2025+HFA-ESC临床共识声明：晚期心力衰竭的多模式成像—第1部分：多模式成像用于晚期心力衰竭患者的评估

Multimodality imaging in advanced heart failure. A clinical consensus statement of the Heart Failure Association of the ESC. Part 1:Multimodality imaging for the evaluation of patients with advanced heart failure

Alberto Aimo1,2+, Laurens F. Tops3*+, Stamatis Adamopoulos4, Michael Bonios4,Ahmet Celik5, Ovidiu Chioncel6,7, Maja Cikes8, Maria G. Crespo-Leiro9,Kevin Damman10, Concetta Di Nora11, Julien Dreyfus12, Finn Gustafsson13,Shahrukh Hashmani14, Marco Masetti15, Ify Mordi16, Sanem Nalbantgil17,Linda W. van Laake18, Ralph Stephan von Bardeleben19, Marco Metra20,Tuvia Ben Gal21,22, and Brenda Moura23

1Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy;2Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy;3Department of Cardiology,Leiden University Medical Center, Leiden, The Netherlands; 4Heart Failure and Heart Transplant Units, Onassis Hospital, Athens, Greece; 5Department of Cardiology,Mersin University,Faculty of Medicine,Mersin,Turkey,6Emergency Institute for Cardiovascular Diseases'C.C.liescu',Bucharest, Romania;7University of Medicine Carol Davila, Bucharest, Romania;8University of Zagreb School of Medicine, Department of Cardiovascular Diseases, University Hospital, Athens, Greece; 5Department of Cardiology,Mersin University,Faculty of Medicine,Mersin,Turkey,6Emergency Institute for Cardiovascular Diseases,C.C.liescu',Bucharest, Romania;7University of Medicine Caroldivila, Bucharest, Romania;8University of Zagreb School of Medicine, Department of Cardiovascular Diseases, University Hospital, Athens, Greece; 5Department of Cardiology,Hospital Technology,Hospital Universitara A Coruna(CHUAC),CIBERCV,Spain;10University of Groningen,Department of Cardiology,University Medical Center Groningen, Groningen,The Netherlands;11Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy;12Cardiology Department, Centre Cardiologique du Nord,Saint-Denis,France;13Rigshospitalet Copenhagen University Hospital,Copenhagen,Denmark;14Royal Brompton Hospital,London,UK;15Heart Failure and Transplant Unit,IRCCS Azaider Spedaliero Universitaria di Bologna, Bologna, Italy; 16Division of Cardiovascular Research, School of Medicine, University of Dundee,UK;17Ege University,Izmir,Turkey;18Department of Cardiology,University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands: 19Heart Valve Center,Mainz,Germany;20Cardiology,Vita-Salute San Raffaele University,IRCCS San Raffaele Hospital.,Milan,Italy,21Department of Cardiology,Rabin Medical Center,Petah Tikva, Israel; 22Faculty of Medicine,Tel Aviv University,Tel Aviv,Israel; and 23Armed Forces Hospital, Porto, and Faculty of Medicine of the University of Porto, Porto, Portugal

Received 14 March 2025; revised 7 June 2025; accepted 27 June 2025

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A. Aimo et al.

Heart failure(HF) represents a significant global health burden, with approximately 10% of patients progressing to advanced stages characterized by severe symptoms and recurrent hospitalizations despite conventional treatments such as guideline-directed medical therapy, devices, and surgery. This clinical consensus statement from the Heart Failure Association of the European Society of Cardiology discusses the applications of imaging modalities in patients with advanced HF. Transthoracic echocardiography remains the cornerstone for initial diagnosis and monitoring, providing critical insights into cardiac volumes, function, and valvular integrity, as well as congestion status.Transoesophageal echocardiography offers detailed evaluations of valve pathology,essential for surgical or transcatheter planning.Cardiovascular magnetic resonance provides comprehensive assessments of biventricular size and function,tissue characterization,and flow dynamics,proving particularly useful for diagnosing specific HF aetologies. Computed tomography offers valuable insights into pulmonary artery diameter, right ventricular volume, and valvular anatomy, which are crucial for guiding percutaneous procedures. Nuclear imaging techniques allow assessing viability and diagnosing non-ischaemic HF conditions, guiding revascularization decisions. Advanced imaging techniques have expanded the understanding and management of right ventricular dysfunction. The integration of these advanced imaging modalities enhances diagnostic accuracy,risk stratification,and therapeutic decision-making,ultimately improving the prognosis and quality of life for patients with advanced HF. This clinical consensus statement highlights the critical role of various imaging modalities in managing patients with advanced HF, excluding those needing mechanical circulatory support or heart transplantation, emphasizing the multifaceted approach required for effective management.

Graphical Abstract

 

Transthoracic echo

● First-line imaging

● Cardiac volumes

•LV function

Valvular integrity

RV function

•LA and RA size

● Pulmonary pressures

● Risk stratification

 

CT

● Pulmonary artery diameter

● RV volume

Valvular heart disease evaluation

● CIED-related infections

•Anatomical assessments for surgery planning


CCTA

● Aortic valve calcium scoring

● Pre-procedural planning for

● Coronary anatomy assessment

 

Transoesophageal echo

● Detailed valve pathology evaluation

● Transcatheter or surgical planning

Stress echo

● Severity of valvular heart disease

•Myocardial viability


Lung ultrasound

● Pulmonary congestion,pleural effusion

 •Valvular disease

● Valvular disease


PET

● Myocardial viability

● Cardiac sarcoidosis

● Cardiac amyloidosis

● Device-related infections

$$\text{ Imaging in advanced heart failure}$$

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Role of different imaging modalities in advanced heart failure(HF). CCTA, coronary computed tomography angiography; CIED, cardiac implantable electronic device; CMR, cardiovascular magnetic resonance; CT, computed tomography; LA, left atrial; LV, left ventricular; PET, positron emission tomography; RA, right atrial; RV, right ventricular.

Keywords

Advanced heart failure● Imaging● Echocardiography● Cardiovascular magnetic resonance● Computed tomography● Nuclear imaging● Diagnosis● Risk prediction● Management

Introduction

Heart failure(HF) is a cardiovascular disease with a significant global burden. Approximately 10% of HF patients progress to the advanced stage, characterized by severe symptoms and recurrent hospitalizations despite conventional treatments such as guideline-directed medical therapy(GDMT), devices, and surgery.1 This clinical consensus statement from the Heart Failure Association of the European Society of Cardiology discusses the applications of imaging modalities in advanced HF. The statement is structured into a first document providing an overview of different imaging modalities, including specific scenarios, and a second document discussing mechanical circulatory support(MCS) and heart transplantation(HT).

Imaging modalities for diagnosis and risk prediction

Transthoracic echocardiography

Cardiac dysfunction requiring advanced therapeutic strategies is a critical aspect in the definition of advanced HF. In recent years,various techniques have been developed to accurately assess the aetiology and severity of myocardial dysfunction. Echocardiography has emerged as the cornerstone technique due to its flexibility,low cost, and easy access. It is essential for estimating disease severity, stratifying risk, guiding clinical decisions, and determining the best therapeutic strategies.2 Some of the main parameters from standard and speckle-tracking echocardiography, with the possible findings in patients with advanced HF, are reported in Figure 1.

The assessment of left ventricular(LV) function is fundamental,as LV functional impairment is central to the pathophysiology of advanced HF. Various parameters, such as ejection fraction(EF),stroke volume, and cardiac output, can be used to evaluate LV function. Pulsed-wave Doppler is typically employed to measure stroke volume and cardiac output at the aortic annulus. LVEF is a widely used index of systolic cardiac function, crucial for diagnosis,classification, and risk stratification.Its also crucial for guiding management, including medical therapy and interventions like valvular surgery and defibrillator implantation. Nonetheless,LVEF has several limitations: it is influenced by loading conditions,operator expertise, and image quality3; it underestimates HF severity in cases of moderate or severe mitral regurgitation(MR),does not correlate well with functional capacity, and LVEF as sole parameter does not allow the diagnosis of HF with preserved

EF(HFpEF),5 which constitutes nearly half of HF cases and can progress to advanced stages.1 Speckle-tracking echocardiography(STE) is a non-invasive, semi-automated technique that tracks the displacement of‘speckles’ in echocardiographic images, offering parameters such as global longitudinal strain(GLS). GLS is a robust marker for myocardial mechanics and early LV dysfunction,reflecting the gradual development of LV impairment and serving as an early diagnostic and prognostic marker in HF.6

Impaired diastolic relaxation may result from intrinsic myocardial damage leading to reduced LV compliance. Several echocardio-graphic parameters may be used to give an estimate of intracardiac pressures.The E/e' ratio, derived from tissue Doppler imaging,is particularly useful in assessing LV end-diastolic pressure and pre-dicting HF prognosis.7

Echocardiography also evaluates LV geometry, as progressive myocardial damage in HF leads to LV dilatation, a sign of advanced disease. LV geometry assessment includes measuring volumes,diameter, and the sphericity index. Three-dimensional(3D)echocardiography offers more accurate and reliable measurements,providing a focused view with superior spatial and temporal reso-lution.8

Right ventricular(RV) function assessment is equally important,especially as RV dysfunction often accompanies advanced HF,and is a strong predictor of outcome. Several conventional and non-conventional parameters of RV function have been evaluated in clinical trials and found to have prognostic implications for patients with HF(Table 7).310-16

Tricuspid annular plane systolic excursion(TAPSE) is a sim-ple and reproducible parameter exploring the longitudinal systolic motion of the right ventricle at the level of the lateral tricuspid annulus. In patients with dilated cardiomyopathy(DCM), a TAPSE<14mm independently predicts the need for urgent HT, and a TAPSE<15mm is a predictor of major cardiac events at 1 and 2 years.12 A systolic velocity(RVS') of the lateral tricuspid annu-lus<9.5cm/s indicates RV systolic dysfunction. In patients with DCM, RVS' has prognostic value beyond other echocardiographic parameters.13 RV fractional area change(FAC) is calculated from the RV end-diastolic and end-systolic areas in a 4-chamber view. A FAC<27% was independently associated with death or need for HT.14 STE measures deformational parameters of the right ventri-cle, such as RV free wall longitudinal strain(RVFWLS). An RVFWLS>-20%Indicates dysfunction, with values>-16% having prognos-tic implications for patients with HF and reduced EF(HFrEF).15 RVFWLS may provide more prognostic information than RV GLS,which includes the interventricular septum.16 Impaired RVFWLS in

A. Aimo et al.

 Figure 1 Possible echocardiographic findings in patients with advanced heart failure. 3D RV EF; three-dimensional right ventricular ejection fraction; DT, deceleration time; E/A, peak early diastolic E wave velocity to peak late diastolic A wave velocity ratio; E/e', early diastolic mitral inflow velocity(E wave) to early diastolic mitral annular velocity(e') ratio; fwRVLS, free wall right ventricular longitudinal strain; LAVI, left atrial volume index; LVEDD, left ventricular end-diastolic diameter; LVEF; left ventricular ejection fraction; LV GLS, left ventricular global longitudinal strain; MR, mitral regurgitation; PALS, peak atrial longitudinal strain; RAP, right atrial pressure; RV FAC, right ventricular fractional area change;RVSI, right ventricular sphericity index; s', peak systolic tricuspid annular velocity; sPAP, systolic pulmonary artery pressure; SV, stroke volume;TAPSE, tricuspid annular plane systolic excursion; TR, tricuspid regurgitation. Modified with permission from Pastore et al.2

patients with preserved TAPSE values indicates a worse outcome.173D echocardiography correlates well with cardiovascular mag-netic resonance(CMR)-based RV volumes and EF measurement,although it tends to underestimate volumes. In DCM patients, a 3D RVEF<43% was independently associated with outcomes.17

None of these RV function parameters reflect RV contractil-ity. As afterload increases, RV contractility initially increases to compensate but eventually deteriorates, leading to a decline in RV function. All of these parameters are pre- and afterload sensitive,making their interpretation challenging, especially when RV func-tion is borderline.

Non-invasive measurements of RV to pulmonary artery coupling provide incremental prognostic value by focusing not only on RV function but also on its adaptation to pulmonary circulation. A decreased TAPSE and pulmonary artery systolic pressure(PASP)ratio is a potent independent predictor of pre-capillary pulmonary

hypertension and prognosis in HF, with a prognostic cut-off value of 0.36 mm/mmHg.18 RV strain indexed to estimated PASP has been shown to be a stronger predictor than the TAPSE/PASP ratio.The 3D RVEF/PASP ratio also demonstrated a prognostic value at least equal to the TAPSE/PASP ratio.16.19 Finally, serial evaluation of RV function is also crucial in patients undergoing MCS implantation,as discussed in Part 2 of this clinical consensus statement.20

The right atrium and left atrium also play crucial roles in the assessment of patients with advanced HF. Right atrial(RA) pressure and the presence of pulmonary hypertension can be evaluated using echocardiography. Left atrial(LA) size and function are assessed through LA volume index(LAVI) and strain measurements,pro-viding insights into LA remodelling and its impact on LV filling pressures.2

Contrast echocardiography may be helpful to rule out or identify intracardi masses, particularly thrombi in advanced HF.

$$\text{ Imaging in advanced heart failure}$$

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Table 1 Parameters to assess right ventricular function and prognostic implications

|Parameter|Strengths|Weaknesses|Cut-off for RV dysfunction3,10,11|Prognostic role| |---|---|---|---|---| |TAPSE|● Easy to obtain ● Widely available|● Angle-dependent ● Only assesses longitudinal function ● Less reliable in the presence of severe tricuspid regurgitation ● Angle-dependent ● Only assesses longitudinal function ● Less reliable in the presence of R ver scutiurgid regurgitation|≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17mm ≤17||

2D, two-dimensional; 3D, three-dimensional; DCM, dilated cardiomyopathy; FAC, fractional area change; HF, heart failure; LVAD, left ventricular assist device; LVEF, left ventricular ejection fraction; RV,right ventricular; RVEF, right ventricular ejection fraction; RVFLWS, right ventricular free wall longitudinal strain; RV GLS, right ventricular global longitudinal strain; TAPSE, tricuspid annular plane systolic excursion.

Finally, echocardiography is crucial to select patients for advanced HF therapies, such as MCS or HT, as discussed in Part 2 of this clinical consensus statement.20

Transoesophageal echocardiography

Transoesophageal echocardiography(TOE) is often performed as part of the workup of patients with mitral or tricuspid valve disease evaluated for possible surgery or percutaneous interventions.21.22 It allows exploring the entire valve and its apparatus in multi-ple views. Both two-dimensional(2D) and 3D TOE offer detailed insights into the mechanisms and aetiologies of mitral and tricus-pid valve diseases. TOE can predict the likelihood of successful transcatheter or surgical valve repair or the necessity for valve replacement. It also enables a more detailed quantification of the severity of regurgitation. TOE is also valuable in the evaluation of mitral stenosis by enabling direct planimetry of the valve area.21-23

Stress echocardiography

Exercise echocardiography can be used to ascertain the severity of valvular heart disease in patients who have discordant echocardio-graphic features.21 Low-dose dobutamine stress echocardiography(DSE) is particularly important for individuals with aortic steno-sis(AS) and LV dysfunction, where the calculated aortic valve

area(AVA) may be less than 1 cm2(indicative of severe AS),but the transvalvular gradient is low. DSE can differentiate true AS(low-flow, low-gradient[LFLG] AS) from pseudo-severe AS.Besides measuring transvalvular gradient and AVA at rest and dur-ing low-dose dobutamine, DSE also assesses contractile reserve,which can help predict the response to treatment.21

Stress echocardiography is also valuable in ischaemic HF for determining the presence of myocardial viability and ischaemia.Both exercise and pharmacological stress(e.g. doubutamine or vasodilator) can be used. This technique assesses myocardial regional wall motion and thickening, identifying areas of hypokine-sis or akinesis. A fixed wall motion abnormality at rest and during stress indicates infarcted myocardium. Low-dose dobutamine imag-ing can identify stunned or hibernating(i.e. viable) myocardium that may improve with revascularization.24

Heart failure with preserved EF is characterized by exercise intolerance, and some physiological abnormalities, such as dias-tolic dysfunction, may become apparent only during exercise. The HFA-PEFF diagnostic algorithm includes a diastolic stress test,such as exercise echocardiography, in cases where the HFA-PEFF score indicates an intermediate probability of HFpEF. Diagnostic criteria include an average E/e'≥15 and/or tricuspid regurgitation(TR) velocity>3.4m/s, which are consistent with HFpEF. Stress echocardiography may also be combined with cardiopulmonary exercise testing, which is referred to as cardiopulmonary exercise

A. Aimo et al.

 Figure 2 Integrated cardiopulmonary ultrasound for the differential diagnosis of respiratory and circulatory failure. ARDS, acute respiratory distress syndrome; HFEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction. Reprinted with permission from Gargani et al.26

testing echocardiography, and may be useful to diagnose HFEPF.For example, a steeper mean pulmonary artery pressure/cardiac output slope may be a sensitive parameter to identify HFEPF.25

Lung ultrasound echocardiography

Lung ultrasound(LUS) is increasingly recognized as a valuable tool in the evaluation of patients with HF. It is highly sensitive and specific for detecting pulmonary congestion, which is common in HF patients, and to distinguish it from other conditions(Figure 2).26 B-lines, which are vertical comet-tal artefacts extending from the pleural line, indicate pulmonary congestion.27 The number of B-lines can be used to detect, semi-quantify, and monitor the degree of pulmonary congestion, providing prognostic information.LUS is also effective in detecting pleural effusions.27

Focused cardiac ultrasound

Echocardiography plays a central role in identifying potential under-lying causes of cardiogenic shock(CS) and associated pathophysiol-ogy. Without identification and treatment of the underlying cause,the outcome is usually fatal.28 A standard echocardiographic eval-uation can quickly provide sufficient information to confirm or exclude conditions such as tamponade, mechanical complications of myocardial infarction, LV outflow tract obstruction, and severe valvular lesions. The evaluation may also include an assessment of LV and RV function and an estimation of left and right filling

pressures.29 When echocardiography is not immediately available,focused cardiac ultrasound(FoCUS) can provide useful preliminary information and is typically followed by a comprehensive echocar-diographic evaluation as soon as possible. The Rapid Ultrasound in Shock(RUSH) examination protocol helps to determine the spe-cific aetiology of undifferentiated shock by evaluating the heart, the inferior vena civa/intra-abdominal and pleural compartments, and large vessels including the aorta(Figure 3).30.31 The RUSH proto-col is both sensitive and specific(0.89 and 0.97, respectively) in diagnosing CS, but it is advisable not to use it to exclude CS.32

Cardiovascular magnetic resonance

Cardiovascular magnetic resonance offers a detailed evaluation of biventricular volumes, systolic function, cardiac flows, masses, and myocardial tissue composition. CMR capability in volume and func-tion assessment is important, as different methods of LVEF and vol-ume assessment have varying performances. CMR uses Simpson's disk summation method for LVEF analysis, which is more accurate and reproducible than other techniques like TTE and radionuclide ventriculography.33 Furthermore, LA conduit strain on CMR was a strong independent prognostic predictor, superior to LV GLS,LVEF,and LAVI and incremental to late gadolinium enhancement(LGE),in patients with DCM.34 Nonetheless, advanced HF represented only a minority of these study populations.

Cardiovascular magnetic resonance also provides comprehen-sive flow measurements through phase-contrast sequences, useful

$$\text{Imaging in advanced heart failure}$$

Step 1:《the pump》

Probe Position A:ParasternalViews Long/ Short Axis

 Probe Position B:

Probe Position B:Subxiphoid View

Probe Position C:ApicalView

Step 2:《the tank》

Probe Position A:IVCViews Probe Position B:FAST/ RUQ add pleural view Probe Position C:FAST/ LUQ add pleural view Probe Position D:FAST/ Pelvis Probe Position E:Lung Views


Step 3:《the pipes》

Probe Position A:Suprasternal Aorta Probe Position B:Parasternal Aorta Probe Position C:Epigastric Aorta Probe Position D:Supraumbilical Aorta Probe Position E:Femoral DVT Probe Position F:Popliteal DVT

 Figure 3 The Rapid Ultrasound in Shock(RUSH) protocol. DVT, deep vein thrombosis; FAST, Focused Assessment Sonography in Trauma;IVC,inferior vena cava;LUQ,left upper quadrant;RUQ,right upper quadrant. Modified with permission from Seif et al.31

for evaluating valvular heart disease and secondary MR in advanced HF patients. Pulmonary transit time by first-pass perfusion CMR was specifically studied in advanced HF patients and shown to independently predict mortality, with stronger prognostic value than clinical and other CMR parameters, including LVEF, RVEF and GLS.35 Emerging four-dimensional(4D) flow CMR allows for detailed study of flow dynamics, wall shear stress, and vortex for-mation, potentially aiding in the evaluation of diastolic dysfunction and valvular heart diseases.

Tissue characterization by CMR includes LGE and parametric mapping techniques, essential for assessing fibrosis, oedema, and myocardial composition. This information may be relevant to establish the aetiology of HF, which has prognostic implications.Moreover, the intramural extent of LGE, wall thickness and motion are possible indicators of myocardial viability in patients with ischaemic cardiomyopathy.36 LGE presence and extent is related to risk of all-cause mortality. HF hospitalization, and sud-den cardiac death in patient with non-ischaemic cardiomyopathy.37 while it predicts survival, response to cardiac resynchronization therapy(CRT) and to coronary revascularization.38,39 LGE is also

a powerful predictor of ventricular arrhythmias in patients with LV dysfunction, including those with non-ischaemic HF.40 CMR is also a good technique to detect intracardiac thrombi, and may be helpful in patients being evaluated for surgical ventricular reconstruction.

In patients with a cardiac implantable electronic device(CIED).CMR can still be performed with precautions, although mag-netic susceptibility artefacts may complicate image interpretation.Techniques like wideband inversion pulses and specific imaging pro-tocols help mitigate these artefacts, ensuring diagnostic efficacy.

Nuclear imaging

Along with DSE and CMR, single-photon emission com-puted tomography(SPECT)with 99mTc-marked tracers and 18F-fluorodeoxyglucose positron emission tomography(18F-FDG-PET) may be used to evaluate and distinguish between viable,stunned, and hibernating myocardial tissue.42 Increased 18F-FDG-PET mismatch correlate with improved outcomes fol-lowing revascularization, particularly when the mismatch is≥7%.43 On the other hand, the 10-year follow-up of the Surgical Treatment

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for Ischemic Heart Failure(STICH) trial did not show a long-term prognostic benefit of a revascularization strategy guided by viability testing through SPECT and DSE.44 Similarly, the Revascularization for Ischemic Ventricular Dysfunction(REVIVED-BCIS2) trial found that revascularization by percutaneous coronary intervention plus optimal medical therapy did not result in a lower incidence of death from any cause or hospitalization for HF compared to optimal med-ical therapy alone in patients with HFrEFE who had viability in at least four segments of the left ventricle assessed through DSE, CMR,SPECT, or FDG-PET.45 18F-FDG-PET can also be used to assess myocardial scar, and has been shown to be useful in estimating responders to CRT in patients with ischaemic cardiomyopathy.

In non-ischaemic HF, nuclear imaging is primarily used for cardiac sarcoidosis,47 cardiac amyloidosis,48 and device-related infections.Most notably, 18F-FDG-PET/computed tomography(CT) has a high sensitivity and specificity for device-related infections in advanced HF patients with MCS devices.49

Computed tomography

Computed tomography is a possible alternative to echocardiogra-phy when acoustic windows are poor, and CMR is not tolerated or contraindicated. With the use of CT, coronary anatomy can be assessed and the presence of coronary artery disease may be eval-uated in patients with a low or intermediate pre-test likelihood.50 As such, CT can be part of the initial evaluation of patients with unexplained LV dysfunction. Chest CT-derived pulmonary artery diameter and RV volume, as indicators of pulmonary hyperten-sion, independently predicted all-cause mortality and HF events in patients with advanced HFrEF51 In addition, CT may be of great value in patients with HF and valvular heart disease, for patient selection and guidance of percutaneous procedures.52

Valve disease assessment: an application of multimodality imaging

In patients with advanced HF, valvular heart disease is often present and is typically treated to improve prognosis.1 In the paragraphs below, the role of multimodality imaging in the assessment and treatment of valvular heart disease in patients with advanced HF will be discussed.

Aortic stenosis

As discussed above, low-dose DSE helps differentiate between truly severe AS and pseudo-severe AS. Aortic valve replacement is advised in patients with true severe AS and contractile reserve demonstrated by DSE.21 Absence of contractile reserve predicts a high operative risk during aortic valve replacement, though it is less associated with long-term outcomes. For patients with pseudo-severe AS, optimization of HF therapy is the mainstay of management.

Computed tomography is essential to assess suitability to tran-scatheter aortic valve replacement and plan this intervention. CT

provides detailed information on aortic valve anatomy, annular size and shape, extent and distribution of valve and vascular calcifica-tion, risk of coronary oostial obstruction, aortic root dimensions,optimal fluoroscopic projections for valve deployment, and feasi-bility of vascular access.53

Mitral regurgitation

Mitral regurgitation is a prevalent situation in patients with advanced HF. MR in the context of HF is often functional, resulting from LV dilatation, remodelling, and dysfunction rather than pri-mary mitral valve disease. The main mechanisms include LV remod-elling and dysfunction, LA dilatation, annular dilatation, and leaflet tethering. MR poses significant diagnostic and therapeutic chal-lenges. It is crucial to accurately assess the presence and severity of MR in these patients, as it directly impacts their clinical manage-ment and prognosis.45 Imaging plays a pivotal role in the evaluation of MR(Figure 4), guiding therapeutic decisions and helping to pre-dict outcomes.

Transthoracic echocardiography is the first-line imaging modality for evaluating MR. It provides detailed information on valve mor-phology,LV size,function, and haemodynamics.54 Colour Doppler imaging is used to assess the severity of MR, characterized by the regurgitant jet area and vena contracta width. Quantitative mea-sures include regurgitant volume, regurgitant fraction, and effec-tive regurgitant orifice area. TOE offers superior resolution of the mitral valve apparatus and is particularly useful for detailed assess-ment of the mechanism of MR, especially in candidates for surgical or percutaneous interventions. Advances in 3D echocardiography allow for comprehensive evaluation of the mitral valve structure and function, providing valuable insights into leaflet motion, coap-tation, and the extent of annular dilatation.55

Cardiovascular magnetic resonance is highly accurate for assess-ing LV volumes, function, and mass. It is particularly useful in cases where echocardiographic windows are suboptimal. CMR can quan-tify the regurgitant volume and fraction and provides additional information on myocardial viability, fibrosis, and scarring.56 CT imaging provides detailed anatomical information about the mitral valve, annulus, and surrounding structures. For example, CT can assess the extent of calcification in the mitral annulus and leaflets,which is crucial for planning percutaneous or surgical procedures.56 SPECT and PET can assess myocardial viability, helping determine the potential benefit of coronary revascularization.

Mitral regurgitation severity has significant prognostic implica-tions in advanced HF. Severe MR is associated with increased mor-tality and higher rates of HF hospitalization.57 Accurate quantifica-tion and characterization of MR using advanced imaging techniques are essential for risk stratification and guiding therapeutic deci-sions.54

Optimizing HF therapy, including the use of GDMT and, if indi-cated, CRT, can reduce the severity of functional MR in many patients. For patients with significant MR despite optimal medi-cal management, surgical or percutaneous interventions may be appropriate. Imaging plays a critical role in selecting appropriate candidates, planning interventions, and guiding transcatheter inter-ventions. ${}^{54}$

$$\text{Imaging in advanced heart failure}$$

 Figure 4 Contribution of imaging before and during transcatheter mitral valve edge-to-edge repair. Severe functional mitral regurgitation with leaflet tethering and a predominantly central jet, assessed by transoesophageal echocardiography(A1), including biplane(A2) and three-dimensional views with and without colour Doppler(A3 and A4). Procedural guiding during transcatheter mitral valve edge-to-edge repair using live biplane transoesophageal views(B1) in addition to fluoroscopy with fusion imaging(B2). Immediate post-procedural result after implantation of two MitraClip devices at the A2/P2(central) level assessed by transoesophageal echocardiography(C1), including three-dimensional views with and without colour Doppler(C2 and C3).

Tricuspid regurgitation

Echocardiography is the first-line imaging modality for assessing tri-cuspid valve morphology,58 which can vary greatly in terms of scal-lop numbers and regurgitant orifice shape.59 It also evaluates the severity and mechanism of TR and its impact on the right ventricle.Assessing TR severity is critical but difficult and is best approached using a comprehensive multiparametric strategy with both 2D and 3D echocardiography.60 Importantly,TR severity varies according to the patient's volume status. TR grades are classified as none,mild,moderate,severe, and possibly, as recently proposed, also massive or torrential.60 A refined TR grading classification has been recently suggested, classifying the‘moderate’ TR severity grade into'mild-to-moderate' and'moderate-to-severe', to align with the classification for MR and enhance accuracy in outcome

prediction.61 TR is mostly functional or secondary, with normal leaflet structure, and is mainly induced by left heart diseases.Func-tional TR is divided into atrial functional TR(caused by annular dilatation due to RA enlargement) and ventricular functional TR(caused by leaflet tethering due to RV enlargement). Organic TR,characterized by abnormal leaflet structure, is rare. A third entity,CIED-induced TR, has been proposed.59

An increasing number of symptomatic patients with severe TR undergo transcatheter interventions. TOE is the imaging modality of choice for patient selection by evaluating the mechanism of TR,the size and location of the gap, the location and impact of CIED leads on leaflets, and the device angle of approach.62 TOE is also essential for guiding transcatheter interventions by ensuring safe device navigation into the right ventricle, imaging leaflet insertion,and confirming grasping. During these procedures, both mid/distal

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 Figure 5 Contribution of imaging during transcatheter tricuspid valve edge-to-edge repair. Procedural guiding using live biplane transoe-sophageal views(A1) and transgastric views with multiplanar reconstructions(A3) in addition to fluoroscopy(A2, A4). Intracardiac echocar-diography(B1) in addition to fluoroscopy(B2). Immediate post-procedural result using three-dimensional transoesophageal echocardiography(C1,C3),fluoroscopy(C2,C4) and biplane transthoracic echocardiography(C5).

Table 2 Clinical advice on multimodality imaging in advanced heart failure

1. Clinical advice based on published evidence

●TTE is crucial for assessing disease severity, stratifying risk, guiding clinical decisions, and informing therapeutic strategies in advanced HF.

● LVEF is a key index of systolic function used for diagnosis, classification, and risk stratification.

● The E/e' ratio assesses LV end-diastolic pressure and predicts HF prognosis.

Tricuspid annular plane systolic excursion<14mm predicts mortality and heart transplantation in patients with LVEF<35%.

● CMR enables accurate assessment of biventricular volumes, systolic function, cardiac flows, masses, and myocardial tissue composition.

● CMR late gadolinium enhancement is of additional value in the risk assessment(all-cause mortality,HF hospitalization,and sudden cardiac death) in patients with non-ischaemic cardiomyopathy.

● CT-derived pulmonary artery diameter and RV volume predict mortality and HF events.

● Aortic valve replacement is recommended in patients with true severe aortic stenosis and contractile reserve.

● Severe mitral and tricuspid regurgitation are linked to increased mortality and HF hospitalization, necessitating accurate quantification and characterization for risk stratification and therapeutic guidance.

2. Clinical advice based on uniform consensus of the Writing Group

Standard echocardiography can quickly confirm or exclude conditions such as tamponade, mechanical complications of myocardial infarction, LV outflow tract obstruction, and severe valvular lesions.

● Multimodality imaging is essential for patient selection and procedural guidance in patients with advanced HF and valvular disease.

3. May be appropriate based on published evidence

●FoCUS provides preliminary information and is generally followed by comprehensive echocardiography.

● The RUSH protocol is sensitive and specific in diagnosing cardiogenic shock but not for exclusion.

4. May be appropriate based on consensus of the Writing Group

● Emerging 4D flow CMR studies of flow dynamics, wall shear stress, and vortex formation, aiding in evaluating diastolic dysfunction and valvular diseases.

5. Area of uncertainty

● The role of myocardial viability assessment via imaging modalities like 18F-FDG-PET in guiding revascularization strategies in ischaemic cardiomyopathy remains debatable.

4D,four-dimensional;18F-FDG-PET,18F-fluoroderoxyglucose positron emission tomography;CMR,cardiovascular magnetic resonance;CT,computed tomography;E/e',early diastolic mitral inflow velocity(E wave) to early diastolic mitral annular velocity(e') ratio; FoCUS, focused cardiac ultrasound; LV,left ventricular; LVEF,left ventricular ejection fraction;HF,heart failure;RUSH,Rapid Ultrasound in Shock;RV,right ventricular;TTE,transthoracic echocardiography.

$$\text{ Imaging in advanced heart failure}$$

11

transoesophageal views and transcardiatic views with live 2D, 3D,or multiplanar reconstructions are used(Figure 5). For patients in whom image quality is insufficient or who are contraindicated for TOE,intracardiac echocardiography may be an alternative.62

Conclusions

The first part of this clinical consensus statement underscores the many roles of various imaging modalities in advanced HF, summa-rized in the Graphical Abstract and in Table 2 with clinical advice.Echocardiography remains an indispensable tool, providing com-prehensive information on LV function, geometry, diastolic pres-sures, and RV and atrial function. This facilitates early diagnosis,risk stratification, and the guidance of therapeutic strategies. The advent and integration of advanced imaging techniques such as STE and 3D echocardiography have further enhanced the accuracy and utility of echocardiographic evaluations in clinical practice. TOE complements TTE by offering detailed evaluations of mitral and tri-cuspid valve diseases, crucial for surgical or transcatheter planning.Stress echocardiography, including exercise and DSE, is valuable in assessing the severity of AS and myocardial ischaemia, guiding therapeutic interventions. In CS, echocardiography and FoCUS are indispensable for rapid diagnosis and management, guiding thera-peutic interventions and improving patient outcomes. CMR plays a pivotal role in advanced HF by enabling a comprehensive evalua-tion of biventricular size and function, tissue characterization, and flow dynamics. It is particularly useful for diagnosing specific HF aetologies. CT serves as an alternative when acoustic windows are poor and CMR is contraindicated, offering valuable insights into pulmonary artery diameter,RV volume, and valvular anatomy,which are crucial for guiding percutaneous procedures. Nuclear imaging techniques are essential for viability assessment, distin-guishing between unstoned, hibernating, and scarred myocardium,and thus guiding revascularization decisions. These modalities also diagnose non-ischaemic HF conditions like cardiac sarcoidosis and amyloidosis and detect device-related infections.

In summary, advanced imaging modalities enhance diagnostic accuracy, risk stratification, and therapeutic decision-making, ulti-mately improving prognosis and quality of life for patients with advanced HF.

Conflict of interest: L.F.T. has received honoraria from Abbott, paid to the institution, outside of the submitted work. S.A. has received honoraria for chairmanship from GSK and AstraZeneca and participates in an advisory board for GSK, outside of the submitted work. M.B. has received sup-port for attending meetings from Abbott, paid to the institution, is owner of the patent“Device for cardiac volume reduction and reshape” Greek INDUSTRIAL PROPERTY ORGANISATION ID: 1009421, participates on an advisory board of Takeda, is member of the board of the Hellenic Society of Transplantation(unpaid), outside of the submitted work. O.C.has received support for attending meetings from Servier and Bl,outside of the submitted work. M.C. has received grants from Abbott, Novartis,Pfizer, NovonDordisk,CorVia, has received honoraria from Abbott, Bayer,Boehringer Ingelheim, GE Healthcare, Novaris, NovoNordisk, Pfizer,Swixt, Kada, Viarris, has received support for attending meetings from NovonDordisk and participates on an advisory board of Astra Zeneca,Bayer,Bristol Myers Squabb, Corteria, NovoNordisk, outside of the submitted work. M.G.C. has received grants from CIBERV, has received consulting

fees from AstraZeneca, NovoNordisk, Abbott, Bayer, has received hono-raria from AstraZeneca, NovoNordisk,Abbott, Pfizer, Astellas, Medtronic,has received support for attending meetings from Abbott, participates on an advisory board of Bayer, outside of the submitted work. K.D. has received honoraria from Abbott, Astra Zeneca, Boehringer Ingelheim, Novartis,FIRE1,Echosense, all paid to the institution, outside of the submitted work.J.D. has received consulting fees from Abbott, Edwards-Lifescience, out-side of the submitted work. F.G. has other financial interests for Abbott(full-time employee since April 7, 2025), outside of the submitted work.I.M. has received grants from Novartis, paid to the institution, outside of the submitted work. L.W.V.L. has received support from the Dutch Heart Foundation Dekker Senior Clinical Scientist 2019(2019T056) has received grants from Medtronic, Abbott, has received honoraria from CVOI, Med-conb, Abbott, outside of the submitted work. R.S.V.B. has received honoraria from Abott Structural, Edwards Lifesciences, Medtronic, Philips, Siemens, is member of the board of Heart Valve Society(unpaid), EU SHD Coali-tion(unpaid), outside of the submitted work. M.M. has received consult-ing fees from Astra-Zeneca, Bayer, Boehringer Ingelheim, NovoNordisk,Roche diagnostics, has received honoraria from Boehringer Ingelheim, has received support for attending meetings from NovoNordisk, is member of the board of the HFA, outside of the submitted work. B.M. has received consulting fees from Servier, Pfizer, AstrisZeneca, Bayer, Boehringer Ingelheim, Vifor Pharma, has received support for attending meetings from Boehringer Ingelheim, outside of the submitted work. The other authors report no conflicts of interest.

References

1. Crespo-Leiro MG,Merra M,Lund LH,Milicic D,Costanzo MR,Filippatos G,et al.Advanced heart failure: A position statement of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2018;20:1505-1535.https://doi.org/10.1002/Jehf.1236

2.Pastore MC,Mandoli GE,Aboumarie HS,Santoro C,Bandera F,D'Andrea A,et al. Working Group of Echocardiography of the Italian Society of Cardiology. Basic and advanced echocardiography in advanced heart fail-ure: An overview. Heart Fail Fail Rev 2020;25:937-948. https://doi.org/10.1007/s10741-019-09865-3

3. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al.Recommendations for cardiac chamber quantification by echocardiography in adults: An update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2015;16:233-270.https://doi.org/10.1093/ehjcji/jev014

4. Namazi F, van der Bijl P, Hirasawa K, Kamperidis V, van Wijngaarden SE,Mertens B,et al. Prognostic value of left ventricular global longitudinal strain in patients with secondary mitral regurgitation. J Am Coll Cardiol 2020;75:750-758.https://doi.org/10.1016/j.jacc.2019.12.024

5.Pieske B, Tschope C, de Boer RA, Fraser AG, Anker SD, Donal E, et al.How to diagnose heart failure with preserved ejection fraction: The HFA-PEFF diagnostic algorithm: A consensus recommendation from the Heart Failure Association(HFA) of the European Society of Cardiology(ESC). Eur Heart J 2019:40:3297-3137. https://doi.org/10.1093/eurheart/ehz641

6.Celuttiene J, Plymen CM, Flachskampf FA, de Boer RA, Grapsa J, Manka R,et al. Innovative imaging methods in heart failure: A shifting paradigm in cardiac assessment. Position statement on behalf of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2018:2016:1533.https://doi.org/10.1002/ejhf.1330

7. Benfari G, Miller WL, Antoine C, Rossi A, Lin G, Oh JK, et al. Diastolic determinants of excess mortality in heart failure with reduced ejection fraction.JACC Heart Fail 2019;7:808-817.https://doi.org/10.1016/j.jchf.2019.04.024

8. Lang RM, Badano LP,Tangw A, Adams DH, Agricola E, Buck T, et al. EAE/ASE recommendations for image acquisition and display using three-dimensional echocardiography.Eur Heart J Cardiovasc Imaging 2012;13:1-46.https://doi.org/10.1093/ehcijor1316

9. Ghio S, Gavazzi A, Campana C, Inserra C, Klersy C, Sebastiani R, et al.Independent and additive prognostic value of right ventricular systolic function and pulmonary artery pressure in patients with chronic heart

12

A. Aimo et al.

failure. J Am Coll Cardiol 2001;37:183-188. https://doi.org/10.1016/s0735-1097(00)01102-5

10. Badano LP, Muraru D, Parati G, Haugaa K, Voigt JU. How to do right ventricular strain. Eur Heart J Cardiovasc Imaging 2020;21:825-827. https://doi.org/10.1093/erjehi/12ea7

11. Adamopoulos S, Bonios M, Ben Gal T, Gustafson F,Abdelhamid M, Adamo M,et al. Right heart failure with left ventricular assist devices: Preoperative, peri-operative and postoperative management strategies. A clinical consensus state-ment of the Heart Failure Association(HFA) of the ESC. Eur J Heart Fail 2024;26:2304-2322.https://doi.org/10.1002/ehf.3323

12 Ghio S, Scusreci F, Klersy C, Sebastiani R, Laudisa L, Campana C, et al.Prognostic usefulness of the tricupid annular plane systolic excursion in patients with congestive heart failure secondary to diopathic or ischemic dialing cardiomyopathy. Am J Cardiol 2000;85:837-842. https://doi.org/10.1016/s0002-9149(99)00877-2

13.de Groote P, Fertin M, Goémine C, Peytty G, Peytros, Fouchen Hossin C, et al.Right ventricular systolic function for risk stratification in patients with stable left ventricular systolic dysfunction. Comparison of radionuclide angiography to echoCoppler parameters. Eur Heart J 2012:33:2672-2679. https://doi.org/10.1093/eurheart/ehs080

14. Kawata T, Daimon M, Kimura K, Nakako T, Lee, SL Hirokawa M, et al. Echocan-diographic assessment of right ventricular function in routine practice: Which parameters are useful to predict one-year outcome in advanced heart failure patients with dilated cardiomyopathy? J Cardi 2017;70:316-322.https://doi.org/10.1016/j.jcc.2017.02.007

15. Seo J.Jing HJ, Park.HJ, Kim GS, Lee HY, BSyn et al. The prognostic value of right ventricular in patients with dilated cardiomyopathy.Eur Heart J Cardiovasc Imaging 2019:20104-1050.https://doi.org/10.1093/ehjci/jez015

16.Vijiac A, Oncial S, Guuz, Ceranceinau, V Bataill, D. Deaconu S, et al.The prognostic value of right ventricular longitudinal strain and 3D ejection fraction in patients with dilated cardiomyopathy. Int J Cardiovasm Imaging 2021;37:3233-3244.https://doi.org/10.1007/s10554-021-0232-z

17.Carlicuo E,Bagoli P,Aniui G,Murone A,Zuch C,Kiero C,S.et al. Prog-nostic value of right ventricular dysfunction in heart failure with reduced ejection fraction: Superiority of longitudinal strain over tricuspid annular plane sys-tolic excursion.Crcardos Imaging 2018:11:e00684.https://doi.org/10.1161/1006894.

18.Guazzi M,Bandera F,Pelissero G,Castelvesio S,Micenanti L,Ghio S,et al.Tri-cupular annular systolic excursion and pulmonary arterial systolic pressure relationship in heart failure: An index of right ventricular contractile function and prognosis. Am J Physiol Heart Circ Phys 2013:1053:H1373-H1381.https://doi.org/10.1152/ajpheart.00157.2013

19.Vijiac A, Bataillia V, Oncial S, Verinceau V, Guuz C, Deacon u, et al.Non-imvasive right ventriculo-arterial coupling as a rehospitalization predictor in dilated cardiomyopathy: A comparison of five different methods. Kardiol Pol 2022:80:182-190.https://doi.org/10.33963/PK.a2021.0190

20Ts LAFo Aima, Adamopopulas S. Bonio M, Celik A, Chioncal O, et al.Multi-modality imaging in advanced failure. A clinical consensus statement of the Heart Failure Association of the ESC. Part 2: Mechanical circulatory support and heart transplantation. Eur J Heart fall in press. https://doi.org/10.1002/fehx.20018

21. Vahanian A, Beyersdor F, Fraz P, Milovicek, M. Baldus S, Bauershets J, et al.;ESC National Cardiac Sociostics; ESC/EACS Scientific Document Group.2021 ESC/EACS Guidelines for the management of valvular heart disease. Eur Heart J 2022:43:561-632. https://doi.org/10.1039/eurieh)hab395

22. Hahn RT, Abraham T, Adams MS, Bruce CJ, Gil Lang RM, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination:Recommendations from the American Society of Echocardiography and the Soci-ety of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr 2013;26:921-964.https://doi.org/10.1016/j.echo.2013.07.009

22. Dreyfus J, Brochet E, Lepatia L, Attias D, Cueff C, Detaint D, al Real-time 3D transosophageal measurement of the mitral valve area in patients with mitral stenosis. Eur. Jchrodagcard 2011:12:750-755. https://doi.org/10.103/ecjohard/178118

24. Bombardini T, Zoppe M, Ciampi Q, Cortiangian L, Agricola E, Salvadori S, et al.Mycardial contractility in the stress echo lab: from pathophysiological toy to clinical tool. Cardiovasc Ultrasound 2013:11:41. https://doi.org/10.1186/1476-7120-11-41

25. Verwerft is S. Loysn, Wants y. Meyman J, Mogani J, Piem and I. Heart failure with preserved ejection fraction: Relevance of a dedicated dyspoea clinic. Eur Heart J2023:44:1544-1556. https://doi.org/10.1093/eurieheart/ehad141

26.Gargani L, Girerd N, Platz E, Pellicori P, Stankovic I, Palazzouli A, et al.Lung ultrasound in acute and chronic heart failure: A clinical consensus

statement of the European Association of Cardiovascular Imaging(EACVI).Eur Heart J Cardovosic Imaging 2023;24:1569-1582.https://doi.org/10.1093/ehci/jeah 1698

27. Leidi F, Casella F, Cogliari C. Bedside lung ultrasound in the evaluation of acute decompensent heart failure. Intern Emerg Med 2016;11:597-601.https://doi.org/10.1007/s11739-016-1403-0

28.Chioné O, Parisis J. Mebazza A, Thiele H, Desch S, Bauersachs J, et al.Epidemiology, pathophysiology and contemporary management of cardiogenic shock-a position statement from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2020;22:1315-1341.https://doi.org/10.1002/ehj.1922

29. Daly M, Long B, Koymman A, Lentz S. Identifying cardiogenic shock in the emergency department. Am J Emerg Med 2020:38:2425-2433.https://doi.org/10.1016/j.ajem.2020.09.045

30.Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid Ultrasound In SHock in the Ejection of the critically ill. Emerg Med Clin North Am 2010;28:29-56.https://doi.org/10.1016/j.emc.2009.09.010

31.Self D, Perera P, Mailhiot T, Riley D, Mandavia D. Bedside ultrasound in resuscitation and the rapid ultrasound in shock protocol. Crit Care Res Prac 2012;2012:503254.https://doi.org/10.1155/2012/503254

32. Keikha M, Saleh-Marijizarani M, Soldoozi Nejat R, Sheikh Motahar Vahedi H,Mirrezaie SM. Diagnostic accuracy of rapid ultrasound in shock(RUSH) exam;a systematic review and meta-analysis. Bull Emerg Trauma 2018;6:271-278.https://doi.org/10.29252/beat-060402

33. Bellenger NG, Burgess Ml, Ray SG, Lahiri A, Coats AJ, Cleland JG, et al.Comparison of left ventricular ejection fraction and volumes in heart failure by echocardiography, radionuclide ventriculography and cardiovascular magnetic resonance; are they interchangeable? Eur Heart J 2000;21:1387-1396.https://doi.org/10.1053/uee.2000.2011

34 Raaf AGs, QS, JL, Henkens M, Henkens MTHM, Slurink BO, Verdonschot JAJ,et al. Left atrial strain has superior prognostic value to ventricular function and delayed-enhancement in dilated cardiomyopathy. JACC Cardiovasc Imaging 2023;15:1015-1026.https://doi.org/10.1016/j.jcmg.2022.01.016

35. Houard L, Amzulescu MS, Colin G, Langel H, Militaru S, Rousseau MF, et al.Prognostic value of pulmonary transit time by cardiac magnetic resonance on mortality and heart failure hospitalization in patients with advanced heart failure and reduced ejection fraction. Circ Cardiovasc Imaging 2021;14:e011680.https://doi.org/10.1161/CIRCIMAGING.120.011680

https://doi.org/10.1161/CIRCIMAGING.120.011680

36.Bettencourt N, Chirribi A, Schuster A, Nagel E. Assessment of myocardial ischemia and viability using cardiac magnetic resonance. Curr Heart Fail Do 2009;14:153.https://doi.org/10.1007/s11897-009-0021-9

17. Kurvilla S, Adenaw N, Katwal AB, Lipinski MJ, Kramer CM, Salerno M. Late gadolinium enhancement on cardiac magnetic resonance predicts adverse car-dovascular outcomes in nonischemic cardiomyopathy: A systematic review and meta-analysis.Circ Cardiac Imaging 2014;7:250-258.https://doi.org/10.1161/CIRIMAGING.113.001144

38.Kwon DH,Obchowski NA,Marwick TH,Menon V,Griffin B, Flamm SD,et al. Jeopardized myocardium defined by late gadolinium enhancement magnetic resonance imaging predicts survival in patients with ischemic cardiomyopathy:Impact of revascularization. J Am Heart Assoc 2018;7:e009394.https://doi.org/10.1161/ja.118.009394.

39. White JA, Yee R.,Yuan X, Krahn A, Skanes A, Parker M, et al. Delayed enhance-ment magnetic resonance imaging predicts response to cardiac resynchroniza-tion therapy in patients with intraventricular dyscosymny. J Am Coll Cardiol 2006:4895-1002. https://doi.org/10.1016/j.jacc.2006.07.046

40.Di Marco A,Anguera I, Schmit M, Klem I, Neilan TG, White JA, et al. Late gadolinium enhancement and the risk for ventricular arrhythmias or sudden death in dilated cardiomyopathy: Systematic review and meta-analysis.JACC Heart Fail 2017;5:28-38.https://doi.org/10.1016/j.jchf.2016.09.017

41. Vuoraminen L,Lehmonen L,Karvonen J,Holmstrom M,Kivisto S,Kaasalainen T.Reducing cardiac implantable electronic device-induced artefacts in cardiac mag-netic resonance imaging. Eur Radiol 2023:33:1229-1242.https://doi.org/10.1007/s00330-0220-0950-w.

42.Saraste A, Knutu J, Benogel F. Phenotyping heart failure by nuclear imaging of myocardial perfusion, metabolism and molecular targets. Eur Heart J Cardiovasc Imaging imaging 2023;23:1418-1328.https://doi.org/10.1093/ehci/jead128

43.D'EGidio G,Nichol G,Williams KA,Guo A,Garrard L,de Kemp R,et al.Increasing benefit from revascularization is associated with increasing amounts of myocardial hibernation: A substudy of the PARR-2 trial. JACC Cardiovasc Imaging 2009:21060-1068.https://doi.org/10.1016/j.jcmg.2009.02.017

49. Panza Il, Ellis AM, Al: Kalidiar HR, Holly TA, Berman DS, Oh JK, et al. Myocardial viability and long-term outcomes in ischemic cardiomyopathy. N Engl J Med 2019:38:739.https://doi.org/10.1056/NEJmo1807365

4. Perera D, Clayton T, Oaken PD, Greenwood JP, Weerackody R, Ryan M, et al.;REVRED-BCIS2 Investigators. Percutaneous revascularization for ischemic left

©2025 European Society of Cardiology.

$$\text{ Imaging in advanced heart failure}$$

13

ventricular dysfunction. N Engl J Med 2022;387:1351-1360.https://doi.org/10.1056/NEjMo2206606

46. Uebleys C, Ulbrich M, Tegmeyer R, Schuessler F, Hasueerck N, Siebermair J,et al. Electrocardiogram-gated 18-FDG PET/CT hybrid imaging in patients with unsatisfactory response in cardiac resynchronization therapy: Initial clinical. J Nucl Med 2011:52:67-71.https://doi.org/10.2967/junmed.110.078709

47. Birnie DH,Kandolin R,Nery PB,Kupar M. Cardiac manifestations of sarcoidosis.Diagnosis and management. Eur Heart J 2017:38:2663-2670.https://doi.org/10.1093/eurheartj/hw328

48bordal A, Sordao A, Sbohari S, Dispenzieri A, Falk RH, Ferrari VA, et al.ASNC/AHA/ASE/EANM/HFHS/ISA/SCR/SNMMI expert consensus re-omndations for multimodality imaging in cardiac amyloidosis: Part 1 of 2- Evidence base and standardized methods of imaging. Circ Cardiovasc Imaging 2021:14:e000029.https://doi.org/10.1161/HCl10000000000000029

70 Nenter H, Dregthe G, Slart R, Damman K, Wouthysen-Bakker M, Postma DF, et al. The value of 18F-FDG PET/CT for the diagnosis of device-related infections in patients with a left ventricular assist device: A systematic review and meta-analysis. Eur J Nucl Med Mol Imaging 2021:48:241-253.https://doi.org/10.1007/s00259-020-04930-8

50. Knudot J, Wijws V, Saraste A, Capodanno D, Barbato E, Funck-Brentano C,et al; ESC Scientific Document Group 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2020:41:407-477.https://doi.org/10.1093/eurheart/ehz/425

51. Colin GC, Gerber DL, de Meester de Ravenstein C, Byl D, Dietz A, Kanga M,et al. Pulmonary hypertension due to left heart disease: Diagnostic and prognostic value of CT in chronic systolic heart failure. Eur Radiol 2018;28:4643-4653.https://doi.org/10.1007/s00330-018-5455-6

52. Bax JJ,Debonaire P. Lancellotti P,Ajone moran Ntopa L.Pf,Min JK,et al.Tran-scatheter interventions for mitral regurgitation: Multimodality imaging for patient selection and procedural guidance. JACC Cardiovasc Imaging 2019;12:2029-2048.https://doi.org/10.1016/j.jcmg.2019.03.036

53.Harowicz MR,Shah A,Zimmerman SL.Preoperative planning for structural heart disease.Radiol Clin North Am 2020:58:733-751.https://doi.org/10.1016/j.rcl.2020.02.005

54. Asgar AW, Mack MJ, Stone GW. Secondary mitral regurgitation in heart failure:Pathophysiology, prognosis, and therapeutic considerations. J Am Coll Cardiol 2015;65:12311248.https://doi.org/10.1016/j.jacc.2015.02.009

55. Marchetti D, Di Lenardra F, Novembre ML, Paolisso P, Schillaci M, Melotti E, et al.Contemporary echocardiographic evaluation of mitral regurgitation and guidance for percutaneous mitral valve repair. J Clin Med 2023;12:7121.https://doi.org/10.3390/jcm12227121

56. Sharma H, Liu B, Mahmoud-Elsayed H, Myerson SG, Steeds RP. Multimodality imaging in secondary mitral regurgitation. Front Cardiovasc Med 2020;7:546279.https://doi.org/10.3389/cvm.2020.546279

57. Pagnesi M, Cali F, Chiarito M, Stolfo D, Baldetti L, Lombardi C M,et al. Prognostic role of mitral regurgitation in patients with advanced heart failure. Eur J Intern Med 2024;112:108.https://doi.org/10.1016/j.ejm.2023.11.002

58.Adamo M,Chioncel O,Pagnesi M,Bayes-Genis A,Abdelhamid M,Anker SD,et al.Epidemiology: pathophysiology, diagnosis and management of chronic right-sided heart failure and trucid degurgitation. A clinical consensus statement of the Heart Failure Association(HFA) and the European Association of Percutaneous Cardiovascular Interventions(EAPCI) of the ESC. Eur J Heart Fail 2024;26:18-33.https://doi.org/10.1002/jehf.3106

950 F. Muraru D, Kreidel F, Lurz P, Hahn RT, Delgado V, et al. Transcatheter treatment for tricuspid valve disease. EuroIntervention 2021;17:791-808.https://doi.org/10.4244/dejei-21-00695

60.Lancellotti P, Pibarot P, Chambers J, la Canna G, Pepi M, Dulgheru R, et al;Scientific. Document Committee of the European Association of Cardiovascular Imaging. Multi-modality imaging assessment of native valvular regurgitation: An EACVI and ESC council of valvular heart disease position paper. Eur Heart J Cardiovasc Imaging 2022;23:e171-e232.https://doi.org/10.1093/ehci/jae253

61. Dreyfus J, Lancellotti P, Burwash IG, Messika-Zeitoun D. Refining the grading of tricuspid regurgitation: Enhancing outcome prediction and patient management.Eur Heart J Cardiovasc Imaging 2024:25:1085-1086.https://doi.org/10.1093/ehci/jacci.2020

62. Hahn RT, Badano IP, Bardano IP, Bardano P, Mazorano JL, et al. Tri-cusidp regurgitation: Recent advances in understanding pathophysiology, severity grading and outcome. Ear Heart J Cardiovasc Imaging 2022:23:913-929.https://doi.org/10.1093/ehci/jej.0009