Background/Objectives: Ventricular recovery after ST-segment elevation myocardial infarction (STEMI) is commonly assessed using either structural (volumetric) or functional (ejection-fraction) criteria, although these may capture different aspects of recovery. We examined whether their cross-classification identifies distinct recovery patterns and whether myocardial mechanics and left atrial function provide additional information. Methods: We prospectively followed 101 patients with first STEMI and single-vessel coronary artery disease treated with PCI. Echocardiography was performed 12–24 h after reperfusion and at 12 ± 2 months. Structural recovery (≥15% reduction in 3D LV end-systolic volume) and functional recovery (≥5-point absolute LVEF increase) were cross-classified into four recovery patterns. Results: Among 53 patients with complete paired measurements, 10 (18.9%) showed concordant recovery, 7 (13.2%) isolated structural recovery, 9 (17.0%) isolated functional recovery, and 27 (50.9%) no recovery; 30.2% therefore showed discordant recovery. The no-recovery group was heterogeneous, including both volumetric deterioration and stable or improving volumes below the recovery threshold. Continuous changes in 3D-ESV and LVEF were only moderately correlated (ρ = 0.353, p = 0.0095), and discordance persisted in sensitivity analyses. Myocardial mechanics and LASR did not differentiate recovery patterns, but several of these baseline markers showed exploratory associations with clinical outcomes after false-discovery-rate correction. Conclusions: Structural and functional recovery after STEMI are complementary rather than interchangeable, and this discordance persisted across extensive sensitivity analyses; however, assignment of individual patients to specific recovery categories remained sensitive to the chosen thresholds and LVEF measurement method. Myocardial mechanics and LASR may provide additional information about clinical expression.

Background: Rapid, disproportionate expansion of post-infarction left ventricular (LV) aneurysms represents a high-risk remodeling phenotype characterized by progressive mechanical deterioration and severe geometric distortion. Methods: A 54-year-old male presented with late anterior myocardial infarction complicated by a partially thrombosed apical LV aneurysm with an initial left ventricular ejection fraction (LVEF) of 35%. Despite clinical stability under optimal guideline-directed medical therapy, serial multimodality imaging at 7 weeks revealed an aggressive, disproportionate expansion of the aneurysmal component to 120 mL, inducing severe ventricular geometric distortion and secondary functional degradation (LVEF 20%). Multimodality imaging demonstrated a favorable geometry of the functional ventricle with preserved contractile function. Results: The patient underwent prompt surgical ventricular restoration using a double-patch Dor technique, effectively excluding the large aneurysm and restoring physiological ventricular geometry. The postoperative course was uneventful. At 6-month follow-up, cardiovascular magnetic resonance confirmed sustained reverse remodeling and significant recovery of systolic LV function (LVEF 47%). Conclusions: This case illustrates that rapid post-infarction aneurysmal expansion may occur despite apparent clinical stability. Comprehensive multimodality imaging may help identify selected patients in whom a reconstructible myocardial substrate supports surgical ventricular restoration despite severely reduced LVEF, even when conventional clinical indications for aneurysmectomy are absent.

Background/Objectives: Anatomical and functional damage of the mitral valve (MV) apparatus in patients with dilated cardiomyopathy (DCM) is secondary to left ventricular (LV) injury, leading to functional mitral regurgitation (FMR). Real-time four-dimensional echocardiography (RT 4DE) is a useful imaging technique in different pathologies, including DCM. Left atrial (LA) strain, as measured by left atrium quantification software, is an accurate technique for evaluating increased filling pressure. The MV has a complex three-dimensional morphology and motion. Four-dimensional echocardiography (4DE) has revolutionized clinical imaging of the mitral valve apparatus. This study aims (1) to characterize the mitral annulus (MA) parameters in patients with DCM and advanced-stage heart failure (HF) according to etiology and (2) to find correlations between left atrial function and MA remodeling in this group of patients, using 4DE quantification software. Methods: A total of 82 patients with DCM and an LV ejection fraction ≤ 40% were recruited. Conventional 2DE and RT 4DE were conducted in DCM patients with a compensated phase of HF before discharge. The measured parameters were left atrial reservoir strain (LASr), annular area (AA), annular perimeter (AP), anteroposterior diameter (A-Pd), posteromedial to anterolateral diameter (PM-ALd), commissural distance (CD), interregional distance (ITD), annular height (AH), nonplanar angle (NPA), tenting height (TH), tenting area (TA), and tenting volume (TV). Results: Measured parameters revealed more advanced damage of LA and MA parameters in ischemic compared to nonischemic etiology. Univariate analysis identified AA, AP, A-Pd, PM-ALd, CD, ITD, TH, TA, and TV (p < 0.0001) as determinants of LASr. Including these parameters in a stepwise multivariate logistic regression, PM-ALd (p = 0.03), TH (p = 0.043), and TV (p = 0.0001) were the best predictors of LAsr in these patients. Conclusions: The results of this study revealed the correlation between LA function depression and MA remodeling in patients with DCM.

Dilated cardiomyopathy (DCM) is a major cause of heart failure and sudden cardiac death, characterized by left ventricular dilation and systolic dysfunction in the absence of significant coronary or valvular disease. Although traditionally viewed as an idiopathic condition, DCM is now recognized as a genetically driven disorder in a substantial proportion of cases. Pathogenic variants affecting structural, cytoskeletal, desmosomal, and nuclear proteins not only initiate myocardial remodeling but also influence disease progression and arrhythmic vulnerability. Importantly, genetic findings do not merely explain disease etiology but also shape its clinical expression. The specific gene involved, as well as the type of mutation, can influence the pattern of ventricular remodeling, the distribution of myocardial fibrosis, and the degree of electrical instability. Cardiac magnetic resonance has emerged as a central tool in bridging molecular insights with clinical assessment. By enabling accurate evaluation of ventricular volumes and function, as well as detailed tissue characterization through late gadolinium enhancement (LGE) and parametric mapping, cardiac magnetic resonance reveals imaging patterns that often mirror the underlying genetic substrate. The integration of genetic testing and advanced imaging provides a more comprehensive understanding of dilated cardiomyopathy, allowing improved risk stratification and supporting a personalized approach to patient management.