Lydia Miletic MD MSc 🇬🇷🇸🇪🇷🇸

Cardiologist. Cardiovascular physiology. Echocardiography & Cardiac MRI

[Peter Blahut @PeterBlahut]

🫀 Pulmonary vein anatomy is more variable than many clinicians realize.

Pulmonary veins are not only an anatomical structure—they represent the principal arrhythmogenic region in atrial fibrillation, harboring approximately 85% of AF triggers and 50% of the arrhythmogenic substrate. ⚡

📊 Common anatomical variants include:
🔹 Four separate pulmonary veins (70%)
🔹 Left common pulmonary vein trunk (30%)
🔹 Right middle pulmonary vein (20%)
🔹 More than four pulmonary veins (10%)
🔹 Right common pulmonary vein trunk (5%)
🔹 Other variants (5%)

Recognition of these anatomical patterns is essential for accurate imaging interpretation, procedural planning, and successful pulmonary vein isolation. 🎯

📖 Full AF guidelines (2026) 👉 https://t.co/YiCSHVTZ3y

#cardiology #medicaleducation #paramedic #MedstudentTwitter #CardioTwitter #FOAMed #MedEd #CardioEd #AFib #EPeeps

[Carlos El-Tallawi, MD, FACC, FASE @HeartToProve]

Severe TR with IVC/HV systolic flow reversal

[EHJ-IMP Editor-in-Chief @EHJIMPEiC]

📄 Can CT + AI improve the diagnosis of Marfan and Loeys-Dietz syndromes?
🔗 DOI: https://t.co/rqUJN463Zm
🧠 Diagnosing heritable thoracic aortic diseases (HTAD) remains challenging—especially when classical criteria are inconsistent or delayed.
This study introduces a machine learning–based CT approach to redefine dural ectasia (DE) and improve diagnostic accuracy.
✨ Why this matters:
👉 Dural ectasia is part of the Ghent criteria, but:
❗ No standardized definition
❗ Poor specificity
❗ Limited diagnostic value in practice
✨ Study highlights:
📊 Cohort:
93 Marfan patients (FBN1 variants)
Loeys-Dietz cohorts (TGFBR1/2, SMAD3)
Matched controls
🔍 Key innovation:
👉 A machine learning algorithm based on just:
✔ 3 vertebral levels (L1, L2, S1)
✔ 4 simple CT measurements:
Spinal canal diameter
Vertebral scalloping
➡️ Designed for accuracy + clinical usability
📈 Results:
🔹 Conventional DE criteria → poor performance
➡️ AUC ≈ 0.68
🔹 New ML-based criteria:
➡️ AUC 0.84 for Marfan
➡️ Accuracy up to 94%
➡️ Outperformed modified Ghent criteria
🔹 Also effective for Loeys-Dietz:
➡️ AUC 0.83 (TGFBR1/2)
➡️ AUC 0.80 (SMAD3)
💡 Clinical implications:
👉 A simple CT scan (already done for aorta evaluation) can now:
✔ Improve early diagnosis
✔ Reduce reliance on delayed genetic testing
✔ Enable earlier referral and management
🚀 Bonus:
👉 A user-friendly online tool provides probability of diagnosis based on CT measurements
🚨 Bottom line:
Machine learning transforms dural ectasia from a weak criterion into a powerful, practical diagnostic tool for Marfan and related syndromes.
#Cardiology #CardiacImaging #CT #ArtificialIntelligence #MarfanSyndrome #LoeysDietz #Aortopathy #PrecisionMedicine #MedicalInnovation 🧠🫀📊

[Julia Grapsa @JGrapsa]

Our ESC Clinical Consensus Statement on Women’s Heart Centres is published in @EurHeartJ merging 4 associations @EACVIPresident @EAPCIPresident @HFA_President @ACVCPresident

Link ➡️ https://t.co/xLwBaHexh9

ESC press release ➡️ https://t.co/SAjnOuePpZ

This is the first statement to define what a Women’s Heart Centre actually is: its structure, its team, its referral pathways, and the training standards clinicians need to lead one.

The problem: CVD is the #1 killer of women. Yet women face systematic delays in diagnosis and treatment and the conditions most likely to affect them (INOCA, MINOCA, pregnancy-related CVD) remain underdiagnosed everywhere.

Our solution: hub-and-spoke Women’s Heart Centres, embedded in existing CV systems, not parallel structures. Advanced diagnostics, multidisciplinary care, research coordination.

For the first time we define:
✅ The nucleus clinical team
✅ Adjunct specialties (cardio-obstetrics, oncology, rheumatology, psychology and more)
✅ Core vs advanced competencies
✅ A pathway toward subspecialty certification

We also set milestones for national and institutional adoption.

This has been a Herculean effort and an important task to lead this document with enormous gratitude to senior author @DrMarthaGulati for her mentorship and friendship - really grateful to @Drroxmehran @rafavidalperez @mmamas1973 @HeartDocSharon @Bharatishivalka @PrSusannaPrice1 @Cosyns @VictoriaDe32503 @d_trabattoni @Marta33717088 @ARakisheva @yappelman @mirvatalasnag @lesleejshaw @alessia_gimelli

#WomensHealth
#Cardiology
#WomensHeartDisease
#CardioTwitter
#ESC
#EACVI
#HeartDisease
#WomensHeartCentre
#CVD
#CardioEd

[EHJ-IMP Editor-in-Chief @EHJIMPEiC]

📄 4D-flow CMR meets diastology: can we finally assess E/e′ with MRI?
🔗 DOI: https://t.co/RH5Q07U7FM
🫀 Diastolic dysfunction (DD) is a key early marker of heart disease—but CMR has traditionally struggled to assess it.
This study introduces a novel solution:
👉 CMR-derived 4D-flow E/e′ for biventricular diastolic function assessment
✨ What’s new?
👉 Combines:
✔ 4D-flow transvalvular velocity (E)
✔ CMR-derived tissue velocity (e′)
➡️ Recreating the classic echo parameter (E/e′) using MRI
📊 As shown in the graphical abstract (page 2):
👉 simultaneous evaluation of LV + RV diastolic function
✨ Study at a glance:
🔹 132 participants
75 healthy controls
57 CVD patients
🔹 Full biventricular assessment with 4D-flow + strain/annular motion
✨ Key findings:
📈 4D-E/e′ is higher in CVD patients
➡️ reflecting impaired relaxation
📊 Excellent diagnostic performance:
➡️ LV DD detection: AUC ~0.90
📌 Best method:
👉 annular velocity–based e′
📉 Hidden disease uncovered:
👉 Among patients WITHOUT prior diastolic assessment:
➡️ 71% had abnormal LV diastolic function
➡️ 61% had abnormal RV diastolic function
⚠️ A major proportion of DD is currently missed in clinical practice
📊 Strong validation vs echocardiography:
✔ E velocity: r = 0.81
✔ E/e′: r = 0.77
➡️ As shown in Figure 3 (page 6):
👉 strong correlation with echo
🧠 Why this matters:
👉 CMR already performed in many patients
➡️ Now it can also provide:
✔ diastolic function assessment
✔ biventricular evaluation
✔ detection of early/subclinical disease
⚡ Key innovation:
👉 First robust demonstration of:
integrated flow + tissue metric (4D-E/e′) using CMR
➡️ Overcomes limitations of:
❗ 2D flow
❗ static imaging planes
💡 Clinical take-home message:
👉 CMR is no longer “systolic-only”
✔ 4D-flow enables comprehensive haemodynamic assessment
✔ Can detect undiagnosed diastolic dysfunction
🚨 Bottom line:
4D-flow CMR brings echocardiographic E/e′ into MRI—unlocking a new era of full functional cardiac assessment.
#Cardiology #CMR #4DFlow #DiastolicDysfunction #HeartFailure #CardiacImaging #EoverEprime #PrecisionMedicine #DigitalHealth 🫀📊

[Ritika Tuli @RitikaTuliMD]

#CardioNuggets™

Microvascular obstruction (MVO)

After a STEMI, restoring epicardial flow with PCI doesn’t always mean true myocardial reperfusion. In >40% of reperfused MIs, the downstream coronary microcirculation is damaged/plugged by:

• distal embolization of thrombus/plaque
• endothelial swelling
• inflammation & edema
• capillary destruction

➡️ Result: blood can’t adequately enter the infarcted myocardium despite a patent epicardial artery (“no-reflow phenomenon”).

Why it matters:
MVO is a marker of severe reperfusion injury and predicts:
• larger infarct size
• adverse LV remodeling
• lower EF recovery
• HF admissions
• ventricular arrhythmias
• higher mortality

How is it diagnosed?
🩺 Angio clues: slow/no-reflow despite open vessel (↓TIMI myocardial perfusion grade)
🫀 Echo: poor myocardial contrast replenishment on myocardial contrast echo
📍Gold standard = Cardiac MRI
• seen as a dark hypoenhanced core within bright late gadolinium enhancement infarcted tissue
• early MVO = first-pass perfusion defect
• late MVO = persistent dark core on LGE images

High-yield pearl:
A patient can have TIMI 3 flow after PCI and still have major myocardial injury because the microvasculature never truly reperfused.

#CardioNugget #MedEd

Image source: https://t.co/vcgvUTP00s

[Scholarship for PhD @ScholarshipfPhd]

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[American College of Cardiology @ACCinTouch]

🫀 SPIRIT-HF at #ACC26: Spironolactone, an aldosterone blocker, compared with placebo, did not show any significant improvement in terms of HF hospitalizations and cardiovascular death at 24 months in patients with #HFpEF or #HFmrEF.

See the results ➡️ https://t.co/OVTyBhYHfM

[AHA Science @AHAScience]

Key updates to this guideline include:

➡️ The use of the American Heart Association PREVENT-ASCVD equations to guide primary-prevention and lipid-lowering therapy decisions.
➡️ Testing Lp(a) at least once in a lifetime and selective apolipoprotein B measurement to improve risk assessment and guide treatment
➡️ The return of LDL-C and non-high-density lipoprotein cholesterol treatment goals (with lower targets for higher-risk groups)
➡️ Expanded use of coronary artery calcium scoring to reclassify risk[ME1.1]

✍🏼 @rblument1 @tygluckman @RonBlankstein @PamelaBMorris @pnatarajanmd @AnnMarieNavar @SethShayMartin @APRN_CNS @nyulangone @DrMichaelShapir @kgradneyrd @eugeniagianos @virani_md @KellieMcLain1 @ijeomaheartdoc @SamiaMoraMD @DrHeatherJohn @dmljmd

[Pradeep Natarajan @pnatarajanmd]

Very honored to write this review on the genetics of coronary artery disease with Prof H. Schunkert and Sir N. Samani https://t.co/ztgKCcbpkO @NEJM

[Daniel Lorenzatti, MD. @danilorenzatti]

@EACVIPresident @iamritu Classic RAC sign. https://t.co/WiYlAHMeNO

[RTHahnMD @hahn_rt]

New Balloon-Expandable Valve! #DURAVR
https://t.co/uEIqGiCUl7 Changing the discussion of Small annulus AS? @EuroInterventio #EuroPCR @EAPCIPresident @escardio @ACCinTouch

[RTHahnMD @hahn_rt]

Two of our @Columbia @HeartValveCntr studies led by Robin LeRUZ made the impactful #tricuspid regurgitation papers list by PCR!! Great overview by @PCRonline! @JACCJournals @ACCinTouch @escardio @Europace

[Harriette Van Spall, MD MPH 🇨🇦 @hvanspall]

Among patients with acute #HF in the #CLOROTIC #RCT

💠 #Diuretic resistance -> worse outcomes

💠#Hydrochlorthiazide effect on weight loss was consistent across categories of diuretic resistance

Trial led by @jc_trullas, subanalysis by Ambarish Pandey

https://t.co/gkQAoZClIV

[Dr. Filippo Cademartiri @FCademartiri]

🫀🔥 Post–Cardiac Injury Syndrome (PCIS): a true paradigm shift in care

This 2025 JACC: Advances State-of-the-Art Review reframes post–cardiac injury syndrome (PCIS) as a modern, increasingly relevant inflammatory disease—no longer a rare post-MI curiosity, but a frequent consequence of today’s cardiac procedures .

🧩 What is PCIS today?
PCIS includes:
🫀 Post–myocardial infarction syndrome (Dressler)
🩺 Post-pericardiotomy syndrome (PPS)
🧷 Post-traumatic / iatrogenic pericarditis

With the explosion of cardiac surgery, PCI, device implantation, and ablation, PPS and post-traumatic pericarditis now dominate—while classic Dressler syndrome has become rare.

🧠 Pathophysiology: inflammation at the core
PCIS is driven by an autoinflammatory immune response triggered by myocardial or pericardial injury:
DAMPs → NF-κB activation
NLRP3 inflammasome → IL-1α / IL-1β releaseThis explains why targeted anti–IL-1 therapies work in refractory disease.
🖥️ Diagnosis: imaging changes everything

Symptoms and biomarkers are nonspecific. The real shift is multimodality imaging:
🩻 Echo → effusions, hemodynamics
🖥️ CT → pericardial thickness, effusion characterization
🧲 CMR (game-changer) → edema + LGE = active inflammation
CMR enables diagnostic confidence, phenotyping, and therapy guidance.

💊 Treatment: from empiric to precision

First line: NSAIDs + colchicine
Steroids: selective use only
🚀 Refractory cases: IL-1 inhibitors (anakinra, rilonacept)
Emerging oral agents targeting NLRP3 are on the horizon
⚠️ Key limitations

Access to CMR and biologics is uneven; costs and equity remain major barriers.
🔮 Bottom line

PCIS care is shifting from symptom-based treatment to imaging-guided, mechanism-based precision medicine.
Less guessing. More biology. Better outcomes.

[Dr. Filippo Cademartiri @FCademartiri]

🫀🔥 Acute myocarditis in daily practice: what clinicians really need to know

This 2025 European Heart Journal – Acute Cardiovascular Care expert review offers a rare, practical roadmap for managing acute myocarditis (AM)—a condition that remains highly heterogeneous, unpredictable, and frustratingly evidence-poor .

🧠 Why myocarditis is so challenging
Acute myocarditis is not one disease but a spectrum: from mild, self-limiting chest pain to fulminant cardiogenic shockin young patients. Despite advances in imaging, virology, and genetics, specific therapies are still largely lacking, and management relies heavily on expert judgment.

🏥 First decision: who needs hospital care—and where?
Risk stratification is key:
⚠️ High-risk features (shock, ventricular arrhythmias, AV block, severe LV dysfunction) → Level 3 CICU
🟡 Intermediate risk → Level 2 monitoring
🟢 Truly low risk → short observation or ward care

The review strongly advocates for a multidisciplinary “myocarditis team”, especially in unstable patients.

🖥️ Imaging hierarchy
Echo → first-line for function and complications
CMR → gold standard for diagnosis (updated Lake Louise criteria) and prognosis
Coronary angiography / CCTA → essential to rule out ACS
PET & spectral CT → emerging tools for complex cases

🧪 Endomyocardial biopsy: when it matters
EMB is not routine, but crucial in:
fulminant or recurrent myocarditis
persistent LV dysfunction
suspected eosinophilic, giant cell, or immune checkpoint inhibitor–related forms

💊 Treatment: less certainty than we’d like
Supportive HF therapy is central
Immunosuppression is not routine—reserved for selected phenotypes
Mechanical circulatory support can be lifesaving as a bridge to recovery

🏃 Discharge & activity
Exercise restriction for 3–6 months is advised, especially if LGE or LV dysfunction persists—though evidence remains weak.

🔮 Bottom line
Acute myocarditis demands early recognition, structured triage, team-based care, and humility about evidence gaps.
Until RCTs deliver answers, expert-driven, phenotype-based management remains the best tool we have 🧭

[Dr. Filippo Cademartiri @FCademartiri]

🫀🧠 HFpEF is not just “diastolic dysfunction”: the microcirculation is the missing link

This 2025 JACC: Advances state-of-the-art review reframes heart failure with preserved ejection fraction (HFpEF)through a crucial, often underrecognized lens: coronary microvascular dysfunction (CMD) .

📊 How common is CMD in HFpEF? Very.
Up to 75% of HFpEF patients—even without obstructive coronary disease—have CMD. And this is not an innocent bystander:
CMD is independently associated with higher HF hospitalizations
Increased mortality and MACE
Worse quality of life

Yet, CMD is rarely sought and even more rarely diagnosed in routine HFpEF care.

🧠 Why CMD matters pathophysiologically
CMD disrupts the heart at multiple levels:
🔻 Reduced coronary flow reserve (CFR) → subendocardial ischemia
🔥 Microinfarctions & fibrosis → stiff myocardium
⚙️ Impaired cardiac–coronary coupling → blunted flow during stress
🧬 Inflammation & endothelial dysfunction → vicious cycle of ischemia and diastolic failure

HFpEF and CMD reinforce each other in a bidirectional loop, rather than a simple cause–effect relationship.

👩‍⚕️ A sex-specific disease
Women are disproportionately affected:
Higher CMD prevalence
Smaller coronary vessels, higher resting flow
Postmenopausal estrogen loss → inflammation, fibrosis, reduced CFR

This helps explain why HFpEF is more common and more complex in women.

🧪 Diagnosis: we’re under-testing
CMD can be assessed by:
PET or CMR perfusion
Invasive coronary functional testing (CFR, IMR, acetylcholine)

But there is no standardized diagnostic pathway in HFpEF—yet.

💊 Therapy: signals, not solutions
Some treatments show promise (SGLT2i, statins, RAAS modulation, lifestyle, GLP-1/GIP agonists), but no therapy specifically targets CMD in HFpEF so far.

🔮 Bottom line
HFpEF is not only a myocardial disease—it’s a microvascular disease.
If we keep ignoring CMD, we will keep failing HFpEF patients.

👉 Understanding and treating HFpEF may finally require looking beyond the ventricle—into the microcirculation.

[EHJ-IMP Editor-in-Chief @EHJIMPEiC]

#EHJIMP 🫀 📊 Severe AS significantly alters supra-aortic blood flow velocities on duplex ultrasound. Findings suggest that carotid ultrasound velocity thresholds may underestimate internal carotid artery stenosis severity in patients with concomitant aortic stenosis. https://t.co/MUfnUvHoq1

[EHJ-IMP Editor-in-Chief @EHJIMPEiC]

#EHJIMP ⏳✨
–7 | End-of-year countdown of the most cited articles 📉📚

On Christmas Day at number 5, another highly influential article that has made a strong impact in cardiovascular imaging, contributing to scientific progress and clinical practice 🫀🖥️📈

🔗 DOI: 10.1093/ehjimp/qyaf054

#CardiovascularImaging #TopCited #ScientificImpact #HeartImaging #Echo #CMR #CardiacCT #ResearchHighlights #EndOfYearCountdown ✨

[Πολεμικό Ναυτικό @NavyGR]

📍 Lorient France

🗓️ 18 Δεκ 25

Φρεγάτα ΚΙΜΩΝ
F 601
🇬🇷⚓🍾

🔗 https://t.co/tuNvyBbxry

#hellenicnavy #hellenic #navy