The following are viewpoints from this state-of-the-art review on myocardial tissue imaging:

1. Myocardial fibrosis, either focal or diffuse, is a common feature of many cardiac conditions and is associated with a poor prognosis for major adverse cardiovascular events.
2. Although histological analysis remains the gold standard for confirming the presence of myocardial fibrosis, endomyocardial biopsy is invasive, has sampling errors, and is not practical in the routine clinical setting.
3. Cardiac imaging modalities offer noninvasive surrogate biomarkers not only for fibrosis but also for myocardial edema and infiltration to varying degrees, and have important roles in the diagnosis and management of cardiac diseases.
4. This review summarizes important pathophysiological features in the development of commonly encountered cardiac diseases, and the principles, advantages, and disadvantages of various cardiac imaging modalities (echocardiography, single-photon emission computer tomography, positron emission tomography, multidetector computed tomography [MDCT], and cardiac magnetic resonance [CMR]) for myocardial tissue characterization, with an emphasis on imaging focal and diffuse myocardial fibrosis.
5. Myocardial reflectivity to ultrasound by echocardiography and the analysis of backscatter signal have been used as a noninvasive method of tissue characterization and marker of collagen deposition.
6. Fibrosis identification with MDCT has shown satisfactory agreement with late gadolinium enhancement (LGE) CMR, particularly in ischemic heart disease. However, the use of MDCT to detect diffuse abnormalities of myocardial tissue is significantly more challenging than the evaluation of regional scar, due the low contrast resolution.
7. Overall, among imaging modalities, CMR offers comprehensive myocardial tissue characterization by providing various diagnostic and prognostic imaging biomarkers.
8. With the advancement of quantitative, pixel-wise CMR mapping technology, it is now feasible to detect changes in acute myocardial injury, as well as focal and diffuse myocardial fibrosis, with high spatial resolution. However, the use of MDCT to detect diffuse abnormalities of myocardial tissue is significantly more challenging than the evaluation of regional scar, due to the low contrast resolution.
9. The effective use of these sophisticated imaging biomarkers for medical decision making, prognostication, and development of therapeutic targets will maximize their clinical usefulness.
10. Available data suggest that advanced cardiac imaging will become an integral part in risk stratification and personalized medicine in the future.

Clinical Topics: Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Interventions and Imaging, Computed Tomography, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Nuclear Imaging

Keywords: Biomarkers, Cardiac Imaging Techniques, Diagnostic Imaging, Echocardiography, Edema, Endomyocardial Fibrosis, Heart Failure, Gadolinium, Magnetic Resonance Imaging, Multidetector Computed Tomography, Myocardial Ischemia, Myocardium, Positron-Emission Tomography, Tomography, Emission-Computed, Single-Photon

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