Multimodality cardiac imaging in advanced heart failure: Diagnosis, risk stratification, and therapeutic guidance

Advanced heart failure represents a high-risk clinical stage in which imaging is used not only to document ventricular dysfunction but also to clarify etiology, assess right-sided reserve, define valvular and pulmonary vascular contributions, stratify risk, and determine suitability for advanced therapies. In this narrative review, guided by the Scale for the Assessment of Narrative Review Articles, we summarized the contemporary role of echocardiography, cardiac magnetic resonance, cardiac computed tomography, and selected nuclear imaging techniques in the evaluation of patients with advanced heart failure. A focused literature search of PubMed and major cardiology society guidance was performed to identify clinically relevant publications on multimodality imaging in advanced heart failure, durable mechanical circulatory support, transplantation, valvular intervention, and risk stratification. Echocardiography remains the first-line modality for bedside assessment of ventricular performance, congestion, filling pressures, and valve disease. Cardiac magnetic resonance is particularly useful for tissue characterization, fibrosis assessment, etiologic clarification, and arrhythmic risk evaluation. Cardiac computed tomography provides high-value anatomical information for procedural planning, including left ventricular assist device implantation and structural interventions. Nuclear imaging plays a more selective role in viability assessment and evaluation of infiltrative or inflammatory cardiomyopathies. A practical multimodality strategy should be question-driven rather than test-driven, with each modality selected according to the next management decision. This approach may improve clinical usefulness, reduce redundant testing, and better support individualized management in advanced heart failure.