The central role of amygdala in stress-related cardiac diseases and an update on long-COVID.

This Focus Issue on imaging contains a Special Article co-published with JACC entitled ‘Valve Academic Research Consortium 3: updated endpoint definitions for aortic valve clinical research’, authored by Martin Leon from the Columbia University Medical Center in New York, USA, and colleagues. The authors note that the Valve Academic Research Consortium (VARC), founded in 2010, was intended to identify appropriate clinical endpoints and standardize definitions of these endpoints for transcatheter and surgical aortic valve clinical trials. Rapid evolution of the field, including the emergence of new complications, expanding clinical indications, and novel therapy strategies, has mandated further refinement and expansion of these definitions to ensure clinical relevance. Thus, several years after the publication of the VARC-2 manuscript, an in-person meeting was held involving >50 independent clinical experts representing several societies, academic research organizations, the US Food and Drug Administration (FDA), and industry representatives to evaluate utilization of VARC endpoint definitions in clinical research, discuss the scope of this focused update, and review and revise specific clinical endpoint definitions. A writing committee of independent experts was convened and subsequently met to further address outstanding issues. There were ongoing discussions with the FDA and many experts to develop a new classification schema for bioprosthetic valve dysfunction and failure. Overall, this multidisciplinary process has resulted in important recommendations for data reporting, clinical research methods, and updated endpoint definitions. New definitions or modifications of existing definitions are being proposed for repeat hospitalizations, access siterelated complications, bleeding events, conduction disturbances, cardiac structural complications, and bioprosthetic valve dysfunction and failure (including valve leaflet thickening and thrombosis). A more granular five-class grading scheme for paravalvular regurgitation (PVR) is being proposed to help refine the assessment of PVR. Finally, more specific recommendations on quality-of-life assessments have been included, which have been targeted to specific clinical study designs (Figure 1). The adoption of these updated and newly proposed VARC-3 endpoints and definitions will ensure homogenous event reporting, accurate adjudication, and appropriate comparisons of clinical research studies involving devices and new therapeutic strategies. In another Special Article entitled ‘Coronavirus disease 2019 in adults with congenital heart disease: a position paper from the ESC working group of adult congenital heart disease, and the International Society for Adult Congenital Heart Disease’, Gerhard-Paul Diller from the University Hospital Münster in Germany, and colleagues note that we are witnessing an unparalleled pandemic caused by a novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) associated with coronavirus disease 2019 (COVID-19). Current data show that SARS-CoV-2 results in mild flu-like symptoms in the majority of healthy and young patients affected. The severity of COVID-19 respiratory syndrome and the risk of adverse or catastrophic outcomes are increased in patients with pre-existing cardiovascular disease. Adult congenital heart disease (ACHD) patients—by definition—have underlying cardiovascular disease. Many ACHD patients are also afflicted with residual haemodynamic lesions such as valve dysfunction, diminished ventricular function, arrhythmias, or cyanosis, have extracardiac comorbidities, and face additional challenges regarding pregnancy. Currently, there are emerging data of the effect of COVID-19 on ACHD patients, but many aspects, especially risk stratification and treatment considerations, remain unclear. In this contribution, the authors discuss the broad impact of COVID-19 on ACHD patients, focusing specifically on pathophysiology, risk stratification for work, self-isolation, hospitalization, impact on pregnancy,