2025+HFA-ESC临床共识声明：晚期心力衰竭的多模式成像—第2部分：机械循环支持和心脏移植

Multimodality imaging in advanced heart failure. A clinical consensus statement of the Heart Failure Association of the ESC. Part 2:Mechanical circulatory support and heart transplantation

Laurens F. Tops 1***,Alberto Aimo2,3,Stamatis Adamopoulos4,Michael Bonios4,Ahmet Celik5, Ovidiu Chioncel6,7, Maja Cikes8, Maria G. Crespo-Leiro9,Kevin Damman10, Concetta Di Nora11, Julien Dreyfus12, Finn Gustafsson13,Shahruk Hashmani14, Marco Masetti15, Ify Mordi16, Sanem Nalbantgil17,Linda W. van Laake18, Ralph Stephan von Bardeleben19, Marco Metra20,Brenda Moura21, and Tuvia Ben Gal 22,23

1Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands;2Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy;3Cardiology Division,Fondazione Toscana Gabriele Monasterio,Pisa,Italy;4Heart Failure and Transplant Units,Onassis Hospital,Athens,Greece;5Department of Cardiology.Faculty of Medicine, Mersin University, Mersin, Turkey,6Emergency Institute for Cardiovascular Diseases'C.C.Iliescu',Bucharest, Romania;7University of Medicine Carol Davila,Bucharest, Romania;8Department of Cardiovascular Diseases, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb,Croatia;9Department of Cardiology,Hospital Universitario A Corufa(CHUAC),CIBERCV,A Corufa,Spain;10Department of Cardiology,University of Groningen,University Medical Center Groningen,Groningen,The Netherlands;11Cardiothoracic Department, Azienda Sanitaria Universitaria Friiull Centrale, Udine, Italy;12Cardiology Department, Centre Cardiologique du Nord,Saint-Dennis,France;13Rigshospitaet Copenhagen University Hospital,Copenhagen,Denmark;14Royal Brompton Hospital,London,UK;15Heart Failure and Transplant Unit,IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy; 16Division of Cardiovascular Research, School of Medicine, University of Dundee, Dundee, UK;17Ege University,Izmir,Turkey;18Department of Cardiology,University Medical Center,Reptan and Utrecht University, Utrecht, The Netherlands; 19Heart Valve Center, Mainz,Germany;20Cardiology,Vita-Salute San Raffaele University,IRCCS San Raffaele Hospital,Milan,Italy;21Armised Forces Hospital,Faculty of Medicine of the University of Porto,Porto, Portugal;22Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel; and 23Faculty of Medicine, Tel Aviv University,Tel Aviv,Israel

Received 14 March 2025; revised 22 July 2025; accepted 30 July 2025

This clinical consensus statement outlines the vital role of multimodality imaging in managing patients with advanced heart failure(HF),particularly those receiving mechanical circulatory support(MCS) and heart transplantation(HT). For both temporary and durable MCS multimodality imaging, primarily echocardiography, is crucial for selecting candidates, ensuring proper device placement, and monitoring in the post-implantation period. Preoperatively, it helps to identify HF phenotypes, assess ventricular functions, detect intracardiac thrombi,and evaluate valvular conditions. Key measurements include ventricular size, ejection fraction, and cardiac output. Intraoperative imaging ensures optimal device placement and complication detection. Post-implantation echocardiography gives an impression of the interplay between heart and MCS, detects early complications, and evaluates ventricular unloading and right ventricular function. Serial imaging evaluations are essential for the management of the patient and the device and for diagnosing and treatment of complications. In temporary MCS, imaging is vital in the weaning process. Imaging is crucial across various post-transplant phases, from early postoperative monitoring to long-term follow-up. Echocardiography is the first-line technique. Cardiovascular magnetic resonance provides detailed evaluation of cardiac structure and function, offering insights into fibrosis, oedema, and myocardial perfusion. Coronary computed tomography angiography and positron emission tomography are possible alternatives for assessing coronary allograft vasculopathy. Overall, multimodality imaging is pivotal for comprehensive management of patients potentially eligible to or undergoing MCS or HT, enhancing diagnostic accuracy and guiding therapeutic decisions.

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L.F. Tops et al.

Graphical Abstract

 # Imaging in advanced HF:MCS and heart transplantation

#

● Candidate selection

•Device and cannula positioning

● Ventricular and valve assessment

● Thrombus detection

TTE/TOE

TTE/TOE

# Heart transplantation

• Graft function monitoring

● Complication detection

● Anastomosis evaluation

● Rejection suspicion

• Outflow graft and cannula visualization

• Thrombus detection

• Device-related complications

CT/CCTA

 ● Graft vasculature

● Myocardial perfusion

CMR

• Graft function

● Oedema and fibrosis evaluation

● Rejection detection

● Myocardial perfusion

PET

• Device-related infection detection

PET

 ● Myocardial perfusion

● Coronary allograft vasculopathy assessment

Applications of imaging modalities in patients who are candidate to or recipients of mechanical circulatory support or heart transplantation.CCTA,coronary computed tomography angiography;CMR,cardiovascular magnetic resonance;CT,computed tomography;HF,heart failure;MCS,mechanical circulatory support; PET,positron emission tomography;TOE,transoesophageal echocardiography;TTE,transthoracic echocardiography

Keywords

Keywords

Echocardiography● Cardiac allograft vasculopathy

Introduction

Several imaging modalities are available for the assessment of patients with advanced heart failure(HF). Conventional techniques such as two-dimensional(2D) transthoracic echocardiography

(TTE) and advanced methods like strain imaging and three-dimensional(3D) transoesophageal echocardiography(TOE)are utilized. Cardiovascular magnetic resonance(CMR), coro-nary computed tomography angiography(CCTA), and positron emission tomography(PET) also provide comprehensive cardiac

©2025 European Society of Cardiology.

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

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assessments. There is currently a paucity of articles describing the use of multimodality imaging in patients with advanced HF and,to even a lesser extent, those who have mechanical circulatory support(MCS) or have undergone heart transplantation(HT).This is the second part of a clinical consensus statement from the Heart Failure Association of the European Society of Cardiology regarding multimodality imaging in patients with advanced HF and it is focused on its roles for diagnosis, risk prediction, and guidance of treatment in patients undergoing MCS or HT.

Temporary mechanical circulatory support

Alongside clinical assessment and invasive haemodynamics, mul-timodality imaging, primarily echocardiography, identifies suitable candidates for temporary MCS.1

The HF phenotype is first determined, distinguishing between predominant left ventricular(LV) or right ventricular(RV) fail-ure and biventricular failure, which require different treatments.Among other parameters, left atrial(LA) dimensions may guide the choice between LA and LV cannulas. Concomitant disorders, such as aortic stenosis/regurgitation or intracardiac shunts, affect the feasibility of veno-arterial extracorporeal membrane oxygenation(VA-ECMO) or percutaneous microaxial flow pump. In addition,multimodality imaging enables assessment of intracardiac thrombi,common in low-output states or post-myocardial infarction, and evaluation of mitral regurgitation(MR) and tricuspid regurgitation(TR),inferior vena cava dimensions, and RV peak systolic pressures to assess congestion and pulmonary pressures pre- and post-MCS implantation. Other clinical settings relevant for the device selec-tion, not requiring imaging, are respiratory failure and cardiac arrest, both supporting VA-ECMO use.

Device-specific assessments, such as arterial and venous vessel dimensions and potential congenital abnormalities, help determine the best temporary support option. Contraindications, including aortic dissection for VA-ECMO and various conditions for percuta-neous microaxial flow pump(e.g. severe right HF or LV thrombus),must be considered.2 During placement, TOE and fluoroscopy are used to optimize cannula/device positioning. For intra-aortic bal-loon pump, the tip of the balloon is positioned 2 cm above the carina line or 1 to 2 cm from the left subclavian artery when TOE is used. For percutaneous microaxial flow pump, the inlet is posi-tioned in the left ventricle, without contacting the mitral valve and papillary muscles and approximately 3.5 cm below the toric valve annulus. For VA-ECMO, TOE can guide positioning of the inflow cannula tip, that should remain free in the right atrium. Final positions are confirmed by echocardiography before leaving the catheterization laboratory or operating room.2 Daily echocardio-graphy, or more frequent checks during haemodynamic changes,monitors ventricular(both LV and RV) and valvular function, par-ticularly for aortic regurgitation(AR), and assesses potential for weaning.2,3

For VA-ECMO, target blood flows in combination with the native cardiac function must provide adequate systemic cardiac output and oxygen delivery. When native cardiac function is not

sufficiently recovered or VA-ECMO flow is disproportionately high, several echo findings may be observed such as sponta-neous contrast in the left ventricle, no or intermittent aortic valve opening, and thrombus formation in the aortic root. When VA-ECMO flow is adjusted according to metabolic and oxygena-tion needs, imaging that reveals intermittent or incomplete aor-tic valve opening, LV distension, and increased LV end-diastolic pressure suggests the need for intervention. The first step is often to reduce VA-ECMO flow or to add inotropes to enhance native cardiac function. If these adjustments are insufficient, adding an unloading device such as percutaneous microaxial flow pump,intra-aortic balloon pump, or performing an atrial septostomy may be necessary.

Weaning attempts are guided by echocardiography, in conjunc-tion with permissive laboratory and right heart catheterization values. In this scenario, measures of‘off-pump’ LV stroke volume or LV ejection fraction,end-diastolic diameter, aortic valve patency,together with tissue Doppler and strain imaging are all informative.

Long-term mechanical circulatory support

Patient selection

Transthoracic echocardiography is the primary imaging modal-ity for initial screening of patients who may be candidates for long-term MCS.4 TTE allows assessment of LV and LA size, LV systolic and diastolic function, valvular abnormalities and cardiac output, as well as pulmonary artery(PA) pressure and RV func-tion. The LV internal dimension at end-diastole(LVIDd) from a 2D parasternal long-axis view is particularly important, as comparing preoperative and postoperative LVIDd helps quantify LV unload-ing,4 with smaller LV cavities associated with fewer postoperative complications.5

Patients with very low LV ejection fraction and LV aneurysms are at high risk for thrombus formation.6 Contrast-enhanced TTE, computed tomography(CT) or CMR may be considered to visualize LV thrombus. The left atrium and LA appendage are other potential thrombus sites, especially in patients with atrial fibrillation; TOE is the preferred imaging modality for evaluating these sites.4

Right ventricular dysfunction before and after LV assist device(LVAD) implantation is a major concern. RV dilatation, defined as an RV short-to-long axis diameter ratio>0.6, and an RV to LV end-diastolic dimension ratio>0.72, are predictors of RV failure after LVAD.7-10 3D echocardiography is preferred for evaluating RV volumes and ejection fraction.11 Parameters such as RV free wall peak longitudinal strain,12 RV fractional area change(FAC), tricus-pid annular plane systolic excursion(TAPSE), and tricuspid s' may be included.13 However, no single echocardiographic parameter accurately predicts RV failure alone. A multiparametric approach,including clinical and invasive haemodynamic information is there-fore useful14(Figure 1).

Assessing valvular disease preoperatively using TTE and TOE as needed is advisable.4 Severe mitral stenosis may impair can-nula inflow, and is therefore corrected during LVAD implantation.

L.F. Tops et al.

 RV/LV ratio>0.72

3D RV volume>61 ml/m2

RVFAC<31%

TDI s'<8 cm/s

RV free wall strain>-14%

HAEMODYNAMICS

 RVSWI=(mean PAP-mean RAP)·SVI

 RA pressure>12

RVSWI

CVP/PCWP

PAI=PA systolic pressure- PA diastolic pressure

PAPi

<2.0

Figure 1 Clinical, echocardiographic and haemodynamic predictors of right ventricular(RV) failure after left ventricular assist device(LVAD)implantation. Several clinical parameters are associated with RV failure after LVAD implantation. In addition, various echocardiographic and haemodynamic parameters are predictive for RV failure. Specific cut-off values that have been used in previous studies are shown here.CVP,central venous pressure;ECMO,extracorporeal membrane oxygenation;IABP,intra-aortic balloon pump;INTERMACS,Interagency Registry for Mechanically Assisted Circulatory Support;LV,left ventricular;PA, pulmonary artery pressure;PAPi, pulmonary artery pulsitacle index;PCWP; pulmonary capillary wedge pressure;RA,right atrial;RAP;right atrial pressure;RRT,renal replacement therapy;RVFAC, right ventricular fractional area change;RVSWI, right ventricular stroke work index;TDI,tissue Doppler imaging.Based on Adamopoulos et al.14

Aortic stenosis may be left uncorrected as LVAD flow bypasses the LV outflow tract.15 MR,especially secondary MR,typically improves with LV unloading,16 does not require surgical or percutaneous intervention, and may be used to guide LVAD speed optimiza-tion. According to the International Society for Heart and Lung Transplantation guideline,17 correction of moderate-to-severe AR is recommended to avoid LV dilatation, ineffective recirculation of blood and HF.18 TR is closely associated with postoperative RV failure. Functioning bioprosthetic valves generally do not require replacement, but it is advisable to replace mechanical aortic valves with bioprosthetic valves to reduce thrombosis risk. LVAD implan-tation is typically avoided in the setting of endocarditis. Patients with congenital heart disease are advised to undergo thorough evaluation with echocardiography, CT, and CMR to define cardiac morphology,large vessels, shunts, and collateral vessels. It is advis-able to correct a patent foramen oveary or atrial septal defect during LVAD surgery to reduce the risk of hypoxaemia and paradoxical embolization.4,19-23

Perioperative assessment

Intraoperative TOE is used to assess cardiac function, LV unload-ing and LVAD function(e.g. outflow graft flow pattern)(Figure 2).

Re-evaluation of RV function and TR severity is crucial, as prompt action with a temporary RV assist device(RVAD) can improve prognosis compared to delayed RVAD placement.24 During intra-operative TOE, X-plane and 2-chamber views confirm proper inflow cannula alignment with the mitral valve opening, and colour flow Doppler demonstrate laminar blood flow into the device.Inflow cannula peak velocities>1.5m/s require extensive inter-rogation with 3D echocardiography.25 Velocities>2m/s in the outflow graft might indicate obstruction26(Figure 2). Air bubbles in the ascending aorta near graft insertion may indicate poor anastomosis or cannula issues.27 TOE or TTE could be repeated immediately after sternal closure, which may alter cannula orien-tation.27 Additionally,performing a ramp test protocol to establish the optimal rotation speed is essential for ensuring proper device function.

It is also important to re-evaluate the degree of AR and interatrial shunts during the intraoperative assessment, as these conditions may be overlooked or underestimated before LVAD implantation and can only be accurately detected and corrected during the operation. AR is best visualized in the mid-oesophageal long- and short-axis views, as well as in the deep transgas-tric views, especially shortly after initiating cardiopulmonary bypass.

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

 Figure 2 Perioperative imaging after implantation of a left ventricular assist device.(A) Three-dimensional transoesophageal echocardiography demonstrating proper alignment of the left ventricular assist device inflow cannula(arrow) with the interventricular septum.(B) Mid-oesophageal 3-chamber view and corresponding M-mode images are typically used to assess aortic valve opening perioperatively.(C) Colour Doppler image of a high-oesophageal view demonstrating the outflow graft connection to the ascending aorta.(D) Pulsed-wave Doppler shows typical outflow cannula velocities and flow patterns(continuous-flow pattern with peak systolic velocities). High systolic velocities(up to 2 m/s) were noted in this patient, however, there were no other signs of cannula malfunction or obstruction.

Early post-implant complications and device dysfunction

pump speed unloads the left ventricle but increases RV preload.Persistent RV failure early postoperatively despite pump adjust-ments and/or inotropes requires temporary mechanical support with an RVAD and sometimes even biventricular assist devices.17

Echocardiography is essential for early detection of post-implant complications and device dysfunction(Table 1).

Clinical suspicion of tamponade is warranted if pericardial effu-sion or a suspected hematoma is visualized together with low-flow alarms and small LV and/or RV chambers. Despite increased intrapericardial pressure, there may not be an exaggerated flow paradox across the atrioventricular valves.27 TTE alone in the early postoperative phase is often insufficient to identify tamponade,and it is advisable to consider TOE with limited delay if suspicion is high.

Postoperatively, it is advisable to routinely assess LV unload-ing using TTE and/or TOE. A dilated left ventricle, persistent secondary MR associated with increased LA size, persistent near-normal aortic valve opening, PA pressure>40 mmHg, and mitral valve E/A peak Doppler velocity>1 are signs of partial, inef-fective LV unloading. In an attempt to achieve better LV unloading,progressive increase in pump speed can be performed; however,if excessive, it can lead to a nearly empty left ventricle, frequently associated with suction events.30

In patients with advanced RV dysfunction or failure, the investiga-tion of a low-flow alarm may reveal that the interventricular septum(IVS) is significantly and continuously displaced towards the left ventricle.28,29 Worsening but not irreversible RV dysfunction, espe-cially when associated with a nearly collapsed left ventricle, may be partially resolved by reducing the pump speed, since high LVAD

A suction event is characterized by an abnormally small LV chamber size leading to a right-to-left ventricular septal shift and LVAD flow wave characteristics(low flow and usually increased pulsatility index alarms). A relatively excessive pump speed might be the sole cause. If this is not the case, it is important to reverse any underlying cause.17

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L.F. Tops et al.

Table 1 Post-implant complications and device dysfunction

Pericardial effusion(with or without tamponade)RV failure Intracardiac thrombus LV failure secondary to partial LV unloading Inadequate LV filling or excessive LV unloading LVAD suction('sucked down' LV cavity) with induced ventricular ectopy or tachycardia LVAD-related continuous aortic insufficiency LVAD-related mitral regurgitation Inflow-cannula abnormality(obstruction-malposition-hyperdynamic apical LV function)Outflow graft abnormality(twisting thrombosis, eOGO)Hypertensive emergency Pump malfunction/pump arrest

eGOO,external outflow graft obstruction; LV, left ventricular; LVAD, left ven-tricular assist device; RV, right ventricular.

In case of pump dysfunction due to suspected pump throm-bosis, TTE and TOE may reveal an increase in LV cavity size,increased aortic valve opening duration, development of MR and very low velocity inflow cannula systolic flow on colour-flow and pulsed-wave Doppler images, with nearly absent diastolic flow leading to an increasing systolic/diastolic ratio in the inflow and outflow cannula.31 If suspicion for thrombus remains high and no thrombus is visualized, a microbubble contrast agent facil-itates LV thrombus detection, which, however, does not need to be visible in cases of pump thrombosis.32 An abnormal ramp test(described below) is very indicative of pump malfunction due to pump thrombosis. If LV size remains enlarged and the aortic valve remains wide open, it is advisable to suspect pump thrombosis. In the case of inflow cannula thrombus, inflow-cannula spectral Doppler velocities may be elevated as blood acceler-ates proximal to the obstruction, whereas outflow-gratert velocities may be relatively decreased and/or show peak velocity varia-tions. Two-dimensional and 3D TTE and TOE may show thrombi obstructing the cannula.15

It is advisable to consider multimodality imaging when pump thrombosis or external outflow graft obstruction is suspected.Given the inability of echocardiography to always view the entire outflow graft, an angio-CT scan is typically performed.33-37

Follow-up of long-term mechanical circulatory support

Multimodality imaging is crucial for assessing LVAD function after its implantation, and in particular LVAD-related complica-tions.30 This includes assessment of LV unloading, RV failure,device malfunction, driveline infections and valvular heart disease(Figure 3).

If LV unloading is suboptimal, the IVS shifts to the right during peak systole, suggesting inadequately low LVAD speeds, device mal-function, or cannula obstruction. Conversely, a small left ventricle

or leftward shift of the IVS could indicate excessive unloading due to high pump speed, potentially resulting in RV dysfunction, wors-ening TR, and onset of RV failure(Figure 3). Proper LV unload-ing can be obtained through echocardiographic measurements during rotor speed adjustments, namely the ramp study. Dur-ing the ramp study, LVAD speed(in the HeartMate3TM device)is increased by 100 rpm increments at 1-min intervals. Stopping criteria are LVIDd<30mm, suction events, or frequent ven-tricular ectopic beats. An optimal LVAD speed is set to ade-quately unload the left ventricle while maintaining minimal/mild MR, intermittent aortic valve opening to prevent development of AR, and to avoid worsening of RV function.38.39 Optimized haemodynamics through invasive ramp tests were shown to reduce all-cause readmission rates, driven by less cardiac-related hospital-izations.40

Routine echocardiographic evaluation for RV function typically includes apical 4-chamber(Figure 3), parasternal short-axis at the level of the aortic root and apex, parasternal RV inflow, subcostal 4-chamber views, and estimation of the TR jet by colour Doppler.Patients undergoing isolated LVAD implantation may experience worsening right HF. RV dysfunction and the PA pulsatility index are powerful determinants of poor outcomes after LVAD implan-tation.41 Reduced RV FAC,elevated right atrial pressures, presence of pulmonary hypertension, and high pulmonary vascular resistance are associated with an increased risk of RV failure and reduced sur-vival.42-44

Despite normal aortic valve function at the time of LVAD insertion,AR develops in a high percentage of patients 1 year after LVAD implantation.43,45 In selected patients with significant AR after LVAD implantation(Figure 3), transcatheter aortic valve replacement may be a viable treatment option.46 MR severity usually improves by unloading the left ventricle and reducing its size, and thus MR does not routinely require surgical repair or valve replacement. However, significant MR after LVAD inser-tion suggests inadequate LV unloading. Assessment can be made by TTE, TOE, or 3D imaging for greater accuracy in under-standing the mechanism of MR.47 Significant postoperative TR contributes to RV dysfunction and the development of a low out-put state. Factors increasing TR include leftward shift of the IVS,decreased RV function post-LVAD implant, and LVAD function increasing RV preload to an already dysfunctional right ventri-cle. TR may be blunted in the presence of elevated right atrial pressure. TR can be reduced by adequately unloading the left ventricle.44

The normal peak velocity in the inflow cannula of axial-flow LVAD ranges from 1 to 2m/s, and pulsed Doppler shows a con-sistently phasic, slightly pulsatile flow pattern. Elevated velocities suggest cannula obstruction, which could be due to cannula throm-bus, cannula angulation or malposition; additionally, regurgitation flow suggests LVAD pump malfunction.47 3D echocardiography is more sensitive than 2D echocardiography in detecting cannula thrombosis.17

Low pump flow with increased power typically indicates pump failure or increased afterload. The typical scenario includes a dilated left ventricle, rightward deviation of the septum, MR, and perma-nent opening of the aortic valve. Pump failure is usually due to

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

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MULTI-MODALITY IMAGING FOR DETECTION OF COMPLICATIONS IN LVAD PATIENTS

  RV failure

 Device malfunction

 Driveline infection

 Aortic valve regurgitation

Mitral regurgitation Septum deviation LV collapse

Septum deviation

LV collapse

 TTE/TOE

RV dilatation RV dysfunction Devtum deviation

 TTE/TOE/CT

Abnormal cannula flow Twisting/ obstruction outflow graft

 ECHO/CT/ PET

Abscess(echo/ CT)High intensity signal at infection site(PET)

 TTE/TOE

Holo-systolic and diastolic regurgitation Permanent AV closure

  Figure 3 Multimodality imaging for detection of complications in left ventricular assist device(LVAD) patients.The different imaging modalities can be used to detect the following complications during follow-up of LVAD patients: inadequate left ventricular(LV) unloading: transthoracic(TTE) and/or transoesophageal echocardiography(TOE) are used to assess LV unloading. Insufficient LV unloading can be revealed by the presence/persistence of mitral regurgitation(upper panel).The lower panel shows excessive LV unloading due to decreased LV preload(severe hypovolaemia and right ventricular[RV] failure) with almost completely collapse of the left ventricle. RV failure: severe dilatation and decreased systolic function are signs of RV failure(upper panel). The lower panel shows leftward deviation of the inter-atrial septum(arrow) in a patient with RV failure. Device malfunction: TTE and/or TOE can detect abnormal flow patterns when device malfunction is suspected. In addition,a computed tomography(CT) scan may reveal twisting of the outflow graft on axial 2-dimensional images(upper panel) and 3-dimensional reconstructions(lower panel). Driveline infection: in addition to abdominal ultrasound, CT enables better visualization of driveline infection or abscess(arrow, upper panel). Combined positron emission tomography(PET) and CT(PET-CT scan) clearly demonstrates a‘hot spot’ at the location of the driveline(lower panel). Aortic valve(AV) regurgitation: parasternal long-axis view with colour Doppler(upper panel) and M-mode(lower panel) of an LVAD patient with severe AV regurgitation. Note the holo-systolic and diastolic regurgitant flow through the closed AV(arrow).

pump thrombosis. Echocardiographic diagnosis can be challenging given the high echogenicity of the LVAD. Frequency of aortic valve opening, valvular insufficiency, and unchanged LVAD parameters at increments of device speed with clinical signs and symptoms can aid in diagnosis. The main causes of increased afterload are kink-ing or obstruction of the outflow cannula and hypertension. Loss of Doppler flow signal or Doppler velocities>2m/s with colour Doppler aliasing at the cannula orifice indicate the former, whereas high blood pressure with normal echocardiographic findings sug-gests the latter.48

Computed tomography is advisable when twisting, kinking, and external compression of the outflow graft causing obstruction are suspected(Figure 3), as it allows visualization of the inflow-cannula position and the entire course of the outflow graft.33-35 Finally,when there is a suspicion of an LVAD-related infection, chest and abdomen CT and 18F fluorodeoxyglucose PET/CT is advisable(Figure 3).

Heart transplantation

Perioperative monitoring

Perioperative monitoring typically includes TOE to ensure the newly transplanted heart can generate sufficient cardiac output and to detect complications from surgery to hospital discharge.49

A comprehensive TOE examination during the final phases of surgery is advised to assess successful de-airing, LV systolic and diastolic function, RV function, and valvular function.50 Increased wall thickness and mass in the left ventricle are common due to oedema from ischaemia-reperfusion injury, but can also be caused by acute rejection. Diastolic function changes may be more sensitive for predicting outcomes than reduced ejection fraction. Suggested views for evaluating LV size and function include mid-oesophageal 4-5 chambers, 2 chambers, and long-axis views;transgastric basal short axis, mid short axis, 2 chambers, and deep 5 chambers.51

$$\text{ L.F. Tops et al.}$$

REJECTION(EARLY/LATE)

 TTE

•Increased LV mass

• Diastolic dysfunction

● Decreased LV strain

 CMR

● T2 mapping:edema

T1 mapping:inflammation

 ● ACR: lymphocytic infiltrates

AMR:endothelial swelling,intravascular macrophages

CARDIAC ALLOGRAFT VASCULOPATHY

TTE

● Diastolic dysfunction

● Decreased LV strain

CT

● Luminal narrowing

● Reduced myocardial perfusion

CAG

Diffuse, concentric luminal narrowing(gold standard)

  IVUS

● Increased maximal intimal thickness(MIT)≥0.5mm

● Higher sensitivity in detecting CAV and assessment of plaque composition

Figure 4 Multimodality imaging for detection of early or late rejection and cardiac allograft vasculopathy(CAV) after heart transplantation.Various imaging modalities are used to diagnose transplant rejection or CAV. Typical findings from each modality are illustrated here.Transthoracic echocardiography(TTE) is the first imaging modality in the screening for transplant rejection. Cardiovascular magnetic resonance(CMR) can detect elevated T2 values, which serve as markers of rejection. However, endomyocardial biopsy(EMB) remains the gold standard for definitive diagnosis. For CAV detection, computed tomography(CT) demonstrates high sensitivity and negative predictive value compared to coronary angiography(CAG), the current gold standard. In addition to CAG, intravascular ultrasound(IVUS) and optical coherence tomography(OCT) offer high-resolution visualization of intimal wall thickness and plaque composition. ACR, acute cellular rejection; AMR, antibody mediated rejection; LV, left ventricular.

Comprehensive RV inspection is crucial as RV failure is a severe complication post-HT, diagnosed by an RV ejection fraction<20%and FAC<35% and complemented with haemodynamic param-eters of RV dysfunction. Suggested views for evaluating RV size and function are mid-oesophageal 4 chambers, RV inflow/outflow views, transgastric basal RV, RV inflow, and RV inflow/outflow views.52.53

Both mid-oesophageal and transgastric views are useful for inspecting heart valves using 2D, colour flow Doppler,3D, and spectral Doppler. TR is common and dynamic post-cardiopulmonary bypass, depending on RV preload, afterload,and contractility. Early accurate evaluation of TR is important,as some patients may require tricuspid valve repair. It is advis-able to diagnose early also transient mild MR due to papillary oedema.55

Transoesophageal echocardiography is essential for evaluating the anastomotic sites of the great vessels, ascending aorta, main PA, and inferior and superior vena cava. PA anastomotic stenosis is common immediately post-HT due to various causes like ves-sel size mismatch, suture constriction, torsion, or kinking.56 Nor-mal PA Doppler velocity is<1m/s, and normal ascending aorta Doppler velocity is<1.4m/s.50

Transoesophageal echocardiography plays a critical role in diag-nosing early complications that can threaten immediate survival post-HT. In cases of haemodynamic instability, TOE helps exclude hyperacute rejection, cardiac tamponade, primary graft dysfunc-tion(PGD), and elevated pulmonary vascular resistance.55 Early detection and management of these complications can significantly improve patient outcomes.

Postoperative complications

Pericardial effusion can present with a delay due to the large peri-cardium cavity resulting from replacing a dilated heart with a nor-mal sized graft. Other common complications include arrhythmia and mediastinal bleeding. Pericardial effusion after HT is monitored by echocardiography, and percutaneous or surgical drainage is per-formed if haemodynamic compromise occurs.57

Primary graft dysfunction is the leading cause of mortality imme-diately after HT, with rates up to 40.2% in the first month.58 PGD typically develops within 24h post-surgery without identifiable aetiology, presenting as left, right, or biventricular dysfunction.59 PGD with LV dysfunction is defined by an ejection fraction<40%,RA pressure>15mmHg, pulmonary capillary wedge pressure>20mmHg, and cardiac index<2L/min/m2 for at least 1h. TOE

Imaging in advanced heart failure

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|Parts|Global erosion with after heart transplantation for different time periods after period assessments|● True or long-term in the first blood(1th), especially for other chest tube removal ● A culture rejection ● Acute collograft ● Carpathic collogath ● Cardiocal plathy PH|● TASE NOT reliable in the first blood(1th), especially for other chest tube removal ● LV volumes, EAC, fancy, EAC, fB, end of per pre-100.2 and 20.8% per per per per decision. ● Infunction: DSE, EMB, end of per pre-100.0% per decision. ● Infunction: DSE, EMB, end of per pre-100.0% per decision. ● Infunction: DSE, EMB, end of per pre-100.0% per decision. ● Infunction: DSE, EMB, end of per pre-100.0% per decision. ● Infunction: DSE, EMB, end of per pre-100.0% per decision. ● Infunction: DSE, EMB, end of per pre-100.0% per decision. ● Infunction: DSE, EMB, end of per pre-100.0% per decision. ● Infunction: DSE, EMB, end of per pre-100.0% per decision. ● Infunction: DSE, EMB, end of per pre-100.0% per decision. ● Infunction: DSE, EMB, end of per pre-100.0% per decision. ● Infunction: DSE, EMB, end of per pre-100.0% per decision. ● Infunction: DSE, EMB, end of per pre-100.0% per decision. ● Infunction: DSE, EMB, end of per pre-100.0% per decision. ● Infunction: DSE, EMB, end of per pre-100.0% per decision. ● Infunction: DSE, EMB, end of per pre-100.0% per decision. ● Infunction: DSE, EMB, end of per pre-100.0% per decision. ● Infunction: DSE, EMB, end of per pre-100.0% per decision. ● Infunction: DSE, EMB, end of per pre-100.0% per decision. ● Infunction: DSE, EMB, end of per pre-100.0% per decision. ● Infunction: DSE, EMB, en| |---|---|---|---|

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L.F. Tops et al.

Table 3 Accuracy of non-invasive imaging techniques for rejection and coronary allograft vasculopathy

||Rejection|CAV| |---|---|---| |CMR|+++|++| |CCTA|-|+++| |PET|-|+++| |DSE|-|+| |SPECT|-|++|

CAV,coronary allograft vasculopathy;CCTA,coronary computed tomography angiography; CMR, cardiovascular magnetic resonance; DSE, dobutamine stress echocardiography; PET, positron emission tomography; SPECT, single-photon emission computed tomography.

is crucial for diagnosing suspected PGD, especially when invasive arterial pressure monitoring is unavailable.59

Acute haemodynamic changes after HT primarily affect RV func-tion, necessitating constant RV evaluation during surgery.60-62 The donor right ventricle is vulnerable to periprocedural myocardial strain, ischaemia, cardioplegia, and surgical trauma. Elevated recip-ient pulmonary vascular resistance can cause rapid and potentially irreversible RV failure. Apical systolic and diastolic shortening in the mid-oesophageal 4-chamber view is ideal for evaluating TAPSE and RV FAC.TAPSE values<0.64cm and FAC values<24% are predictive of postoperative nitric oxide use and RV failure.63

Imaging after heart transplantation

While echocardiography is essential, it often needs to be comple-mented with other diagnostic tools such as endomyocardial biopsy,coronary angiography, and CMR55(Figure 4). The roles of echocar-diography vary depending on the time since the HT(Table 2). In the early postoperative phase(2-4 weeks after surgery), echocar-diography evaluates graft function and post-surgical complications.TOE is preferred over TTE until the patient is extubated. Echocar-diograms repeated every 24-72h are necessary to monitor graft

function and detect complications like pericardial effusion.55 In the mid-term phase, routine endomyocardial biopsies are per-formed. Echocardiography evaluates graft function and excludes biopsy-related complications such as pericardial effusion or tam-ponade and TR. Diastolic function may be impaired due to arterial hypertension,steroids, or calcineurin inhibitors. Coronary allograft vasculopathy(CAV) is typically ruled out with coronary angiogra-phy,CT or CMR.55 In the long-term phase, biopsies are no longer routinely performed. Several modalities may allow screening for rejection and CAV(Table 3).

Cardiovascular magnetic resonance-based T1 and T2 mapping provide valuable information about fibrosis and oedema, respec-tively, which correlate with histological findings of rejection.64 Furthermore, late gadolinium enhancement analysis assesses myocardial fibrosis, which is associated with the risk of CAV.65 Myocardial perfusion reserve evaluates microcirculation status,which is often impaired in CAV patients.

Coronary angiography is commonly used to detect CAV, but it has limitations due to the diffuse nature of the disease. Other imag-ing modalities are available(Figure 4 and Table 4). Intravascular ultra-sound allows measuring intima-media thickness,67-69 while optical coherence tomography offers higher resolution, but requires more contrast and lacks established abnormal value thresholds.70 Coro-nary fractional flow reserve and index of myocardial resistance are gaining interest for their ability to assess the coronary microcircu-lation and predict clinical outcomes.71,72 CCTA has a high negative predictive value compared to coronary angiography for detec-tion of coronary stenosis.73,74 PET enables accurate assessments of global and regional myocardial blood flow with lower radiation exposure compared to angiography and single-photon emission CT(SPECT).PET-derived myocardial blood flow measurements have good correlation with invasive measurements and help stratify the risk of major adverse cardiovascular events.75 Due to its low sensi-tivity for CAV, dobutamine stress echocardiography is not typically used as a first-line screening method.76,77 SPECT has moderate diagnostic accuracy, but its limited accuracy for low-grade CAV makes it less suitable for screening.78-80

Table 4 Imaging modalities to diagnose and evaluate coronary allograft vasculopathy

||Coronary angiography|IVUS|OCT|Invasive coronary physiology(FFR/IMR)| |---|---|---|---|---| |Diagnosis of CAV|$+$|$++$|$++$|$+/-$| |Sensitivity to detect CAV|$+$|$++$|$++$|$++$| |Stenosis assessment|$+$|$++$|$++$|$-$| |Intima resolution|$-$|$+$|$++$|$-$| |Penetration/depth|0|$++$|$+$|$-$| |Prognostic information(evidence)|$++$|$++$|$+$|$+$| |Contrast use|$+$|$0^{a}$|$+$|$0^{a}$| |Risk|$+$|$++$|$++$|$++$| |Cost|$+$|$++$|$++$|$++$|

CAV,coronary allograft vasculopathy;FFR,fractional flow reserve;IMR,index of myocardial resistance;IVUS,intravascular ultrasound;OCT,optical coherence tomography.2Requires coronary angiography with contrast to place intracoronary wire.

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

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Table 5 Clinical advice on multimodality imaging in advanced heart failure

1. Clinical advice based on published evidence

● RV dysfunction is common in advanced HF and is a strong predictor of outcome, with several evaluated parameters having prognostic significance.

● For routine transthoracic echocardiographic evaluation of RV function, it is advisable to include quantitative measures(e.g.RV volumes)from standard apical and parasternal images and TR jet estimation by colour Doppler.

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

● Multimodality imaging provides essential information to identify candidates for temporary MCS and optimize device selection and placement.

● In multimodality evaluation, it is advisable to include assessment of LV and RV function, intracardiac thrombi or shunts, and valvular abnormalities, all crucial for MCS device selection and management.

Combining clinical, echocardiographic and invasive haemodynamic information is advisable for monitoring and management in the direct postoperative phase in patients with MCS or after HT.

● Comprehensive echocardiography rapidly confirms or excludes postoperative conditions like tamponade, mechanical complications, and severe valvular lesions.

● The use of multimodality imaging(echocardiography and CT) is advisable when there is a suspicion of LVAD pump thrombosis or twisting/external obstruction of the outflow graft.

● It is advisable to use echocardiography to routinely assess LV unloading in LVAD patients, both in the clinical and outpatient setting.

● CMR is a valuable tool in the assessment of rejection after HT.

3. May be appropriate based on published evidence

● Echocardiographic guided‘ramp test’ may be performed to ensure optimized speed settings of the LVAD.

Intravascular ultrasound and optical coherence tomography may provide critical information to detect coronary allograft vasculopathy.

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

● Daily echocardiographic evaluation is advisable in patients with temporary MCS, including assessment of the potential for weaning.

5. Area of uncertainty

● No single echocardiographic parameter reliably predicts RV failure after LVAD implantation, necessitating further research.

● The role of non-invasive imaging modalities(e.g. SPECT) in the screening for coronary allograft vasculopathy remains to be determined.

CMR,cardiovascular magnetic resonance;CT,computed tomography;HF,heart failure;HT,heart transplantation;LV,left ventricular assist device;MCS,mechanical circulatory support;RV,right ventricular;SPECT,single-photon emission computed tomography;TR,tricuspid regurgitation.

Conclusions

Multimodality imaging has an important role in the evaluation and management of patients who may be eligible for or have undergone MCS or HT(Graphical Abstract and Table 5). For temporary MCS,multimodality imaging, primarily echocardiography, helps patient identification and post-implantation monitoring. Serial examina-tions allow managing complications and guiding the weaning pro-cess. Echocardiography also helps to identify suitable patients for long-term MCS, evaluate preoperative conditions, and monitor postoperative outcomes. After HT imaging is critical from early postoperative monitoring to long-term follow-up. CMR provides detailed evaluation of cardiac structure and function. CCTA and PET are emerging as effective alternatives for assessing CAV.

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, NovoNordisk,CorVia, has received honoraria from Abbott, Bayer,Boehringer Ingelheim, GE Healthcare, Novartis, NovoNordisk, Pfizer,Swixx, Takeda, Viatis, has received support for attending meetings from NovoNordisk and participates on an advisory board of Astra Zeneca, Bayer Bristol Myers Squibb, 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,Ehosense, all paid to the institution, outside of the submitted work.J.D. has received consulting fees from Abbott, Edwards-Lifescience, out-of the submitted work. F.G. has other financial interests for Abbott(full-time employee since April 7, 2025), outside of the submitted work.IM. 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-con,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

12

L.F. Tops et al.

the board of the HFA, outside of the submitted work. B.M. has received consulting fees from Servier, Pizer, Vrastris, Astrena,Zebena, Beller, Boehringer Inlegheim, Vifor Pharma, has received honoraria from Servier, Pfizer, Via-rstra, Enazenza, Bayer, Boehringer Inlegheim, Vifor Pharma, has received support for attending meetings from Boehringer Inlegelheim, outside of the submitted work. The other authors report no conflicts of interest.

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