Carmelo De Gori

Cardiomyopathies are increasingly managed with disease-modifying and phenotype-specific therapies, creating a need for imaging biomarkers that can reliably capture treatment response over time. Cardiovascular magnetic resonance (CMR) is uniquely suited to this role because it combines highly reproducible assessment of cardiac structure and function with detailed tissue characterization. Cine imaging enables serial evaluation of ventricular volumes, mass, and ejection fraction; late gadolinium enhancement identifies focal replacement fibrosis and arrhythmogenic substrate; and native T1/T2 mapping with extracellular volume quantification provides quantitative markers of diffuse fibrosis, oedema, inflammation, and infiltrative burden. In this review, we discuss the role of CMR in therapy monitoring across the spectrum of cardiomyopathies. In dilated cardiomyopathy, CMR tracks reverse remodelling and helps identify persistent scar and non-response despite guideline-directed therapy or cardiac resynchronization. In non-dilated and arrhythmogenic cardiomyopathies, serial tissue characterization helps refine dynamic arrhythmic risk. In hypertrophic cardiomyopathy, CMR documents structural and interstitial changes during treatment with myosin inhibitors and after septal reduction. In amyloid and metabolic/storage cardiomyopathies, mapping techniques are particularly useful for demonstrating stabilization or regression of myocardial disease under targeted treatments. Overall, CMR offers a framework for standardized longitudinal follow-up and for the development of biologically meaningful surrogate endpoints in clinical trials. Wider harmonization of acquisition, analysis, and reporting will be essential to fully integrate CMR into individualized therapeutic decision-making.

Aims: Photon-counting computed tomography (PCCT) enables simultaneous assessment of left ventricular morphology, function, and myocardial tissue characterization. Whether sex influences PCCT findings across hypertrophic phenotypes remains uncertain. Methods and results: We studied consecutive adults with a left ventricular hypertrophic phenotype undergoing PCCT. Patients were classified as hypertrophic cardiomyopathy (HCM), transthyretin amyloid cardiomyopathy (ATTR-CM), or secondary left ventricular hypertrophy (LVH). Sex differences in PCCT-derived left ventricular mass index, volumes, ejection fraction (EF), late iodine enhancement (LIE), and extracellular volume (ECV) were assessed overall and by aetiology. In patients with clinically indicated cardiovascular magnetic resonance (CMR) within ±12 months, sex effects on CT-CMR agreement were also evaluated. Among 182 patients, 50 were women and 132 were men; 83 had paired PCCT-CMR data. In the overall cohort, women had lower left ventricular mass index, smaller left ventricular volumes, higher EF, slightly lower ECV, and lower LIE extent than men. In HCM, women and men showed similar wall thickness, left ventricular mass, LIE burden, and ECV. In secondary LVH, women had smaller volumes and higher EF, without meaningful differences in tissue markers. In ATTR-CM, women appeared less remodelled and less infiltrative, although only four women were included. CT-CMR agreement for wall thickness, left ventricular mass, EF, scar extent, and ECV was similar in women and men. Diagnostic ECV thresholds were also consistent across sexes. Conclusion: Sex influences PCCT hypertrophic phenotypes mainly through remodelling and functional adaptation rather than major differences in tissue characterization. CT-CMR agreement and diagnostic ECV thresholds appear robust across sexes.

Background: Preventive imaging for cardiothoracic risk is fragmented across separate pathways. Photon-counting CT (PCCT) may consolidate coronary, aortic–carotid, and pulmonary assessment into a single session while maintaining diagnostic performance and controlling dose. Methods: ACTA is an ongoing, general-practitioner–initiated, risk-enriched screening study (age 45–75 years; diabetes ≥10 years, current/recent smoking, or Framingham hard coronary artery disease risk ≥10%). The protocol integrates non-contrast calcium scoring, ultra-high-resolution coronary CT angiography, a high-pitch thoraco-cervical sweep, and brief late iodine enhancement (LIE). Incidental findings trigger predefined, guideline-concordant referrals. The primary endpoint is the prevalence of obstructive (≥50%) and/or extensive (≥2-vessel) coronary artery disease. This interim analysis includes participants imaged 11 Jan–21 Jun 2025. Results: Of 223 invited, 172 underwent PCCT; all completed without complications. Mean dose-length product was ∼740 mGy·cm; the effective dose was 12.6 mSv (IQR 10.5–17.1 mSv), and weight-adapted contrast equalled ∼0.44–0.48 gI/kg. Any coronary atherosclerosis was present in 129/172 (75%); the primary endpoint was met in 98/172 (57%). Carotid plaques occurred in 94/170 (55%); Lung-RADS 3–4 in 16/172 (9%); emphysema in 41/172 (24%). Management actions included invasive coronary angiography in 8/172 (5%), targeted vascular and pulmonary referrals, initiation/intensification of prevention therapies, and structured follow-up. Incidental extracardiac findings were common but managed via protocolized pathways. Conclusions: Single-session PCCT feasibly consolidates comprehensive cardiothoracic assessment with controlled radiation/iodine exposure and structured downstream care. Preliminary yield suggests actionable information in high-risk, asymptomatic adults; ongoing follow-up and prespecified economic analyses will determine clinical outcomes and cost-effectiveness.

Aims: Metabolic syndrome (Mes) and diabetes are emerging cardiometabolic determinants of coronary atherosclerotic disease (CAD) risk besides LDL-cholesterol (LDL-C) and established risk factors. We aimed to assess whether, in patients with chronic coronary syndrome (CCS), cardiometabolic risk is prevalent and independently associated with residual CAD risk in subjects with low LDL-C. Methods and results: The cross-sectional HURRICANE study (Health improvement by Understanding RR In CAd and NEw targets for treatment) included 479 patients with CCS (mean age 65 ± 11 years, 70% male), undergoing cardiac computed tomography angiography (CCTA). A severe/extensive CAD or a moderate-high CAD risk were defined, on patient level, by CCTA-derived CAD-RADS2 and Leiden scores. Metabolic syndrome was present in 31% of patients, diabetes or pre-diabetes in 21% and 26%, severe/extensive CAD and moderate-high Leiden score in 51% and in 61%, more frequently in the two lower LDL-C categories. Multivariate logistic regression models, included age, sex, smoking status, family history, LDL-C categories (<70, 70–99 100–129, and ≥130 mg/dL), MeS, or its components and medications. Independent predictors of moderate-high Leiden score were age, male sex, the lowest LDL-C category and MeS (OR 2.12, 95% CI: 1.26–3.56) or pre-diabetes (OR 1.90, 95% CI: 1.12–3.21) and diabetes (OR 6.13, 95% CI: 1.93–19.45). In the lowest LDL-C group, higher CAD-RADS2 and Leiden scores were more frequent in patients with cardiometabolic risk. Conclusion: Results of this cross-sectional study suggest that dysregulation of glucose metabolism is the prevalent component of residual cardiometabolic and coronary atherosclerotic risk in patients with CCS and low LDL-C under current treatment.

Background and Objectives: Nonischemic cardiomyopathies comprise a wide spectrum of heart muscle disorders characterized by different morphological, functional, and tissue abnormalities. Cardiovascular magnetic resonance (CMR) represents the gold standard imaging modality for assessing cardiac morphology, systolic function, and tissue characterization, thereby aiding in early diagnosis, precise phenotyping, and tailored treatment. The aim of this review is to provide an up-to-date overview of CMR techniques for studying myocardial perfusion and their applications to nonischemic cardiomyopathy, not only to rule out an underlying ischemic aetiology but also to investigate the pathophysiological characteristics of microcirculatory dysfunction in these patients. Materials and Methods: We performed a structured review of the literature focusing on first-pass gadolinium perfusion sequences, stress protocols, and emerging pixel-wise perfusion mapping approaches. Studies were selected to illustrate the methods for image acquisition, post-processing, and quantification of myocardial blood flow (MBF) and myocardial perfusion reserve (MPR), as well as to highlight associations with clinical endpoints. Results: First-pass CMR perfusion imaging reliably detects diffuse and regional microvascular dysfunction across cardiomyopathies. Semi-quantitative parameters (e.g., upslope, MPRI) and quantitative MBF mapping (mL/g/min) have demonstrated that impaired perfusion correlates with disease severity, extent of fibrosis, and adverse outcomes, including heart failure hospitalization, arrhythmias, and mortality. Novel automated pixel-wise mapping enhances reproducibility and diagnostic accuracy, distinguishing coronary microvascular dysfunction from balanced three-vessel disease. Microvascular dysfunction—present in approximately 50–60% of dilated cardiomyopathy (DCM), 40–80% of hypertrophic cardiomyopathy (HCM), and >95% of cardiac amyloidosis (CA) patients—has emerged as a key driver of adverse outcomes. Perfusion defects appear early, often preceding overt hypertrophy or fibrosis, and provide incremental prognostic value beyond conventional CMR metrics. Conclusions: CMR represents a powerful tool for detecting myocardial perfusion abnormalities in nonischemic cardiomyopathies, improving phenotyping, risk stratification, and personalized management. Further standardization of quantitative perfusion techniques will facilitate broader clinical adoption.

Optimal medical treatment in patients with stable coronary artery disease (CAD) reduced morbidity and mortality but left a substantial residual risk (RR) of disease progression and events. According to recent evidence, insulin resistance or pre-diabetes together with elevated levels of triglycerides, low levels, and functionality of HDL-cholesterol, often associated with a chronic inflammatory state, are deemed to be relevant components of cardiometabolic and vascular RR. In the present project, we aim at discovering specific individual genetic/molecular profiles subtending emerging cardiometabolic and vascular risk patterns and associated with more severe stable CAD phenotypes. To this end, we will analyse clinical data, blood samples, and imaging data already gathered in a retrospective population of 561 patients with suspected stable coronary disease and will develop integrated predictive models of severity and extent of disease defined by qualitative and quantitative analysis of coronary plaques by cardiac computed tomography. The new predictive models, which will incorporate relevant clinical and genetic/molecular variables associated with more severe coronary atherosclerosis, will be validated in a similar prospective population of patients and extended to the prediction of progression (at 1 year follow-up) of coronary disease phenotypes, occurring despite optimal medical treatment. Registration ClinicalTrials.gov ID: NCT06601153

Mitral annular disjunction (MAD) was a frequent incidental finding at cardiac MRI examinations performed for various clinical indications; longer MAD length and coexisting bileaflet mitral valve prolapse were associated with a higher prevalence of arrhythmia.

Olfactory dysfunction (OD) is one of the most common symptoms in COVID-19 patients and can impact patients’ lives significantly. The aim of this review was to investigate the multifaceted impact of COVID-19 on the olfactory system and to provide an overview of magnetic resonance (MRI) findings and neurocognitive disorders in patients with COVID-19-related OD. Extensive searches were conducted across PubMed, Scopus, and Google Scholar until 5 December 2023. The included articles were 12 observational studies and 1 case report that assess structural changes in olfactory structures, highlighted through MRI, and 10 studies correlating the loss of smell with neurocognitive disorders or mood disorders in COVID-19 patients. MRI findings consistently indicate volumetric abnormalities, altered signal intensity of olfactory bulbs (OBs), and anomalies in the olfactory cortex among COVID-19 patients with persistent OD. The correlation between OD and neurocognitive deficits reveals associations with cognitive impairment, memory deficits, and persistent depressive symptoms. Treatment approaches, including olfactory training and pharmacological interventions, are discussed, emphasizing the need for sustained therapeutic interventions. This review points out several limitations in the current literature while exploring the intricate effects of COVID-19 on OD and its connection to cognitive deficits and mood disorders. The lack of objective olfactory measurements in some studies and potential validity issues in self-reports emphasize the need for cautious interpretation. Our research highlights the critical need for extensive studies with larger samples, proper controls, and objective measurements to deepen our understanding of COVID-19’s long-term effects on neurological and olfactory dysfunctions.

We derived reference values of left-ventricular (LV) and right-ventricular (RV) strain parameters in a cohort of 100 healthy subjects by feature tracking cardiac magnetic resonance (FT-CMR). Global and regional strain values were calculated for the LV; circumferential and radial_SAX strain parameters were derived from the short-axis (SAX) stack, while longitudinal and radial_LAX strain parameters were assessed in three long-axis (LAX) views. Only global longitudinal strain (GLS) was calculated for the RV. Peak global LV circumferential strain was −16.7% ± 2.1%, LV radial_SAX strain was 26.4% ± 5.1%, LV radial_LAX strain was 31.1% ± 5.2%, LV GLS was −17.7% ± 1.9%, and RV GLS was −23.9% ± 4.1%. Women presented higher global LV and RV strain values than men; all strain values presented a weak relationship with body surface area, while there was no association with age or heart rate. A significant association was detected between all LV global strain measures and LV ejection fraction, while RV GLS was correlated to RV end-diastolic volume. The intra- and inter-operator reproducibility was good for all global strain measures. In the regional analysis, circumferential and radial strain values resulted higher at the apical level, while longitudinal strain values were higher at the basal level. The assessment of cardiac deformation by FT-CMR is feasible and reproducible and gender-specific reference values should be used.