Purpose of Review Transcatheter valve interventions require careful planning and rely heavily on multimodality imaging. In contrast to echocardiography and computed tomography cardiovascular magnetic resonance (CMR) remains underused in clinical practice.

Choosing the most appropriate test or protocol to ensure patient safety along with accurate and informative results can be challenging. The aim of this article is to review important considerations when choosing a nuclear stress perfusion study. Single-photon emission computed tomography (SPECT) has a sensitivity of 70% and a specificity of 78% for the diagnosis of coronary artery disease (CAD), and positron emission tomography (PET) has a sensitivity of 90% and specificity of 88%. The addition of either SPECT or PET to cardiac-gated computed tomography (CCTA) confers an increase in specificity when compared to CCTA alone, at the cost of a lower sensitivity. SPECT sets itself aside because of its relative low cost and easy accessibility. PET has a superior diagnostic performance and lower radiation exposure, but is less available and relatively more expensive for most clinicians. When ordering a nuclear stress perfusion test, the type of protocol and radiotracers used should be tailored to achieve the best overall accuracy and prognostic assessment with the lowest radiation dose achievable.

This review addresses the role of serial coronary computed tomography angiography (CTA) on the evaluation of atherosclerosis progression, risk stratification, and targeting individual pharmacotherapy. The presence, extent, and severity of coronary artery disease (CAD) detected by coronary CTA are associated with an adverse prognosis. Similarly, the presence of high-risk plaque features such as positive remodeling, low-attenuation plaque, spotty calcifications, and napkin-ring sign are associated with major adverse cardiac events. More recently, examinations using serial coronary CTA have also shown that these static CTA plaque features are associated with a more rapid progression of atherosclerosis on follow-up imaging and may identify a subset of patients at increased risk for plaque rupture. While the impact of serial CTA findings on management and hard outcomes remains a topic of ongoing investigation, available data supports the ability of statin therapy to reduce CTA-identified plaque burden and modify plaque composition. Coronary CTA identifies various plaque features associated with an increased risk of plaque progression and adverse cardiac events. Available data support the use of CTA to individualize statin therapy and utilize serial CTA imaging to study the impact of pharmacotherapy on plaque burden and outcomes.

In hypertrophic cardiomyopathy (HCM), the presence of vessel abnormalities with microvascular dysfunction is a well-known feature. The aim of this review is to present the evidences that support this notion and to describe the physiopathologic and clinical consequences of microvascular dysfunction. After having demonstrated the presence and significance of microvascular dysfunction in HCM, the myocardial blood flow (MBF) measurement by positron emission tomography (PET) is ready to develop into a clinical tool for disease evaluation, in particular for patient prognostication. Alternative methods are becoming available, but they are not yet equally reliable. By means of MBF measurement using quantitative PET, the importance of microvascular dysfunction in HCM has been clearly demonstrated, explaining the chest pain and the ischemic abnormalities frequently registered in this disease. The physiopathologic implications of microvascular dysfunction have been established, and an increasing number of reports indicate that the assessment of microvascular dysfunction is as well important for patient characterization and prognostication. Most recently, perfusion measurements using magnetic resonance imaging have been used, but their role is still under debate.

The article Coronary CTA for Surveillance of Cardiac Allograft Vasculopathy, written by Nishant R. Shah, Ron Blankstein, Todd Villines, Hafiz Imran, Alan R. Morrison and Michael K. Cheezum, was originally published electronically on the publisher’s internet portal.

This review will discuss the current nuclear imaging techniques for defining ischemia and hibernation/viability, their advantages and disadvantages, and the data related to their use to direct revascularization decisions. Recent interventional trials highlight the importance of functional imaging in trying to determine who may benefit from revascularization. Outcome benefit from revascularization has previously been shown in patients with significant ischemia, and flow quantification from positron emission tomography (PET) may allow for further risk stratification; similar data may soon be available with single-photon emission computed tomography (SPECT) as well using the newer cadmium-zinc-telluride (CZT) cameras. Some degree of equipoise still exists regarding the utilization of myocardial viability to guide revascularization in patients with ischemic cardiomyopathy, with recent studies presenting conflicting results. There is a niche for radionuclide imaging in helping to guide revascularization decision-making, and advances in recent years are providing new mechanisms by which we may better clarify the particular circumstances in which it can and should be applied. However, most data at this time is limited to observational cohorts and inferences from other randomized trials. The results of upcoming trials like ISCHEMIA and AIMI-HF will hopefully provide the needed evidence to support current clinical practice, or may change our algorithms altogether.

Anti-inflammatory therapies in systemic inflammatory diseases (SID) improve disease-associated disability and may also reduce cardiovascular events. Further optimization of treatment to directly target the inflammation affecting the cardiovascular system represents a potential goal of contemporary treatment. Yet, lack of non-invasive means to detect cardiovascular involvement and to monitor the response to treatment limit such advancements. This is also reflected in the recent 2017 ESC position paper on clinical management of cardiac involvement in SIDs, whose recommendations continue to rely on insensitive, radiation-heavy and invasive diagnostic methods. Absence of evidence and the context of a life-long chronic disease, necessitating ongoing monitoring and serial assessments, puts such recommendations in question. The growing evidence-base for the performance of cardiovascular magnetic resonance (CMR) in patients with SID, and especially of T1 and T2 mapping, offers a viable pathway towards identification of cardiovascular involvement and may potentially guide cardiovascular-specific therapies. In this review, we appraise the current evidence for the role of CMR in management of cardiac involvement patients with SID. We propose an interdisciplinary framework with a central role for CMR to support the clinical management of cardiac involvement in SID patients.

Cardiac magnetic resonance (CMR) has emerged in recent years as a reliable tool to assess, in a single examination after a reperfused myocardial infarction, the initially area at risk (AAR), the final infarct size (IS), and from their difference the salvaged myocardium (SM). The aim of the present review is to summarize recent advances in the CMR imaging of SM. While there is consensus on the use of late gadolinium enhancement (LGE) to calculate IS, how to assess the AAR is a debated topic. The use of T2-weighted short-TI inversion recovery (T2W-STIR) is to date supported by a large amount of data, but it is affected by several limitations. Newer techniques have been developed to overcome T2W-STIR limitations, some of them have been already used in randomized clinical trials (RCTs) while others are showing promising results. The use of CMR to generate surrogate endpoints in RCTs is gaining attention; in this context, analysis of data from recent RCTs suggests that the assessment of SM as outcome measure could be useful to reduce sample sizes and costs of trials. CMR is a reliable technique for the assessment of SM. LGE is the gold standard for IS measurement, while which is the best technique for the evaluation of AAR is still debated. When using CMR-derived endpoints in RCTs, the assessment of SM is advisable.

Purpose of ReviewThe aim of this review is to highlight recent advancements, current trends, and the expanding role for cardiac CT (CCT) in the evaluation of ischemic heart disease, nonischemic cardiomyopathies, and some specific congenital myocardial disease states.Recent FindingsCCT is a highly versatile imaging modality for the assessment of numerous cardiovascular disease states. Coronary CT angiography (CCTA) is now a well-established first-line imaging modality for the exclusion of significant coronary artery disease (CAD); however, CCTA has modest positive predictive value and specificity for diagnosing obstructive CAD in addition to limited capability to evaluate myocardial tissue characteristics.SummaryCTP, when combined with CCTA, presents the potential for full functional and anatomic assessment with a single modality. CCT is a useful adjunct in select patients to both TTE and CMR in the evaluation of ventricular volumes and systolic function. Newer applications, such as dynamic CTP and DECT, are promising diagnostic tools offering the possibility of more quantitative assessment of ischemia. The superior spatial resolution and volumetric acquisition of CCT has an important role in the diagnosis of other nonischemic causes of cardiomyopathies.

Tissue characterization using imaging is important to understand the pathophysiology of atherosclerosis and subsequent outcomes. In this review, the clinical utility of virtual histology intravascular ultrasound (VH-IVUS), which provides a quantitative and more objective evaluation of tissue characterization compared with grayscale IVUS, will be summarized. Patient clinical characteristics, including coronary risk factors and medications, are associated with lesion morphology, especially plaque vulnerability. Different levels of vulnerability cause different clinical presentations and associated long-term outcomes. For example, in the first natural history study (Providing Regional Observations to Study Predictors of Events in the Coronary Tree [PROSPECT]), we showed that large plaque burden, small lumen area, and presence of thin-cap fibroatheroma were associated with subsequent outcomes at 3-year follow-up. VH-IVUS has contributed significantly to our understanding of atherosclerosis.