025;111:741–43. This letter was updated post-publication in response to editorial concerns regarding wording.

Background Accurate pre-ablation differentiation between left (LVOT) and right (RVOT) ventricular outflow tract arrhythmias (OTVAs) using ECG algorithms is essential for decision on vascular access and treatment strategy. However, the most reliable ECG algorithm remains unclear. We conducted a systematic review and network meta-analysis (NMA) to compare the diagnostic accuracy of available algorithms. Methods We searched MEDLINE, EMBASE and Cochrane databases through 7 May 2025 for studies evaluating ECG algorithms against ablation-confirmed OTVA origin. A Bayesian diagnostic test accuracy NMA was performed to estimate pooled sensitivity, specificity, diagnostic odds ratios (DORs) and a superiority index (S) for each algorithm. Study quality was assessed using the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies) tool. Results From 620 records, 22 studies (3483 patients; 2706 RVOT, 777 LVOT) evaluating 21 ECG algorithms were included. The ‘Weighted hybrid score’ algorithm showed the highest diagnostic accuracy (S=21.2 (0.3, 39.0); DOR=275.8 (7.1, 1642.5)), with pooled sensitivity of 0.83 (0.53, 0.98) and specificity of 0.92 (0.68, 0.99). Conversely, the ‘Earliest onset or peak/nadir in lead V2’ algorithm had the lowest accuracy. Conclusions Among existing ECG algorithms, the ‘Weighted hybrid score’ demonstrates superior diagnostic performance for differentiating LVOT from RVOT arrhythmias and is recommended for clinical application. PROSPERO registration number CRD42024567531.

Transthyretin amyloidosis (ATTR) is a condition caused by TTR protein misfolding and amyloid deposition, particularly in the heart and nervous system, leading to organ dysfunction. Advances in therapeutic strategies have revolutionised the management of ATTR amyloidosis. Treatments available in clinical practice include TTR stabilisers (tafamidis and acoramidis), which prevent the dissociation of TTR tetramer into monomers and oligomers that subsequently form amyloid fibrils, and gene-silencing therapies (patisiran, inotersen and vutrisiran), which suppress the hepatic synthesis of TTR, which is the amyloid precursor protein. Novel treatment strategies that are at various stages of development include Clustered Regularly Interspaced Short Palindromic Repeats-Cas9 gene-editing technology (nexiguran ziclumeran), which, if successful, offers the prospect of a single-dose treatment, and monoclonal (cormitug and ALXN220) and pan-amyloid antibodies (AT-02) that seek to target and remove amyloid fibrils that have deposited in the myocardium. Amyloid removal remains a significant unmet clinical need, and hence, the ability to promote amyloid degradation and clearance through the use of antiamyloid therapies would represent a groundbreaking advancement in the treatment of ATTR amyloidosis. The success of ATTR-specific disease-modifying therapies has already altered the treatment landscape and changed the perception of ATTR amyloidosis from a progressive and fatal disease to one that is treatable through the availability of highly effective disease-modifying therapies. However, important questions remain, including the long-term safety of these drugs, whether combining therapies with different mechanisms of action has an additive prognostic benefit and how best to monitor the treatment response.

Background Baseline health and driving data might allow clinicians to personalise medical driving restrictions after implantable cardioverter-defibrillator (ICD) implantation. Methods Using 22 years of population-based administrative data from British Columbia, Canada, we identified licensed drivers with a first ICD implantation between 1998 and 2018. After stratifying by ICD indication (primary vs secondary prevention of sudden cardiac death), we used baseline health and driving data and logistic regression to estimate each driver’s 1-year crash risk. We assessed optimism-corrected discrimination and calibration of the final model using 200 bootstrapped samples. Results In the first year after implantation, there were 352 crashes among 3652 primary prevention ICD recipients and 270 crashes among 3408 secondary prevention ICD recipients. Crash prediction models exhibited poor discrimination (c-statistics 0.60 and 0.61, respectively) but good calibration (calibration slopes 1.14 and 1.07). The strongest predictors of crash among primary prevention ICD recipients were male sex, active vehicle insurance in the past year and the number of crashes in the past year. The strongest predictors of crash among secondary prevention ICD recipients were male sex, no history of seizure, an active prescription for opioids and active vehicle insurance in the past year. Conclusions Crash prediction models based on health and driving data had a limited ability to distinguish individuals who subsequently crashed from individuals who did not. Observed crash risks are likely to be strongly influenced by unobserved changes in road exposure (the hours or miles of driving per week), limiting the application of these risk scores by clinicians and policy-makers.

Transthyretin amyloidosis (ATTR) is a condition caused by TTR protein misfolding and amyloid deposition, particularly in the heart and nervous system, leading to organ dysfunction. Advances in therapeutic strategies have revolutionised the management of ATTR amyloidosis. Treatments available in clinical practice include TTR stabilisers (tafamidis and acoramidis), which prevent the dissociation of TTR tetramer into monomers and oligomers that subsequently form amyloid fibrils, and gene-silencing therapies (patisiran, inotersen and vutrisiran), which suppress the hepatic synthesis of TTR, which is the amyloid precursor protein. Novel treatment strategies that are at various stages of development include Clustered Regularly Interspaced Short Palindromic Repeats-Cas9 gene-editing technology (nexiguran ziclumeran), which, if successful, offers the prospect of a single-dose treatment, and monoclonal (cormitug and ALXN220) and pan-amyloid antibodies (AT-02) that seek to target and remove amyloid fibrils that have deposited in the myocardium. Amyloid removal remains a significant unmet clinical need, and hence, the ability to promote amyloid degradation and clearance through the use of antiamyloid therapies would represent a groundbreaking advancement in the treatment of ATTR amyloidosis. The success of ATTR-specific disease-modifying therapies has already altered the treatment landscape and changed the perception of ATTR amyloidosis from a progressive and fatal disease to one that is treatable through the availability of highly effective disease-modifying therapies. However, important questions remain, including the long-term safety of these drugs, whether combining therapies with different mechanisms of action has an additive prognostic benefit and how best to monitor the treatment response.

Milestone articles have highlighted the frequency and types of statistical errors in research,1–5 yet fundamental errors persist across various disciplines. With a background in biostatistics and over 200 articles reviewed for journals such as Heart and Addiction since 2021, two differing and distinct research areas, I (DJG) have identified 10 common statistical mistakes that authors frequently make. Together with two academic colleagues, we present these issues in a concise, direct and accessible way to help researchers avoid them. This article will not repeat the pitfalls documented previously; rather, it reflects independent observations on statistical and presentational issues frequently made by authors across various medical fields. Ever wondered why your manuscript keeps getting rejected? It might be due to these common statistical mistakes. By highlighting these errors, we aim to save authors time with revisions and reviewers time in repeatedly...

Background Non-dilated left ventricular cardiomyopathy (NDLVC), characterised by non-ischaemic scar/fatty replacement or isolated systolic dysfunction without dilatation, lacks validated risk stratification tools. We aimed to define cardiac magnetic resonance (CMR)-based phenotypes and evaluate their association with clinical outcomes. Methods In 515 patients with NDLVC (mean age 45 (16) years), three phenotypes were classified by CMR: late gadolinium enhancement (LGE+)/H– (LGE with preserved left ventricular ejection fraction (LVEF), n=130), LGE–/H+ (hypokinesia without LGE, n=226) and LGE+/H+ (LGE with reduced LVEF, n=159). The primary endpoint was all-cause death/heart transplantation; secondary endpoints included heart failure (HF) events and malignant ventricular arrhythmia (MVA). Results Over a mean follow-up of 6.5 (1.9) years, 29 patients (5.6%) reached the primary endpoint, while 81 (15.7%) and 19 (3.7%) experienced HF and MVA, respectively. The LGE+/H+ subgroup demonstrated the highest risk for composite clinical endpoints compared with other phenotypic groups (p<0.001). Multivariable analysis identified New York Heart Association class >II (HR 3.42, 95% CI 1.58 to 7.39, p=0.002), LVEF (HR 0.91 per 1% increase, 95% CI 0.88 to 0.95, p<0.001) and LGE extent (HR 1.14 per 3% increase, 95% CI 1.07 to 1.21, p<0.001) as independent predictors of the primary endpoint, with excellent discriminative power (C-statistic 0.862). In the adjusted model, LGE extent also independently predicted HF (HR 1.11 per 3%, 95% CI 1.06 to 1.17, p<0.001). The univariable Cox regression analysis indicated LGE extent was significantly associated with MVA (HR 1.12 per 3%, 95% CI 1.02 to 1.23, p=0.021). Conclusion CMR phenotyping enables risk stratification in NDLVC. LGE extent provides an objective marker to identify high-risk patients—even with preserved ejection fraction—supporting its integration into routine evaluation.

Background Insomnia symptoms are prevalent in older adults and linked to cardiovascular disease (CVD), but the role of long-term symptom trajectories remains unclear. We investigated associations between insomnia symptoms, their trajectories over time and incident CVD in a population-based cohort. Methods This longitudinal study included 12 102 participants aged ≥50 years without baseline CVD from the US Health and Retirement Study (2002–2018). Insomnia symptoms (non-restorative sleep, difficulty initiating/maintaining sleep, early awakening) were assessed at baseline; trajectories were modelled over 4 years (2002–2006) using latent class analysis. Cox models estimated HRs for incident CVD (heart disease or stroke), adjusted for sociodemographics, lifestyle and comorbidities. Results During a median of 10.2-year follow-up, 3962 incident CVD events occurred. Compared with no symptoms, participants with one, two, or three to four symptoms had higher CVD risk (HR 1.16, 95% CI 1.05 to 1.27; HR 1.16, 95% CI 1.05 to 1.28; HR 1.26, 95% CI 1.15 to 1.38, respectively). Four trajectories were identified: persistent low (56.3%), decreasing (27.1%), increasing (7.2%) and persistent high (9.5%). Compared with persistent low, increasing (HR 1.28, 95% CI 1.10 to 1.50) and persistent high (HR 1.32, 95% CI 1.15 to 1.50) trajectories were associated with elevated CVD risk. Conclusions Greater burden of insomnia symptoms at baseline and trajectories over time were associated with higher CVD incidence in older adults.

Milestone articles have highlighted the frequency and types of statistical errors in research,1–5 yet fundamental errors persist across various disciplines. With a background in biostatistics and over 200 articles reviewed for journals such as Heart and Addiction since 2021, two differing and distinct research areas, I (DJG) have identified 10 common statistical mistakes that authors frequently make. Together with two academic colleagues, we present these issues in a concise, direct and accessible way to help researchers avoid them. This article will not repeat the pitfalls documented previously; rather, it reflects independent observations on statistical and presentational issues frequently made by authors across various medical fields. Ever wondered why your manuscript keeps getting rejected? It might be due to these common statistical mistakes. By highlighting these errors, we aim to save authors time with revisions and reviewers time in repeatedly...

Outflow tract ventricular arrhythmias (OT-VAs) are the most common type of idiopathic VAs.1 Despite their often benign clinical presentation, patients may experience symptoms that may severely impact quality of life, and, in case of high ectopic burden, OT-VA may also lead to VA–induced cardiomyopathy.2 Radiofrequency catheter ablation (RFCA) has emerged as a valuable therapeutic option for OT-VA, particularly given its high success rates and minimal complication risk. Accurate localisation of the ectopic foci—whether arising from the right ventricular outflow tract (RVOT) or left ventricular outflow tract (LVOT)—is a critical step for procedure planning and optimisation, determining essential aspects such as vascular access, anticoagulation strategy and potential procedural challenges and complications.3 4 In this regard, ECG morphology analysis serves as a simple, widely accessible and non-invasive method for estimating the site of origin. However, the close anatomical relationship between RVOT and LVOT...

Clinical introduction A 52-year-old was referred by his general practitioner with new atrial fibrillation. The patient reported 6 weeks of mild dyspnoea which was non-limiting, New York Heart Association (NYHA) class II. He had no chest pain, syncope, fevers or palpitations. Background was notable for Bentall procedure with Dacron graft and Medtronic-Hall mechanical aortic valve replacement at age 20 for severe aortic regurgitation (AR), aortic root dilatation and left ventricular (LV) dilatation. Prior echocardiography images were not available but reports indicated ‘free’ AR, severely dilated LV and normal LV ejection fraction (LVEF). He had been lost to cardiology follow-up after discharge from cardiothoracic clinic and had no subsequent imaging. He had good adherence to warfarin with International Normalised Ratio (INR) consistently within therapeutic range. He also took levetiracetam for epilepsy, though he had been seizure-free for over 10 years. Admission troponin was elevated at 3718 ng/L, NT-proBNP 12 852 pg/mL, C-reactive protein...

Since the introduction of non-dilated left ventricular cardiomyopathy (NDLVC) as a distinct clinical entity by the European Society of Cardiology (ESC) in 2023, this phenotype has been a subject of significant interest and ongoing investigation.1 Nearly 2 years on, a substantial body of evidence has been accumulated on NDLVC, contributing to a more refined understanding of the condition. However, a word of caution is warranted: current literature remains entirely retrospective. What are the implications of this? First, the available data originate predominantly from large cardiomyopathy centres, which maintain extensive long-term registries often encompassing hundreds, even thousands, of patients. Second, patients with NDLVC have typically been identified through retrospective ‘extraction’ from these databases using the newly proposed ESC diagnostic criteria. While such an approach is methodologically valid and logistically convenient, it carries inherent limitations: preselection bias (younger patients, positive family history of cardiomyopathy, severe courses and advanced structural...

Background Accurate pre-ablation differentiation between left (LVOT) and right (RVOT) ventricular outflow tract arrhythmias (OTVAs) using ECG algorithms is essential for decision on vascular access and treatment strategy. However, the most reliable ECG algorithm remains unclear. We conducted a systematic review and network meta-analysis (NMA) to compare the diagnostic accuracy of available algorithms. Methods We searched MEDLINE, EMBASE and Cochrane databases through 7 May 2025 for studies evaluating ECG algorithms against ablation-confirmed OTVA origin. A Bayesian diagnostic test accuracy NMA was performed to estimate pooled sensitivity, specificity, diagnostic odds ratios (DORs) and a superiority index (S) for each algorithm. Study quality was assessed using the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies) tool. Results From 620 records, 22 studies (3483 patients; 2706 RVOT, 777 LVOT) evaluating 21 ECG algorithms were included. The ‘Weighted hybrid score’ algorithm showed the highest diagnostic accuracy (S=21.2 (0.3, 39.0); DOR=275.8 (7.1, 1642.5)), with pooled sensitivity of 0.83 (0.53, 0.98) and specificity of 0.92 (0.68, 0.99). Conversely, the ‘Earliest onset or peak/nadir in lead V2’ algorithm had the lowest accuracy. Conclusions Among existing ECG algorithms, the ‘Weighted hybrid score’ demonstrates superior diagnostic performance for differentiating LVOT from RVOT arrhythmias and is recommended for clinical application. PROSPERO registration number CRD42024567531.

Johnson LS, Economou Lundeberg J, Wuopio J, et al. Response to: Correspondence on ‘Estimated sodium intake and premature ventricular complexes: data from the population-based Swedish CArdioPulmonary bioImage study’ by Campbell. Heart 2025;111:741–43. This letter was updated post-publication in response to editorial concerns regarding wording.

Since the introduction of non-dilated left ventricular cardiomyopathy (NDLVC) as a distinct clinical entity by the European Society of Cardiology (ESC) in 2023, this phenotype has been a subject of significant interest and ongoing investigation.1 Nearly 2 years on, a substantial body of evidence has been accumulated on NDLVC, contributing to a more refined understanding of the condition. However, a word of caution is warranted: current literature remains entirely retrospective. What are the implications of this? First, the available data originate predominantly from large cardiomyopathy centres, which maintain extensive long-term registries often encompassing hundreds, even thousands, of patients. Second, patients with NDLVC have typically been identified through retrospective ‘extraction’ from these databases using the newly proposed ESC diagnostic criteria. While such an approach is methodologically valid and logistically convenient, it carries inherent limitations: preselection bias (younger patients, positive family history of cardiomyopathy, severe courses and advanced structural...

Background Baseline health and driving data might allow clinicians to personalise medical driving restrictions after implantable cardioverter-defibrillator (ICD) implantation. Methods Using 22 years of population-based administrative data from British Columbia, Canada, we identified licensed drivers with a first ICD implantation between 1998 and 2018. After stratifying by ICD indication (primary vs secondary prevention of sudden cardiac death), we used baseline health and driving data and logistic regression to estimate each driver’s 1-year crash risk. We assessed optimism-corrected discrimination and calibration of the final model using 200 bootstrapped samples. Results In the first year after implantation, there were 352 crashes among 3652 primary prevention ICD recipients and 270 crashes among 3408 secondary prevention ICD recipients. Crash prediction models exhibited poor discrimination (c-statistics 0.60 and 0.61, respectively) but good calibration (calibration slopes 1.14 and 1.07). The strongest predictors of crash among primary prevention ICD recipients were male sex, active vehicle insurance in the past year and the number of crashes in the past year. The strongest predictors of crash among secondary prevention ICD recipients were male sex, no history of seizure, an active prescription for opioids and active vehicle insurance in the past year. Conclusions Crash prediction models based on health and driving data had a limited ability to distinguish individuals who subsequently crashed from individuals who did not. Observed crash risks are likely to be strongly influenced by unobserved changes in road exposure (the hours or miles of driving per week), limiting the application of these risk scores by clinicians and policy-makers.

Background Bicuspid aortic regurgitation (AR) is common in younger patients who often do not meet guideline-based criteria for aortic valve (AV) surgery at diagnosis. However, identifying early predictors of disease progression may aid in risk stratification and surgical timing. Methods From a single-centre registry of 1927 patients with bicuspid AV, we identified 335 patients with moderate or severe AR, excluding those with severe aortic stenosis (AS), endocarditis or other major valvular diseases. Among them, 199 patients (mean age 52±14.0 years; 80% male) did not initially meet the surgical criteria and were included in the final analysis. Clinical data and echocardiographic parameters, including speckle-tracking-derived strain measurements, were analysed. The primary outcome was progression to AV surgery during follow-up. Results Over a mean follow-up of 4.9 years, 41 patients (21%) underwent AV surgery, primarily for symptom onset or left ventricular (LV) enlargement. In multivariable Cox regression, three independent predictors of future surgery were identified: LV mass index ≥113 g/m² (HR 4.49, 95% CI 1.74 to 11.6, p=0.002), left atrial (LA) reservoir strain <28% (HR 3.07, 95% CI 1.40 to 6.74, p=0.005) and concomitant moderate AS (HR 3.19, 95% CI 1.40 to 7.28, p=0.006). Conclusion In patients with significant bicuspid AR who do not initially meet indications for AV surgery, increased LV mass index, impaired LA reservoir strain and concomitant moderate AS are early predictors of surgical progression. These parameters may enhance surveillance strategies and inform earlier surgical referral in selected patients.

Robin Bouleau<br />Jan 1, 2026; 112:21-27<br />Arrhythmias and sudden death

Amir Zaghi<br />Dec 23, 2025; 0:heartjnl-2025-326503v2-heartjnl-2025-326503<br />Heart failure and cardiomyopathy

Waqas Akhtar<br />Dec 18, 2025; 0:heartjnl-2025-326896v1-heartjnl-2025-326896<br />Consensus statement

Ziyi Xie<br />Dec 9, 2025; 0:heartjnl-2025-326413v1-heartjnl-2025-326413<br />Cardiac risk factors and prevention

Mengmeng Chen<br />Dec 9, 2025; 0:heartjnl-2025-326443v1-heartjnl-2025-326443<br />Valvular heart disease

Mustafa Eray Kilic<br />Dec 1, 2025; 111:1175-1183<br />Systematic review

David Kylhammar<br />Oct 1, 2025; 111:904-909<br />Aortic and vascular disease

Peter S Sever<br />Aug 1, 2025; 111:769-775<br />Cardiac risk factors and prevention

William A E Parker<br />Aug 1, 2025; 111:753-762<br />Reviews

Qian Zhang<br />Jul 1, 2025; 111:662-670<br />Reviews