Chianese, Salvatore (2025) Beyond ejection fraction: clinical applications of advanced cardiac imaging for comprehensive assessment of cardiac function and arrhythmic risk. [Tesi di dottorato]

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Abstract

Cardiovascular diseases remain the leading cause of morbidity and mortality worldwide, highlighting the need for accurate, reproducible, and early diagnostic tools. Over the past two decades, cardiovascular imaging has evolved from a primarily anatomical modality into a powerful means of assessing myocardial function, tissue characterization, and risk stratification. The integration of advanced imaging techniques has allowed clinicians and researchers to move beyond traditional parameters such as ejection fraction, offering deeper insights into the complex interplay between myocardial structure, function, and electrical stability. Among these innovations, the assessment of left ventricular function has been revolutionized by techniques such as myocardial deformation imaging, parametric mapping in cardiac magnetic resonance (CMR), and artificial intelligence–based image analysis. These approaches provide sensitive markers of subclinical dysfunction, capable of identifying disease processes before conventional parameters become abnormal. The right ventricle once considered the “forgotten chamber,” has emerged as a key determinant of prognosis in a wide spectrum of cardiovascular and pulmonary diseases. Novel echocardiographic and CMR-based methods now enable accurate quantification of right ventricle size, function, and strain, offering valuable prognostic information and guiding clinical management. In parallel, the recognition of cardiotoxicity as a major complication of oncologic therapies has led to the incorporation of advanced imaging protocols in cardio-oncology. Non-invasive imaging plays a central role in detecting early myocardial injury, differentiating reversible from irreversible damage, and guiding preventive or therapeutic strategies. Finally, the expanding field of imaging-based arrhythmic risk stratification underscores the potential of structural and functional imaging markers to complement electrophysiological data. Scar burden, myocardial fibrosis, and regional mechanical dispersion, as identified by CMR and echocardiographic strain imaging, have shown promise in identifying patients at risk for sudden cardiac death beyond conventional criteria. Taken together, these developments position cardiovascular imaging at the heart of precision medicine — enabling individualized diagnosis, risk assessment, and therapeutic guidance. This thesis aims to explore and synthesize these advances, focusing on the novel applications of imaging in the assessment of ventricular function, detection of cardiotoxicity, and prediction of arrhythmic events.

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