Ferumoxytol is an ultrasmall superparamagnetic iron oxide (USPIO) nanoparticle that was originally approved by the U.S. FDA for treating iron deficiency anemia in patients with chronic kidney disease. It has since emerged as an off-label, versatile intravascular contrast agent for cardiovascular magnetic resonance (CMR) imaging, and in 2025, received FDA approval for brain imaging. This review provides an overview of ferumoxytol-enhanced CMR applications primarily focused on the heart, outlines its key imaging and pharmacokinetic properties, and summarizes its diagnostic safety profile. Unlike gadolinium-based contrast agents (GBCAs), which rapidly wash out from the circulation, ferumoxytol has high r1 and r2 relaxivities and remains confined to the intravascular compartment for prolonged periods. Once metabolized by the reticuloendothelial system, its iron core is incorporated into the body’s hematopoietic pathways. These unique properties enable steady-state and delayed-phase imaging, simplify complex imaging workflows, and facilitate accelerated multidimensional cardiac imaging methods. Emerging applications for ferumoxytol-enhanced CMR include myocardial perfusion assessment, multidimensional imaging, vascular and hemodynamic evaluation, and comprehensive structural heart disease imaging. Ferumoxytol expands the clinical applications of CMR by enabling imaging techniques that are not feasible with conventional GBCAs and broadening imaging options for patients in whom GBCA administration may be less desirable based on individualized clinical risk-benefit assessment, including selected patients with renal insufficiency, very young children, and pregnant women.
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
