Myocardial infarction with nonobstructive coronary arteries (MINOCA) refers to a clinical syndrome where a patient meets the criteria for acute MI, but coronary angiography shows no obstructive coronary artery disease. MINOCA accounts for 6% to 8% of all myocardial infarctions and is more common in non-ST-elevation MI than ST-elevation MI. Up to 60% of cases of MINOCA are seen in women, which disproportionately affects younger and middle-aged women. Patients are typically younger than those with obstructive MI and have fewer traditional risk factors. Formal recognition aids the development of targeted research, standardized care, and improved outcomes.

Mitral regurgitation (MR) is a common valvular pathology and is widely known to cause morbidity and mortality. Quantification of MR severity is critical for determining surveillance strategies and to guide timing of procedural intervention. There are numerous ways to quantify regurgitant volume, each with their own strengths and weaknesses. In this article, we review multimodality imaging of the mitral valve and explore the most common and widely used imaging modalities and methods to evaluate MR severity.

Thoracic aortic disease involves diverse degenerative, syndromic, and genetic conditions, posing lifelong risks of high morbidity and mortality. Early detection and multimodal imaging are crucial for effective surveillance and reducing complications. Understanding imaging characteristics and disease-specific features enables personalized management strategies. Emerging research on parameters like aortic length and indexed ratios promises to refine risk assessment and surgical timing beyond traditional size criteria. However, data gaps remain for heterogeneous groups such as hereditary thoracic aortopathies and vascular Ehlers-Danlos syndrome. As medicine advances toward personalized care, a comprehensive framework for multimodal imaging is essential for optimal patient outcomes.

Multimodality imaging plays a critical role in the evaluation of prosthetic valve function. Although echocardiography-both transthoracic and transesophageal-remains the first-line diagnostic tool, complementary imaging modalities such as cardiac computed tomography, cardiac MRI, and PET provide valuable additional information. Accurate assessment of prosthetic valve dysfunction often requires an integrative imaging approach owing to the complexity of structural and functional abnormalities. This article outlines the strengths and limitations of each imaging modality and presents illustrative clinical cases that demonstrate the necessity of a multimodal strategy in diagnosing and managing prosthetic valve complications.

Tricuspid regurgitation is a relatively common and progressive valvular heart disease that significantly affects quality of life and is associated with high mortalities as severity increases. Multimodality imaging is crucial for diagnosis, detailed assessment of the right heart and tricuspid valve, and selecting the most appropriate treatment strategy. This article reviews currently used imaging modalities-echocardiography, cardiac magnetic resonance, and cardiac computed tomography-and their applicability in clinical practice.

Cardiomyopathies and heart failure (HF) represent a diverse group of cardiac conditions that significantly impact global health. The increasing complexity of these disorders demands more precise tools for diagnosis, risk assessment, and treatment guidance. Over the past decade, multimodality imaging has become a cornerstone in the evaluation of cardiomyopathies, offering distinct advantages in structural, functional, and tissue-level assessment that surpass any single imaging technique. Here, we provide a contemporary review of the role of echocardiography, cardiac magnetic resonance, cardiac computed tomography, nulceare imaging and artificial intelligence applications in cardiomyopathy and HF.

Inflammatory cardiomyopathies encompass a heterogeneous spectrum of disorders characterized by myocardial inflammation, including but not limited to myocarditis-which may be infectious, autoimmune, or drug/toxin-induced-cardiac sarcoidosis, and cardiac transplant rejection. Despite advances in diagnosis and management, these conditions remain a significant cause of left ventricular dysfunction, heart failure, arrhythmias, and cardiovascular mortality worldwide. Diagnosis is often challenging due to their patchy myocardial involvement and diverse clinical presentations. In this article, we will explore the current role of multimodality imaging in the evaluation of inflammatory cardiomyopathies- with a focus on myocarditis, identify existing knowledge gaps, and highlight future directions.

The diagnosis and management of hypertrophic cardiomyopathy (HCM) requires accurate and comprehensive imaging. Advances in imaging technology and clinical understanding have significantly enhanced the ability to characterize the phenotype, assess risk, monitor disease progression, and guide therapy. This article highlights the complementary roles of echocardiography, cardiac magnetic resonance, computed tomography, and nuclear imaging in the evaluation of HCM and explores emerging research and innovation that are shaping future diagnostic and therapeutic strategies.

Pericardial disorders are a significant subset of common cardiac conditions with notable morbidity and mortality. Advances in treatment, particularly for pericarditis, have heightened interest in diagnosis and management of these disorders. Multimodality imaging consisting of echocardiography, cardiac magnetic resonance (CMR), and cardiac computed tomography (CCT) plays a pivotal role in the assessment of these pericardial disorders. Echocardiography offers real-time functional evaluation while CMR provides more detailed tissue characterization, and CCT excels in identifying calcification and delineating anatomy. Together, these imaging techniques enable accurate diagnosis, guide management, and inform treatment strategies highlighting the value of comprehensive imaging approach in pericardial pathology.

Transthoracic echocardiography (TTE) plays the primary role in the assessment of patients with aortic stenosis (AS). Alternative imaging modalities are important for the confirmation of AS severity in patients with discordant AS or inadequate assessment by TTE. Multimodality imaging can inform prognosis in patients with AS. In this article, we discuss the role of multimodality imaging for accurate diagnosis of AS severity and assessment of prognosis to inform patient management. We provide an overview of the use of computed tomography for procedural planning for transcatheter aortic valve replacement.

Transvenous lead failure associated with cardiac pacing and defibrillation remains an important clinical problem, with an estimated incidence between 1 to 2%. Oversensing of non-physiological signals usually precede lead impedance changes and may result in clinical compliations such as pacing inhibition and inappropriate shocks. Device based algorithms that identify non-physiological signals can be used in conjunction with remote monitoring to facilitate early diagnosis and management of lead failure and avoid serious adverse outcomes. This review highlights mechanisms of lead failure and proposes a diagnostic approach to suspected lead failure.

Cardiac implantable electronic device (CIED) infections are a highly morbid and potentially fatal complication of CIED implantation. Prompt diagnosis is paramount to the proper management of such infections. This review seeks to highlight the pathophysiology, risk factors, diagnostic approach, and prevention strategies for CIED infection, with an emphasis on pocket infection. Management will be discussed in detail, with complete device removal representing the standard of case, but with conservative management representing a potential alternative for patients at high risk for extraction. The high prevalence of CIED in the cardiac population renders understanding of this subject essential for the practicing clinician.

The approach to a patient with a cardiac implantable electronic device (CIED) and bacteremia requires a high index of suspicion. The microorganism and duration of bacteremia affect the pretest probability of CIED infection. When transesophageal echocardiography findings are equivocal, fluorodeoxyglucose-PET/computed tomography can increase the sensitivity and specificity for CIED infection. Confirmed CIED infection warrants complete system extraction. In patients with persistent gram-positive bacteremia despite antimicrobial therapy and unclear involvement of the CIED, the device is sometimes empirically extracted. Long-term effects of extraction (such as risk of suboptimal/failed cardiac resynchronization therapy reimplant) should be factored into decisions regarding empiric CIED extraction.

Cardiac implantable electronic devices (CIEDs) are being implanted at increasing rates. Patients with CIEDs require more lead management in contemporary clinical practice, given the increased survival of heart failure patients. There are multiple indications for extraction with the strongest class I indications being in patients with CIED infections. Extraction with complete hardware removal is underutilized and often delayed when it is utilized in patients with CIED infections, resulting in higher mortality. Patient and provider preferences are critical to decision-making when considering extraction. Lead extraction referral and management care pathways are needed in order to optimize care for our patients with CIEDs.

Transvenous lead extraction (TLE) has evolved significantly since the introduction of cardiac pacing systems in the 1950s. The need for TLE has grown due to the increasing complexity of cardiac devices and patients, alongside rising infection rates and regulatory recalls. Despite its challenges, improved institutional support and advanced training programs have made TLE more accessible. Modern TLE indications are well-defined, evolving through scientific statements to include comprehensive lead management best practices and safety protocols. However, underutilization persists, particularly in infection management, highlighting the need for continued education and adherence to guidelines.

With increasing volume of cardiac implantable electronic devices in the last decade, the indications for device extraction have increased. Multidisciplinary collaboration between cardiothoracic surgeons, cardiac anesthesiologists, and cardiac electrophysiologists has been recognized as an essential pre-requisite in pre-procedural planning to limit complications from this inherently risky procedure. Fortunately, the tools and techniques have continued to evolve to make extraction safer and more effective. This article discusses traditional and non-traditional techniques for transvenous lead extraction in addition to retrieval of leadless pacemakers.

Transvenous lead extraction is performed for device infection, lead failure, or to provide access for additional leads/device upgrade. A patient-centered risk assessment for transvenous lead extraction can be determined using a combination of clinical factors and several imaging modalities. Predicting a complex lead extraction, for example, one that will require powered tools or the use of a femoral approach, is aided by pre-procedural imaging and clinical assessment. Procedural imaging utilizing fluoroscopy, transesophageal echocardiography, and intracardiac echocardiography during an extraction can improve safety and identify complications rapidly.

Cardiac implantable electronic devices (CIEDs) can be lifesaving but complications associated with CIEDs can lead to significant morbidity and mortality. Effective techniques to remove these devices are critical to reducing complications and improving quality of life. Percutaneous extraction techniques are effective for removing the majority of CIEDs but surgical lead extraction is still required in certain situations. Surgical lead extraction volumes are generally low at most centers but familiarity with the techniques and principles is important for maintaining a comprehensive lead management program. This review discusses indications and techniques for surgical lead extraction and considerations for device reimplantation.

In this article, the authors review the approach to infections associated with surgically placed leads, leads placed in unusual locations such as azygous veins, extraction of active fixation coronary sinus leads, and the role of hybrid extractions in difficult cases. The authors also review strategies to mitigate the risk of paradoxic embolism among patients undergoing transvenous lead extraction.