Sudden cardiac death (SCD) is a devastating complication of several different cardiovascular disorders. Over the age of 40 years the most common cause of SCD is due to coronary artery disease and myocardial infarction. In the young under the age of 40 years, inherited/genetic cardiovascular disorders are more common, including the inherited arrhythmia syndromes and the primary cardiomyopathies. Detailed evaluation of the premorbid clinical history, including a detailed family history, and comprehensive expert postmortem examination is essential. In SCD cases where no cause of death is identified at postmortem, a "molecular autopsy", i.e. genetic testing of a blood or tissue sample collected at postmortem, should be performed, with the aim of identifying a pathological genetic variant that would account for the death of the decedent, i.e. the cause of death. Establishing a cause of SCD can provide a degree of psychological relief for loved ones by providing answers and relieving uncertainty. Furthermore, clinical and genetic screening of family members is essential in the prevention of adverse clinical outcomes and SCD events in surviving relatives. Care should ideally be provided in a specialized multidisciplinary clinic setting, and this model of care should be supported and developed in countries where such services do not currently exist, reducing racial disparities and overcoming socioeconomic factors. Newer genetic and molecular developments may further improve and refine our diagnostic and management strategies with the ultimate goal to prevent SCD in our communities.

RHD is a chronic condition resulting from untreated streptococcal throat infections and recurrent attacks of ARF. It primarily affects children and young adults and the greatest risk for a primary episode of ARF is in those aged 5 to 15 years. The peak prevalence of RHD occurs many years later, frequently between 25 and 45 years of age, possibly highlighting the aftermath of recurrent episodes of ARF. Acute Rheumatic Fever (ARF) and Rheumatic heart disease (RHD) remain a significant yet often overlooked health challenge in India. Despite being a preventable and treatable condition, RHD continues to affect many patients and places a heavy burden on our healthcare system. As we stand at the precipice of progress in combating ARF and RHD, a renewed call to critically review our control strategies and research priorities is imperative. Although there have been advances in medical knowledge, the battle against this preventable yet persistently devastating disease demands a heightened sense of urgency and a commitment to innovation. The path forward requires a comprehensive re-evaluation, and much work lies ahead to achieve our goal of eradicating ARF and RHD. Eliminating RHD from India is not only imperative but also a moral and ethical obligation. By addressing underlying social determinants, strengthening healthcare systems, and implementing evidence-based diagnostic and therapeutic interventions, we can achieve this goal.

Atrial functional mitral regurgitation (AFMR) may account for a substantial proportion of functional MR, although its prevalence varies by population and diagnostic definition. AFMR increases mortality risk regardless of left ventricular (LV) function. The mechanism involves mitral annular dilation and "atriogenic leaflet tethering." Key echocardiographic features include preserved left ventricular ejection fraction (LVEF; typically >50%), significant left atrial (LA) enlargement, mitral annular dilation, and minimal leaflet tethering. Medical therapy, including renin-angiotensin system inhibition/angiotensin receptor-neprilysin inhibition (ARNI) and sodium-glucose co-transporter 2 (SGLT2) inhibitors, may favorably influence LA remodeling and AFMR severity, although AFMR-specific evidence remains limited. In patients with concomitant atrial fibrillation/flutter, restoration of sinus rhythm with cardioversion or catheter ablation may improve LA function and reduce AFMR severity. Surgical mitral annuloplasty is an also an option for low-risk patients with concomitant procedures. Mitral transcatheter edge-to-edge repair (M-TEER) in AFMR has had outcomes comparable to ventricular functional MR (VFMR). Maintaining a low post-procedural mean pressure gradient (MPG < 5 mmHg) is crucial. Preliminary experience with transcatheter indirect mitral valve annuloplasty (Carillon device) has also shown feasibility. Mitral replacement platforms face challenges due to high risk of LV outflow tract obstruction and atrial migration.