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Background/Objectives: Twiddler’s syndrome is an uncommon but clinically important complication of implantable cardiac devices, in which generator rotation within the pocket results in lead torsion, lead retraction, and device malfunction. Recurrence can necessitate repeated surgical intervention and may be preventable through early risk identification and procedural strategies. Methods: We describe a single-centre case series of three female patients with pacemaker-associated Twiddler’s syndrome. Clinical presentation, timing of lead retraction, management strategies (including pocket location and fixation approach), recurrence, and follow-up outcomes were reviewed. Results: All patients were older women and developed symptomatic device failure early after implantation, with radiographic confirmation of lead retraction and coiling occurring within three weeks in all cases. Recurrence was observed when enhanced preventive measures were not employed. Notably, in one patient, recurrence occurred after an initial revision in a second prepectoral pocket, prompting subsequent reimplantation in a subpectoral location with reinforced fixation and structured patient and family counselling, after which no further recurrence occurred at one year. In the remaining cases, revision with reinforced generator fixation and counselling was associated with stable lead position and satisfactory device function during follow-up. Conclusions: Twiddler’s syndrome most commonly presents in the first weeks following implantation. Proactive identification of at-risk patients and consideration of reinforced fixation and pocket strategies at the index procedure may reduce recurrence and avoid repeat interventions. Full article

Background: Left ventriculo-arterial coupling (VAC) integrates the interaction between left ventricular contractility and the arterial system, representing a key determinant of cardiovascular efficiency. In rapidly changing hemodynamic states such as septic or cardiogenic shock, conventional indices of pressure or flow alone may be misleading. VAC provides a unified physiological framework to assess global cardiovascular performance and guide therapy. Objective: To review the physiological foundations, bedside assessment, and therapeutic applications of VAC in critically ill patients with rapidly fluctuating circulatory conditions. Methods and Content: The article revisits the underlying principles of VAC, expressed as the ratio between arterial elastance (Ea) and end-systolic elastance (Ees), and discusses their derivation from the pressure–volume relationship. Practical echocardiographic methods for bedside estimation, including the non-invasive single-beat approach, are outlined with illustrative figures. The review further examines how VAC patterns evolve in sepsis, cardiogenic shock, and heart failure and how this integrative index clarifies paradoxical responses to vasoactive and inotropic therapies. Specific therapeutic phenotypes are proposed according to Ea/Ees profiles, providing a structured approach to optimise coupling and restore circulatory efficiency. Summary: VAC offers a physiology-based perspective on cardiovascular performance, enabling clinicians to interpret complex hemodynamic changes beyond traditional measures of ejection fraction or mean arterial pressure. Its dynamic tracking may refine the assessment of therapeutic trajectories and improve bedside decision-making. Conclusions: By integrating ventricular and arterial function into a single measure, VAC bridges cardiovascular physiology and clinical practice. Its incorporation into routine critical care monitoring could enhance individualised hemodynamic management and serve as a foundation for future outcome-driven studies. Methodology: This narrative review was conducted using a structured literature search to ensure comprehensive coverage of contemporary evidence regarding ventriculo-arterial coupling (VAC) in critical care and shock states. A systematic search of PubMed/MEDLINE, Embase, and Scopus databases was performed from database inception through October 2025. The following key search terms were used: “ventriculo-arterial coupling”; “arterial elastance”; “end-systolic elastance”; “Ea/Ees”; “pressure–volume loops”; “septic shock”; “cardiogenic shock”; “critical care echocardiography”; “point-of-care ultrasound”; “mechanical circulatory support”. Reference lists of relevant articles, review papers, and consensus documents were also manually screened to identify additional pertinent studies. Only English-language publications were included. Both seminal foundational studies and recent contemporary investigations were reviewed to provide historical context and up-to-date clinical applicability. Full article

Background: Atherosclerotic cardiovascular disease (ASCVD) is one of the most important causes of morbidity worldwide. Registries show an impressive decline in prevalent ASCVD morbidity over the last years. Whether this decline is due to the improvement in treatment options for ASCVD or whether we are also able to prevent first ASCVD events is still unknown. Methods: A nationally representative real-world data longitudinal prescription (LRx) database (IQVIA) was used over a period from 2008 to 2019. All patients ≥20 years were included from the moment they had been prescribed ASCVD medication. The primary outcome was the standardized incidence of first ASCVD events among men and women of different age groups. The secondary outcome of this study was to identify comorbidities in the year 2019. Results: The prescription data on 296.050 individuals were analyzed, and the results indicate the standardized cumulative incidence (%) among women of first ASCVD event prescriptions. This rise in incidence was most pronounced for young women (women 20–39 yr: + 109.46%). The comorbidity analysis indicated that, e.g., thyroid hormones were significantly more often prescribed in the young patients with a first ASCVD event than in those patients without ASCVD events. Conclusions: Prescriptions for the first ASCVD event increased over a period of 12 years among young women. This study suggests that although ASCVD as a whole has decreased over time, this does not seem to be the case for first ASCVD events and that young women are particularly affected. Full article

Background/Objectives: Transcatheter edge-to-edge repair (TEER) has become an established therapeutic option for selected patients with mitral regurgitation (MR). However, primary (degenerative) and secondary (functional) MR represent distinct disease entities, characterized by different pathophysiological mechanisms, clinical trajectories, and determinants of benefit. This review aims to provide an interventional cardiology-oriented synthesis of TEER, emphasizing the fundamental differences between primary and secondary MR and their implications for patient selection, procedural strategy, and outcome interpretation. Methods: A targeted literature search was performed in PubMed and Embase to identify pivotal randomized trials, registries, guideline documents, and high-quality reviews addressing TEER in MR. The available evidence was synthesized narratively, with a focus on mechanistic insights, TEER-specific imaging and procedural endpoints, and clinically relevant outcomes. Results: In primary MR, TEER functions as a valve-centered therapy, with procedural success primarily determined by anatomical suitability and the balance between durable MR reduction and avoidance of elevated transmitral gradients. In secondary MR, TEER should be considered an adjunctive intervention within a comprehensive heart failure strategy, with benefit dependent on patient phenotype, myocardial substrate, optimization of background therapy, and appropriate timing. Emerging phenotypes, such as atrial functional MR, further challenge traditional classification and highlight the need for mechanism-based selection. Across MR subtypes, residual MR and transmitral gradients emerge as key post-procedural endpoints with differential prognostic implications. Conclusions: TEER represents a phenotype-specific intervention rather than a uniform solution for MR. Recognizing the distinct interventional paradigms of primary and secondary MR is essential to optimizing patient selection, procedural decision-making, and clinical outcomes. Full article

We present the case of a 27-year-old woman diagnosed with Löffler’s endomyocarditis complicated by intraventricular thrombus and cerebral infarction. She was treated with prednisolone and anticoagulation therapy; however, tapering of corticosteroids resulted in recurrence of intraventricular thrombosis. Given disease relapse after medication withdrawal, lifelong anticoagulation was indicated. At 29 years of age, she sought pregnancy counseling. Conception was permitted after stabilization of prednisolone dosage, with a planned switch from a vitamin K antagonist to therapeutic-dose unfractionated heparin during pregnancy. Following disease stabilization, she conceived via artificial insemination. Serial echocardiography at 22 and 34 weeks of gestation demonstrated preserved cardiac function without thrombus recurrence. She delivered a healthy infant by emergency cesarean section at 39 weeks of gestation due to fetal distress. No thrombus recurrence was observed postpartum, and she remained clinically stable during 13 months of follow-up. This represents the case of a successful pregnancy in a woman with a history of recurrent intraventricular thrombosis due to Löffler’s endomyocarditis, highlighting the importance of early diagnosis, sustained immunosuppression, individualized anticoagulation, and multidisciplinary preconception planning. Full article

“Pinch-Off Syndrome,” first described by Hinke, is a mechanical complication of totally implantable central venous catheters inserted via subclavian venous access. It occurs when the catheter is compressed between the clavicle and the first rib. Compression can cause transient catheter obstruction and may result in rupture or even complete resection and embolization of the catheter. In this case report, we describe our experience of percutaneous transvenous removal of an embolized port-a-cath fragment within the right heart chambers following a rupture. We used the “retrieval snare” technique and subsequent reimplantation through internal jugular access. The intervention occurred in the same session and involved a multidisciplinary team for a 55-year-old man in need of adjuvant chemotherapy. Full article

Biventricular Takotsubo cardiomyopathy (TCM) is a rare variant characterized by involvement of both the left and right ventricles. This variant is associated with greater hemodynamic instability and longer hospital stays compared to the isolated left ventricular-only variant. We report the case of a 67-year-old female patient who underwent elective resection of a left adrenal adenoma. While her preoperative and intraoperative courses were uneventful, she developed cardiogenic shock postoperatively, necessitating prolonged intensive care unit (ICU) management and vasopressor support. Further evaluation revealed elevated high-sensitivity troponin levels and reduced ejection fraction on echocardiography (30–35%). Hypokinesis was noted in the apical and mid-ventricular segments of both ventricles. A coronary angiogram performed two months prior to admission showed no significant coronary artery disease. Based on these findings, a diagnosis of biventricular TCM was established. The patient was managed supportively and discharged in stable condition with ongoing therapy, including beta-blockers, renin–angiotensin–aldosterone system inhibitors (RAASis), and statins. Follow-up echocardiography showed resolution of regional wall motion abnormalities. Although rare, biventricular TCM is associated with increased severity and a higher risk of complications. Early recognition and timely management are essential to improve outcomes in affected patients. Full article

The role of cardiac implantable electronic devices (CIEDs), including implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT) devices, in patients supported with left ventricular assist devices (LVADs) remains controversial. Although ICDs clearly reduce the risk of sudden cardiac death (SCD) and improve outcomes in advanced heart failure (HF), their benefit in patients with continuous-flow mechanical circulatory support is less certain. Initial small studies involving LVAD patients, particularly those with older pulsatile devices, suggested that ICDs confer a survival benefit during LVAD support. However, more recent evidence has been inconsistent. Some studies show modest protection against arrhythmic death, whereas others show no improvement in overall mortality. Similarly, CRT does not appear to offer significant additional hemodynamic benefits after LVAD implantation, and current evidence does not strongly support its routine continuation. Device-related complications—including lead failure, infection, electromagnetic interference, and inappropriate shocks—are major clinical concerns that can offset potential benefits. Accordingly, current guidelines recommend maintaining pre-existing ICD or CRT devices in LVAD patients but do not endorse the routine implantation of new devices after LVAD placement. The existing evidence highlights the need for a nuanced and individualized approach to CIED therapy in patients with LVAD. Future research should focus on randomized trials, registry-based analyses, and the exploration of novel technologies such as leadless pacing, subcutaneous ICDs, and advanced programming algorithms. Patient-centered outcomes, particularly quality of life and ethical considerations—such as ICD deactivation in end-of-life scenarios—must be considered in decision-making in this evolving field. Full article

Background: This study investigates the impact of engagement with online health platforms (OHPs), perceived treatment effectiveness, and country of residence on patient attitudes toward atrial fibrillation (AF) treatments, mediated by threat perception and behavioral evaluation within an adapted Health Belief Model (HBM). Methods: A cross-sectional survey conducted in June 2024 included 589 members of two professionally curated OHPs: the AFIP Foundation (Amsterdam, The Netherlands) and StopAfib.org (Decatur, United States). Data were analyzed using Structural Equation Modeling (SEM) to examine both direct and indirect relationships among engagement behaviors, perceived treatment effectiveness, country of residence, and patient attitudes toward AF treatments (PAAT). Results: Results indicate that higher engagement (i.e., frequency of OHP visits and time spent on the OHP) positively predicts more favorable PAAT, whereas the number of content types consumed showed no significant mediating effect via threat perception or behavioral evaluation. Conclusions: By increasing awareness of AF and reinforcing the perceived effectiveness of treatments, OHPs can serve as effective tools for patient education and support. From a managerial perspective, these findings provide actionable insights for platform operators and healthcare stakeholders on which engagement factors most effectively enhance patient attitudes toward treatment options. Full article

Mitral annular disjunction (MAD) is a structural abnormality of the mitral valve increasingly detected with advanced cardiac imaging, particularly cardiac magnetic resonance (CMR). However, the clinical impact of different degrees of disjunction and the lack of standardized measurement criteria remain controversial. This study aimed to describe a series of patients with MAD assessed by CMR and to discuss, in the context of current literature, potential cut-off values that may distinguish physiological from pathological MAD. We retrospectively identified all CMR examinations performed at our institution over a 6-month period in which MAD was visible in at least two cine steady-state free precession (SSFP) projections. For each patient, we recorded MAD extent, presence of mitral valve prolapse/regurgitation, late gadolinium enhancement (LGE) pattern, and main clinical presentation. Nine patients (mean age 57 years; 5 men) were included. Larger MAD distances (>4 mm) were frequently associated with non-ischemic LGE in the basal lateral wall and with valvular abnormalities, whereas smaller disjunctions (≤3 mm) were often observed in patients without significant structural disease. Non-ischemic LGE was present in 6/9 patients, all with MAD > 5 mm. These observations, together with published data, support the hypothesis that small degrees of MAD may represent a frequent anatomical variant, while more extensive disjunction, especially when associated with fibrosis, may indicate a pathological substrate for arrhythmias. Standardized CMR-based criteria and validated MAD cut-off values are needed to improve risk stratification and to incorporate MAD assessment into routine clinical practice. Full article

Background: Prosthesis patient mismatch (PPM) is associated with poor outcomes in literature. Prevention of mismatch is crucial in aortic valve replacement, yet there is no current consensus on preventative strategies. Objectives: This study introduces a novel clinical framework, nomenclature, and algorithm for contemporary Heart Team practice, providing a systematic approach for a tailored surgical strategy to anticipate and prevent mismatch. Methods: This was a single-center observational study performing a descriptive analysis of an evolving practice on 100 consecutive patients operated for aortic valve stenosis between 2020 and 2024. A step-by-step No-Mismatch algorithm was designed for the Heart Team to triage, discuss, and decide the surgical strategy prior to the procedure, identifying patients at risk of mismatch, and guiding the surgeon’s plan to prevent PPM and consider a Lifetime Valve Strategy. Results: The algorithm identified 26% of patients at risk of mismatch requiring a No-Mismatch strategy, and 20% at risk of small valve implantation requiring a Lifetime Valve Strategy. This cohort included 51 urgent cases. Valve pathology included 35% congenital, 59% degenerative, 1% rheumatic, and 5% redo operations. Valve implant type: 82% biological, including 29% rapid deployment valve (RDV), and 18% mechanical; 20% of patients required aortic root enlargements (AREs). Pre-, intra-, and post-operative data are presented. Mortality occurred at 1%. All degrees of mismatch were prevented. Conclusions: The surgeon was able to predict mismatch and elected either ARE, RDV, or a mechanical valve as required. Patient selection and a No-Mismatch Heart Team approach are essential to provide a tailored strategy for aortic valve interventions. Full article

Background: Serum albumin is a well-known marker of nutritional and inflammatory status and has been associated with adverse outcomes in heart failure (HF). However, its predictive value for length of hospital-stay and short-term mortality in elderly HF patients remains underexplored. Objectives: To investigate the association between serum albumin levels at hospital admission and length of stay, as well as post-admission mortality, in a cohort of elderly patients hospitalized for HF. Methods: We conducted a retrospective analysis of 56 consecutive patients aged ≥65 years admitted for HF. Comorbidities were assessed using the Cumulative Illness Rating Scale for Geriatrics (CIRS-G), and inflammatory status was measured via C-reactive protein (CRP). Negative binomial regression with robust confidence intervals was employed to evaluate the relationship between serum albumin and length of hospital-stay, adjusting for age, comorbidity burden, and CRP. Cox proportional hazards models were used to assess mortality at 6 months and 1 year, adjusting for age, comorbidity, CRP, and HF subtype, with Kaplan–Meier curves illustrating unadjusted survival differences according to albumin levels and HF subtype. Results: Mean age was 78.6 ± 7.5 years, with 69.6% female patients. Mean serum albumin at admission was 3.58 ± 0.60 g/dL, and mean length of stay was 14.8 ± 10.1 days. Each 1 g/dL increase in albumin was associated with a 32% reduction in length of stay (adjusted IRR = 0.68; 95% CI: 0.54–0.85; p = 0.01), independently by age, inflammatory status and comorbidity. Serum albumin was independently associated with reduced risk of death at 6 months (HR 0.30; 95% CI: 0.11–0.82; p = 0.019) and 1 year (HR = 0.41; 95% CI: 0.17–0.96; p = 0.041). Conclusions: Serum albumin at hospital admission independently predicts length of stay and short-term mortality in elderly patients with HF. Albumin measurement, simple, cheap and universally available biomarker, is helpful for early risk stratification and may guide clinical management in this vulnerable population. Full article

Background: In cardiology, vasoregulation is one of the most important targets of pharmacotherapy. SOMNOtouch™-NIBP (SOMNOmedics AG, Randersacker, Germany) is a cuffless device designed for continuous, non-invasive blood pressure measurements, and it appears to be ready for use in infants and children with congenital heart disease. For infants, minor methodological modifications are required due to their small body size. Methods: Using this device, we demonstrate fluctuations in diastolic blood pressure in three patients: an infant with hypoplastic left heart syndrome after Norwood stage 1 and 2 operations; an infant with Tetralogy of Fallot with heart failure due to pulmonary overcirculation after an aorto-pulmonary shunt implantation; and a 13-year-old girl with chronic cyanosis due to a congenitally corrected transposition of the great arteries (ccTGA) with a ventricular septal defect and pulmonary stenosis. The measurement procedures are completely non-invasive and feasible in an outpatient setting. Results: The results demonstrate strong correlations between blood pressure and oxygen saturation levels as well as heart rate variability. We discuss our results in relation to current concepts of hypoxic pulmonary/systemic vasoconstriction and hypoxemia-related pathways. Conclusions: The cuffless device for continuous, non-invasive blood pressure measurement seems to be useful for infants with and without congenital heart defects who receive pharmacotherapies that modulate vasoregulation. These patients should also be non-invasively monitored for safety reasons and for a better understanding of their pathophysiology. Full article

Heart transplantation is the gold standard in patients with end stage heart failure, offering vastly improved survival, mortality and quality of life. However, hypertension occurring after cardiac transplantation is a serious issue, with the incidence ranging from 50 to 80% of patients. The pathophysiology of the hypertension encompasses a more varied and unique set of causes than those identified in non-organ transplant patients, particularly related to the use of calcineurin inhibitors (CNIs) especially cyclosporine. An in-depth understanding of hypertension after heart transplantation remains a critical issue that necessitates further clarification, due to its deleterious long-term consequence such as impaired graft survival, cardiac allograft vasculopathy (CAV), and overall survival. This article provides a comprehensive review of the prevalence, risk factors, etiology, complications, and management of hypertension after heart transplantation. Full article

Background/Objectives: Cardiovascular disease (CVD) and cerebrovascular disease (CeVD) remain leading causes of death in the United States, with Mississippi consistently reporting some of the nation’s highest mortality rates. Despite earlier national declines, recent evidence suggests stagnation or increases, particularly in high-burden regions. This study examined short-term trends in CVD and CeVD mortality in Mississippi between 2018 and 2022, stratified by age, sex, and race. Methods: Mortality data for adults aged ≥45 years were obtained from the Mississippi Statistically Automated Health Resource System (MSTAHRS). Age-adjusted mortality rates were calculated per 100,000 population and standardized to the 2000 U.S. population. Joinpoint regression was used to estimate annual percent change (APC) and average annual percent change (AAPC) with 95% confidence intervals (CIs). Analyses were stratified by sex, and within each racial group (White, Black, Other), mortality trends were further examined across age categories (45–54, 55–64, 65–74, 75–84, ≥85 years). Results: Cardiovascular mortality increased significantly among White women in midlife (ages 45–74), while “Other race” men in early midlife and “Other race” women in the oldest age group showed steep increases. Although Black adults did not experience significant changes over time, their mortality rates remained consistently higher than those of White adults. Conclusions: Progress in reducing cardiovascular and cerebrovascular mortality in Mississippi has reversed in several subgroups, particularly midlife White women and smaller racial populations. These findings mirror national stagnation and pandemic-related disruptions, highlighting the urgent need for equity-focused prevention, improved healthcare access, and targeted interventions addressing structural determinants of health. Full article

Tricuspid atresia (TA) is a cyanotic congenital heart defect defined by agenesis of the tricuspid valve and resultant right ventricular hypoplasia, representing 1.4–2.9% of congenital heart disease. Survival depends on interatrial and interventricular shunts that permit systemic and pulmonary blood flow, with staged surgical palliation culminating in the Fontan procedure. While surgical advances have improved long-term outcomes, Fontan circulation remains a delicate physiology characterized by preload dependence, elevated pulmonary vascular resistance, chronic venous hypertension, and a prothrombotic state. These features predispose patients to arrhythmias, lymphatic complications, hepatic congestion, and progressive circulatory failure. For anesthesiologists, perioperative management of TA and Fontan patients is uniquely complex. Anesthetic considerations include meticulous preload optimization, modulation of systemic and pulmonary vascular resistance, and ventilatory strategies that minimize adverse effects on venous return. Additional challenges include the high risk of air embolism, individualized anticoagulation needs, and hemodynamic sensitivity to patient positioning. Preoperative evaluation with echocardiography and electrocardiography provides critical insight into anatomy and physiology, while intraoperative planning must emphasize goal-directed fluid management, careful agent selection, and tailored ventilation. Postoperatively, vigilant monitoring, effective pain control, and prevention of complications are essential. This review synthesizes classification systems, pathophysiology, and the evolution of surgical palliation, while emphasizing anesthetic principles for the perioperative care of patients with TA and Fontan circulation. As survival improves and the population of Fontan patients expands, a nuanced understanding of this physiology is essential for optimizing outcomes across cardiac and non-cardiac surgical settings. Full article

Restrictive cardiomyopathy (RCM) poses a significant challenge in diagnosis, is frequently identified in advanced stages, and has limited therapeutic options, which may lead to adverse cardiovascular outcomes. This narrative review examines the application of artificial intelligence (AI) across key diagnostic modalities and delineates priorities for translational advancement. The discussed diagnostic tools include echocardiography, cardiac magnetic resonance (CMR), electrocardiography (ECG), and electronic health records (EHR). A targeted, non-systematic search of PubMed and Scopus was performed to identify studies focused on model development, validation, or diagnostic accuracy concerning RCM and related infiltrative disorders. The findings suggest that AI can enable earlier detection, standardize imaging protocols, and enhance phenotype-driven management of RCM. Nonetheless, several challenges exist, including limited data access, the absence of external validation, variability across imaging devices and locations, and the imperative for transparent, explainable systems. Key priorities for successful implementation encompass establishing multi-center collaborations, detecting and correcting bias, clinician involvement in deployment, and integrating multimodal data, including imaging, signal data, and -omics. If effectively integrated into clinical practice, AI has the potential to redefine the management of RCM from a condition recognized primarily in its later stages to one characterized by early detection, dynamic risk assessment, and personalized treatment strategies. Full article

Background: Randomized controlled trials (RCTs) are the foundation of evidence-based medicine. However, the rapid pace of technological innovation in cardiovascular surgery and interventional cardiology challenges the traditional RCT framework. Observational studies may hold renewed value in fields where device evolution outpaces the time required to validate clinical outcomes. Methods: This analysis evaluates 270 randomized and non-randomized studies in transcatheter aortic valve implantation (TAVI), one of the most rapidly evolving areas in cardiovascular medicine. The investigation follows two lines: first, mapping the timeline of major RCTs against the introduction of new prosthetic models; second, comparing the prevalence, duration, and role of randomized (R) versus non-randomized (NR) studies. Results: The timeline reveals a persistent misalignment between innovation and validation. New prosthetic models frequently enter the market while RCTs for prior generations are still ongoing. For example, the Sapien 3 valve was approved, while trials on Sapien XT were still enrolling. Similarly, newer Evolut and Acurate models were introduced during ongoing studies of earlier versions, often prompting new studies before existing ones concluded. This leapfrogging effect fragments the evidence base and delays definitive comparisons. In parallel, randomized trials have increased in number and tend to be shorter in duration, reflecting a maturing field. However, non-randomized studies remain crucial for early testing and post-market surveillance. Conclusions: In a field with rapid technological evolution a sort of Zeno’s paradox occurs: long-term validation cannot keep pace with fast innovation, resetting the evidence base with each new model. To overcome this paradox, a paradigm shift in evidence generation is desirable. Future strategies must augment adaptive trial designs, leverage real-world data and use higher-level, advanced analyses to incorporate subjective variables and phenotypic diversity, to reduce confounding factors and speed up data access. Higher-level, integrative evidence analytics could help Achilles walk alongside the tortoise. Full article

Background: Myocardial scar and fibrosis predict adverse cardiac outcomes. Late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) is the reference standard for detection. However, it requires gadolinium-based contrast agents (GBCAs), which may be unsuitable for some patients. Cine balanced steady-state free precession (bSSFP) sequences are universally acquired in routine CMR. They may enable contrast-free scar detection via radiomics analysis. Aim: To systematically review the diagnostic accuracy of cine CMR radiomics for myocardial scar or fibrosis detection. The reference standard is visual or threshold-based LGE. Methods: This review followed PRISMA guidelines and was registered in PROSPERO (CRD420251121699). We searched MEDLINE, Embase, and Cochrane Library up to 8 August 2025. Eligible studies compared cine CMR radiomics with LGE-based assessment in patients with suspected or known scar/fibrosis. Quality was assessed using QUADAS-2 and Radiomics Quality Score (RQS). Results: Five retrospective studies (n = 1484) were included. Two focused on myocardial infarction, two on hypertrophic cardiomyopathy, and one on ischaemic versus dilated cardiomyopathy. Diagnostic performance was good to excellent (AUC 0.74–0.96). Methodological heterogeneity was substantial in reference standards, segmentation, preprocessing, feature selection, and modelling. Only one study used external validation. QUADAS-2 showed high bias risk in patient selection and index test domains. RQS scores were low (30–42%), indicating limited reproducibility and validation. Conclusions: Cine CMR radiomics shows promise as a non-contrast alternative for detecting myocardial scar and fibrosis. However, methodological standardisation, multicentre validation, and prospective studies are needed before clinical adoption. Full article