Infective endocarditis (IE) is a life-threatening condition with a rising incidence, demanding rapid and precise diagnosis. While echocardiography remains the cornerstone of initial evaluation, its limitations in complex cases—such as those involving prosthetic valves or cardiac devices—are well-known. This review synthesizes current evidence and guidelines to outline a practical, multimodality imaging approach for IE. We emphasize that integrating advanced techniques like cardiac computed tomography (CT) and [18F]-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) early in the diagnostic pathway, particularly in high-risk scenarios, significantly enhances diagnostic certainty, guides therapeutic decisions, and improves patient outcomes. A tailored imaging strategy, driven by clinical presentation and integrated within a multidisciplinary endocarditis team, is paramount for modern IE management.

Mitral regurgitation (MR) is a broadly diffuse valvular heart disease (VHD) with a significant impact on the healthcare system and patient prognosis. Transcatheter mitral valve interventions (TMVI) are now well-established techniques included in the therapeutic armamentarium for managing patients with mitral regurgitation, either primary or functional MR. Even if the guidelines give indications regarding the correct management of this VHD, the wide heterogeneity of patients’ clinical backgrounds and valvular and heart anatomies make each patient a unique case, in which the appropriate device’s selection requires a multimodal imaging evaluation and a multidisciplinary discussion. Proper pre-procedural evaluation plays a pivotal role in judging the feasibility of TMVI, while a cooperative work between imagers and interventionalist is also crucial for procedural success. This manuscript aims to provide an exhaustive overview of the main parameters that need to be evaluated for appropriate device selection, pre-procedural planning, intra-procedural guidance and post-operative assessment in the setting of TMVI. In addition, it tries to give some insights about future perspectives for structural cardiovascular imaging.

Mitral regurgitation (MR) is a broadly diffuse valvular heart disease (VHD) with a significant impact on healthcare system and patient’s prognosis. Transcatheter mitral valve interventions (TMVI) are now well-established techniques included in the therapeutic armamentarium for managing patients with mitral regurgitation, either primary or functional MR. Even if guidelines give indications regarding the correct management of this VHD, the wide heterogeneity of patient’s clinical background, valvular and heart’s anatomy make each patient a unique case, in which the appropriate device’s selection requires a multimodality imaging evaluation and a multidisciplinary discussion. Proper pre-procedural evaluation plays a pivotal role to judge the feasibility of TMVI, as well as a cooperative works between imagers and interventionalist is crucial for procedural success. This manuscript aims to provide an exhaustive overview of the main parameters that need to be evaluated for appropriate device selection, pre-procedural planning, intraprocedural guidance and post-operative assessment in the setting of TMVI. In addition, it tries to give some insights about next perspective of structural cardiovascular imaging.

Background: Cardiac metastases are more common than primary cardiac malignancy. Typical presentation includes arrhythmias. Echocardiography is the initial imaging test for the detection of cardiac metastasis, although echocardiography with contrast agent, cardiac magnetic resonance, and computed tomography may be helpful. Herein, we described a case of cardiac metastasis with electrocardiogram (EKG) mimicking acute coronary syndrome. Case summary: A 78-year-old man with a recent diagnosis of lung squamous cell carcinoma was referred to our cardiology department for marked EK Gabnormalities (ST-segment elevation in V2–V4) in the absence of ischaemic symptoms. A transthoracic echocardiogram showed an isoechoic mass at the left ventricular apical segments apparently incorporating the myocardial wall. A contrast echocardiography with SonoVue revealed a late uptake of the contrast. Cardiac magnetic resonance showed an ovular image in the para-apical area consistent with a secondary lesion. Coronary angiography excluded significant stenosis. Finally, the patient was transferred to the oncology department for specific management. Discussion: Our case describes a cardiac metastasis with EKG mimicking acute coronary syndrome. This finding is not uncommon among these patients. EKG findings of myocardial ischaemia or injury, particularly localized and prolonged ST elevation, in the absence of ischaemic symptoms have been reported in previous studies as high specificity for cardiac metastasis in patients with malignancy. We want to highlight the importance of using all cardiac imaging techniques in the differential diagnosis of cardiac masses; cardiac magnetic resonance certainly represents the gold standard, but a simple echocardiography with ultrasonic enhancing agent is definitely helpful.

A 62–year–old man was admitted to our emergency department for worsening nocturnal dyspnea and orthopnea for 15 days. Finding of Acute Pulmonary Edema in a setting of non datable high ventricular response atrial fibrillation (AF) associated with severe LV dysfunction. NT–proBNP 8.252 pg/ml. ECG: atrial fibrillation with high ventricular response (120/bpm). TTE: Severe left ventricular systolic disfunction (EF 20%). TOE/3D TOE: evidence of voluminous oval–shaped thrombotic formation (10 x 17 mm) protruding in LA and completely occluding the left atrial appendage (LAA). LA thrombosis in patients with AF is relatively rare and represents a contraindication to rhythm control strategies. Once an LAA thrombus is identified, effective anticoagulation is recommended for at least three weeks or until LAA thrombus resolution is detected. Available evidence on left atrial thrombus dissolution largely refers to the use of vitamin K antagonist oral anticoagulant (VKAs), but their effectiveness may be influenced by variability in the level of anticoagulant activity obtained, wich may be suboptimal. In a recent prospective observational study has been evaluated the effectiveness of Edoxaban for the resolution of LA thrombosis in 25 patients with AF: it has been demonstrated a complete thrombus resolution in 56% of patients at 4 weeks, similar to studies using VKAs and the other NOACs. Use of NOACs in this setting represents a great field of interest for the near future. In our experience, indeed, after confirmed diagnosis of LAA thrombus, we started anticoagulant therapy with warfarin (currently the first choice), however due to poor INR control, we switched to continuous infusion of unfractionated heparin (UFH), wich represents, in a hospital setting, a safe and effective method for thrombus dissolution, allowing continuous monitoring of efficacy and a rapid cessation of effect in case of major bleeding. In this way we obtained complete thrombus dissolution in about 3 weeks. At the meantime we initiate a rate control therapy, an optimized treatment for HFrEF and intravenous diuretics. Our experience highlights the need of great ductility in the choice of anticoagulant therapy in patients with evidence of voluminous LAA thrombus, monitoring treatment’s efficacy parameters and being ready to change strategy if necessary and it reminds that auricular thrombosis is often inserted in a wider picture of heart disease wich requires multiple other specifics treatments.