Search Results (44)

Cardiovascular disease is traditionally interpreted through macrocirculatory parameters such as cardiac output, vascular resistance, and epicardial coronary anatomy. However, clinical outcomes frequently diverge from predictions based solely on these indices, particularly in syndromes such as heart failure with preserved ejection fraction (HFpEF), cardiogenic shock, and sepsis-associated myocardial dysfunction. Increasing evidence suggests that the integrity of the microvascular–immune interface plays a central role in determining tissue perfusion and cardiovascular resilience. This review proposes a staged framework of cardiovascular decompensation centered on progressive failure of this interface. In Stage 1, chronic cardiometabolic and inflammatory stress produces a primed but compensated microvascular state characterized by endothelial activation, glycocalyx vulnerability, pericyte remodeling, platelet sensitization, and reduced lymphatic reserve. Perfusion is preserved at rest, but vasodilatory reserve and microvascular stability are reduced, narrowing the effective perfusion window under physiologic stress. In Stage 2, acute insults such as infection, ischemia, or neurohumoral activation precipitate threshold instability within the microcirculation. Perfusion becomes governed by the arterial pressure–critical closing pressure (Pa − Pcrit) relationship rather than traditional arterial–venous gradients. As this window narrows, segmental capillary derecruitment and heterogeneous flow emerge, producing loss of hemodynamic coherence in which systemic blood pressure and cardiac output may appear preserved despite impaired tissue perfusion. In Stage 3, inflammatory amplification and immunothrombotic processes consolidate microvascular dysfunction. Pericyte contraction, endothelial injury, cytokine escalation, and neutrophil extracellular trap formation promote platelet–fibrin deposition and capillary obstruction, transforming reversible conductance failure into structural microvascular impairment. This framework provides a unifying physiologic lens for diverse cardiovascular syndromes, including Type 2 myocardial infarction, HFpEF decompensation, and cardiogenic shock. It also suggests that therapeutic efficacy may depend less on macrocirculatory normalization alone and more on preserving microvascular integrity before immunothrombotic consolidation occurs. Although this model remains hypothesis-generating, it highlights the microvascular–immune interface as a central determinant of cardiovascular stability and a potential target for future precision hemodynamic and immunomodulatory strategies. Full article

Angina or objective myocardial ischaemia in the absence of obstructive coronary artery disease, referred to as ANOCA/INOCA, represents a prevalent and clinically significant condition associated with persistent symptoms, impaired quality of life, and increased healthcare utilisation. Contemporary evidence has reframed these syndromes as manifestations of coronary vascular dysfunction, encompassing structural and functional coronary microvascular dysfunction, epicardial vasospasm, microvascular spasm, and mixed phenotypes. In this context, multimodality imaging should not be conceptualised as sequential test accumulation, but rather as a structured, mechanism-based diagnostic strategy aimed at defining the underlying coronary endotype. The 2024 ESC Guidelines for chronic coronary syndromes endorse dedicated diagnostic pathways beyond a stenosis-centred paradigm and support the use of invasive coronary function testing (ICFT) in selected patients with persistent symptoms or inconclusive non-invasive findings. An integrated approach combining anatomical assessment (coronary computed tomography angiography or invasive angiography ± pressure-based indices), quantitative perfusion imaging (positron emission tomography or stress cardiovascular magnetic resonance), and ICFT (including coronary flow reserve, microvascular resistance indices, and acetylcholine provocation testing) enables comprehensive characterisation of coronary physiology and vasomotor function. This review proposes a pragmatic framework linking diagnostic findings to targeted therapy through a test-to-endotype-to-therapy paradigm. We summarise the strengths and limitations of each modality, discuss implementation challenges, and highlight the clinical relevance of endotype-driven management. By shifting from a stenosis-centred to a physiology- and mechanism-based approach, this strategy has the potential to close the longstanding gap between diagnosis and treatment in patients with ischaemia beyond obstructive coronary disease. Full article

Cardiac positron emission tomography (PET) has undergone substantial development in recent years, moving beyond conventional perfusion imaging toward a multiparametric and increasingly quantitative assessment of cardiovascular disease. This article provides a critical narrative overview of the recent cardiac PET literature, with particular emphasis on studies published over the last five years, and discusses both established tracers and emerging radiopharmaceuticals in contemporary cardiology. Among established applications, 18F-FDG remains relevant for myocardial viability assessment and selected inflammatory indications, although its prognostic and therapeutic implications are less uniform than earlier narratives suggested. For myocardial perfusion imaging, 13N-ammonia and 82Rb PET provide robust assessment of myocardial blood flow and myocardial flow reserve, but their clinical interpretation remains strongly influenced by acquisition protocols, software reproducibility, and methodological standardization. The review also addresses newer tracers, including 68Ga-FAPI for fibroblast activation, 18F-flurpiridaz for high-performance perfusion imaging, 18F-FDOPA for cardiac sympathetic dysfunction, and amyloid-binding PET radiopharmaceuticals for cardiac amyloidosis. Overall, recent evidence supports cardiac PET as a powerful platform for physiologic and molecular imaging, but not as a uniform or methodologically neutral technology. Its current value lies in selective, question-driven clinical use, whereas broader implementation will depend on tracer-specific validation, harmonized quantitative workflows, and clear demonstration of incremental benefit over existing imaging strategies. Full article

Background: This narrative review introduces the “From Plaque to Perfusion” framework, a clinically pragmatic approach that maps multimodality imaging technologies to critical decision points in the acute coronary syndrome (ACS) patient journey. By integrating non-invasive assessment, invasive procedural guidance, and post-event tissue characterisation, this framework provides a structured pathway for deep phenotyping of ACS. Artificial intelligence (AI) is highlighted as an essential enabling layer that enhances diagnostic precision, automates quantification, and supports scalable, data-driven care. Contemporary ACS management pathways, while effective, often leave residual clinical uncertainty. The diagnostic objective has evolved beyond confirming myocardial injury to comprehensively phenotyping the entire ACS cascade: defining the plaque substrate, identifying the culprit mechanism, and quantifying the myocardial consequence. This requires a systematic integration of advanced imaging modalities. Methods: This narrative review is based on a comprehensive literature search of major medical databases (PubMed/MEDLINE, Scopus, Embase, Google Scholar) for high-level evidence, including randomized controlled trials, meta-analyses, and international expert consensus documents published between January 2010 and February 2026. Results: The “From Plaque to Perfusion” framework consists of three core stages. First, non-invasive assessment with coronary computed tomography angiography (CCTA), fractional flow reserve (FFR-CT), and PET-CT defines plaque substrate and vascular inflammation. Second, invasive precision in the catheterization laboratory, guided by optical coherence tomography (OCT) and intravascular ultrasound (IVUS), resolves the culprit mechanism and optimizes percutaneous coronary intervention (PCI). Third, post-event tissue characterization with cardiac magnetic resonance (CMR) quantifies myocardial injury and refines prognosis. AI-driven platforms are shown to enhance each stage by automating analysis, standardizing interpretation, and providing actionable metrics for clinical decisions, including complex scenarios like Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA). Conclusions: The “From Plaque to Perfusion” framework, enabled by AI, reframes ACS imaging as an integrated, mechanism-driven pathway. This approach moves beyond isolated test interpretation toward a scalable model of precision, phenotype-led care that promises to improve diagnostic certainty and personalize patient management. Full article

Background: The prevalence of chronic total occlusion (CTO) lesions is as high as 30% in patients undergoing coronary angiography (CAG). Some CTO patients do not undergo revascularization due to procedural complexity and high risks. This study aimed to investigate the value of cadmium-zinc-telluride (CZT) SPECT dynamic myocardial perfusion imaging (MPI) for risk stratification and prognosis assessment in patients with coronary CTO. Methods: This study retrospectively included 62 patients who underwent CZT SPECT dynamic MPI examination and were diagnosed with CTO by angiography. The primary endpoint was major adverse cardiovascular events (MACEs), defined as cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, hospitalization for heart failure, late coronary revascularization, or hospitalization for unstable angina. Results: Over a median follow-up of 17 months (IQR 11–23), 15 MACEs occurred. The stress myocardial blood flow (sMBF) and coronary flow reserve (CFR) in the CTO territory were significantly lower in the MACEs group compared to the non-MACEs group (all p < 0.05). Receiver operating characteristic analysis determined the optimal cut-off values for predicting MACEs as sMBF < 0.75 (sensitivity 78.7%, specificity 73.3%, AUC = 0.74, p < 0.05) and CFR < 1.39 (sensitivity 70.2%, specificity 80.0%, AUC = 0.75, p < 0.01). Kaplan–Meier survival analysis showed that patients with impaired sMBF (p < 0.001) or impaired CFR (p < 0.01), defined by these cut-off values, had significantly worse clinical outcomes. Conclusions: The results of this study indicate that sMBF and CFR obtained from CZT SPECT dynamic MPI provide valuable prognostic prediction for patients with coronary CTO lesions, offering critical evidence for identifying high-risk patients requiring active intervention. Full article

Background: Motion is a long-standing problem in cardiac PET/CT. An automated data-driven motion correction (DDMC) algorithm for within-reconstruction motion correction (MC) has been developed and validated in static images from [¹³N]NH₃ and ⁸²Rb PET/CT. This study aims to validate DDMC in dynamic [¹³N]NH₃ PET/CT, and to explore the added value of DDMC in the evaluation of myocardial motion. Methods: Thirty-six PET/CT studies from normal patients and forty-three scans from patients with myocardial ischemia were processed using QPET software without MC (NMC), using manual in-software MC (ISMC), and DDMC. Differences in the mean values of rest-, stress-MBF, and CFR; and differences in effect size related to the use and type of MC method were explored. Moreover, motion vectors provided by DDMC were analyzed to evaluate differences in myocardial motion between scan phases and axes, and to elucidate changes in MBF quantification in relation to the motion extent. Results: In both subgroups, repeated measures ANOVA showed that the use of MC significantly increased regional and global stress-MBF and CFR values (p < 0.05), regardless of the MC method. Paired t-test analysis demonstrated a comparable ES between MC tools, despite minor differences in Cx, RCA and global rest-MBF values. High-intensity motion (>6 mm) proved to be present almost exclusively in the Z (cranio-caudal) direction. In the same axis, motion was significantly higher during stress than rest, regardless of patients’ subgroup. Finally, the Jonckheere trend test showed a significant trend caused by motion in s-MBF values, in which lower stress-MBF values were observed in response to motion extent increments. Conclusions: DDMC is feasible to perform in [¹³N]NH₃ dynamic acquisitions and provides similar MBF/CFR values than manual ISMC. The use of DDMC reduces post-processing times and observer variability, and allows a more extensive evaluation of motion. MC is highly recommended when using QPET, as motion in the Z-axis during stress scans negatively impacts stress-MBF quantification. Full article

Non-obstructive coronary artery disease (NOCAD) encompasses a heterogeneous group of conditions in which patients present with angina, ischemia or myocardial infarction despite the absence of obstructive epicardial stenoses. This spectrum includes myocardial infarction with non-obstructive coronary arteries (MINOCA) and angina or ischemia with non-obstructive coronary arteries (ANOCA/INOCA), entities increasingly recognized as clinically significant and associated with adverse outcomes. Advances in cardiac computed tomography (CT) have expanded the diagnostic capabilities beyond the exclusion of obstructive coronary artery disease, enabling comprehensive anatomical, functional and tissue-level assessment relevant to NOCAD. CT allows precise identification of non-obstructive atherosclerosis, high-risk plaque features, myocardial bridging and structural vascular remodelling. Quantitative and qualitative characterization of plaque burden correlates with ischemic risk and provides prognostic information that complements traditional stenosis-based evaluation. Emerging CT-derived biomarkers, such as pericoronary fat attenuation index and epicardial adipose tissue metrics, offer insight into vascular inflammation and microvascular dysfunction, key mechanisms in NOCAD. Functional CT techniques, such as CT-derived fractional flow reserve and CT perfusion imaging, enable non-invasive assessment of hemodynamic significance and microvascular impairment, although their routine use is limited by methodological variability and evolving clinical evidence. Beyond coronary evaluation, CT also provides myocardial tissue characterization, detects extracardiac causes of symptoms and contributes to comprehensive differential diagnosis. Despite its strengths, cardiac CT remains limited by spatial resolution, radiation exposure and its inability to directly visualize the microcirculation. Nevertheless, ongoing technological refinement and integration of computational modelling are likely to enhance its diagnostic and prognostic role. Full article

Coronary artery bypass grafting (CABG) remains a cornerstone of treatment for patients with advanced or complex coronary artery disease, yet long-term success is influenced by graft patency, progression of native disease, and ventricular remodeling. Optimizing the follow-up of these patients requires a structured approach in which multimodality cardiovascular imaging plays a central role. Echocardiography remains the first-line modality, providing readily available assessment of ventricular function, valvular competence, and wall motion, while advanced techniques, such as strain imaging and myocardial work, enhance sensitivity for subclinical dysfunction. Coronary computed tomography angiography (CCTA) offers excellent diagnostic accuracy for graft patency and native coronary anatomy, with emerging applications of CT perfusion and fractional flow reserve derived from CT (FFR-CT) expanding its ability to assess lesion-specific ischemia. Cardiovascular magnetic resonance (CMR) provides comprehensive tissue characterization, quantifying scar burden, viability, and inducible ischemia, and stress CMR protocols have demonstrated both safety and independent prognostic value in post-CABG cohorts. Nuclear imaging with single-photon emission computed tomography (SPECT) and positron emission tomography (PET) remains essential for quantifying perfusion, viability, and absolute myocardial blood flow, with hybrid PET/CT approaches offering further refinement in patients with recurrent symptoms. In patients after CABG, multimodality imaging is tailored to the patient’s characteristics, symptoms, and pre-test probability of disease progression. In asymptomatic patients, imaging focuses on surveillance, risk stratification, and the early detection of subclinical abnormalities, whereas in symptomatic individuals, it focuses on establishing the diagnosis, defining prognosis, and guiding therapeutic interventions. Therefore, the aim of our review is to propose updated and comprehensive guidance on the crucial role of multimodality cardiovascular imaging in the evaluation and management of post-CABG patients and to provide a practical, evidence-based framework for optimizing outcomes. Full article

Multimodal imaging plays a central role in optimizing the evaluation and management of myocardial ischemia by leveraging the complementary strengths of echocardiography, cardiac magnetic resonance imaging (CMR), single photon emission computed tomography (SPECT), positron emission tomography (PET), and invasive coronary angiography (ICA). Noninvasive functional imaging is typically recommended for patients with intermediate to high pre-test probability of coronary artery disease, while coronary computed tomography angiography (CCTA) is preferred for low to intermediate risk. Stress echocardiography is valuable for detecting wall motion abnormalities and is particularly effective in multivessel or left main disease, where perfusion techniques may miss balanced ischemia. CMR offers high spatial resolution and quantitative assessment of myocardial blood flow (MBF), while SPECT and PET quantify ischemic burden, with PET providing superior accuracy for MBF and microvascular disease. ICA remains the gold standard for defining the presence, location, and severity of epicardial coronary stenosis. It is indicated when noninvasive imaging reveals high-risk features, when symptoms are refractory to medical therapy, or when noninvasive results are inconclusive. While ICA offers high spatial resolution, it alone cannot assess the hemodynamic significance of intermediate lesions, nor the coronary microvasculature. Adjunctive invasive hemodynamic and provocative coronary testing (e.g., Fractional Flow Reserve—FFR, invasive Coronary Flow Reserve—CFR, Index of Microcirculatory Resistance—IMR, acetylcholine test) provide essential insights, especially in ischemia with nonobstructive coronary arteries. Given its procedural risks, ICA should be reserved for cases where it will impact management. Intravascular imaging may be used to further characterize lesions. In summary, modality selection should be individualized based on patient characteristics, comorbidities, contraindications, and the need for anatomical versus physiological data. Integrating noninvasive and invasive modalities provides a comprehensive, patient-centered approach to ischemia evaluation. Full article

Cardiac computed tomography (CT) has long evolved as a highly accurate screening tool for coronary artery disease. New technologies such as multi-detector rows and artifact reduction by a new motion correction algorithm have made it possible to evaluate coronary artery stenosis with higher diagnostic accuracy and lower radiation exposure. In addition to the anatomical evaluation of coronary arteries, the introduction of fluid dynamic analysis enables the measurement of coronary fractional flow reserve (FFR) for each stenotic lesion, which can only be achieved through invasive catheter evaluation. Myocardial ischemia can now also be detected using myocardial stress perfusion CT imaging. In addition, with the advent of dual-energy imaging or new image reconstruction technology, the addition of late contrast phase imaging enables myocardial late enhancement and left ventricular (LV) extracellular volume (ECV) analysis, which was previously possible only with cardiac magnetic resonance imaging (MRI). It has also been reported that LV ECV may be useful in predicting prognosis in cases with cardiomyopathies. In addition, retrospective imaging of the entire heart in a single cardiac cycle is now possible with lower radiation exposure, enabling not only morphological evaluation of the heart and valves but also myocardial strain analysis, which has conventionally been evaluated mainly by echocardiography and is expected to be applied in clinical practice in the future. Cardiac CT, which overcomes the weaknesses of other modalities while demonstrating greater usefulness through the latest technological development, is expected to expand its field of application to the entire heart analysis. The purpose of this review is to provide an overview of the technological development of cardiac CT, which has seen remarkable development in recent years, along with its clinical utility, with the aim of enabling clinicians to fully utilize it in daily practice. Full article

Background/Objectives: Despite growing evidence on quantitative computed tomography (CT) analysis of coronary plaques and pericoronary adipose tissue (PCAT), their association with myocardial perfusion (MP) in patients with first acute myocardial infarction (AMI) with obstructive coronary artery disease (MICAD) and non-obstructive coronary arteries (MINOCA) remain unclear. The aim of this study was to assess the relationship between quantitative CT coronary plaque components and PCAT characteristics with MP, myocardial blood flow (MBF) and coronary flow reserve (CFR) obtained by dynamic single-photon emission computed tomography (SPECT) in patients with AMI. Methods: Patients with a first episode of AMI were included in the study. All patients underwent coronary CT angiography with quantitative assessment of plaque volume (PV) and burden (PB), as well as PCAT volume and attenuation. Dynamic SPECT was performed on cadmium–zinc–telluride gamma-camera for quantitative assessment of MP parameters, stress and rest MBF, and CFR. Results: A total of 31 patients (median age 62 [56–70] years) were analyzed, including MICAD (n = 21) and MINOCA (n = 10). MICAD patients had significantly higher total PV and PB, mainly due to non-calcified and fibrofatty components (p < 0.05), while low-attenuation (LAP) and calcified plaques (CP) did not differ between groups. PCAT volumes were higher in MICAD (p < 0.05), whereas PCAT attenuation showed no differences. Dynamic SPECT revealed lower stress MBF and CFR in MICAD (p < 0.05). Correlation analysis showed positive associations of PV and PB with MP summed stress and rest scores, except LAP or CP; PB was negatively associated with MBF. In addition, PCAT volume correlated negatively with stress and rest MBF and CFR, as well as PCAT attenuation correlated positively with stress-induced MP abnormalities. Conclusions: Patients with MICAD demonstrated a greater extent of atherosclerosis and larger PCAT volume compared with MINOCA. Moreover, PCAT volume demonstrated inverse associations with MBF and CFR, indicating a potential link between PCAT characteristics and microvascular dysfunction. Full article

Purpose: While peak oxygen uptake ($\stackrel{.}{\mathrm{V}}$O_2peak) is the gold standard method for assessing exercise tolerance, there is a tendency for underestimation. Several other cardiopulmonary exercise testing (CPET) variables may provide additive prognostic value beyond $\stackrel{.}{\mathrm{V}}$O_2peak alone. The aim of this study was to examine if alternative CPET indices of exercise tolerance are (a) impaired in people with T2D and (b) independently associated with measures of cardiovascular structure and function measured via echocardiography and cardiac MRI. Methods: Participants with type 2 diabetes (T2D) and healthy controls underwent cardiac magnetic resonance imaging, transthoracic echocardiography, and a CPET. Multiple linear regression was used to determine the relationship between indices of exercise tolerance and markers of cardiovascular structure and function. Results: A total of 84 people with T2D and 36 healthy volunteers were included in the analysis. All CPET outcomes were worse in those with T2D vs. the controls. Three CPET outcomes were associated with markers of cardiovascular structure and function: $\stackrel{.}{\mathrm{V}}$O₂ recovery with mean aortic distensibility (β = 0.218, p = 0.049); heart rate recovery with early filling velocity on transmitral Doppler/early relaxation velocity (β = −0.270, p = 0.024), left ventricular mass/volume ratio (β = −0.248, p = 0.030) and mean aortic distensibility (β = 0.222, p = 0.029); and $\stackrel{.}{\mathrm{V}}$O₂ at the ventilatory threshold with myocardial perfusion reserve (β = 0.273, p = 0.018). Perspective: These lesser-used CPET indices could be used to identify which people with T2D are at elevated risk of progression to symptomatic heart failure. However, larger longitudinal studies are required to confirm these findings and their potential clinical application. Full article

Background/Objectives: To validate an artificial intelligence-based arterial input function (AI-AIF) deep learning model for myocardial blood flow (MBF) quantification during stress perfusion and assess its extension to rest perfusion, enabling myocardial perfusion reserve (MPR) calculation. Methods: Sixty patients with or at risk for vascular cognitive impairment, prospectively enrolled in the CRUCIAL consortium, underwent quantitative stress and rest myocardial perfusion imaging using a 3 T MRI system. Perfusion imaging was performed using a dual-sequence (DS) protocol after intravenous administration of 0.05 mmol/kg gadobutrol. Retrospectively, the AI-AIF was estimated from standard perfusion images using a 1-D U-Net model trained to predict an unsaturated AIF from a saturated input. MBF was quantified using Fermi function-constrained deconvolution with motion compensation. MPR was calculated as the stress-to-rest MBF ratio. MBF and MPR estimates from both AIF methods were compared using Bland–Altman analyses. Results: Complete stress and rest perfusion datasets were available for 31 patients. A bias of −0.07 mL/g/min was observed between AI-AIF and DS-AIF for stress MBF (median 2.19 vs. 2.30 mL/g/min), with concordant coronary artery disease classification based on the optimal MBF threshold in over 92% of myocardial segments and coronary arteries. Larger biases of 0.12 mL/g/min and −0.30 were observed for rest MBF (1.12 vs. 1.02 mL/g/min) and MPR (2.31 vs. 1.84), respectively, with lower concordance using the optimal MPR threshold (85% of segments, 72% of arteries). Conclusions: The AI-AIF model showed comparable performance to DS-AIF for stress MBF quantification but requires further training for accurate rest MBF and MPR assessment. Full article

(1) Background: Our aim was to evaluate the diagnostic performance of combined coronary computed tomography angiography (CCTA) and dynamic CT myocardial perfusion imaging (CT-MPI) for detecting hemodynamically significant coronary artery disease (CAD) in patients with intermediate pretest probability. (2) Methods: Patients with an intermediate pretest probability of CAD were retrospectively enrolled. All patients underwent CCTA and dynamic CT-MPI using a third-generation dual-source CT scanner prior to invasive coronary angiography (ICA). Anatomically significant stenosis was defined as ≥50% luminal narrowing on both CCTA and ICA. Fractional flow reserve (FFR) was performed during ICA in selected cases. Hemodynamically significant CAD was defined per vessel as FFR ≤ 0.80, angiographic stenosis ≥70%, or having undergone revascularization. The diagnostic performance of CCTA alone and CCTA combined with CT-MPI was compared against this reference standard. (3) Results: Seventy-four patients (mean age, 66.8 ± 11.1 years; 59 men) were included. The median coronary calcium score was 508.5 Agatston units (interquartile range: 147–1173). ICA and CCTA detected anatomically significant stenoses in 137 (61.7%) and 146 (65.8%) coronary vessels, respectively, and in 62 (83.8%) and 71 (95.9%) patients, respectively. Hemodynamically significant stenosis was present in 56 patients (76%) and 99 vessels (45%). On a per-vessel basis, CCTA alone yielded a sensitivity of 96.7%, specificity of 60.3%, positive predictive value (PPV) of 64.4%, and negative predictive value (NPV) of 96.1%. Combined CCTA and CT-MPI demonstrated a sensitivity of 90.1%, specificity of 84.3%, PPV of 82.7%, and NPV of 91.1%. The area under the receiver operating characteristic curve improved from 0.787 (95% confidence interval: 0.73–0.84) for CCTA to 0.872 (95% confidence interval: 0.82–0.91) for the combined approach (p < 0.05). The median total radiation dose for both CCTA and CT-MPI was 8.05 mSv (interquartile range: 6.71–11.0). (4) Conclusions: In patients with intermediate pretest probability of CAD, combining CCTA with dynamic CT-MPI significantly enhances the diagnostic performance for identifying hemodynamically significant coronary stenosis compared to CCTA alone. Full article

Cardiac allograft vasculopathy (CAV) is a leading cause of allograft dysfunction and failure. CAV prevention, early detection, and management are essential to increasing allograft survival. In this comprehensive review, we discuss various invasive and non-invasive modalities that are being utilized for CAV detection. Invasive coronary angiography provides a visualization of vascular anatomy but is limited in detecting the microvasculature and diffuse and early structural changes. The addition of intracoronary assessment techniques, including intravascular ultrasound, optical coherence tomography, and coronary flow reserve assessment, offer(s) superior sensitivity in identifying CAV. Non-invasive imaging modalities, such as cardiac magnetic resonance imaging, computed tomography angiography, and positron emission tomography, provide complementary insights into CAV with myocardial perfusion and allograft function while reducing procedural risks. Our aim is to guide clinicians in selecting appropriate imaging strategies tailored to individual recipients, to improve detection, monitoring, and outcomes in CAV. Full article