Die kardiovaskuläre Bildgebung liefert wichtige Informationen für die Diagnostik kardiovaskulärer Erkrankungen, für Therapieentscheidungen sowie zur individuellen Prognoseabschätzung. Die Magnetresonanztomographie (MRT) spielt dabei eine wachsende Rolle. Sie gibt Informationen zur kardialen Anatomie, zur kardialen Funktion, Perfusion, Vitalität und Inflammation sowie zum Blutfluss. Häufige Indikationen für eine kardiovaskuläre MRT sind die Beurteilung bei koronarer Herzkrankheit, Kardiomyopathien, entzündlichen Herzkrankheiten, Herzinsuffizienz, Herzklappenerkrankungen und angeborenen Herzfehlern. Dieser 2‑teilige Beitrag liefert einen praxisnahen Überblick.

Zum 1. Januar 2025 wurde in Deutschland die nichtinvasive Koronarangiographie mit dem CT (CCTA) als neue Leistung der gesetzlichen Krankenversicherungen (GKV) für Patienten mit Verdacht auf eine chronische koronare Herzkrankheit (KHK: chronisches Koronarsyndrom [CCS]) in den Katalog der GKV-Leistungen (EBM) aufgenommen. Die Indikation zur CCTA als Ursache der von den Patienten geschilderten Beschwerden bei einer Vortestwahrscheinlichkeit (VTW) von 15–50

Die kardiovaskuläre Bildgebung ist wichtig für die Diagnostik kardiovaskulärer Erkrankungen, für Therapieentscheidungen sowie zur individuellen Prognoseabschätzung. Die Magnetresonanztomographie (MRT) spielt dabei eine wachsende Rolle. Sie liefert Informationen zur kardialen Anatomie, Funktion, Perfusion, Vitalität und Inflammation sowie zum Blutfluss. Häufige Indikationen für eine kardiovaskuläre MRT sind die Beurteilung bei koronarer Herzkrankheit, Kardiomyopathien, entzündlichen Herzkrankheiten, Herzinsuffizienz, Herzklappenerkrankungen und angeborenen Herzfehlern. Dieser 2‑teilige Artikel gibt einen praxisnahen Überblick.

Left ventricular dysfunction occurs early in the ischemic cascade. Strain parameters such as global longitudinal strain (GLS) and global circumferential strain (GCS) detect subtle contractile changes, but strain reduction may be observed in situations not related to ischemia. This study assessed whether GLS and GCS may support the identification of a low likelihood of myocardial ischemia in the absence of scarring. Patients were selected from an all-comers registry who underwent vasodilator-perfusion cardiac magnetic resonance imaging (CMR) and showed no evidence of ischemic late gadolinium enhancement. Patients with perfusion deficits were compared with a control group without ischemia and with normal morphological and functional volumetric parameters. GLS and GCS were quantified, and their ability to differentiate ischemic from non-ischemic patients was evaluated using receiver operating characteristic analysis. Among 1434 patients with perfusion analysis, 451 had normal findings and 112 demonstrated a perfusion defect without LGE. GLS and GCS were significantly reduced in ischemic patients (− 16.66 ± 4.6

Cardiovascular imaging is an essential component of modern cardiology. Its information is important for diagnosing cardiovascular diseases, for treatment decisions and therapy management, and for assessing individual prognosis. Magnetic resonance imaging (MRI) plays a growing role in this field. It provides information on cardiac anatomy, function, perfusion, viability, inflammation and blood flow. Frequent indications for cardiovascular MRI include the assessment of coronary artery disease, cardiomyopathies, inflammatory heart disease, heart failure, valvular heart disease and congenital heart defects. This two-part article provides a practical overview.

Cardiovascular imaging is an essential component of modern cardiology. It provides important information for the diagnostics of cardiovascular diseases, for treatment decisions and management and for an individual assessment of the prognosis. Magnetic resonance imaging (MRI) plays a growing role in this field, as reflected in an increasing number of guideline recommendations for its targeted use. It provides information on cardiac anatomy, cardiac function, perfusion, viability, inflammation and blood flow. Frequent indications for cardiovascular MRI include the assessment of coronary artery disease, cardiomyopathy, inflammatory heart diseases, heart failure, valvular heart diseases and congenital heart defects. This two-part article provides a practical overview.

Left heart disease (LHD) may cause or coexist in pulmonary hypertension (PH). Left atrial (LA) deformation identifies LHD in PH, however, feature-tracking (FT) deformation imaging remains underused due to limited inter-vendor agreement. Manual long axis strain (LAS) has been introduced as a software independent approach for deformation assessment. Consequently, we sought to compare their diagnostic accuracies for identification of LHD in PH. Patients referred to both right heart catheterisation (RHC) and cardiovascular magnetic resonance (CMR) imaging were enrolled in this monocentric registry. Patients were classified by RHC according to current guideline recommendations. CMR assessment included FT-deformation imaging for LA total strain (Es) and left ventricular (LV) global longitudinal strain (GLS) as well as LV/LA LAS. In total n = 209 PH patients were included with n = 126 undergoing exercise-stress testing (n = 55 normal, n = 72 pre-capillary, n = 27 combined post-/precapillary, n = 15 isolated postcapillary, n = 34 exercise and n = 6 unclassified PH). LAS showed strong correlation with FT for both LA (r = 0.78, p < 0.001) and LV (r = 0.83, p < 0.001) deformation. LA (AUC 0.81 vs. 0.81, p = 0.89) and LV LAS (AUC 0.75 vs. 0.77, p = 0.55) equally identified LHD at rest compared to their respective FT counterpart. LA LAS showed good diagnostic performance for identification of LHD unmasked during exercise stress for pulmonary capillary wedge pressure (PCWP) ≥25mmHg (AUC 0.73 vs. 0.79, p = 0.042) and PCWP/Cardiac Output (CO) Slope > 2 (AUC = 0.66 vs. 0.73, p = 0.045) but significantly inferior to LA Es. LV LAS showed similar performance compared to LV GLS, but worse compared to LA LAS. Software-independent LAS shows strong correlation to its FT counterparts and good diagnostic accuracy for detection of LHD in PH. However, for detection of masked LHD detected during exercise-stress only, FT LA Es remains the most accurate parameter.

BACKGROUND:Diabetes mellitus (DM) promotes myocardial remodeling through advanced glycation end-products, interstitial fibrosis, and microvascular dysfunction. We investigated whether native T1 mapping captures this adverse phenotype and provides incremental prognostic information beyond established clinical risk factors in a real-world population. METHODS:Patients undergoing CMR were enrolled in a prospective single-center all-comer registry. CMR parameters were compared between groups, adjusted for LV end-diastolic volume index and major fibrosis-inducing comorbidities. Prognostic significance for the composite endpoint of all-cause mortality, heart failure hospitalization, and appropriate ICD shock therapy was assessed using Cox regression. Incremental value was evaluated by likelihood-ratio testing, IDI, and NRI. RESULTS:Among 3614 patients (DM n = 635, 18%), DM patients showed higher native T1 and impaired GLS (1137 ms [1134-1139] vs. 1147 ms [1141-1153], p < 0.001; -16.05% [-16.2 to -15.9] vs. -13.8% [-14.2 to -13.4], p < 0.001). The T1 difference persisted after adjustment for fibrosis-inducing comorbidities. In the multivariable model (N = 2426, 82 events), native T1 and lower LVEF were independently associated with outcomes. GLS was independently prognostic only when replacing LVEF. DM patients with T1 > 1123 ms showed the poorest prognosis. Adding native T1 improved global model fit (LR χ2 = 7.94, p = 0.0048), discrimination (C-index 0.758 → 0.771), reclassification (NRI = 0.113, p = 0.013). CONCLUSIONS:Patients with DM exhibit distinct structural and functional myocardial phenotypes. Native T1 captures diffuse myocardial alterations associated with adverse outcomes and provides modest incremental prognostic information beyond established clinical risk factors within the observed follow-up period, supporting comprehensive CMR phenotyping for risk stratification in DM.

Purpose Approximately 30% of patients with atrial fibrillation (AF) develop heart failure (HF), but the underlying mechanisms and their impact on the left ventricle (LV) remain unclear. Fibrosis and inflammation are suspected contributors. This study aimed to investigate LV tissue characteristics in patients with and without AF using cardiac magnetic resonance imaging (CMR). Methods Patients from a single-center CMR registry were categorized by AF status, adjudicated by two blinded investigators. LV fibrosis was assessed by native T1 and extracellular volume (ECV), while T2 indicated inflammation. Results were adjusted for LV ejection fraction (LVEF), end-systolic volume index (ESVi), and late gadolinium enhancement mass (LGEmass). Prognostic value was tested with multivariable Cox regression, using all-cause mortality or HF hospitalization at one year as the endpoint. Results Of 2,879 patients with one-year follow-up, 590 had AF. They showed lower LVEF and higher ESVi and LGEmass. After adjustment, AF was linked to higher T1 (p = 0.006), T2 (p = 0.01), and ECV (p < 0.001). Eighty-five patients reached the endpoint. In multivariable analysis, only T1 independently predicted outcome. Kaplan-Meier analysis showed patients with T1 above the median (1125 ms) had worse outcomes than those below, even without AF. The combination of AF and elevated T1 carried the poorest prognosis (p = 0.001). Conclusion AF is closely associated with LV fibrosis and inflammation, with T1 emerging as an independent predictor of outcome. These findings suggest a mechanistic pathway with important prognostic implications. Prospective studies are warranted to confirm these associations and explore their role in patient stratification and management.

Myocardial inflammation is a key driver of adverse outcomes; yet its clinical recognition remains challenging because of heterogeneous presentation and non-standardised prognostic frameworks. While prior studies linked troponin and late gadolinium enhancement (LGE) by cardiovascular magnetic resonance imaging (CMR) to outcomes, the relative prognostic value of individual non-invasive markers has not been systematically evaluated. We systematically evaluated the prognostic value of biomarkers and non-invasive imaging variables in patients with clinically suspected myocardial inflammation presenting to tertiary centres and referred for CMR diagnostic evaluation. The primary endpoint was major adverse cardiovascular events (MACE). A total of 722 patients (median age: 50 years [IQR: 40–61]; 422 males [58

BACKGROUND:Pulmonary hypertension (PH) is classified as precapillary, isolated postcapillary pulmonary hypertension (IpcPH), combined postcapillary and precapillary (CpcPH), or exercise PH. IpcPH associated with left heart disease can lead to pulmonary vascular remodeling and eventually CpcPH. Conversely, precapillary PH may be diagnosed in the presence of cardiovascular comorbidities, including left heart disease. Atrial functional impairment is a frequent finding in cardiopulmonary disease, reflecting both intrinsic atrial cardiomyopathy and congestion. Consequently, we sought to investigate this across the PH spectrum. METHODS:Patients referred to both right heart catheterization and cardiovascular magnetic resonance imaging were enrolled in this monocentric registry. Patients were classified by right heart catheterization according to current guideline recommendations. Cardiovascular magnetic resonance assessment included left/right ventricular and left atrial (LA)/right atrial volumes and deformation imaging. RESULTS:The study population consisted of N=209 patients (n=55 normal, n=72 precapillary, n=27 CpcPH, n=15 IpcPH, n=34 exercise, and n=6 unclassified PH). N=126 patients underwent additional exercise stress right heart catheterization. Median LA reservoir function was lowest and similar in IpcPH (10.0%) and CpcPH (10.0%), which were significantly impaired compared with normal hemodynamics (30.8%, both P<0.001), precapillary (28.2%, both P<0.001), and exercise PH (26.9%, IpcPH: P=0.039, CpcPH: P=0.048). LA reservoir function and left ventricular global longitudinal strain showed good diagnostic performance to identify patients with left cardiac involvement evident at rest (pulmonary capillary wedge pressure ≥15 mm Hg; area under the curve, 0.81 versus 0.77; P=0.20), whereas LA reservoir function emerged superior for identification of exercise stress induced pulmonary capillary wedge pressure ≥25 mm Hg (area under the curve, 0.79 versus 0.70, P=0.039). CONCLUSIONS:LA functional impairment is a sign of left heart involvement in patients with PH. Left atrial reservoir function emerged superior for the identification of left heart disease unmasked during exercise stress compared with left ventricular global longitudinal strain. Consequently, LA strain may become an innovative method to detect early-stage left heart disease in PH.

Technical developments over the last few decades have enabled the non-invasive detailed visualization of the coronary arteries using computed tomography (CT). Coronary CT angiography (CTA) enables the visualization of the coronary artery anatomy, the identification and characterization of atherosclerotic coronary plaques and the estimation of the resulting luminal stenosis. The main clinical indication for coronary CTA is the diagnostic work-up of de-novo (wie es im Original ja auch war) suspected obstructive coronary artery disease (CAD). According to the most recent clinical practice guidelines issued by the European Society of Cardiology in 2024, coronary CTA is recommended if the clinical likelihood of obstructive CAD is >5-50%. Most patients with new symptoms fall into this category. The new central role of coronary CTA is based on strong evidence from large studies published in recent years. With the integration of coronary CTA into the service catalog of public health insurances in Germany from 2025 onwards, the clinical application of the method will probably expand further. To ensure a high level of quality, structured training programs and the integration of cardiological expertise into the entire process are essential: from selection of the most appropriate test and patient preparation, to CT examination and analysis up to the integration of findings into the clinical context. This article, consisting of two parts, provides a practical overview of the topic. Part 1 presents technical aspects of CT, provides information about the diagnostic performance of coronary CTA, describes the procedure for establishing the indications for coronary CTA when CAD is suspected, addresses rare indications and contraindications, summarizes the preparation and implementation of a CT examination, names certification options and provides current information for the provision of coronary CTA in outpatient care. Part 2 explains the procedure for analyzing the image data and creating a structured report, provides an image impression of coronary CTA using case studies, compiles an overview of important position papers and outlines some further developments in cardiac CT imaging.

Technische Entwicklungen der letzten Jahrzehnte haben es ermöglicht, die Koronararterien mit der Computertomographie (CT) nicht-invasiv detailliert darzustellen. Die koronare CT-Angiographie (koronare CTA) ermöglicht neben der Beschreibung der Koronaranatomie die Erkennung atherosklerotischer Plaques in den Koronarien, deren Charakterisierung und die Abschätzung der resultierenden Stenose. Die wesentliche klinische Indikation für eine koronare CTA ist die Abklärung des Verdachts auf eine obstruktive koronare Herzkrankheit (KHK). Entsprechend der aktuellen Leitlinie der European Society of Cardiology wird die koronare CTA bei einer klinischen Wahrscheinlichkeit für eine obstruktive KHK von > 5–50

Load dependence on left ventricular (LV) strain is under constant debate with its interference with prognostic implications remaining unclear. Consequently, we sought to investigate their interaction and prognostic value following acute myocardial infarction (AMI) using state-of-the-art cardiac magnetic resonance (CMR) imaging. In total, 1235 patients (n = 795 ST-elevation [STEMI] and 440 non-STEMI) underwent CMR in median 3 days following AMI. Infarct characteristics were described by CMR using tissue characterisation (infarct size, microvascular obstruction, area at risk) and deformation imaging including LV global longitudinal and circumferential strain (GLS/GCS). Non-invasive haemodynamic indices included effective arterial elastance Ea (end-systolic pressure (ESP)/stroke volume) and the non-geometric LV end-systolic afterload index NGI [(ESP × LV end-systolic volume (ESV))/LV mass] for estimation of LV afterload. LV contractility was assessed using end-systolic elastance Ees (ESP/LV ESV). Ventriculo–arterial coupling was described as Ea/Ees. Major adverse cardiac events (MACE) were recorded within the first year. All haemodynamic indices were impaired in patients with MACE during follow-up compared to patients without (p < 0.001–0.005). Ventriculo–arterial coupling showed the highest correlation to infarct properties (infarct size r = 0.51, p < 0.001) and deformation imaging (GLS r = 0.54, GCS r = 0.72, p < 0.001). GLS and GCS were associated with MACE independently of all haemodynamic indices (p < 0.001 for all except of GCS-Ea/Ees p = 0.024). Non-invasive haemodynamic indices are associated with outcome following AMI with ventriculo–arterial coupling showing the most prominent association to infarct properties and outcome. GCS showed higher correlation to haemodynamic indices compared to GLS whilst both are independent predictors for MACE.

Background: The diagnostic performance of preprocedural CT angiography in detecting coronary artery disease (CAD) in patients scheduled for transcatheter aortic valve implantation (TAVI) has been reported. However, data on predictors of diagnostic inaccuracy are sparse. We sought to investigate clinical characteristics and imaging criteria that predict the inaccurate assessment of coronary artery stenosis based on pre-TAVI-CT. Methods: The patient- and vessel-level analysis of all CT datasets from 192 patients (mean age 82.1 ± 4.8 years; 63.5% female) without known CAD or severe renal dysfunction was performed retrospectively in a blinded fashion. Significant CAD was defined as a CAD-RADS™ 2.0 category ≥ 4 by CT. Invasive coronary angiography (ICA) served as the reference standard for relevant CAD (≥70% luminal diameter stenosis or fractional flow reserve ≤ 0.80). Pertinent clinical characteristics and imaging criteria of all true-positive (n = 71), false-positive (n = 30), false-negative (n = 4), and true-negative patient-level CT diagnoses (n = 87) for relevant stenosis according to ICA were assessed. Results: In the univariate per-patient analysis, the following parameters yielded discriminative power (p < 0.10) regarding inaccurate CAD assessment by pre-TAVI-CT: age, atrial fibrillation, scanner generation, and image quality. Factors independently associated with CT diagnostic inaccuracy were determined using multivariable logistic regression analysis: a younger age (odds ratio [OR] 0.87; 95% confidence interval [CI] 0.80 to 0.94; p < 0.01) and insufficient CT image quality (OR 0.6; CI 0.41 to 0.89; p < 0.01). Conclusions: Our results demonstrate younger age and poor CT image quality to predict less accurate CAD assessments by pre-TAVI-CT in comparison with ICA. Knowledge of these predictors may aid in more efficient coronary artery interpretations based on pre-TAVI-CT.

OBJECTIVE:To evaluate changes in cardiac magnetic resonance (CMR) tissue characteristics in patients with active cardiac sarcoidosis (CS) confirmed by positron emission tomography (PET)-CT undergoing immunomodulatory therapy (IMT), and to explore their potential use for inflammation monitoring. DESIGN:Retrospective observational cohort study. SETTING:Tertiary care referral centre in Germany. PARTICIPANTS:From a cohort of 47 patients with CS, 24 patients with PET-confirmed active myocardial inflammation and complete baseline and follow-up CMR imaging after ≥6 months of IMT were included. PRIMARY AND SECONDARY ENDPOINTS:Primary outcome: Changes in CMR-derived tissue characteristics (T1, T2 mapping, late gadolinium enhancement (LGE) mass). SECONDARY OUTCOMES:Changes in functional (ejection fraction (EF) and global longitudinal strain (GLS)) and morphological parameters (end-diastolic/systolic volume indices (EDVi/ESVi)). RESULTS:Patients with PET-confirmed active CS show increased global T1 and T2 compared with healthy volunteers. Over the course of IMT, significant reductions in global T2 (median (IQR): 39 (38-41) ms vs 37 (36-39) ms; p=0.002), LGE-region T2 (43 (40-46) ms vs 41 (38-42) ms; p=0.003), and relative LGE mass (23% (17-38) vs 15% (8-32); p=0.006) were observed. No significant differences were found in EF (p=0.78), GLS (p=0.49), EDVi (p=0.56), ESVi (p=0.28) or native T1 values (p=0.23). CONCLUSION:In patients with PET-confirmed active CS undergoing IMT, serial CMR demonstrated measurable changes in T2 mapping and LGE parameters, suggesting a potential role for CMR tissue characterisation in monitoring myocardial inflammation. However, due to the observational design and absence of a control group, causal treatment effects cannot be confirmed. Further prospective studies are needed to validate the utility of CMR for treatment monitoring in CS.