Multimodal diagnostic imaging for early mitral valve disease: integration of current and emerging modalities—a narrative review

Introduction

Background

Mitral valve disease (MVD) affects more than 24 million individuals worldwide and remains a major cause of cardiovascular morbidity and mortality (1). Its epidemiology varies globally, with, degenerative mitral regurgitation (MR) predominating in high-income countries, and rheumatic mitral stenosis (MS) continues to be prevalent in low- and middle-income regions (2,3). Early detection is crucial, as delayed diagnosis and intervention may lead to irreversible left ventricular (LV) dysfunction, pulmonary hypertension, atrial fibrillation, and heart failure, in addition to premature death (1,4).

“Early MVD” refers to structural or functional mitral abnormalities identified through imaging before the onset of clinical symptoms, representing a critical window for timely management and improved outcomes (5).

Rationale and knowledge gap

Over the past decade, remarkable advancements in cardiac imaging have transformed the diagnostic landscape of MVD. Transthoracic and transesophageal echocardiography (TEE), remain first-line modalities for evaluating valve morphology and function, while cardiac magnetic resonance (CMR), computed tomography (CT), and positron emission tomography (PET), offer detailed insights into myocardial structure, perfusion, and tissue characteristics (4,5). However, clinical integration of these modalities remains inconsistent, particularly in the early stages of disease when intervention can alter prognosis most effectively.

Despite multiple guidelines and reviews addressing imaging in advanced valvular disease, comprehensive evaluation of early-stage MVD, focusing on quantitative thresholds, prognostic imaging biomarkers, and emerging imaging technologies, remains limited (4). Moreover, accessibility challenges in resource-limited regions and the evolving role of artificial intelligence (AI) and hybrid imaging modalities remain underexplored.

Objective

This narrative review aims to synthesize recent evidence on multimodal imaging in the early detection and management of MVD, emphasizing advances from 2020 to 2025. It summarizes each modality’s diagnostic utility, quantitative benchmarks, and clinical applications, while highlights emerging technologies such as AI-enhanced analysis, fusion imaging, and four-dimensional (4D) flow CMR. The review also discusses strategies to improve accessibility and cost-effectiveness in low-resource settings, with the ultimate goal of proposing a patient-centered, multimodal imaging framework for early MVD diagnosis and management. This article is presented in accordance with the Narrative Review reporting checklist (available at https://cdt.amegroups.com/article/view/10.21037/cdt-2025-442/rc).

Methods

This narrative review was conducted to synthesize contemporary evidence on multimodal diagnostic imaging for the early detection and management of MVD. A comprehensive literature search was conducted across PubMed, Scopus, and Google Scholar for studies published between January 2020 and August 2025. The search strategy summary is presented in Table 1, and a detailed example search string is provided in Table S1, as required.

Search terms included combinations of “mitral valve disease”, “early diagnosis”, “echocardiography”, “cardiac MRI”, “cardiac CT”, “PET”, “artificial intelligence”, “fusion imaging”, “4D flow”, and “valvular heart disease”. Reference lists of key articles and recent international guidelines (e.g., American College of Cardiology/American Heart Association, European Society of Cardiology/European Association for Cardio-Thoracic Surgery), were also manually reviewed to identify additional relevant sources.

Inclusion criteria encompassed peer-reviewed original studies, meta-analyses, clinical practice guidelines, consensus statements, and high-quality narrative or state-of-the-art reviews, defined as reviews published in reputable cardiovascular imaging journals, containing clearly stated objectives, comprehensive literature appraisal, and up-to-date content relevant to early-stage MVD. Exclusion criteria included non-English publications, case reports, and studies focused solely on advanced or end-stage MVD, in order to maintain emphasis on early detection.

Study selection and data extraction were performed independently by the author. For each eligible publication, information regarding diagnostic performance, quantitative thresholds, prognostic markers and clinical integration strategies was extracted. Any uncertainties were resolved by re-evaluation of the article and cross-comparison with guideline recommendations. When full-text articles were unavailable, alternative accessible versions or secondary indexed sources were sought.

The initial database search identified 1,284 records. After removing 312 duplicates, 972 titles and abstracts were screened for relevance. Of these, 186 full-text articles were retrieved for eligibility assessment. Full texts that were inaccessible were pursued through alternative sources such as institutional repositories, and preprint servers. Seven articles remained unavailable and were excluded. A total of 63 publications met the predefined inclusion criteria and were incorporated into the final synthesis.

Although this is not a systematic review, predefined selection criteria, comprehensive database searches, and methodological transparency were applied to reduce selection bias. A narrative synthesis approach was used to summarize major technological advancements, clinical applications, and gaps in current practice, incorporating literature from both high-income and low- to middle-income regions to reflect global variability in imaging availability and cost-effectiveness.

Epidemiology and clinical implications of early MVD

MVD, including common primary abnormalities such as mitral valve prolapse (MVP), affects an estimated 2–3% of the global population, with prevalence increasing markedly with age (6). While, degenerative MR remains the most common subtype in high-income countries, and rheumatic MS continues to impact low- and middle-income regions (2). Recent epidemiologic data from the Global Burden of Disease Study highlight that rheumatic heart disease continues to impose a substantial burden of morbidity and mortality, particularly in the Middle East and North Africa (3).

Although often asymptomatic, early-stage MVD is not benign. Subclinical hemodynamic alterations, including left atrial (LA) enlargement, early ventricular dilation, and rising pulmonary pressures, frequently precede clinical symptoms and predict later deterioration (6). Imaging thus plays a critical role in identifying these early markers. Studies consistently demonstrate that early intervention, particularly in primary MR before the development of systolic dysfunction, offers superior long-term outcomes, with greater than 90% 10-year survival following timely surgical repair (7-9).

Key imaging thresholds, including left ventricular ejection fraction (LVEF) <60%, left ventricular end-systolic dimension (LVESD) >40 mm, LA volume index >60 mL/m², and pulmonary artery systolic pressure (PASP) >50 mmHg, assist clinicians in recognizing early adverse remodeling and determining when to escalate surveillance or consider intervention (4,7). The increasing availability of advanced imaging has also enhanced the recognition of secondary (functional) MR, improving risk stratification and therapeutic planning, particularly for patients eligible for transcatheter edge-to-edge repair (TEER) (5,10). Consequently, early multimodal imaging is essential not only for diagnosis but also for prognostic assessment and longitudinal management of MVD across diverse populations.

Echocardiography

Echocardiography remains the cornerstone of MVD assessment due to its real-time imaging capabilities, accessibility, and diagnostic versatility. It allows dynamic evaluation of valve morphology, leaflet motion, ventricular function, and flow dynamics, making it indispensable for both initial assessment and longitudinal follow-up.

Transthoracic echocardiography

TTE serves as the first-line imaging modality for suspected MVD, offering comprehensive assessment of mitral valve anatomy and function. Quantitative parameters such as the effective regurgitant orifice area (EROA) and regurgitant volume are used to grade MR severity, while the mitral valve area (MVA) is key for evaluating stenosis. According to ASE guidelines, an EROA ≥0.2 cm² and regurgitant volume ≥30 mL suggest moderate severity, while values ≥0.4 cm² and ≥60 mL indicate severe MR. In MS, an MVA ≤1.5 cm² signifies severe stenosis (4,10).

Recent advances in three-dimensional TTE (3D TTE) have enhanced spatial resolution, improving the visualization of prolapse or flail segments, with contemporary studies demonstrating high diagnostic accuracy (11). Additionally, speckle-tracking strain imaging detects early subclinical myocardial dysfunction even in asymptomatic patients, as validated in foundational algorithm-level studies (12).

TEE

TEE provides superior spatial resolution and is particularly valuable when TTE windows are suboptimal. It is the modality of choice for evaluating posterior leaflet pathology, sub-valvular structures, vegetations, and prosthetic valves (5,13). Real-time 3D TEE has transformed the evaluation of complex valve anatomy, especially in Barlow’s disease and infective endocarditis, and is plays a vital role in pre-procedural planning for surgical or transcatheter intervention, including TEER (14,15).

Stress echocardiography

Stress echocardiography is a critical adjunct in the evaluation of asymptomatic or borderline MR cases. It reveals exercise-induced pulmonary hypertension (PASP >60 mmHg) and reduced contractile reserve, both of which are associated with adverse outcomes and may prompt earlier surgical referral. In ischemic MR, stress echocardiography provides insight into functional severity and assists in differentiating between reversible and fixed myocardial dysfunction (16).

Limitations and standardization

Despite its diagnostic strengths, echocardiography is operator-dependent and subject to variability due to image quality and loading conditions. The standardization of acquisition and quantification protocols, as outlined in the American Society of Echocardiography (ASE) and the European Association of Cardiovascular Imaging (EACVI) guidelines, is essential for reproducibility. Institutional quality assurance programs and ongoing operator training further minimize interobserver differences (10,13).

Emerging trends

The integration of AI-assisted echocardiographic analysis is improving automation in quantification and reducing interobserver variability by up to 25% in early MR grading. Moreover, handheld echocardiography and tele-echocardiography platforms are expanding access to early screening in low-resource environments. Collectively, these innovations reinforce echocardiography’s central role in both early diagnosis and longitudinal monitoring of MVD (17).

CMR

CMR is widely regarded as the reference standard for quantifying ventricular volumes, mass, and function, offering excellent accuracy and reproducibility. In the evaluation of MVD, CMR is particularly valuable when echocardiographic findings are inconclusive, discordant or limited by image quality. Its ability to provide tissue characterization, and flow quantification without ionizing radiation makes it indispensable in the assessment of early and complex disease (18).

Role in early MVD

In early-stage MVD, CMR offers precise measurement of regurgitant volume and regurgitant fraction using phase-contrast velocity mapping, allowing differentiation between mild, moderate, and severe MR. Beyond flow quantification, parametric mapping techniques, including native T1 mapping and extracellular volume (ECV) quantification, can detect diffuse myocardial fibrosis prior to the onset of systolic dysfunction, thereby refining risk stratification. Elevated ECV (>30%) on CMR has been independently associated with early adverse ventricular remodeling and increased likelihood of future mitral valve intervention in asymptomatic primary MR (19,20). Furthermore, Ricci et al. utilized UK Biobank data to establish normative reference values for mitral annular dimensions, facilitating early identification of pathological annular dilation (21).

Technical advances and clinical integration

According to the Society for Cardiovascular Magnetic Resonance (SCMR), the parametric mapping and late gadolinium enhancement (LGE) have become integral components of contemporary CMR protocols for evaluating valvular heart disease. These techniques allow detailed assessment of myocardial injury, fibrosis burden, and subclinical remodeling, supporting clinical decision-making even in patients with preserved ejection fraction (22,23).

Additionally, CMR plays an expanding role in procedural planning for transcatheter mitral interventions, providing accurate quantification of LA and LV volumes, leaflet length, and annular geometry. In cases with ambiguous echocardiographic windows, CMR-derived measurements guide device selection and procedural strategy, improving outcomes and procedural safety (19,24).

Advantages and limitations

CMR offers high reproducibility for volumetric and flow measurements and does not rely on geometric assumptions. It combines high spatial and temporal resolution with robust tissue characterization, enabling comprehensive assessment of both valve and myocardium in a single study. However, cost, limited availability, longer acquisition times, and contraindications in certain implanted devices may restrict widespread use, particularly in resource-limited regions (22).

Recent innovations, including faster acquisition sequences, compressed sensing, and AI-based reconstruction algorithms, are reducing scan times and improving patient tolerance, paving the way for broader clinical implementation (25).

CT

Cardiac CT serves as a valuable adjunct imaging modality, particularly in patients with inadequate echocardiographic windows. It is primarily used for anatomical evaluation and procedural planning in MVD, offering high-resolution visualization when functional imaging alone is insufficient (26).

Role in early MVD

Multidetector CT enables high-resolution imaging of the mitral valve complex and adjacent structures, providing essential anatomical data when echocardiographic images are limited or discordant. Its application is especially critical in pre-procedural planning for transcatheter mitral valve replacement (TMVR) and TEER (27). CT facilitates accurate annular sizing, assessment of leaflet and annular calcification, and evaluation of the left ventricular outflow tract (LVOT) to prevent post-procedural obstruction. As demonstrated by Fongrat et al., precise CT-based anatomical assessment and device sizing significantly reduce procedural complications, such as paravalvular leak and hemolysis (28). Furthermore, concurrent coronary artery evaluation allows comprehensive risk stratification in patients considered for surgical or transcatheter interventions.

Advances in CT technology

Recent advancements in dual-source scanners and low-dose acquisition protocols, have markedly reduced radiation exposure, without compromising image quality. These improvements make CT safer and more applicable for elderly or high-risk populations (29). Moreover, 4D CT provides dynamic visualization of valve motion across the cardiac cycle, improving early detection of subtle leaflet prolapse, restriction, or annular abnormalities that may be overlooked on static imaging (30).

Advantages and limitations

Cardiac CT offers rapid image acquisition, high spatial resolution, and excellent visualization of calcific lesions and prosthetic material. Its ability to simultaneously assess coronary anatomy and valvular structure in a single scan enhances procedural efficiency. However, CT’s limitations include exposure to ionizing radiation and the need for iodinated contrast, which restricts its use in patients with renal impairment or contrast allergies (26). Additionally, CT provides limited information on valve hemodynamics compared with echocardiography or CMR.

Despite these constraints, emerging technological, such as photon-counting CT and AI-based reconstruction, are improving soft-tissue differentiation and reducing radiation dose, further expanding CT’s role in early and procedural evaluation of MVD (31).

PET

PET, provides metabolic and molecular information that complements structural imaging modalities in MVD. Although PET is not routinely used as a first-line tool for asymptomatic or early-stage MVD, emerging developments in molecular tracers have opened new opportunities for detecting early fibro-inflammatory activity and microcalcification, pathophysiologic processes that precede overt structural degeneration (32). PET therefore represents a potential adjunct for identifying preclinical remodeling when echocardiography, CT, or CMR remain normal or equivocal.

Role in early MVD

In the context of early MVD, PET contributes mainly by identifying subclinical inflammatory or fibroblast activity that may signal early remodeling. Novel tracers such as 68Ga-FAPI (fibroblast activation protein inhibitor) have demonstrated the ability to detect early fibro-inflammatory processes within valvular and perivalvular tissue, offering insights beyond conventional structural imaging (33). Because fibroblast activation precedes leaflet thickening, annular dilation, and extracellular matrix expansion, FAPI PET may help identify early degenerative processes in individuals with preclinical MVP or early myxomatous transformation.

Similarly, 18F-NaF PET detects microcalcification at a molecular stage before macroscopic calcification becomes visible on CT. Studies have shown its ability to identify early valvular mineralization (34), which may be relevant in patients at risk of early calcific mitral annular pathology.

These applications align more closely with the definition of early MVD established in this review, characterized by asymptomatic, imaging-identified structural abnormalities, making PET a candidate for future early-detection pathways as tracer development progresses.

Hybrid and fusion imaging

The integration of PET with CT or CMR allows for simultaneous anatomical and metabolic assessment, improving localization and characterization of active disease. PET-CT provides detailed structural correlation, while PET-CMR adds functional and tissue-level context. In early MVD, these approaches are particularly valuable for localizing early fibro-inflammatory or microcalcific activity along the leaflets or mitral annulus. They also help identify subclinical myocardial involvement associated with MVP-mediated arrhythmia or early remodeling (35). In addition, hybrid imaging can clarify subtle abnormalities when echocardiography or CMR alone is inconclusive (36).

Advantages and limitations

PET offers high molecular sensitivity, quantitative assessment via standardized uptake values, and unique insight into early disease biology. However, limitations include high cost, limited availability, and radiation exposure. In addition, physiological myocardial uptake of FDG can obscure interpretation, necessitating careful patient preparation with glucose control and dietary modulation (32). Although promising, PET use in early MVD requires further validation in larger prospective studies.

A comparative summary of the core strengths, limitations, and applications of each modality is presented in Table 2.

Integrative multimodal imaging approach and clinical pathways

A patient-centered diagnostic strategy that integrates multiple imaging modalities is essential for the early and accurate assessment of MVD, particularly in complex or inconclusive cases. No single modality can provide complete structural, functional, and metabolic information; therefore, a multimodal approach ensures complementary strengths are utilized effectively to guide diagnosis and management.

Sequential imaging strategy

The diagnostic sequence typically begins with transthoracic echocardiography (TTE) as the first-line tool for initial screening and functional assessment, owing to its accessibility and real-time evaluation capabilities. In patients with suboptimal acoustic windows or complex lesions, TEE provides superior spatial resolution for detailed anatomical characterization.

CMR follows as the preferred technique for quantifying regurgitant volume, ventricular remodeling, and myocardial fibrosis, whereas CT plays a pivotal role in procedural planning, for surgical or transcatheter interventions through precise annular and spatial measurements. In selected cases, such as suspected prosthetic valve endocarditis or myocardial inflammation, PET offers valuable metabolic insights that complement structural imaging (4,37).

Clinical integration and decision pathways

The optimal imaging sequence is guided by clinical presentation, initial echocardiographic findings, and the suspected mechanism of disease. In early or asymptomatic MVD, particularly early MVP, multimodal imaging enhances diagnostic confidence by confirming subtle structural abnormalities, annular changes, and early indicators of adverse remodeling. When transthoracic echocardiography raises uncertainty regarding prolapse morphology, annular dynamics, or early regurgitation, TEE or three-dimensional imaging provides additional structural detail. CMR is useful when early myocardial involvement is suspected, such as detecting diffuse interstitial fibrosis that may predict progression. CT has a limited but complementary role in evaluating annular structure when long-term surveillance or potential future intervention is being considered. PET is reserved for select cases in which inflammatory or fibro-inflammatory processes could influence early disease trajectory.

The multidisciplinary heart team, integrating imaging specialists, cardiologists, interventionalists, and surgeons, is central to modern valvular care, ensuring appropriate follow-up intervals, determine when further imaging is needed, and identify early candidates for referral to specialized valve centers. This collaborative decision-making framework enhances diagnostic accuracy, reduces unnecessary interventions, and ensures early disease is managed proactively and consistently with guideline-directed care (38,39).

Proposed workflow

A structured diagnostic pathway for the evaluation and management of patients with suspected MVD is illustrated in Figure 1. The algorithm emphasizes a tiered approach beginning with TTE for screening, followed by TEE, CMR, CT, and PET as indicated based on clinical suspicion and disease complexity.

Figure 1 Clinical decision algorithm for multimodal imaging in early MVD. A structured diagnostic pathway for the evaluation and management of patients with suspected mitral valve disease. *, quantitative thresholds guide escalation to advanced imaging and potential intervention. **, clinical data: (LVESD >40 mm, LVEF <60%, LA volume index >60 mL/m², PASP >50 mmHg, symptoms). AI, artificial intelligence; CMR, cardiac magnetic resonance; CT, computed tomography; LA, left atrial; LVEF, left ventricular ejection fraction; LVESD, left ventricular end-systolic dimension; MR, mitral regurgitation; MS, mitral stenosis; MVD, mitral valve disease; PET, positron emission tomography; TEE, transesophageal echocardiography; TTE, transthoracic echocardiography.

Quantitative thresholds commonly used to guide escalation to advanced imaging and potential intervention include: (LVESD >40 mm, LVEF <60%, LA volume >60 mL/m², PASP >50 mmHg). This integrative approach supports early detection, precise risk stratification, and optimized procedural planning while minimizing redundant testing.

Clinical implications and long-term outcomes

Early prognostic markers and disease progression

Early and accurate imaging-based detection of MVD is critical for optimizing management before the onset of symptoms or irreversible structural changes. In mild or asymptomatic MR, multimodal imaging supports surveillance by identifying early markers of disease progression, including subtle declines in LVEF, early LA remodeling, and rising PASP. Stress echocardiography further refine risk assessment in early or borderline MR by detecting latent pulmonary hypertension and impaired contractile reserve, both of which indicate an increased likelihood of progression (4,12).

Advanced imaging modalities contribute to early prognostic assessment without necessarily indicating advanced disease. CMR, for example, detects diffuse interstitial fibrosis using T1 and ECV mapping, even when LVEF remains preserved, which has been shown to predict adverse remodeling and the need for closer follow-up in asymptomatic MR (18-20). Similarly, CT can assist in early anatomic characterization when echocardiography is inconclusive, although its procedural planning applications are more relevant in advanced disease and therefore not emphasized here.

Impact on patient-centered outcomes

Early detection and timely imaging-guided management improve patient-centered outcomes by preventing symptom onset and maintaining exercise tolerance and quality of life. Studies demonstrate that intervening before the onset of LV dysfunction is associated with improved functional status and reduced symptom burden compared with delayed intervention (40). Early identification of high-risk features through multimodal imaging therefore supports more proactive, individualized care.

Long-term outcomes

Timely diagnosis and intervention during the early stages of MVD, before ventricular dilation or fibrosis, patients experience superior long-term outcomes, including lower mortality, reduced incidence of atrial fibrillation, and decreased likelihood of future heart failure (41,42). Multimodal imaging also supports effective longitudinal monitoring, allowing clinicians to track subtle structural changes and adjust management accordingly. Emerging models such as the Whole-Life Cycle Management System encourage structured, imaging-driven follow-up to maintain long-term stability and prevent disease progression (43).

Improving accessibility in low-resource settings

Bridging the imaging gap

Echocardiography remains the most practical first-line imaging modality in low- and middle-income countries (LMICs) due to its portability, affordability, and non-invasive nature. However, major disparities persist due to limited access to trained personnel and advanced imaging infrastructure. To address these disparities, global initiatives now emphasize scalable, digitally enabled approaches that enhance diagnostic reach and consistency (44).

Telemedicine and training initiatives

Tele-echocardiography programs have substantially improved access to expert interpretation in underserved regions, with studies reporting significant increase in specialist consultations and diagnostic accuracy following the integration of remote, real-time mentorship systems (45). Complementary initiatives, such as the American Society of Echocardiography (ASE) Global Outreach Program, have trained over 5,000 echocardiographers since 2020 through online modules and field-based workshops, reducing operator variability and improving diagnostic reliability (46).

Portable and handheld imaging solutions

Advances in portable and handheld ultrasound technology have revolutionized point-of-care screening, particularly for rheumatic and early degenerative valve disease. When coupled with teleconsultation platforms and focused training, these devices allow for early, community-level detection. The 2023 World Heart Federation guidelines support simplified echocardiographic protocols optimized for handheld systems, facilitating large-scale screening programs and regional registries in LMICs (47,48).

Cost-effectiveness considerations

In resource-limited settings, echocardiography remains the most cost-effective modality, with a per-diagnosis cost estimated at $50–100, compared with approximately $500–1,000 for CMR or CT, and over $2,000 for PET due to radiotracer expenses (49,50). Innovations such as low-dose CT protocols and AI-assisted CMR reconstruction are further reducing procedural costs by 20–30%, expanding feasibility even in constrained environments (51). In high-income regions, CMR has demonstrated cost-effective by preventing unnecessary interventions, Siddiqui et al. [2022] found that CMR changed management in 71% of patients due to superior diagnostic precision (52). However, comprehensive cost-effectiveness data for advanced modalities in LMICs remain limited and warrant further evaluation through incremental cost-effectiveness ratio (ICER) analyses.

Global health and policy frameworks

The Whole-Life Cycle Management System proposed by Wang et al., provides a structured framework for integrating imaging, digital health, and longitudinal care. By combining telemedicine, portable imaging, and regional training centers, this model aims to standardize workflows and reduce diagnostic delays, ultimately improving outcomes and equity in valvular heart disease care worldwide (43).

Emerging technologies and future directions

AI and machine learning (ML)

AI and ML are revolutionizing cardiovascular imaging by automating image interpretation and improving diagnostic precision. In MVD, AI-enhanced echocardiography has demonstrated high diagnostic accuracy for MR severity assessment (53,54). Sadeghpour et al. reported that an ML-based multiparametric model achieved 92% sensitivity and 87% specificity for detecting moderate-to-severe MR, outperforming conventional approaches by reducing interobserver variability by 25% (55).

Similarly, AI-assisted 3D echocardiography has been shown to reduce analysis time by 30% and enhancing detection accuracy for valvular abnormalities, including early MR (56). Beyond diagnosis, AI-driven models are increasingly applied to risk prediction, workflow optimization, and automated quantification, although robust validation across diverse populations remains necessary.

Fusion and hybrid imaging

Techniques such as TEE-fluoroscopy, PET-CT, and PET-CMR integrate structural, functional, and metabolic data, enhancing both diagnosis and procedural guidance in complex MVD. For instance, hybrid 3D echocardiography-CT-derived models have reduced transcatheter procedural complications (e.g., paravalvular leak) by around 20%, particularly in complex valve anatomies (57).

Despite promising results, quantitative data for early MVD detection remain limited and largely derived from small-scale studies, warranting further validation.

Advances in CMR

Recent innovations in CMR, including 4D flow imaging and parametric mapping, have expanded its utility in early-stage MVD. 4D flow CMR enables visualization of three-dimensional intracardiac flow dynamics across the cardiac cycle, detecting subtle regurgitant jets and vortices that precede overt dysfunction. Gorecka et al. demonstrated that 4D flow CMR detected early regurgitant jets with 90% sensitivity and 85% specificity, surpassing traditional 2D techniques (58). Additionally, Zhuang et al. reported that 4D flow CMR estimated regurgitant volume within 5% of echocardiographic values, aiding in precise intervention timing (59).

Parametric mapping, particularly T1 and ECV quantification, detects diffuse myocardial fibrosis, serving as an early marker of adverse remodeling and prognostic deterioration (20). Despite these advantages, high acquisition costs and the need for specialized expertise currently limit widespread implementation.

Noval PET tracers

Emerging PET technologies, including low-dose system and novel tracers such as 68Ga-FAPI enable detection of early fibro-inflammatory remodeling in cardiovascular tissues. Early studies report that 68Ga-FAPI PET can visualize fibroblast activation associated with valvular and myocardial remodeling, offering complementary insights beyond conventional 18F-FDG imaging (60,61).

A detailed overview of these emerging imaging modalities, including AI, fusion imaging, advanced CMR, and novel PET techniques, is summarized in Table 3.

Future directions

Future diagnostic pathways for MVD are expected to integrate AI-driven analytics, multimodal fusion imaging, and advanced tissue characterization into unified platforms that enable real-time clinical decision-making.

Future research should prioritize large-scale validation of AI-based diagnostic algorithms across diverse populations, standardization of fusion imaging and 4D flow CMR acquisition/analysis protocols, and comprehensive cost-effectiveness and prognostic validation studies to guide clinical implementation. Expanding tele-imaging and portable imaging technologies within global health initiatives will further enhance accessibility and equity in cardiovascular diagnostics.

Through these ongoing innovations, multimodal cardiovascular imaging is advancing toward precision phenotyping, enabling earlier intervention, improved patient stratification, and more efficient, sustainable cardiovascular care worldwide.

Limitation

This article is a narrative review, and therefore it does not follow the structured methodology of a systematic review. The literature search may not have captured all relevant studies despite attempts at comprehensive screening. Study selection and data extraction were performed by a single author, which may introduce selection and interpretation bias. The review includes studies with heterogeneous designs, imaging protocols, and outcome measures, limiting direct comparability across sources. Evidence for some emerging modalities—such as AI-enhanced imaging, 4D flow CMR, and novel PET tracers—remains preliminary, and findings should be interpreted with caution. Finally, data from LMICs are limited, restricting the generalizability of conclusions regarding global accessibility and implementation.

Conclusions

Diagnostic imaging is fundamental to the early detection, characterization, and management of MVD. Echocardiography remains the first-line tool due to its accessibility, dynamic assessment capability, and cost-effectiveness. CMR enhances early-stage evaluation by providing precise quantification of regurgitant volume and subclinical myocardial fibrosis, while CT offers complementary anatomical detail in selected cases. Emerging techniques, including AI, hybrid imaging, and 4D flow CMR, are refining the ability to identify structural and functional abnormalities before symptoms develop, allowing earlier intervention and more accurate risk stratification.

As healthcare systems aim for earlier, more equitable diagnosis, integrating multimodal imaging with tele-echocardiography, portable ultrasound technologies, and standardized training frameworks will be crucial for ensuring equitable access, particularly in resource-limited settings. Continued research should emphasize validation of novel imaging biomarkers, cost-effectiveness analyses, and harmonized diagnostic pathways. Collectively, these advancements reinforce the central role of multimodal imaging in improving early MVD detection, guiding timely management, and ultimately enhancing long-term patient outcomes.

Acknowledgments

None.

Footnote

Reporting Checklist: The author has completed the Narrative Review reporting checklist. Available at https://cdt.amegroups.com/article/view/10.21037/cdt-2025-442/rc

Peer Review File: Available at https://cdt.amegroups.com/article/view/10.21037/cdt-2025-442/prf

Funding: None.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://cdt.amegroups.com/article/view/10.21037/cdt-2025-442/coif). The author has no conflicts of interest to declare.

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