Multiparametric Cardiac MRI for the Diagnosis and Differentiation of Cardiomyopathy Phenotypes: Current Applications and Future Perspectives

Abstract

Introduction. Cardiomyopathies are myocardial diseases characterized by structural and functional abnormalities in the absence of coronary artery disease, arterial hypertension, or valvular pathology sufficient to explain the observed changes. Their origin may be either genetic or acquired. Cardiac magnetic resonance imaging (CMR) is the leading non-invasive diagnostic tool that enables comprehensive assessment of cardiac morphology, function, and tissue characteristics. The use of LGE and parametric techniques (T1-, T2-mapping, and ECV) facilitates the detection of fibrosis, infiltration, and edema. In 2023, the European Society of Cardiology introduced a phenotype-based classification in which CMR plays a central role, highlighting five main phenotypes: hypertrophic, dilated, non-dilated left ventricular, arrhythmogenic right ventricular, and restrictive cardiomyopathy.

Aim. To demonstrate the key role of multiparametric CMR in identifying, differentiating, and prognosticating cardiomyopathies through analysis of characteristic CMR features and application of a systematic interpretative approach.

Review and discussion. Over the past decades, cardiomyopathy classifications have evolved substantially – from the basic morphological forms of the WHO/ISFC (DCM, HCM, RCM) to the contemporary phenotype-based model of ESC 2023. A pivotal milestone was the introduction of multiparametric CMR, which combines precise morpho-functional assessment with quantitative tissue characterization. CMR enables accurate evaluation of chamber volumes, ventricular function, and myocardial tissue changes (fibrosis, edema, infiltration) using LGE, T1- and T2-mapping, and ECV. The presence and extent of LGE are associated with an increased risk of sudden cardiac death, whereas parametric mapping techniques provide valuable diagnostic insights into diffuse myocardial processes even in the absence of contrast administration.

The current ESC classification distinguishes five principal phenotypes–hypertrophic, dilated, non-dilated left ventricular, arrhythmogenic right ventricular, and restrictive cardiomyopathy. In all these phenotypes, CMR plays a central role in diagnosis, risk stratification, and therapeutic decision-making.

In Ukraine, multiparametric CMR is gradually being implemented in leading cardiac surgery centers. However, wider adoption remains limited by the high cost of software, lack of dedicated workstations, and shortage of trained specialists. The future development of the method depends on protocol standardization, improved accessibility, and integration into national clinical guidelines.

Conclusions. Multiparametric cardiac magnetic resonance imaging is a key method for the diagnosis and differentiation of cardiomyopathy phenotypes. It provides a precise assessment of cardiac volumes, function, and myocardial tissue characteristics (LGE, T1-, T2-mapping, and ECV), enabling determination of disease etiology and differentiation of its variants. This technique is essential for accurate diagnosis, risk stratification, and selection of optimal management strategies for patients with cardiomyopathies.