Quantitative stress perfusion cardiac magnetic resonance (CMR) imaging is an emerging and powerful clinical tool that improves the diagnostic accuracy of stress perfusion CMR for noninvasive assessment of epicardial coronary artery disease, microvascular dysfunction, aortic stenosis, and cardiac allograft vasculopathy.

Cardiac MRI provides comprehensive insights into orthotopic heart transplant (OHT) allograft structure and function with advanced tissue characterization and quantitative myocardial perfusion techniques and can be considered a complementary noninvasive tool for investigation and monitoring of major complications that limit the durability of OHT.

The aim of this study was to verify if multiparametric quantitative CMR can detect mild-to-moderate cardiac allograft vasculopathy (CAV) in patients post-orthotopic heart transplant (OHT). 51 patients (age = 50.0 ± 13.6 years, 29% female) post-OHT 0–6 years (mean 3.2 ± 1.5 years) who underwent CMR from 2011 to 2019 were retrospectively included. Multiparametric CMR included CINE imaging covering the left ventricle (LV), pre- and post-contrast T1 mapping, and T2 mapping, extracellular volume fraction (ECV) calculation, and 2D-feature tracking strain. CAV0 (‘CAV negative’) patient variables were compared with CAV1-CAV2 (‘CAV positive’) variables. Logistic regression was used to determine predictors of CAV status. Myocardial T2 was higher in CAV positive compared with CAV negative patients (54.5 ± 7.7 ms vs. 50.2 ± 3.3 ms, p < 0.05), as was ECV (31.3 ± 5.3% vs. 27.4 ± 4.1%, p < 0.05). Radial and circumferential peak systolic strain rates were attenuated in CAV positive vs. CAV negative patients (radial: 1.4 ± 0.4 s-1 vs. 1.8 ± 0.3 s-1, circumferential: -0.9 ± 0.2 s-1 vs. -1.1 ± 0.1 s-1, p < 0.05),as well as circumferential and longitudinal peak diastolic strain rates (0.7 ± 0.7 s-1 vs. 1.0 ± 0.5 s-1, and 0.8 ± 0.3 s-1 vs. 0.9 ± 0.3 s-1, p < 0.05, respectively). CAV positive vs. negative status correlated with ECV (rho 0.41, P < 0.01), T2 (rho 0.29, p < 0.05), radial and circumferential peak systolic strain rate (rho − 0.48, P < 0.01 and rho 0.47, p < 0.001, respectively), and circumferential and longitudinal peak diastolic strain rates (rho − 0.34, p < 0.05 and rho − 0.35, p < 0.01, respectively). Logistic regression revealed that a model including ECV, peak radial and circumferential systolic strain rates and longitudinal diastolic strain rate was significant for distinguishing CAV positive vs. negative status with a receiver operator characteristic area under curve of 0.85 ± 0.06 (CI 0.73–0.97), p < 0.005. A model combining functional (strain) and tissue parameters (ECV) was predictive of CAV status, indicating the potential of multiparametric CMR for non-invasive prediction of CAV status in OHT recipients.

Multiparametric CMR can detect cardiac amyloidosis (CA) in patients with undifferentiated concentric left ventricular hypertrophy (LVH). A retrospective patient search was performed for patients ≥ 18 years of age who received 1.5T CMR from January 2018 to August 2022 to evaluate for myocardial infiltration in the setting of known concentric LVH at a tertiary medical center. Clinical records were reviewed for positive diagnosis or exclusion of CA. CMR were post-processed to evaluate ventricular volumes and function, native T1 mapping, and extracellular volume (ECV). Late gadolinium enhancement (LGE) was qualitatively evaluated and each segment categorized into vascular or non-vascular LGE using the American Heart Association 16 segment model. Feature tracking strain (FTS) was performed on a subset of CA positive and CA negative patients. Group comparisons were made using one-way ANOVA (parametric) or Kruskal-Wallis (non-parametric) tests. Receiver operator characteristic (ROC) analysis with area under curve (AUC) values were generated for both individual and combined parameters using binary logistic regression (IBM SPSS Statistics V26.0, and DATATab 2025) to determine optimal cut-off parameters for detection of CA. CMR were performed in 278 patients for myocardial infiltration evaluation in the setting of known concentric LVH (mean age 63.2 ± 14.9, 46% female). Diagnostic groups were determined as follows: CA positive ( n = 60), CA negative ( n = 100) and CA unknown ( n = 118). CA positive patients, when compared to both CA negative and CA unknown groups, respectively, demonstrated significantly higher age (69.9 ± 10.3 vs. 59.7 ± 14.2 and 62.9 ± 16.4 years), native T1 (1122.4 ± 64.6 vs. 1056.8 ± 69.7 and 1051.4 ± 54.0 ms), ECV (46.4 ± 11.5 vs. 32.1 ± 7.2 and 32.1 ± 7.6%) and number of segments with infarct-atypical LGE (10.2 ± 7.3 vs. 2.7 ± 4.7 and 2.0 ± 4.3). ROC AUC values were calculated for native T1 (0.80), ECV (0.88), and number of infarct-atypical LGE segments (0.76). A 4 parameter model including age, native T1, ECV, number of segments with non-vascular LGE demonstrated an AUC of 0.91 for detection of CA, with a sensitivity of 92% and specificity of 81%, which when applied to the CA unknown group, indicated 13 patients (11%) in this group may have CA. CA positive patients demonstrated reduced basal peak systolic strain and diastolic strain rates when compared to CA negative patients; a model combining these parameters with patient age demonstrated an AUC of 0.79 for detection of CA. Multiparametric CMR can discriminate CA positive patients from CA negative and undifferentiated LVH patients in a real-world tertiary center population. These findings demonstrate that CMR has significant diagnostic potential for detection of CA in patients with undifferentiated LVH.

Hypertrophic heart disease comprises a heterogeneous group of myocardial disorders characterized by increased left ventricular wall thickness arising from diverse pathologic processes. Despite differing etiologies, these diseases frequently demonstrate overlapping phenotypic features, which can create significant diagnostic challenges. Accurate differentiation is clinically important, given the prognostic implications associated with each condition, and the application of disease-specific therapeutic strategies. Cardiovascular magnetic resonance (CMR) has become central to the evaluation of hypertrophic heart disease due to its high spatial resolution and unique capability for comprehensive multiparametric tissue characterization. Beyond standardized assessment of ventricular volumes, function, mass, and wall thickness, CMR provides detailed characterization of myocardial fibrosis, edema, and tissue composition through late gadolinium enhancement imaging and parametric mapping techniques, including native T1, T2, and extracellular volume mapping. This review summarizes the contemporary role of CMR in the assessment of hypertrophic heart diseases, with emphasis on imaging features that aid differential diagnosis, and clinically relevant findings that influence management and prognosis.