The present review synthesizes key conceptual and diagnostic advances reflected in the European Society of Cardiology (ESC) 2025 guidelines for myocarditis and compares them with contemporary U.S. scientific statements and consensus pathways. We highlight evolving disease definitions, diagnostic and risk stratification frameworks, and the expanding role of multimodality cardiovascular imaging in the evaluation and management of myocarditis. The 2025 ESC guidelines introduce the unified concept of inflammatory myopericardial syndrome, integrating myocarditis, pericarditis, and overlapping phenotypes into a single diagnostic continuum. Contemporary European and U.S. guidance increasingly prioritize noninvasive imaging, particularly cardiac magnetic resonance (CMR) using updated Lake Louise criteria, for diagnosis, risk stratification, and longitudinal assessment. Endomyocardial biopsy remains the reference standard but is now reserved primarily for high-risk presentations or when histopathologic confirmation may alter management. Advances in imaging techniques, including tissue characterization, quantitative parametric mapping, and emerging molecular imaging strategies, are improving diagnostic sensitivity for detecting myocardial inflammation, and may enable more precise phenotypic classification across inflammatory cardiomyopathies. Modern diagnostic approaches to myocarditis reflect a transition from biopsy-centered paradigms towards integrated, imaging-driven strategies. Continued harmonization of international guidelines and prospective validation of imaging-guided diagnostic pathways will be essential to improve diagnostic precision and patient outcomes.
The right ventricle (RV) and tricuspid valve (TV) are important determinants of cardiovascular outcomes. With the rapid evolution of transcatheter tricuspid valve interventions, comprehensive multimodality imaging has become essential for patient selection, procedural guidance, and prognostic stratification. Strain and volumetric parameters enable earlier detection of myocardial dysfunction and refined assessment of patients undergoing transcatheter interventions, although uncertainties regarding thresholds and standardization remain. Echocardiography, cardiac magnetic resonance (CMR), and computed tomography (CT) have improved RV phenotyping and understanding of RV–TV interactions. This review synthesizes contemporary evidence regarding imaging assessment of the RV and tricuspid valve, emphasizing the complementary strengths of multimodality imaging and its clinical applications.
This review aims to systematically evaluate the environmental impacts of key cardiac imaging modalities, identify current operational practices that disproportionately contribute to the carbon footprint, and propose evidence-based strategies to optimize imaging protocols for climate sustainability while preserving diagnostic accuracy and patient outcomes. There has been a significant increase in the utilization of cardiac magnetic resonance imaging (CMR), cardiac computed tomography (CT), cardiac positron emission tomography (PET) and single-photon emission computed tomography (SPECT) which comes with an unacknowledged cost to our environment with respect to carbon footprint, energy consumption and barriers to safe disposal of contrast agents. However, we are yet to incorporate environmental sustainability metrics in our major diagnostic guidelines. In CMR, protocol refinements such as limiting the number of localizing images, using specific faster mapping sequence and optimizing protocols such that cine SSFP can be moved into the contrast wait period can lower energy use and scan time. PET/SPECT/CT sustainability is enhanced by stress-first protocols, tailoring CT dose to clinical need, and promoting circular manufacturing of scanners and cyclotron components. In echocardiography, the major opportunity lies in redesigning ultrasound contrast agent packaging to enable multi-dose use, minimizing single-use plastic waste. Collectively, climate-conscious imaging is achievable by powering down devices, integrating the use of sustainability index, utilizing green data storage centers and optimizing protocols and machines both of the acquisition and vendor side. Future research should quantify the environmental savings of these strategies and support scalable implementation across diverse practice settings.
Pregnancy induces cardiovascular adaptations, including increased cardiac output, blood volume, and heart rate, to support fetal development. These changes can sometimes unmask or exacerbate underlying myocardial dysfunction. Traditional echocardiographic measures, such as left ventricular ejection fraction (LVEF), often fail to detect subtle myocardial dysfunction. The purpose of this review is to evaluate the use of myocardial strain by echocardiography for early identification of myocardial impairment. In pathological pregnancies, speckle-tracking echocardiography reveals subclinical myocardial dysfunction across various conditions. Women with gestational diabetes mellitus (GDM) exhibit significantly reduced LV global longitudinal strain (GLS), even in the absence of overt systolic dysfunction. They also have reduced right ventricular (RV) GLS, indicating biventricular dysfunction, and reduced left atrial (LA) reservoir and conduit strain, suggesting early diastolic dysfunction. Hypertensive disorders of pregnancy (HDP), such as preeclampsia and gestational hypertension, have been linked to lower GLS values reflecting early myocardial dysfunction before overt changes in LVEF. HDP also show reduced RV strain indices and altered LA mechanics. Additionally, women with peripartum cardiomyopathy (PPCM) exhibit markedly lower GLS, often below −15
Artificial intelligence (AI) is expeditiously reshaping healthcare by refining diagnosis, treatment, and patient care. AI, a transformative force in both cardiology and oncology, is now being increasingly explored for its potentials in the arising field of cardio-oncology. In the field of Cardio-Oncology, risk prediction and stratification using clinical characteristics, combined with imaging such as electrocardiography, multimodality cardiovascular imaging, and laboratory studies such as biomarkers powered by AI can assist in identifying cardiotoxicity with better precision and efficiency. In addition, surveillance of cardiotoxicity through longitudinal follow-up is an important area that AI can aid to offer improved efficiency, high precision, and consistency when processing high throughput data. Nonetheless, other applications of AI in telemedicine and digital health, translation science, drug discovery, and healthcare education hold significant promise in the domain of cardio-oncology. In conclusion, AI can advance the field of cardio-oncology and further research is necessary to assess its current limitations, overcome existing challenges, and transform research into real-life practice.
Intravascular ultrasound (IVUS) provides a comprehensive real-time assessment of coronary artery lesions, can guide its treatment strategies during percutaneous coronary intervention (PCI) and ensure optimization after intervention. Despite this, use of IVUS remains low, likely from lack of appropriate training or perceived complexity in performing and interpreting the images, which in turn prohibits patients from availing its benefit. Our narrative review article aims to summarize the recent and existing published literature on IVUS during PCI, serving as a guiding tool for the operators. The clinical benefit of IVUS use during PCI for acute or chronic coronary syndrome, complex lesions, concomitant renal dysfunction and even stent optimization has been found to be incremental. These findings are based on the clinical trials and various studies demonstrating superiority of IVUS guided PCI as compared to angiographic guided PCI. Though over the years, IVUS recommendations have evolved, incorporated into clinical guidelines it usage continues to encounter certain challenges which are also addressed. In this review article, we summarize the evidence supporting the use of IVUS during PCI for a wide array of coronary artery disease, the challenges it encounters and also the future directions of its use.
This chapter summarizes the role of optical coherence tomography (OCT) in guiding percutaneous coronary intervention (PCI), highlighting its impact on lesion assessment, optimal stent sizing and placement, and post-procedural optimization. OCT has shown to improve procedural and long-term clinical outcomes over angiography alone. It offers high-resolution imaging that enables precise plaque characterization, including fibrous, lipid-rich, and calcific morphologies, with direct implications for lesion preparation. Accurate measurement of vessel size and lesion length enables stent selection and landing zone identification. After stent deployment, OCT identifies suboptimal results such as underexpansion, malapposition, edge dissections, and tissue prolapse, guiding immediate optimization. The use of OCT is now endorsed with a Class Ia recommendation by European and U.S. guidelines. By enabling anatomy-based procedural planning and results assessment, OCT has transformed PCI into a more precise procedure. Its use contributes to reduced complications, improved stent placement, and better long-term outcomes.
This review critically evaluates the most recent literature on the role of various imaging modalities, including echocardiography, computed tomography (CT), cardiac magnetic resonance imaging (CMR), single-photon emission tomography (SPECT) and fluorodeoxyglucose positron emission tomography (FDG-PET) in cardiac sarcoidosis (CS) detection and management. The review also discusses emerging advancements, such as artificial intelligence (AI) integration and hybrid imaging techniques. CS is a challenging disease to diagnose due to its heterogeneous presentation and often subtle cardiac involvement. Multimodality imaging plays a crucial role in the contemporary work-up of CS, allowing for more accurate diagnosis, risk stratification, and treatment monitoring. Current imaging techniques, including echocardiography, CMR, SPECT, FDG-PET and hybrid modalities such as PET/CT and PET/MR offer complementary information on myocardial inflammation, fibrosis, and functional impairment, thereby enhancing diagnostic confidence and guiding management decisions. Additionally, emerging applications of artificial intelligence and machine learning are showing promise in automating image interpretation, improving diagnostic precision, and supporting personalized risk stratification. The integration of advanced imaging with AI-driven tools represents a future direction for optimizing clinical outcomes in patients with cardiac sarcoidosis.
To analyze the diagnostic utility of cardiac magnetic resonance (CMR) images, including post-contrast sequences and late gadolinium enhancement (LGE) findings in Takotsubo syndrome (TTS). TTS usually mimics acute coronary syndrome, making differential diagnosis challenging. CMR plays a key role in TTS diagnosis, particularly through T2 weighted/T2 mapping and LGE sequences. While TTS is not characterized by fibrosis replacement, LGE is detected in approximately 25
The scope of this review is to provide an up-to-date overview of the current evidence on the role of intravascular imaging (IVI) in the diagnosis, management and outcomes of patients presenting with stent failure and to highlight evidence gaps and future perspectives in this field. Based on the results of several large, randomized, prospective trials, there is convincing evidence to support IVI imaging guidance of percutaneous coronary intervention (PCI) procedures, particularly in the setting of complex coronary lesions, in order to reduce the occurrence of hard clinical endpoints, including cardiac death, target lesion revascularization and stent failure. On the other hand, due to their ability to identify underlying mechanisms leading to the occurrence of stent failure, current guidelines and consensus statements strongly advocate the use of IVI in this setting. However, specific evidence supporting this recommendation relies primarily on observational studies, of either prospective or retrospective nature, while randomized, prospective trials evaluating the prognostic value of IVI in the management of stent failure are virtually absent. However, based on findings of observational studies, several ongoing randomized trials, primarily in patients presenting with ISR, are evaluating the role of IVI in guiding treatment modalities, in an attempt to develop personalized IVI-based treatment approaches. Despite the high performance of current-generation drug-eluting stents (DES), widespread adoption of PCI in patient cohorts characterized by increasing age and coronary lesion complexity contributes to the occurrence of stent failure, which is associated with substantial morbidity and mortality. Identifying and addressing the root causes leading to the occurrence of stent failure represent central, indispensable steps in the treatment of patients presenting with this condition, while coronary angiography has considerable intrinsic limitations in this regard. On the other hand, due to the high spatial resolution and improved ability to identify relevant pathogenetic mechanisms, incorporation of IVI modalities in the management of patients presenting with stent failure, has the potential to enable tailored therapeutic approaches, thereby personalizing treatment algorithms. Indeed, a growing body of evidence supports the use of IVI modalities as a tool to improve acute procedural results as well as to reduce the risk of recurrence in patients presenting with stent failure.
This review examines recent developments in computed tomography-derived extracellular volume (CT-ECV) assessment, focusing on acquisition protocols, clinical applications, and emerging technologies. CT-derived extracellular volume fraction (CT-ECV) has emerged as a robust tool for myocardial characterisation across various cardiac conditions. Recent advancements in technology, including photon-counting detector CT and artificial intelligence integration, have enhanced image quality and workflow efficiency while reducing radiation exposure. CT-ECV demonstrates particular utility in cardiac amyloidosis detection, cancer therapy-related cardiac dysfunction monitoring, and risk stratification in aortic stenosis. The technique boosts the utility of CCTA by adding myocardial tissue characterisation to coronary evaluation. Synthetic ECV calculation and automated post-processing further streamline clinical implementation. While protocol standardisation remains an important goal, CT-ECV’s ability to provide valuable prognostic information positions it as an increasingly important tool in cardiovascular imaging. As evidence accumulates supporting its clinical value, CT-ECV is likely to play a growing role in patient care and research. CT-ECV has matured into a versatile and powerful tool for myocardial characterisation across a spectrum of cardiac conditions. The integration of cutting-edge technologies, such as photon-counting detector CT and artificial intelligence, has significantly enhanced image quality and streamlined workflow efficiency while simultaneously reducing radiation exposure. This evolution addresses previous limitations and expands the clinical applicability of CT-ECV.
Hypoattenuated leaflet thickening (HALT) has emerged as an important post-procedural finding after transcatheter aortic valve replacement (TAVR). HALT is characterized by localized thickening of the leaflets of bioprosthetic valves due to thrombus deposition, potentially leading to leaflet dysfunction and reduced mobility. Although initially thought to be clinically silent, HALT has now been linked with subclinical valve thrombosis and carries implications for valve durability, as well as patient outcomes, including stroke and heart failure. The introduction of advanced and multidimensional imaging techniques, particularly multi-detector computed tomography (MDCT), has led to a greater understanding of the pathophysiology of HALT, allowing for detailed visualization and assessment of leaflet morphology, function, and mobility. This review article explores the current understanding of HALT, its pathophysiology, risk factors, clinical relevance, and the role of multimodal imaging for establishing an accurate diagnosis. We also discuss technical considerations in managing HALT, including anticoagulation strategies, their role in preventing thrombus formation and improving long-term outcomes. Additionally, we highlight the ongoing debate regarding optimal follow-up and therapeutic strategies to balance HALT-related risks with the broader clinical benefits of TAVR.
The purpose of this paper is to review the current role of intravascular imaging (IVI) in the diagnosis and management of peripheral artery disease (PAD) through its application in endovascular interventions of the lower extremities. IVI, an established adjunctive tool for coronary intervention, has become increasingly used during peripheral endovascular revascularizations. Intravascular ultrasound (IVUS) is the predominant IVI modality used during peripheral intervention. The use of optical coherence tomography (OCT) in the peripheral vasculature is limited. Growing data from retrospective studies, meta-analyses and new clinical trials have demonstrated that IVUS-guidance may improve endovascular procedural and clinical outcomes, such as improved patency and reduced rates of major adverse limb events. IVI provides unique information of the vasculature before, during, and after endovascular intervention. This allows for accurate vessel measurements and detailed lesion characterization, assisting diagnostic dilemmas and guiding procedures to optimize stent deployment (e.g. sizing, apposition, expansion) and detect complications post-intervention (e.g. dissection, stent fracture). Expert consensus largely supports the implementation of IVI, and IVUS specifically, during endovascular interventions for PAD. However, more robust clinical data evaluating the efficacy, safety, long-term outcomes and cost-effectiveness of IVI modalities are still needed.
Single photon emission computed tomography (SPECT) and positron emission tomography (PET) cardiac imaging have evolved, providing innumerable data points for the clinician reader to analyze to achieve accurate diagnosis and guide management. The advent of artificial intelligence (AI) could play a pivotal role in better harnessing these data and improving nuclear cardiology workflows. In this review, we explored the current applications of AI in various aspects of nuclear cardiology. Innovative studies have explored the use of AI, particularly deep learning models, to identify ideal patient candidates for stress-only imaging to reduce radiation exposure and acquisition time. Furthermore, there is published evidence that deep learning can provide efficient methods to achieve reliable image segmentation, attenuation correction, and image registration. In addition, AI-based disease diagnosis and risk prediction models have been shown to perform similarly if not better than expert readers in some settings. Beyond coronary artery disease, there are promising results of deep learning algorithms to improve diagnostic imaging for cardiac sarcoidosis and amyloidosis. Recent advancements in AI models provide an opportunity to refine the nuclear cardiology workflow ranging from patient selection to disease prediction and reporting. Promising results from these early studies need to be replicated in larger heterogenous patient populations to demonstrate generalizability prior to widespread adoption in clinical practice.
Systemic inflammation is a major trigger for cardiovascular disease (CVD) and consequent heart failure (HF). Our purpose is to present the impact of inflammation in the development of HF in autoimmune rheumatic diseases (ARDs) and the emerging role of Cardiovascular Magnetic Resonance (CMR). ARDs represent the best example of systemic inflammation and are associated with increased risk of cardiovascular disease (CVD) finally leading to heart failure with preserved (HFpEF) or reduced ejection fraction (HFrEF). Systemic and local inflammation of the CV system may lead to myo-pericarditis, autoimmune inflammatory cardiomyopathy (AIC), valvular heart disease (VHD) and macro-/micro-coronary artery disease (CAD). Furthermore, the anti-rheumatic medication, used to control systemic inflammation, may also lead to myocardial cytotoxic effect. Silent clinical presentation is the main characteristic of CVD in ARDs, which makes the early, accurate diagnosis challenging. Furthermore, although there is great progress in the development of new anti-rheumatic medication, the CVD incidence/mortality in ARDs is still higher, compared to the rest of the population. High clinical awareness and use of new advanced technologies, such as CMR that can perform function and tissue characterization in the same examination, was proven useful for early diagnosis, risk stratification and treatment evaluation of CVD in ARDs. Lastly, the cardio-protective effect of anti-rheumatic and the immunomo-dulatory effect of cardiac medication hold the promise for better CVD control and potentially mortality reduction.
The purpose of this paper is to summarize the recent myocardial perfusion cardiovascular magnetic resonance (CMR) studies in the context of the diagnostic and prognostic value of epicardial coronary artery disease (CAD), coronary microvascular dysfunction (CMD) and the non-ischemic heart disease. Recent developments of the sequence and the post-processing of myocardial perfusion CMR images have enabled the quantitative assessment of myocardial perfusion, facilitating a significant shift from qualitative to quantitative assessment of stress perfusion CMR. Quantitative assessment of perfusion CMR allows objective and accurate assessment of myocardial ischemia in the detection of CAD, and may have the potential to assess CMD. Moreover, the integration of quantitative perfusion CMR with cine for functional assessment and late gadolinium enhancement and T1/T2 mapping for tissue characterization techniques allows for a deeper understanding of the pathophysiology and a capability of prognostic stratification for various cardiovascular diseases.
The purpose of this paper is to review the results of studies from the last 3 years, presenting the current state of knowledge on the pathophysiological effect of polycystic ovary syndrome (PCOS) on the cardiovascular system, with cardiac involvement using non-invasive cardiovascular investigations. PCOS is a complex endocrine disorder that has a significant impact on the cardiovascular system. Recent studies confirm that PCOS increases the risk of cardiovascular disease (CVD) as well as the occurrence of cardiovascular events (CVE), including myocardial infarction (MI), coronary artery disease, and revascularization. These findings support the need for early screening and implementation of CVD prevention in women with PCOS. Current evidence documents important and previously unrecognized mechanisms by which PCOS may adversely affect the cardiovascular system in affected women. Further studies are needed to in-depth characterisation of the cardiovascular phenotype of patients with PCOS. There is still a lack of studies using advanced cardiac imaging methods, including cardiac magnetic resonance imaging (CMR).
4-dimensional phase-contrast flow measurement (4D Flow) has an increasing clinical and scientific potential in patients with congenital heart disease (CHD). In this review, we present up-to-date information about the benefits of 4D Flow in adults with CHD (ACHD). Due to sequence and software developments 4D is now routinely used for clinical blood flow measurements in ACHD patients. An increasing number of studies also shows that 4D Flow-derived advanced hemodynamic markers cannot only explain cardiovascular conditions but that they can help in ACHD management. Moreover, with the use of computational fluid dynamics and deep learning techniques 4D Flow might help in exploring and developing personalized medical treatment strategies. Utilization of 4D Flow has become widely spread in research as well as in clinical practice allowing to explore morphological and hemodynamical consequences in ACHD.
It was previously believed that the presence of myocardial viability in patients with significant coronary artery disease improved outcomes following revascularisation, but the landmark STITCH trial found no significant correlation between viability and overall survival. However, the study used single photon emission contrast tomography or dobutamine stress echocardiography for viability assessment, but late gadolinium enhanced cardiac magnetic resonance imaging (LGE-CMR) has since become the gold standard for viability assessment. Additionally, there has been significant progress in heart failure pharmacotherapy. Leveraging these advances, the REVIVED study authors revisited the role of revascularisation on heart failure patient clinical outcomes. Similar to the STITCH study, REVIVED also identified a lack of correlation between viability and outcomes, confirming its limited role in revascularisation decision making. The purpose of this review is to discuss the advances in myocardial viability imaging and the role of LGE-CMR scar assessment beyond the REVIVED study. Myocardial scar predisposes to ventricular arrythmias and sudden cardiac death (SCD). It is the authors’ opinion that beyond REVIVED, focus should be placed on optimising the management of ventricular arrhythmias through visualisation and characterisation of cardiac scar to improve clinical outcomes. A significant proportion of SCDs occur in patients who remain unprotected if guided by current recommendations. Several studies have confirmed the presence and burden of scar as a better predictor of clinical outcomes in comparison to the current gold standard of left ventricular ejection fraction (LVEF). The potential of machine learning and radiomics to visualise cardiac anatomy and characterise scar, leveraged with the ability to integrate segmented CMR and clinical electroanatomic maps intraoperatively shows promise in improving outcomes in VT ablations and delivering precision treatment based on individual risk.
This review aims to evaluate the current diagnostic standards for cardiac allograft vasculopathy (CAV) in heart transplant recipients, with a focus on the role of positron emission tomography (PET) myocardial perfusion imaging (MPI). The review addresses the efficacy of PET as a non-invasive alternative to invasive coronary angiography (ICA) and discusses recent guidelines and advancements in the detection and management of CAV. Recent research underscores the potential role of PET imaging in detecting CAV, particularly by assessing myocardial blood flow (MBF) and myocardial flow reserve (MFR). PET has emerged as a highly effective tool, offering potential advantages in diagnostic accuracy, cost-effectiveness, and reduced radiation exposure compared to ICA. The 2023 International Society for Heart and Lung Transplantation guidelines list PET MPI as a Class IIa indication for non-invasive CAV screening, highlighting its superior prognostic value. Studies demonstrate that PET-derived MBF and MFR correlate well with invasive measures and predict adverse outcomes, emphasizing the role of PET MPI in the early detection and management of CAV. Additionally, PET MPI can potentially reduce the need for frequent invasive procedures, thereby lowering healthcare costs. PET MPI significantly enhances the detection and prognostication of CAV in heart transplant recipients, providing a non-invasive, accurate, and cost-effective alternative to ICA. Integrating PET into routine surveillance protocols can improve early diagnosis and management of CAV, ultimately enhancing patient outcomes. Large multicenter studies are needed to optimize surveillance strategies and to further validate the role of PET in CAV detection and management.
