Cardiovascular multimodality imaging in women: a scientific statement of the European Association of Cardiovascular Imaging of the European Society of Cardiology

Cardiovascular diseases (CVD) represent an important cause of mortality and morbidity in women. It is now recognized that there are sex differences regarding the prevalence and the clinical significance of the traditional cardiovascular (CV) risk factors as well as the pathology underlying a range of CVDs. Unfortunately, women have been under-represented in most CVD imaging studies and trials regarding diagnosis, prognosis, and therapeutics. There is therefore a clear need for further investigation of how CVD affects women along their life span. Multimodality CV imaging plays a key role in the diagnosis of CVD in women as well as in prognosis, decision-making, and monitoring of therapeutics and interventions. However, multimodality imaging in women requires specific consideration given the differences in CVD between the sexes. These differences relate to physiological changes that only women experience (e.g. pregnancy and menopause) as well as variation in the underlying pathophysiology of CVD and also differences in the prevalence of certain conditions such as connective tissue disorders, Takotsubo, and spontaneous coronary artery dissection, which are all more common in women. This scientific statement on CV multimodality in women, an initiative of the European Association of Cardiovascular Imaging of the European Society of Cardiology, reviews the role of multimodality CV imaging in the diagnosis, management, and risk stratification of CVD, as well as highlights important gaps in our knowledge that require further investigation.

Multimodality imaging for the diagnosis of left ventricular apical hypoplasia: A case presentation and review of the literatures

Left ventricular apical hypoplasia is a rare malformation recently described congenital abnormality characterized by: (1) truncation of the left ventricle, with the septum projecting toward the right ventricle; (2) abnormal papillary muscle originating from the flattened left ventricular apex; (3) a narrow right ventricle encompassing the periapical area of the left ventricle; (4) fatty infiltration of the apex of the left ventricle. We reported a case of LVAH and reviewed the patient's clinical presentation. And its morphologic characteristics were revealed by multimodality imaging, including echocardiography and cardiac magnetic resonance imaging. Additionally, we reviewed 41 cases from 32 reports to summarize the pathogenesis and analyzed the imaging manifestations of LVAH in this study, aiming to provide new ideas for the diagnosis and clinical management of LVAH patients.

A Biodegradable "One-For-All" Nanoparticle for Multimodality Imaging and Enhanced Photothermal Treatment of Breast Cancer

Silver sulfide nanoparticles (Ag2S-NP) hold promise for various optical-based biomedical applications, such as near-infrared fluorescence (NIRF) imaging, photoacoustics (PA), and photothermal therapy (PTT). However, their NIR absorbance is relatively low, and previous formulations are synthesized using toxic precursors under harsh conditions and are not effectively cleared due to their large size. Herein, sub-5 nm Ag2S-NP are synthesized and encapsulated in biodegradable, polymeric nanoparticles (AgPCPP). All syntheses are conducted using biocompatible, aqueous reagents under ambient conditions. The encapsulation of Ag2S-NP in polymeric nanospheres greatly increases their NIR absorbance, resulting in enhanced optical imaging and PTT effects. AgPCPP nanoparticles exhibit potent contrast properties suitable for PA and NIRF imaging, as well as for computed tomography (CT). Furthermore, AgPCPP nanoparticles readily improve the conspicuity of breast tumors in vivo. Under NIR laser irradiation, AgPCPP nanoparticles significantly reduce breast tumor growth, leading to prolonged survival compared to free Ag2S-NP. Over time, AgPCPP retention in tissues gradually decreases, without any signs of acute toxicity, providing strong evidence of their safety and biodegradability. Therefore, AgPCPP may serve as a "one-for-all" theranostic agent that degrades into small components for excretion after fulfilling diagnostic and therapeutic tasks, offering good prospects for clinical translation.

Multimodality Cardiac Imaging and the Imaging Workforce in the United States: Diversity, Disparities, and Future Directions

Innovations in cardiac imaging have fundamentally advanced the understanding and treatment of cardiovascular disease. These advances in noninvasive cardiac imaging have also expanded the role of the cardiac imager and dramatically increased the demand for imagers who are cross-trained in multiple modalities. However, we hypothesize that there is significant variation in the availability of cardiac imaging expertise and a disparity in the adoption of advanced imaging technologies across the United States. To evaluate this, we have brought together the leaders of cardiovascular imaging societies, imaging trainees, as well as collaborated with national imaging accreditation commissions and imaging certification boards to assess the state of cardiac imaging and the diversity of the imaging workforce in the United States. Aggregate data confirm the presence of critical gaps, such as limited access to imaging and imaging expertise in rural communities, as well as disparities in the imaging workforce, notably among women and underrepresented minorities. Based on these results, we have proposed solutions to promote and maintain a robust and diverse community of cardiac imagers and improve equity and accessibility for cardiac imaging technologies.

Current and Evolving Multimodality Cardiac Imaging in Managing Transthyretin Amyloid Cardiomyopathy

Amyloid transthyretin (ATTR) amyloidosis is a protein-misfolding disease characterized by fibril accumulation in the extracellular space that can result in local tissue disruption and organ dysfunction. Cardiac involvement drives morbidity and mortality, and the heart is the major organ affected by ATTR amyloidosis. Multimodality cardiac imaging (ie, echocardiography, scintigraphy, and cardiac magnetic resonance) allows accurate diagnosis of ATTR cardiomyopathy (ATTR-CM), and this is of particular importance because ATTR-targeting therapies have become available and probably exert their greatest benefit at earlier disease stages. Apart from establishing the diagnosis, multimodality cardiac imaging may help to better understand pathogenesis, predict prognosis, and monitor treatment response. The aim of this review is to give an update on contemporary and evolving cardiac imaging methods and their role in diagnosing and managing ATTR-CM. Further, an outlook is presented on how artificial intelligence in cardiac imaging may improve future clinical decision making and patient management in the setting of ATTR-CM.

Hereditary Thoracic Aortic Diseases

Advances in both imaging techniques and genetics have led to the recognition of a wide variety of aortic anomalies that can be grouped under the term 'hereditary thoracic aortic diseases'. The present review aims to summarize this very heterogeneous population's clinical, genetic, and imaging characteristics and to discuss the implications of the diagnosis for clinical counselling (on sports activity or pregnancy), medical therapies and surgical management.

Multimodality imaging for comprehensive non-invasive diagnosis of aorto-left ventricular tunnel in infancy

BACKGROUND

Aorto-left ventricular tunnel (ALVT) is a paravalvular communication between aorta and left ventricle. It is one of the rare congenital heart diseases which could present with heart failure.

CASE PRESENTATION

A case of ALVT was diagnosed in infancy. Preliminary assessment was possible using conventional echocardiography; however, functional assessment and accurate anatomy of ALVT were further verified via variable imaging modalities starting from speckle tracking and three-dimensional echocardiography to cardiac CT angiogram. The tunnel was successfully repaired with uneventful recovery.

CONCLUSIONS

Multimodality imaging can accurately assess cardiac function and demonstrate the anatomy of ALVT noninvasively to plan for successful intervention.

Contemporary applications of multimodality imaging in infective endocarditis

INTRODUCTION

Infective endocarditis (IE) is an increasingly important condition with significant morbidity and mortality. With advancements in cardiovascular interventions including prosthetic valve implantation and utilization of intracardiac devices, the prevalence of IE is rising in the modern era. Early detection and management of this condition are critical.

AREAS COVERED

This review presents a contemporary review of the applications of multi-modality imaging in IE, taking a comparative approach of the various imaging modalities.

EXPERT OPINION

Transthoracic and transesophageal echocardiography are essential imaging modalities in establishing the diagnosis of IE, as well as evaluating for complications of IE. Other imaging modalities such as cardiac computed tomography and nuclear imaging play an important role as adjuvant imaging modalities for the evaluation of IE, particularly in prosthetic valve IE and cardiovascular implantable device associated IE. It is crucial to understand the strengths, weaknesses, and clinical application of each imaging modality, to improve the diagnosis, management, and outcomes of patients with IE.

Intramural aortic stenting of an anomalous right coronary artery arising from the left valsalva sinus: A leap into the dark?

A 69-year-old man with unstable angina underwent coronary angiography showing no lesion in the left coronary artery and critical stenosis in the proximal right coronary artery (RCA) arising from the left sinus of Valsalva.

Tricuspid Regurgitation: From Imaging to Clinical Trials to Resolving the Unmet Need for Treatment

Tricuspid regurgitation (TR) is a highly prevalent and heterogeneous valvular disease, independently associated with excess mortality and high morbidity in all clinical contexts. TR is profoundly undertreated by surgery and is often discovered late in patients presenting with right-sided heart failure. To address the issue of undertreatment and poor clinical outcomes without intervention, numerous structural tricuspid interventional devices have been and are in development, a challenging process due to the unique anatomic and physiological characteristics of the tricuspid valve, and warranting well-designed clinical trials. The path from routine practice TR detection to appropriate TR evaluation, to conduction of clinical trials, to enriched therapeutic possibilities for improving TR access to treatment and outcomes in routine practice is complex. Therefore, this paper summarizes the key points and methods crucial to TR detection, quantitation, categorization, risk-scoring, intervention-monitoring, and outcomes evaluation, particularly of right-sided function, and to clinical trial development and conduct, for both interventional and surgical groups.

Multimodality Imaging in Cranial Giant Cell Arteritis: First Experience with High-Resolution T1-Weighted 3D Black Blood without Contrast Enhancement Magnetic Resonance Imaging

In order to support or refute the clinical suspicion of cranial giant cell arteritis (GCA), a supplemental imaging modality is often required. High-resolution black blood Magnetic Resonance Imaging (BB MRI) techniques with contrast enhancement can visualize artery wall inflammation in GCA. We compared findings on BB MRI without contrast enhancement with findings on 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography/low-dose computed tomography (2-[18F]FDG PET/CT) in ten patients suspected of having GCA and in five control subjects who had a 2-[18F]FDG PET/CT performed as a routine control for malignant melanoma. BB MRI was consistent with 2-[18F]FDG PET/CT in 10 out of 10 cases in the group with suspected GCA. In four out of five cases in the control group, the BB MRI was consistent with 2-[18F]FDG PET/CT. In this small population, BB MRI without contrast enhancement shows promising performance in the diagnosis of GCA, and might be an applicable imaging modality in patients.

Imaging in patients with cardiovascular implantable electronic devices: part 2-imaging after device implantation. A clinical consensus statement of the European Association of Cardiovascular Imaging (EACVI) and the European Heart Rhythm Association (EHRA) of the ESC

Cardiac implantable electronic devices (CIEDs) improve quality of life and prolong survival, but there are additional considerations for cardiovascular imaging after implantation-both for standard indications and for diagnosing and guiding management of device-related complications. This clinical consensus statement (part 2) from the European Association of Cardiovascular Imaging, in collaboration with the European Heart Rhythm Association, provides comprehensive, up-to-date, and evidence-based guidance to cardiologists, cardiac imagers, and pacing specialists regarding the use of imaging in patients after implantation of conventional pacemakers, cardioverter defibrillators, and cardiac resynchronization therapy (CRT) devices. The document summarizes the existing evidence regarding the role and optimal use of various cardiac imaging modalities in patients with suspected CIED-related complications and also discusses CRT optimization, the safety of magnetic resonance imaging in CIED carriers, and describes the role of chest radiography in assessing CIED type, position, and complications. The role of imaging before and during CIED implantation is discussed in a companion document (part 1).

Massive Right Ventricle Enlargement in Unrepaired Sinus Venosus Atrial Septal Defect: Repair or Not?

Sinus venosus atrial septal defect (SVASD) with partial anomalous pulmonary venous return is a rare congenital heart defect that may present in adulthood when right heart enlargement has already occurred. We describe a case of unrepaired sinus venosus atrial septal defect and partial anomalous pulmonary venous return with massive right heart enlargement and recurrent atrial arrhythmias.

Multimodality Imaging in Advanced Heart Failure for Diagnosis, Management and Follow-Up: A Comprehensive Review

Advanced heart failure (AHF) presents a complex landscape with challenges spanning diagnosis, management, and patient outcomes. In response, the integration of multimodality imaging techniques has emerged as a pivotal approach. This comprehensive review delves into the profound significance of these imaging strategies within AHF scenarios. Multimodality imaging, encompassing echocardiography, cardiac magnetic resonance imaging (CMR), nuclear imaging and cardiac computed tomography (CCT), stands as a cornerstone in the care of patients with both short- and long-term mechanical support devices. These techniques facilitate precise device selection, placement, and vigilant monitoring, ensuring patient safety and optimal device functionality. In the context of orthotopic cardiac transplant (OTC), the role of multimodality imaging remains indispensable. Echocardiography offers invaluable insights into allograft function and potential complications. Advanced methods, like speckle tracking echocardiography (STE), empower the detection of acute cell rejection. Nuclear imaging, CMR and CCT further enhance diagnostic precision, especially concerning allograft rejection and cardiac allograft vasculopathy. This comprehensive imaging approach goes beyond diagnosis, shaping treatment strategies and risk assessment. By harmonizing diverse imaging modalities, clinicians gain a panoramic understanding of each patient's unique condition, facilitating well-informed decisions. The aim is to highlight the novelty and unique aspects of recently published papers in the field. Thus, this review underscores the irreplaceable role of multimodality imaging in elevating patient outcomes, refining treatment precision, and propelling advancements in the evolving landscape of advanced heart failure management.

The Role of Multimodality Imaging in Patients with Congenital Heart Disease and Infective Endocarditis

Infective endocarditis (IE) represents an important medical challenge, particularly in patients with congenital heart diseases (CHD). Its early and accurate diagnosis is crucial for effective management to improve patient outcomes. Multimodality imaging is emerging as a powerful tool in the diagnosis and management of IE in CHD patients, offering a comprehensive and integrated approach that enhances diagnostic accuracy and guides therapeutic strategies. This review illustrates the utilities of each single multimodality imaging, including transthoracic and transoesophageal echocardiography, cardiac computed tomography (CCT), cardiovascular magnetic resonance imaging (CMR), and nuclear imaging modalities, in the diagnosis of IE in CHD patients. These imaging techniques provide crucial information about valvular and intracardiac structures, vegetation size and location, abscess formation, and associated complications, helping clinicians make timely and informed decisions. However, each one does have limitations that influence its applicability.

Multimodality imaging in marantic endocarditis associated with cancer: a multicentric cohort study

AIMS

We aimed to assess the role of multimodality imaging (MMI) in the diagnosis of marantic endocarditis (ME) associated with cancers and to describe the clinical characteristics, management, and outcome of these patients.

METHODS AND RESULTS

In a retrospective multicentric study including four tertiary centres for the treatment of endocarditis in France and Belgium, patients with a diagnosis of ME were included. Demographic, MMI [echocardiography, computed tomography (CT), and 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT)], and management data were collected. Long-term mortality was analysed. Between November 2011 and August 2021, 47 patients with a diagnosis of ME were included. Mean age was 65 ± 11 years. ME occurred in 43 cases (91%) on native valves. Vegetations were detected by echocardiography in all cases and in 12 cases (26%) by CT. No patient had an increased cardiac 18F-FDG valve uptake. The most common cardiac valve involved was aortic (34 cases, 73%). Twenty-two patients (46%) had a known cancer before ME, and 25 cases (54%) were diagnosed thanks to multimodality imaging. 18FDG PET/CT was performed in 30 patients (64%) and allowed a new diagnosis of cancer in 14 patients (30%). Systemic embolism was frequent (40 patients, 85% of cases). Forty-one patients (87%) were treated medically with anticoagulation therapy. One-year mortality was 55% (26 patients).

CONCLUSION

ME remains associated with a high risk of complications and death.

Myocardial Fibrosis: Emerging Target for Cardiac Molecular Imaging and Opportunity for Image-Guided Therapy

Myocardial fibrosis is a major contributor to the development and progression of heart failure. Significant progress in the understanding of its pathobiology has led to the introduction and preclinical testing of multiple highly specific antifibrotic therapies. Because the mechanisms of fibrosis are highly dynamic, and because the involved cell populations are heterogeneous and plastic, there is increasing emphasis that any therapy directed specifically against myocardial fibrosis will require personalization and guidance by equally specific diagnostic testing for successful clinical translation. Noninvasive imaging techniques have undergone significant progress and provide increasingly specific information about the quantity, quality, and activity of myocardial fibrosis. Cardiac MRI can precisely map the extracellular space of the myocardium, whereas nuclear imaging characterizes activated fibroblasts and immune cells as the cellular components contributing to fibrosis. Existing techniques may be used in complementarity to provide the imaging biomarkers needed for the success of novel targeted therapies. This review provides a road map on how progress in basic fibrosis research, antifibrotic drug development, and high-end noninvasive imaging may come together to facilitate the success of fibrosis-directed cardiovascular medicine.

3D print and multi-modality imaging guided transcatheter closure of multiple left ventricular pseudoaneurysms

Left ventricular pseudoaneurysm (PSA) after surgical aortic valve replacement (AVR) is a known but uncommon complication. It is associated with risks such as thromboembolism and life-threatening rupture. Surgical repair has traditionally been utilized in low-risk patients but transcatheter closure has become a promising therapeutic option. This case report describes the utility of multimodality imaging in pre-, intra-, and post-procedural evaluation of transcatheter PSA closure and is among the first to demonstrate the utility of 3D print model.

Updates on Improving Imaging Modalities for Traumatic Brain Injury

The Center for Disease Control and Prevention reports that traumatic brain injury (TBI) was related to over 64,000 deaths in the United States in 2020, equating to more than 611 TBI-related hospitalizations and 176 TBI-related deaths per day. There are both long- and short-term sequelae involved with the pathophysiology of TBI that can range from mild to severe. Recently, more effort has been devoted to understanding the long-term consequences of TBI and how early detection of these injuries can prevent late clinical manifestations. Obtaining proper, detailed imaging is key to guiding the direction of intervention, but there is a gap in the understanding of how TBI imaging can be used to predict and prevent the long-term morbidities seen with even mild forms of TBI. There have been significant strides in the advancement of TBI imaging that allows for quicker, more affordable, and more effective imaging of intracranial bleeds, axonal injury, tissue damage, and more. Despite this, there is still room for improved standardization and more data supporting the justification of using certain imaging modalities. This review aims to outline recent advancements in TBI imaging and areas that require further investigation to improve patient outcomes and minimize the acute and chronic comorbidities associated with TBI.

Functional Diversity in Radiolabeled Nanoceramics and Related Biomaterials for the Multimodal Imaging of Tumors

Nanotechnology advances have the potential to assist toward the earlier detection of diseases, giving increased accuracy for diagnosis and helping to personalize treatments, especially in the case of noncommunicative diseases (NCDs) such as cancer. The main advantage of nanoparticles, the scaffolds underpinning nanomedicine, is their potential to present multifunctionality: synthetic nanoplatforms for nanomedicines can be tailored to support a range of biomedical imaging modalities of relevance for clinical practice, such as, for example, optical imaging, computed tomography (CT), magnetic resonance imaging (MRI), single photon emission computed tomography (SPECT), and positron emission tomography (PET). A single nanoparticle has the potential to incorporate myriads of contrast agent units or imaging tracers, encapsulate, and/or be conjugated to different combinations of imaging tags, thus providing the means for multimodality diagnostic methods. These arrangements have been shown to provide significant improvements to the signal-to-noise ratios that may be obtained by molecular imaging techniques, for example, in PET diagnostic imaging with nanomaterials versus the cases when molecular species are involved as radiotracers. We surveyed some of the main discoveries in the simultaneous incorporation of nanoparticulate materials and imaging agents within highly kinetically stable radio-nanomaterials as potential tracers with (pre)clinical potential. Diversity in function and new developments toward synthesis, radiolabeling, and microscopy investigations are explored, and preclinical applications in molecular imaging are highlighted. The emphasis is on the biocompatible materials at the forefront of the main preclinical developments, e.g., nanoceramics and liposome-based constructs, which have driven the evolution of diagnostic radio-nanomedicines over the past decade.

Use of Generalizability Theory Evaluating Comparative Reliability of the Scapholunate Interval Measurement With X-ray, CT, and US

RATIONALE AND OBJECTIVES

There is no universally accepted standard technique for measuring the scapholunate interval and no specific sources of measurement error have been identified. We aimed to establish a set of normal radiological criteria for the scapholunate interval that could be used in comparative studies of wrist pathology to determine interobserver reliability and to identify potential errors that might influence measurements.

MATERIALS AND METHODS

A total of 60 healthy volunteers participated in the study. Scapholunate interval was measured by three independent observers using X-ray, CT, and US in four positions, including neutral, fist, radial and ulnar deviation. Inter-observer reliability was tested using intraclass correlation coefficient. Generalizability theory was applied to evaluate specific sources of measurement error related to participant, observer, imaging modality and measurement position.

RESULTS

In neutral position, the scapholunate interval measured by X-ray, CT, and US was 3.1 mm, 3.5 mm and 3.5 mm respectively. The interval remained constant during fist and radial deviation but decreased during ulnar deviation. Correlation coefficients ranged from 0.874 to 0.907 for X-ray, 0.773-0.881 for CT and 0.964-0.979 for US. In the generalizability study, the participant x modality x position interaction accounted for the largest proportion of total variance (29%).

CONCLUSION

X-ray, CT, and US are reliable modalities for measuring the scapholunate interval, with US having the highest reliability. Participant and position factors may independently contribute to measurement error. Therefore, standardized measurement positions are recommended to obtain reliable measurement results.

Stalactites in the Right Ventricle

Heart metastatic tumors are more frequent than primary heart tumors. Cardiac metastasis is a rare phenomenon, occurring mainly by direct spread, especially from lung cancer. Cardiac metastases may be asymptomatic or cause arrhythmias, nonspecific electrocardiographic alterations, or mimic a myocardial infarction. In this case report, we illustrate a rare case of pulmonary adenocarcinoma, which through the bloodstream developed a stalactite-shaped metastasis within the right ventricle of conspicuous size (20 mm × 34 mm × 12 mm). In addition, the tumor compressed the right pulmonary trunk, causing pulmonary hypertension. It is essential to characterize metastasis with multimodality imaging. Such lesions within the right cavities can cause massive pulmonary embolism, as in our case, leading to the patient's death, thrombolytic therapy not being effective.

Multimodality Imaging in Patients with Hypertrophic Cardiomyopathy and Atrial Fibrillation

Ventricular hypertrophy is associated with diastolic dysfunction, resulting in increased left atrial (LA) pressure, enlargement, fibrosis, and decreased LA function. Hypertrophic cardiomyopathy (HCM) is characterized by myocyte disarray, myocardial fibrosis, and hypertrophy. Notably, a thickened and noncompliant LV results in the impairment of diastolic function. These conditions promote LA remodeling and enlargement, which contribute to developing and maintaining atrial fibrillation (AF). AF is an atrial arrhythmia that occurs frequently in HCM, and evaluating the morphology and physiology of the atrium and ventricle is important for treatment and prognosis determination in HCM patients with AF. In addition, it provides a clue that can predict the possibility of new AF, even in patients not previously diagnosed with AF. Cardiac magnetic resonance (CMR), which can overcome the limitations of transthoracic echocardiography (TTE), has been widely used traditionally and even enables tissue characterization; moreover, it has emerged as an essential imaging modality for patients with HCM. Here, we review the role of multimodal imaging in patients with HCM and AF.

An Unusual Case of Parasitic Constrictive Pericarditis

Parasitic constrictive pericarditis is a rare entity. We present a case of a 75-year-old man who presented with dyspnea, ascites, and pedal edema and was found to have constrictive pericarditis on multimodality imaging with positive serology for Strongyloides Stercoralis. Treatment required ivermectin and radical pericardiectomy with significant clinical improvement. (Level of Difficulty: Intermediate.).

Unmet Needs in the Assessment of Right Ventricular Function for Severe Tricuspid Regurgitation

Tricuspid regurgitation (TR) is a highly prevalent valvular heart disease that has been long overlooked, but lately its independent association with adverse cardiovascular outcomes was recognized. The time point to intervene and repair the tricuspid valve is defined by the right ventricular (RV) dilation and dysfunction that comes up at a later stage. While guidelines favor tricuspid valve repair before severe RV dysfunction ensues, the definition of RV dysfunction in a universal manner remains vague. As a result, the candidates for transcatheter or surgical TR procedures are often referred late, when advanced RV dysfunction is established, and any derived procedural survival benefit is attenuated. Thus, it is of paramount importance to establish a universal means of RV function assessment in patients with TR. Conventional echocardiographic indices of RV function routinely applied have fundamental flaws that limit the precise characterization of RV performance. More recently, novel echocardiographic indices such as strain via speckle-tracking have emerged, demonstrating promising results in the identification of early RV damage. Additionally, evidence of the role of alternative imaging modalities such as cardiac computed tomography and cardiac magnetic resonance, for RV functional assessment in TR, has recently arisen. This review provides a systematic appraisal of traditional and novel multimodality indices of RV function in severe TR and aims to refine RV function assessment, designate future directions, and ultimately, to improve the outcome of patients suffering from severe TR.

Early Biological Valve Failure: Structural Valve Degeneration, Thrombosis, or Endocarditis?

Biological valve failure (BVF) is an inevitable condition that compromises the durability of biological heart valves (BHVs). It stems from various causes, including rejection, thrombosis, and endocarditis, leading to a critical state of valve dysfunction. Echocardiography, cardiac computed tomography, cardiac magnetic resonance, and nuclear imaging play pivotal roles in the diagnostic multimodality workup of BVF. By providing a comprehensive overview of the pathophysiology of BVF and the diagnostic approaches in different clinical scenarios, this review aims to aid clinicians in their decision-making process. The significance of early detection and appropriate management of BVF cannot be overstated, as these directly impact patients' prognosis and their overall quality of life. Ensuring timely intervention and tailored treatments will not only improve outcomes but also alleviate the burden of this condition on patients' life. By prioritizing comprehensive assessments and adopting the latest advancements in diagnostic technology, medical professionals can significantly enhance their ability to manage BVF effectively.

Multimodality imaging features of parosteal lipomas

OBJECTIVE

To examine the multimodality imaging characteristics of parosteal lipomas.

MATERIALS AND METHODS

With IRB approval, our institutional imaging database and medical record were retrospectively reviewed from 1990-2020 for cases of pathologically-proven and/or imaging diagnosed parosteal lipomas.

RESULTS

There were 22 patients (12 males, 10 females) with a mean age of 57.1 ± 12.7 years (range 31-80 years). 11/22 cases (50%) were pathologically-confirmed on biopsy or surgical resection and 11/22 (50%) had imaging features compatible with parosteal lipoma. Lesions occurred most commonly along the femur (8/22, 36%), followed by the forearm (3/22, 14%). All cases demonstrated a juxtacortical fatty mass containing an osseous excrescence that was firmly attached to the cortical surface. The osseous excrescences were characterized as pedunculated in 16/22 (73%) and sessile in 6/22 (27%). The average largest dimension of the osseus excrescences was 2.4 ± 1.6 cm (range 0.8-6.1 cm) and the lipomatous portions 7.8 ± 3.8 cm (range 2.0-19.5 cm). The excrescences contained mature bone in 12/22 (55%) cases and a mixture of mature bone and radiating bone spicules in 10/22 (45%). There were non-lipomatous elements in the fatty portion of the mass in 13/22 (59%) of cases. Most cases (19/22, 85%) had cortical thickening/periostitis near the base of the osseous stalk. Two patients had a bone scan that demonstrated uptake in the osseous excrescence, and two patients had an FDG PET/CT that demonstrated no uptake.

CONCLUSION

Parosteal lipomas are a rare benign lipomatous tumor with pathognomonic multimodality imaging features that may obviate the need for biopsy.

Optical Breast Imaging: A Review of Physical Principles, Technologies, and Clinical Applications

Optical imaging involves the propagation of light through tissue. Current optical breast imaging technologies, including diffuse optical spectroscopy, diffuse optical tomography, and photoacoustic imaging, capitalize on the selective absorption of light in the near-infrared spectrum by deoxygenated and oxygenated hemoglobin. They provide information on the morphological and functional characteristics of different tissues based on their varied interactions with light, including physiologic information on lesion vascular content and anatomic information on tissue vascularity. Fluorescent contrast agents, such as indocyanine green, are used to visualize specific tissues, molecules, or proteins depending on how and where the agent accumulates. In this review, we describe the physical principles, spectrum of technologies, and clinical applications of the most common optical systems currently being used or developed for breast imaging. Most notably, US co-registered photoacoustic imaging and US-guided diffuse optical tomography have demonstrated efficacy in differentiating benign from malignant breast masses, thereby improving the specificity of diagnostic imaging. Diffuse optical tomography and diffuse optical spectroscopy have shown promise in assessing treatment response to preoperative systemic therapy, and photoacoustic imaging and diffuse optical tomography may help predict tumor phenotype. Lastly, fluorescent imaging using indocyanine green dye performs comparably to radioisotope mapping of sentinel lymph nodes and appears to improve the outcomes of autologous tissue flap breast reconstruction.

Multimodality imaging in diagnosing lipomatous atrial septal hypertrophy with atrial septal defect: a case report

Background

Lipomatous atrial septal hypertrophy (LASH) with atrial septal defect (ASD) is a rare congenital anomaly. Although LASH is a histologically benign cardiac lesion characterized by excessive fat deposition in the interatrial septum that spares the fossa ovale, it has been associated with supraventricular arrhythmias or sick sinus syndrome. Application of multimodal imaging is crucial for accurate diagnosis, appropriate treatment of LASH with ASD, and follow-up.

Case summary

A 68-year-old female patient presented with recurrent chest tightness and palpitation. Multimodal imaging revealed the characterizations of LASH and ASD. Two-dimensional transesophageal echocardiography showed a "dumbbell"-shaped involvement of the cephalad and caudal regions with sparing of a single secundum ASD. The septum with a brightness feature is an uncommon condition characterized by the deposition of unencapsulated fat cells in the atrial septum. Real-time four-dimensional transesophageal echocardiography reflected the lipomatous hypertrophy of the atrial septum and an oval-shaped ASD. Cardiac computer tomography angiography later confirmed this finding. The patient achieved a good clinical response with an ASD percutaneous occlusion guided by intracardiac echocardiography (ICE).

Conclusion

This case demonstrates a LASH combined with ASD. Multimodality imaging can provide an accurate diagnosis and may guide the procedure for precise occlusion.

Rapidly Progressive Metastatic Angiosarcoma of the Heart: A Case Report

Cardiac angiosarcoma is a rare, malignant neoplasm affecting the heart. We present the clinical history of a 40-year-old patient diagnosed with metastatic angiosarcoma of the heart. The patient complained of shortness of breath, and a cardiac computed tomography scan revealed a mass in the right atrium and pericardial effusion. Transthoracic and transesophageal echocardiography provided detailed anatomical and functional information, and cardiac magnetic resonance imaging and fluorodeoxyglucose-positron emission tomography/computed tomography were used to assess distant metastasis and characterize the mass in detail. Early differential diagnosis and comprehensive evaluation of a cardiac mass are vital for determining appropriate treatment strategies to improve patient outcomes. The pathological results from the endocardial biopsy confirmed the diagnosis of primary angiosarcoma. The patient underwent surgical resection of the right atrial mass but died within one month because of the locally advanced nature of the angiosarcoma and its rapid progression. The patient's medical journey sheds light on the challenges associated with diagnosing and treating this rare condition, particularly the rapid progression of its cardiac manifestations.

Optimal left ventricular ejection fraction in risk stratification of patients with cardiac sarcoidosis

AIMS

Identifying patients with cardiac sarcoidosis (CS) who are at an increased risk of sudden cardiac death (SCD) poses a clinical challenge. We sought to identify the optimal cutoff for left ventricular ejection fraction (LVEF) in predicting ventricular arrhythmia (VA) and all-cause mortality and to identify clinical and imaging risk factors in patients with known CS.

METHODS AND RESULTS

This retrospective cohort included 273 patients with well-established CS. The primary endpoint was a composite of VA and all-cause mortality. A modified receiver operating curve analysis was utilized to identify the optimal cutoff for LVEF in predicting the primary composite endpoint. Cox proportional hazard regression analysis was used to identify independent risk factors of the outcomes. At median follow-up of 7.9 years, the rate of the primary endpoint was 38% (83 VAs and 32 all-cause deaths). The 5-year overall survival rate was 97%. The optimal cutoff LVEF for the primary composite endpoint was 42% in the entire cohort and in subjects without a history of VA. Younger age, history of VA, lower LVEF, and any presence of scar by cardiac magnetic resonance (CMR) imaging and/or positron emission tomography (PET) were found to be independent risk factors for the primary endpoint and for VA, whereas lower LVEF, baseline NT-proBNP, and any presence of scar were independent risk factor of all-cause mortality.

CONCLUSION

Among patients with CS, a mild reduction in LVEF of 42% was identified as the optimal cutoff for predicting VA and all-cause mortality. Prior VA and scar by CMR or PET are strong risk factors for future VA and all-cause mortality.

Post-cardiac injury syndrome after surgical repair of atrial septal defect: Reporting a rare occurrence

A 16-year-old male with past medical history of congenital atrial septal defect surgical repair, presented with recurrent pericarditis secondary to post-cardiotomy injury syndrome (PCIS), After failing medical therapy, he ultimately underwent pericardiectomy for symptom resolution, PCIS is underdiagnosed in children and should be considered in patients with recurrent chest, pain.

A Late-Detected Paraganglioma in a Young Patient with Resistant Hypertension and Severe Aortic Regurgitation-A Case Report and Review of the Literature

BACKGROUND

Paraganglioma is a rare neuroendocrine tumor derived from chromaffin cells. The overproduction of catecholamines accounts for the presenting symptoms and cardiovascular complications. The clinical presentation frequently overlaps with the associated cardiac diseases, delaying the diagnosis. Multimodality imaging and a multidisciplinary team are essential for the correct diagnosis and adequate clinical management.

CASE SUMMARY

A 37-year-old woman with a personal medical history of long-standing arterial hypertension and radiofrequency ablation for atrioventricular nodal reentry tachycardia presented with progressive exertional dyspnea and elevated blood pressure values, despite a comprehensive pharmacological treatment with six antihypertensive drugs. The echocardiography showed a bicuspid aortic valve and severe aortic regurgitation. The computed tomography angiography revealed a retroperitoneal space-occupying solid lesion, with imaging characteristics suggestive of a paraganglioma. The multidisciplinary team concluded that tumor resection should be completed first, followed by an aortic valve replacement if necessary. The postoperative histopathology examination confirmed the diagnosis of paraganglioma. After the successful resection of the tumor, the patient was asymptomatic, and the intervention for aortic valve replacement was delayed.

DISCUSSION

This was a rare case of a late-detected paraganglioma in a young patient with resistant hypertension overlapping the clinical presentation and management of severe aortic regurgitation. A multimodality imaging approach including transthoracic and transesophageal echocardiography, computed tomography, and magnetic resonance imaging had an emerging role in establishing the diagnosis and in guiding patient management and follow-up. The resection of paraganglioma was essential for the optimal timing of surgical correction for severe aortic regurgitation. We further reviewed various cardiovascular complications induced by pheochromocytomas and paragangliomas.

Approach to the Patient with Acute Aortic Syndromes in Light of the New Consensus Statement on Multimodality Imaging in Thoracic Aortic Diseases

Acute aortic syndromes comprise a range of interrelated conditions including aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer, and contained or not contained aortic aneurysm rupture. These syndromes are potentially life threatening; therefore, a rapid and accurate diagnosis is crucial. A new Clinical Consensus Statement on Aortic and Peripheral Vascular Disease has recently been published, and we will try to highlight the main innovations in the document.

A Rare Case of Isolated Right Ventricular Loeffler's Endocarditis in Primary Hypereosinophilic Syndrome

Hypereosinophilic syndrome (HES) is a systemic disorder with various manifestations, characterized by hypereosinophilia and caused by primary or secondary conditions. Loeffler's endocarditis (LE) represents a frequent cardiac manifestation of HES, caused by infiltration of the myocardium by eosinophilic cells, which determines endocardial damage, with subsequent inflammation, thrombosis, and fibrosis of either one or both ventricles. The diagnosis of cardiac involvement is based on a multimodality approach (i.e., two-dimensional transthoracic echocardiography [2D-TTE], speckle-tracking echocardiography [STE], and cardiac magnetic resonance [CMR]), with different findings depending on the stage of disease. STE may be useful in the initial phase when traditional imaging techniques may result negative, whereas CMR allows myocardial tissue characterization along with a better definition of the right ventricle. We present a rare case of LE with isolated right ventricular involvement in a patient with HES caused by chronic eosinophilic leukemia with constitutively activated fusion tyrosine kinase on chromosome 4q12, successfully treated with imatinib mesylate.

Multimodality Cardiac Imaging in COVID-19 Infection

COVID-19 infection often produces cardiovascular complications, which can range from mild to severe and influence the overall prognosis. Imaging is the cornerstone for diagnosing initial COVID-19 cardiovascular involvement as well as treatment guidance. In this review, we present the current state of the literature on this subject while also emphasizing possible algorithms for indicating and executing these investigations.

Radioactive and Fluorescent Dual Modality Cysteine Cathepsin B Activity-Based Probe for Cancer Theranostics

Cysteine cathepsin B (CTS-B) is a crucial enzyme that is overexpressed in numerous malignancies and contributes to the invasion and metastasis of cancer. Therefore, this study sets out to develop and evaluate an activity-based multimodality theranostic agent targeting CTS-B for cancer imaging and therapy. A CTS-B activity-based probe, BMX2, was synthesized and labeled efficiently with ⁶⁸Ga and ⁹⁰Y to produce ⁶⁸Ga-BMX2 for multimodality imaging and ⁹⁰Y-BMX2 for radiation therapy. The affinity and specificity of BMX2 binding with the CTS-B enzyme were determined by fluorescent western blots using recombined active human CTS-B enzyme (rh-CTS-B) and four cancer cell lines including HeLa, HepG2, MCF7, and U87MG, with CA074 as the CTS-B inhibitor for control. Confocal laser scanning microscope imaging and cell uptake measurement were also performed. Then, in vivo PET imaging and fluorescence imaging were acquired on HeLa xenografts. Finally, the therapeutic effect of ⁹⁰Y-BMX2 was tested. BMX2 could be specifically activated by rh-CTS-B and stably bound to the enzyme. The binding of BMX2 with CTS-B is time-dependent and enzyme concentration-dependent. Although CTS-B expression varied between cell lines, all showed significant uptake of BMX2 and ⁶⁸Ga-BMX2. In vivo optical and PET imaging showed a high tumor uptake of BMX2 and ⁶⁸Ga-BMX2 and accumulation for more than 24 h. ⁹⁰Y-BMX2 could significantly inhibit HeLa tumor growth. The development of ⁶⁸Ga/⁹⁰Y-BMX2, a radioactive and fluorescent dual modality theranostic agent, demonstrated an effective theranostic approach for PET diagnostic imaging, fluorescence imaging, and radionuclide therapy of cancers, which may have a potential for clinical translation for cancer theranostics in the future.

When Echocardiography Is Challenging in Localizing Bioprosthetic Aortic Regurgitation: Dye Don't Lie

Transesophageal echocardiography is the main imaging modality for localizing and quantifying prosthetic aortic regurgitation. We describe a case of bioprosthetic aortic paravalvular leak (PVL) where transesophageal echocardiography was inadequate; aortic root angiography and computed tomography fusion were critical in diagnosing and guiding closure. Multimodality imaging can be pivotal in localizing PVL and guiding transcatheter PVL closure. (Level of Difficulty: Intermediate.).

Imaging of Bioprosthetic Valve Dysfunction after Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) has become the standard of care in elderly high-risk patients with symptomatic severe aortic stenosis. Recently, TAVI has been increasingly performed in younger-, intermediate- and lower-risk populations, which underlines the need to investigate the long-term durability of bioprosthetic aortic valves. However, diagnosing bioprosthetic valve dysfunction after TAVI is challenging and only limited evidence-based criteria exist to guide therapy. Bioprosthetic valve dysfunction encompasses structural valve deterioration (SVD) resulting from degenerative changes in the valve structure and function, non-SVD resulting from intrinsic paravalvular regurgitation or patient-prosthesis mismatch, valve thrombosis, and infective endocarditis. Overlapping phenotypes, confluent pathologies, and their shared end-stage bioprosthetic valve failure complicate the differentiation of these entities. In this review, we focus on the contemporary and future roles, advantages, and limitations of imaging modalities such as echocardiography, cardiac computed tomography angiography, cardiac magnetic resonance imaging, and positron emission tomography to monitor the integrity of transcatheter heart valves.

Case report: Multimodality imaging revealing ruptured giant coronary artery aneurysm presenting with hemoptysis

Giant coronary artery aneurysm (CAA) is a relatively uncommon disease that is defined by a focal dilation of at least 20 mm and characterized by various clinical symptoms. However, cases presenting primarily with hemoptysis have not been reported. A man in his late 20 s suffering from persistent chest pain for over 2 months was transferred to our emergency department for intermittent hemoptysis lasting for 12 h. Bronchoscopy detected fresh blood in the left upper lobe bronchus without a definite bleeding source. Magnetic resonance imaging (MRI) demonstrated a heterogeneous mass and the high-intensity signals suggested active bleeding. coronary computed tomography (CT) angiography demonstrated a giant ruptured CAA wrapped in a large mediastinal mass Coronary angiography confirmed the CAA originating from the left anterior descending artery. The patient underwent an emergency sternotomy and an enormous hematoma arising from a ruptured CAA densely adhering to the left lung was identified. The patient recovered uneventfully and was discharged on the 7th day later. The ruptured CAA masquerading as hemoptysis highlights the indispensability of multimodality imaging for accurate diagnosis. Urgent surgical intervention is desirable in such life-threatening conditions.

Solving the Riddle of Sudden Cardiac Death in Hypertrophic Cardiomyopathy: The Added Role of Cardiac Magnetic Resonance

Cardiac magnetic resonance (CMR) has been recently implemented in clinical practice to refine the daunting task of establishing the risk of sudden cardiac death (SCD) in patients with hypertrophic cardiomyopathy (HCM). We present an exemplificative case highlighting the practical clinical utility of this imaging modality in a 24-year-old man newly diagnosed with an apical HCM. CMR was essential in unmasking a high risk of SCD, which appeared low-intermediate after traditional risk assessment. A discussion examines the essential role of CMR in guiding the patient's therapy and underlines the added value of CMR, including novel and potential CMR parameters, compared to traditional imaging assessment for SCD risk stratification.

The Role of Multimodality Imaging in the Diagnosis and Follow-Up of Malignant Primary Cardiac Tumors: Myxofibrosarcoma-A Case Report and Literature Review

Cardiac tumors are a very rare but heterogenous group of diseases that may reveal themselves through a variety of nonspecific cardiac symptoms that may pose a challenge to the diagnostic process. Myxofibrosarcoma is a particularly rare type of cardiac tumor that carries a poor prognosis, thus making accurate and timely diagnosis essential. A 61-year-old woman presented with fatigue and shortness of breath during mild exercise, symptoms that have progressively worsened during the previous year. Multimodality imaging consisting of transthoracic and transesophageal echocardiography (TTE and TEE), cardiac magnetic resonance (CMR), cardiac computer tomography (CCT), and fluorodeoxyglucose positron emission computer tomography (18F-FDG PET-CT) was used for the diagnosis and postoperative follow-up of a myxofibrosarcoma.

Multimodality Imaging of Right Heart Function: JACC Scientific Statement

Right ventricular (RV) size and function assessed by multimodality imaging are associated with outcomes in a variety of cardiovascular diseases. Understanding RV anatomy and physiology is essential in appreciating the strengths and weaknesses of current imaging methods and gives these measurements greater context. The adaptation of the right ventricle to different types and severity of stress, particularly over time, is specific to the cardiovascular disease process. Multimodality imaging parameters, which determine outcomes, reflect the ability to image the initial and longitudinal RV response to stress. This paper will review the standard and novel imaging methods for assessing RV function and the impact of these parameters on outcomes in specific disease states.

Harnessing the power of Raman spectroscopic imaging for ophthalmology

Eye diseases can cause great inconvenience to people's daily life; therefore, it is necessary to study the causes of ocular diseases and related physiological processes. Raman spectroscopic imaging (RSI) is a non-destructive, non-contact detection technique with the advantages of label-free, non-invasive and highly specific. Compared with other mature imaging technologies, RSI can provide real-time molecular information and high-resolution imaging at relatively low cost, making it very suitable for quantitative detection of biological molecules. RSI can reflect the overall situation of the sample, revealing the content distribution of the same substance in different areas of the sample. This review focuses on the recent advances in ophthalmology, with particular emphasis on the powerful use of RSI techniques, as well as its combination with other imaging techniques. Finally, we prospect the wider application and future potential of RSI approaches in ophthalmology.