Multimodal Imaging Techniques in Myocardial Ischemia: Current Applications and Future Prospects

A special issue of Medicina (ISSN 1648-9144). This special issue belongs to the section "Cardiology".

Deadline for manuscript submissions: 30 October 2025 | Viewed by 2072

Special Issue Editors


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Guest Editor
Cardiology Unit, Heart Centre, Fondazione Gabriele Monasterio—Regione Toscana, 54100 Massa, Italy
Interests: clinical cardiology; advanced cardiovascular imaging; cardiac magnetic resonance; transthoracic echocardiography; transesophageal echocardiography
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Guest Editor
Cardiac Surgery Unit, Fondazione Toscana Gabriele Monasterio, 54100 Massa, Italy
Interests: cardiothoracic surgery; clinical cardiology; advanced cardiovascular imaging; cardiac magnetic resonance; transthoracic echocardiography; transesophageal echocardiography

Special Issue Information

Dear Colleagues,

The advancement in multimodal imaging techniques has significantly enhanced the diagnostic accuracy and management of myocardial ischemia. Contemporary modalities such as echocardiography, cardiac magnetic resonance imaging (CMR), intracoronary imaging, and coronary computed tomography angiography (CCTA) have revolutionized the evaluation of patients with suspected ischemic heart disease, both acute and chronic.

Echocardiography remains a cornerstone for initial assessment due to its wide availability, cost-effectiveness, and ability to provide a real-time evaluation of cardiac function and structure. Its role in stress testing, particularly in identifying wall motion abnormalities, is pivotal in diagnosing ischemia.

CMR stands out for its superior tissue characterization and functional assessment. It excels in detailed visualization of myocardial scarring and fibrosis, offering critical insights into myocardial viability and infarct size. CMR's ability to assess perfusion and detect microvascular obstruction further augments its utility in the acute setting, as well as in chronic ischemic conditions.

Intracoronary imaging, in particular intra-vascular ultrasound (IVUS) and optical coherence tomography (OCT), offers nowadays the opportunity to study the vessel wall disease, including plaque features, dissections, and post-stenting results.

CCTA has transformed the non-invasive assessment of coronary artery disease (CAD). Its high-resolution imaging facilitates the identification of both obstructive and non-obstructive coronary plaques, providing comprehensive insights into coronary anatomy. This enhances its role in ruling out CAD, especially in patients with low to intermediate pre-test probability. Emerging diagnostic categories such as myocardial infarction with non-obstructive coronary arteries (MINOCAs) and ischemia with non-obstructive coronary arteries (INOCAs) have underscored the necessity of these advanced imaging techniques. These modalities aid in the precise characterization of these entities, guide appropriate management, and reduce diagnostic ambiguity.

Through a collection of comprehensive reviews and original research, we invite experts in the field to contribute their findings and perspectives on the integration of echocardiography, CMR, intravascular imaging, and CCTA into clinical practice. This Special Issue aims to underscore the transformative impact of these advanced imaging modalities on patient outcomes and explore the potential of emerging technologies to further refine and revolutionize the field of ischemic heart disease diagnosis and management. We look forward to your valuable contributions, which will shed light on the future direction of this dynamic and pivotal area of cardiology.

Dr. Fausto Pizzino
Dr. Giovanni Concistrè
Guest Editors

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Keywords

  • myocardial ischemia
  • cardiac magnetic resonance
  • coronary computed tomography angiography
  • intravascular imaging
  • myocardial infarction with non-obstructive coronary arteries
  • ischemia with non-obstructive coronary arteries
  • coronary artery disease

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Published Papers (1 paper)

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Review

35 pages, 2225 KiB  
Review
Myocardial Perfusion Imaging with Cardiovascular Magnetic Resonance in Nonischemic Cardiomyopathies: An In-Depth Review of Techniques and Clinical Applications
by Ilir Sharka, Giorgia Panichella, Chrysanthos Grigoratos, Matilda Muca, Carmelo De Gori, Petra Keilberg, Giovanni Novani, Valerio Barra, Hana Hlavata, Matteo Bianchi, Denisa Simona Zai, Francesca Frijia, Alberto Clemente, Giancarlo Todiere and Andrea Barison
Medicina 2025, 61(5), 875; https://doi.org/10.3390/medicina61050875 - 10 May 2025
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Abstract
Background and Objectives: Nonischemic cardiomyopathies comprise a wide spectrum of heart muscle disorders characterized by different morphological, functional, and tissue abnormalities. Cardiovascular magnetic resonance (CMR) represents the gold standard imaging modality for assessing cardiac morphology, systolic function, and tissue characterization, thereby aiding [...] Read more.
Background and Objectives: Nonischemic cardiomyopathies comprise a wide spectrum of heart muscle disorders characterized by different morphological, functional, and tissue abnormalities. Cardiovascular magnetic resonance (CMR) represents the gold standard imaging modality for assessing cardiac morphology, systolic function, and tissue characterization, thereby aiding in early diagnosis, precise phenotyping, and tailored treatment. The aim of this review is to provide an up-to-date overview of CMR techniques for studying myocardial perfusion and their applications to nonischemic cardiomyopathy, not only to rule out an underlying ischemic aetiology but also to investigate the pathophysiological characteristics of microcirculatory dysfunction in these patients. Materials and Methods: We performed a structured review of the literature focusing on first-pass gadolinium perfusion sequences, stress protocols, and emerging pixel-wise perfusion mapping approaches. Studies were selected to illustrate the methods for image acquisition, post-processing, and quantification of myocardial blood flow (MBF) and myocardial perfusion reserve (MPR), as well as to highlight associations with clinical endpoints. Results: First-pass CMR perfusion imaging reliably detects diffuse and regional microvascular dysfunction across cardiomyopathies. Semi-quantitative parameters (e.g., upslope, MPRI) and quantitative MBF mapping (mL/g/min) have demonstrated that impaired perfusion correlates with disease severity, extent of fibrosis, and adverse outcomes, including heart failure hospitalization, arrhythmias, and mortality. Novel automated pixel-wise mapping enhances reproducibility and diagnostic accuracy, distinguishing coronary microvascular dysfunction from balanced three-vessel disease. Microvascular dysfunction—present in approximately 50–60% of dilated cardiomyopathy (DCM), 40–80% of hypertrophic cardiomyopathy (HCM), and >95% of cardiac amyloidosis (CA) patients—has emerged as a key driver of adverse outcomes. Perfusion defects appear early, often preceding overt hypertrophy or fibrosis, and provide incremental prognostic value beyond conventional CMR metrics. Conclusions: CMR represents a powerful tool for detecting myocardial perfusion abnormalities in nonischemic cardiomyopathies, improving phenotyping, risk stratification, and personalized management. Further standardization of quantitative perfusion techniques will facilitate broader clinical adoption. Full article
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