Cardiology has always been a field that has pushed the boundaries of innovation without forgetting old traditions. The foundation of our practice still reaches back to Lannaec's innovative use of auscultation and Einthoven's work on the electrocardiogram. But our drive to create innovative and practical tools for patient care has shaped modern medicine. It is this innovative spirit that led Harvey Feigenbaum, MD, who had roots in invasive cardiac catheterization, to adopt and push forward a generation of clinical echocardiography. This history of developing and integrating new technologies is unique to the field of cardiology, and it is important to reflect upon this tradition as we evaluate the modern era of multimodality imaging.

'Multimodality imaging' itself can be a challenging concept to define. Rather than being simply a license to increase the amount of imaging, its essence is encapsulated by the more precise phrase of "Effective Multimodality Imaging," coined by Weissman, et al. At a basic level, the concept behind effective multimodality imaging is the utilization of specific imaging expertise to reduce layered testing and subsequent downstream costs by improving initial test selection. But beyond this, multimodality imaging should be viewed as a distinct subspecialty of cardiology where the thoughtful integration of new imaging technologies is used to improve patient care.

An illustration of the value added with multimodality imaging lies within the realm of structural heart disease interventions. Transcatheter aortic valve replacement (TAVR) is now widely adopted, and this adoption has heralded a new age of collaborative imaging. In TAVR, the recognition that poor outcomes were partly driven by paravalvular regurgitation, vascular access complications and stroke coincided with technologic improvements and post processing tools developed for coronary computed tomography angiography (CTA). Utilizing the power of gated CTA scans with fully 3D datasets for the pre-procedural planning of TAVR allowed for the acquisition of motion-free images of the heart throughout the cardiac cycle. This led to our current understanding of the dynamic and complex nature of the aortoannuluar complex and its importance for prosthetic valve sizing. Gated CTA is now an important part of pre-procedural planning for TAVR in most high-volume centers and its thoughtful integration for TAVR has set the stage for the planning of even more complex procedures.

For the trainee, the world of imaging can be exciting but increasingly complex. Although the importance of exposure to multiple imaging modalities was recognized in the 2015 ACC COCATS 4 training guidelines, imaging exposure to different modalities is often limited by the expertise and case volume of a given institution; achieving true competence often requires supplementation with additional years of dedicated training. In addition to the extra training time, fellows now undergo the burden of Board certification in multiple imaging modalities, which has become an expensive and daunting prospect.

For the graduating fellow looking for their first job, the challenges continue for an individual who wants to have a truly integrative multimodality imaging practice. The first practicality comes from simply finding a position where multimodality imaging is valued as a specific and unique discipline. In most centers, imaging modalities are in silos of expertise that may be physically and philosophically separated. In such a model, it is rare for an institution to have a clinical need in every discipline one has trained in. Thus, finding an imaging position often requires flexibility and likely some compromise in location, job description and compensation. For young imagers who have dedicated years to additional training, these can be difficult compromises to make.

The Early Career imager is also faced with difficulties. If a collaborative structure is not pre-existing, substantial portions of their time may be spent on programmatic development and education. There are also the professional challenges in maintaining adequate case volumes, staying current with multiple complex imaging modalities, maintaining multiple board certifications and facing down the realities of the often poor reimbursement structure for advanced imaging.

However, one must not forget that the burdensome nature of testing in cardiology is a problem of our own making. In forging new territory, exams have been valuable in standardizing training and establishing competence to practice newly emerging fields of cardiology. It is the existence of these pathways of certification that have allowed cardiologists to make new technologies an integral part of cardiovascular care. And despite the current challenges, the future of multimodality imaging is bright. Cardiology is growing exponentially with more complex patients and advanced interventions. As individual imaging modalities continue to mature, this young field of integrative multimodality imaging will become an essential service line that will only continue to grow in importance.

This article was authored by James Lee, MD.