2023 Korean Society of Echocardiography position paper for the diagnosis and management of valvular heart disease, part II: mitral and tricuspid valve disease.

This manuscript represents the official position of the Korean Society of Echocardiography on valvular heart diseases. This position paper focuses on the diagnosis and management of valvular heart diseases with referring to the guidelines recently published by the American College of Cardiology/American Heart Association and the European Society of Cardiology. The committee sought to reflect national data on the topic of valvular heart diseases published to date through a systematic literature search based on validity and relevance. In the part II of this article, we intend to present recommendations for diagnosis and treatment of mitral valve disease and tricuspid valve disease.

Early unloading and clinical outcomes in patients with fulminant myocarditis undergoing VA-ECMO: results of a multicenter retrospective study.

INTRODUCTION AND OBJECTIVES: Although venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides effective cardiocirculatory support in patients with fulminant myocarditis, the most effective timing of venting is uncertain. We aimed to investigate the benefit of early venting among patients who underwent VA-ECMO for fulminant myocarditis. METHODS: Among 841 patients with acute myocarditis from 7 hospitals in the Republic of Korea, 217 patients with fulminant myocarditis who underwent VA-ECMO were included in this analysis. The patients were categorized into 2 groups: an early unloading group that underwent venting within 24 hours of ECMO insertion, and the no or delayed unloading group. The primary outcome was a composite of death, cardiac replacement, or cardiovascular rehospitalization. RESULTS: Among 217 patients, 56 underwent early venting, 54 underwent delayed venting, and 107 did not undergo venting. On spline curves in 110 patients who underwent venting, rapid deterioration was observed as the timing of venting was delayed. The incidence of the primary outcome was lower in the early venting group than in the no or delayed unloading group (37.5% vs 58.4%; HR, 0.491; 95%CI, 0.279-0.863; P = .014). Among patients not experiencing the primary outcome within 6 months, clinical outcomes were similar after 6 months (P = .375). CONCLUSIONS: Early left heart unloading within 24 hours of ECMO insertion is associated with a lower risk of a composite of death, cardiac replacement therapy, and cardiovascular rehospitalization in patients with fulminant myocarditis undergoing VA-ECMO. Registered at ClinicalTrials.gov (NCT05933902).

Discordant Uptake of Leg Thrombi Versus Pulmonary Emboli on 68 Ga-FAPI-46 PET/CT.

ABSTRACT: Fibroblast activation protein inhibitor (FAPI) PET is gaining clinical relevance for visualizing activated fibroblasts in various diseases. Here, we report discordant FAPI uptake between venous thrombi of the lower extremities and pulmonary emboli. An 86-year-old man complained of left leg swelling and acute dyspnea; he was diagnosed with deep vein thrombosis involving the left femoral vein and acute pulmonary thromboembolism. Positive FAPI uptake was observed only in the thrombi of the left femoral vein, but not in the pulmonary emboli. Such discrepancies may indicate different thrombus constituents and chronologies even in the same patient.

Timing of heart failure development and clinical outcomes in patients with acute myocardial infarction.

Background and objectives: To investigate the clinical relevance of the timing of heart failure (HF) development on long-term outcome in patients with acute myocardial infarction (AMI). Materials and methods: A total of 1,925 consecutive AMI patients were divided into 4 groups according to the timing of HF development; HF at admission (group I, n = 627), de novo HF during hospitalization (group II, n = 162), de novo HF after discharge (group III, n = 98), no HF (group IV, n = 1,038). Major adverse cardiac events (MACE) defined as the development of death, re-hospitalization, recurrent MI or revascularization were evaluated. Results: HF was developed in 887 patients (46.1%) after an index AMI. HF was most common at the time of admission for AMI, but the development of de novo HF during hospitalization or after discharge was not uncommon. MACE was developed in 619 out of 1,925 AMI patients (31.7%). MACE was highest in group I, lowest in group IV, and significantly different among groups; 275 out of 627 patients (43.9%) in group I, 64 out of 192 patients (39.5%) in group II, 36 out of 98 patients (36.7%) in group III, and 235 out of 1,038 patients (22.6%) in group IV (P < 0.001). MACE free survival rates at 3 years were 56% in group I, 62% in group II, 64% in group III, and 77% in group IV (P < 0.001). Conclusions: HF was not uncommon and can develop at any time after an index AMI, and the development of HF was associated with poor prognosis. The earlier the HF has occurred after AMI, the poorer the clinical outcome was. To initiate the guideline directed optimal medical therapy, therefore, the development of HF should be carefully monitored even after the discharge from an index AMI.

COVID-19 vaccination-related myocarditis: a Korean nationwide study.

AIMS: A comprehensive nationwide study on the incidence and outcomes of COVID-19 vaccination-related myocarditis (VRM) is in need. METHODS AND RESULTS: Among 44 276 704 individuals with at least 1 dose of COVID-19 vaccination, the incidence and clinical courses of VRM cases confirmed by the Expert Adjudication Committee of the Korea Disease Control and Prevention Agency were analyzed. COVID-19 VRM was confirmed in 480 cases (1.08 cases per 100 000 persons). Vaccination-related myocarditis incidence was significantly higher in men than in women (1.35 vs. 0.82 per 100 000 persons, P < 0.001) and in mRNA vaccines than in other vaccines (1.46 vs. 0.14 per 100 000 persons, P < 0.001). Vaccination-related myocarditis incidence was highest in males between the ages of 12 and 17 years (5.29 cases per 100 000 persons) and lowest in females over 70 years (0.16 cases per 100 000 persons). Severe VRM was identified in 95 cases (19.8% of total VRM, 0.22 per 100 000 vaccinated persons), 85 intensive care unit admission (17.7%), 36 fulminant myocarditis (7.5%), 21 extracorporeal membrane oxygenation therapy (4.4%), 21 deaths (4.4%), and 1 heart transplantation (0.2%). Eight out of 21 deaths were sudden cardiac death (SCD) attributable to VRM proved by an autopsy, and all cases of SCD attributable to VRM were aged under 45 years and received mRNA vaccines. CONCLUSION: Although COVID-19 VRM was rare and showed relatively favorable clinical courses, severe VRM was found in 19.8% of all VRM cases. Moreover, SCD should be closely monitored as a potentially fatal complication of COVID-19 vaccination.

Sex-Specific Predictors of Long-Term Mortality in Elderly Patients with Ischemic Cardiomyopathy.

Ischemic heart failure (HF) is one of the most common causes of morbidity and mortality in the world-wide, but sex-specific predictors of mortality in elderly patients with ischemic cardiomyopathy (ICMP) have been poorly studied. A total of 536 patients with ICMP over 65 years-old (77.8 ± 7.1 years, 283 males) were followed for a mean of 5.4 years. The development of death during clinical follow up was evaluated, and predictors of mortality were compared. Death was developed in 137 patients (25.6%); 64 females (25.3%) vs. 73 males (25.8%). Low-ejection fraction was only an independent predictor of mortality in ICMP, regardless of sex (HR 3.070 CI = 1.708-5.520 in female, HR 2.011, CI = 1.146-3.527 in male). Diabetes (HR 1.811, CI = 1.016-3.229), elevated e/e' (HR 2.479, CI = 1.201-5.117), elevated pulmonary artery systolic pressure (HR 2.833, CI = 1.197-6.704), anemia (HR 1.860, CI = 1.025-3.373), beta blocker non-use (HR2.148, CI = 1.010-4.568), and angiotensin receptor blocker non-use (HR 2.100, CI = 1.137-3.881) were bad prognostic factors of long term mortality in female, whereas hypertension (HR 1.770, CI = 1.024-3.058), elevated Creatinine (HR 2.188, CI = 1.225-3.908), and statin non-use (HR 3.475, CI = 1.989-6.071) were predictors of mortality in males with ICMP independently. Systolic dysfunction in both sexes, diastolic dysfunction, beta blocker and angiotensin receptor blockers in female, and statins in males have important roles for long-term mortality in elderly patients with ICMP. For improving long-term survival in elderly patients with ICMP, it may be necessary to approach sex specifically.

Predictors of Progression of Tricuspid Regurgitation in Patients with Persistent Atrial Fibrillation.

Previous studies have shown that tricuspid regurgitation (TR) can be developed in patients with atrial fibrillation (AF) due to annular dilatation. This study aimed to investigate the incidence and predictors of the progression of TR in patients with persistent AF. A total of 397 patients (66.9±11.4 years, 247 men; 62.2%) with persistent AF were enrolled between 2006 and 2016 in a tertiary hospital, and 287 eligible patients with follow-up echocardiography were analyzed. They were divided into two groups according to TR progression (progression group [n=68, 70.1±10.7 years, 48.5% men] vs. non-progression group [n=219, 66.0±11.3 years, 64.8% men]). Among 287 patients in the analysis, 68 had worsening TR severity (23.7%). Patients in the TR progression group were older and more likely to be female. Patients with left ventricular ejection fraction <50% were less frequent in the progression group than those in the non-progression group (7.4% vs. 19.6%, p=0.018). Patients with mitral valve disease were more frequent in the progression group. Multivariate analysis with COX regression demonstrated independent predictors of TR progression, including left atrial (LA) diameter >54 mm (HR 4.85, 95%CI 2.23-10.57, p<0.001), E/e' (HR 1.05, 95%CI 1.01-1.10, p=0.027), and no use of antiarrhythmic agents (HR 2.20, 95%CI 1.03-4.72, p=0.041). In patients with persistent AF, worsening TR was not uncommon. The independent predictors of TR progression turned out to be greater LA diameter, higher E/e', and no use of antiarrhythmic agents.

Epidemiologic Profile of Patients With Valvular Heart Disease in Korea: A Nationwide Hospital-Based Registry Study.

BACKGROUND: Valvular heart disease (VHD) is a common cause of cardiovascular morbidity and mortality worldwide; however, its epidemiological profile in Korea requires elucidation. METHODS: In this nationwide retrospective cohort study from the Korean valve survey, which collected clinical and echocardiographic data on VHD from 45 medical centers, we identified 4,089 patients with VHD between September and October 2019. RESULTS: The aortic valve was the most commonly affected valve (n = 1,956 [47.8%]), followed by the mitral valve (n = 1,598 [39.1%]) and tricuspid valve (n = 1,172 [28.6%]). There were 1,188 cases of aortic stenosis (AS) and 926 cases of aortic regurgitation. The most common etiology of AS was degenerative disease (78.9%). The proportion of AS increased with age and accounted for the largest proportion of VHD in patients aged 80-89 years. There were 1,384 cases of mitral regurgitation (MR) and 244 cases of mitral stenosis (MS). The most common etiologies for primary and secondary MR were degenerative disease (44.3%) and non-ischemic heart disease (63.0%), respectively, whereas rheumatic disease (74.6%) was the predominant cause of MS. There were 1,172 tricuspid regurgitation (TR) cases, of which 46.9% were isolated and 53.1% were associated with other valvular diseases, most commonly with MR. The most common type of TR was secondary (90.2%), while primary accounted for 6.1%. CONCLUSIONS: This report demonstrates the current epidemiological status of VHD in Korea. The results of this study can be used as fundamental data for developing Korean guidelines for VHD.

Association between myocardial ischemia and plaque characteristics in chronic total occlusion.

BACKGROUND: Myocardial ischemia varies in chronic total occlusion (CTO) despite the occluded artery. We analyzed whether it is associated with the plaque characteristics of the occluded segment. METHODS: We retrospectively enrolled 100 patients with CTO who underwent myocardial perfusion single-photon emission computed tomography (SPECT) and coronary computed tomography angiography (CCTA) within 2 months. CTO-related ischemia was classified as moderate to severe (summed difference score [SDS] of the CTO territory ≥ 5) or mild or none (SDS < 5) on SPECT. Using CCTA, the atherosclerotic plaques of the occluded segment were subdivided into low-density (- 100-30 HU), intermediate-density (31-350 HU), and high-density (351-1000 HU) plaques. The plaque composition was compared according to the severity of CTO-related ischemia. RESULTS: Moderate-to-severe CTO-related ischemia (n = 23) showed significantly higher proportion of intermediate-density plaques (72.4% vs. 64.0%), intermediate/low-density (7.10 vs. 3.65) and intermediate-to-high/low-density (7.78 vs. 3.80) plaque ratios, frequent shorter occlusion (30% vs. 6%), and lower volume (26.5 mm3 vs. 58.8 mm3) and proportion (11.4% vs. 20.8%) of low-density plaques. Multivariable analysis revealed significant associations between higher proportion of intermediate-density plaques and moderate-to-severe CTO-related ischemia, independent of occlusion length. CONCLUSION: Higher proportion of intermediate-density plaques in the occluded segment was associated with the moderate-to-severe CTO-related ischemia.

A Case Report for Acute Myopericarditis After NVX-CoV2373 (Novavax®) COVID-19 Vaccination.

Post-vaccination myocarditis after administration of the NVX-CoV2373 coronavirus disease 2019 (COVID-19) vaccine has been reported in a limited population. We report the first biopsy-proven case of myopericarditis after administration of second dose of NVX-CoV2373 COVID-19 vaccine (Novavax®) in Korea. A 30-year-old man was referred to emergency department with complaints of chest pain and mild febrile sense for two days. He received the second dose vaccine 17 days ago. Acute myopericarditis by the vaccination was diagnosed by cardiac endomyocardial biopsy. He was treated with corticosteroid 1 mg/kg/day for 5 days and tapered for one week. He successfully recovered and was discharged on the 12th day of hospitalization. The present case suggests acute myopericarditis as a vaccination complication by Novavax® in Korea.

Impact of Cardiac Troponin Elevation on Mortality of Patients with Acute Heart Failure: Insights from the Korea Acute Heart Failure (KorAHF) Registry.

We aimed to conduct the largest study evaluating the impact of cardiac troponin (TnI) status on mid- and long-term mortality in patients admitted for acute heart failure (AHF) as compared between patients with ischemic (IHF) vs. non-ischemic heart failure (non-IHF). Among 5625 patients from the Korea Acute Heart Failure (KorAHF) registry, 4396 eligible patients with TnI measurement were analyzed. The patients were included on admission with the diagnosis of AHF, and TnI level was measured on the day of admission. A TnI value of <0.05 ng/mL was considered normal. The patients were divided into four groups according to the etiology of heart failure and the status of TnI: non-IHF with normal TnI (n = 1009) vs. non-IHF with elevated TnI (n = 1665) vs. IHF with normal TnI (n = 258) vs. IHF with elevated TnI (n = 1464). The primary outcome was death from all causes according to the etiology (non-IHF vs. IHF) and TnI elevation during the entire follow-up period of 784 days (IQR 446−1116). Elevation of TnI was observed in 71.2% of all patients with AHF. Patients with IHF had higher all-cause mortality compared to those with non-IHF. Elevated TnI was associated with higher 90-day and post-90-day mortality in the non-IHF group. IHF as compared to non-IHF and elevation of TnI were independent predictors of mortality also in the adjustment analysis. In the IHF group, however, elevated TnI had a higher mortality with only 90-day follow-up (18.6% vs. 25.9%, log-rank p < 0.001), not in the post-90-day follow-up (31.1% vs. 32.5%, log-rank p = 0.799). In conclusion, elevated TnI in patients with heart failure is associated with increased all-cause mortality regardless of the etiology of HF. Elevation of TnI was associated to a higher post-90 day mortality in patients with non-IHF but not in patients with IHF.

Awareness of cardiovascular disease among Korean women: Results from a nationwide survey.

Women underestimate the risk of cardiovascular disease (CVD). It is essential to assess and raise awareness regarding CVD among women to reduce disease burden and mortality. Therefore, we investigated the awareness regarding CVD among Korean women. We conducted a nationwide survey between December 2020 and January 2021 among a representative sample of Korean women using random-digit-dialing telephonic interviews. We sought information regarding the awareness of CVD risk; recognition of symptoms and signs; and knowledge of the cause and prevention of and appropriate response to CVD. A total of 1,050 women (mean age, 60.2 ± 11.9 years) participated in the study. Approximately 52.0% of participants were unaware of CVD, and only 26% of participants had heard of CVD. Participants considered that compared to other diseases, CVD was not an important health issue for women, and few of them thought that cerebrovascular diseases and CVD were the leading causes of death (10.9% and 7.6%, respectively). After adjustment for possible confounding factors, age >70 years, rural residence, and educational attainment below college were independently associated with a lack of awareness regarding CVD. The awareness regarding CVD being the leading cause of death in women is low, and most women do not consider it an important health issue. Therefore, special attention must be paid to educate the public regarding CVD in women.

Characteristics and Clinical Outcomes of Cancer Patients who Developed Constrictive Physiology After Pericardiocentesis.

BACKGROUND AND OBJECTIVES: This study aimed to identify the characteristics and clinical outcomes of cancer patients who developed constrictive physiology (CP) after percutaneous pericardiocentesis. METHODS: One-hundred thirty-three cancer patients who underwent pericardiocentesis were divided into 2 groups according to follow-up echocardiography (CP vs. non-CP). The clinical history, imaging findings, and laboratory results, and overall survival were compared. RESULTS: CP developed in 49 (36.8%) patients after pericardiocentesis. The CP group had a more frequent history of radiation therapy. Pericardial enhancement and malignant masses abutting the pericardium were more frequently observed in the CP group. Fever and ST segment elevation were more frequent in the CP group, with higher C-reactive protein levels (6.6±4.3mg/dL vs. 3.3±2.5mg/dL, p<0.001). Pericardial fluid leukocytes counts were significantly higher, and positive cytology was more frequent in the CP group. In baseline echocardiography before pericardiocentesis, medial e' velocity was significantly higher in the CP group (8.6±2.1cm/s vs. 6.5±2.3cm/s, p<0.001), and respirophasic ventricular septal shift, prominent expiratory hepatic venous flow reversal, pericardial adhesion, and loculated pericardial fluid were also more frequent. The risk of all-cause death was significantly high in the CP group (hazard ratio, 1.53; 95% confidence interval,1.10-2.13; p=0.005). CONCLUSIONS: CP frequently develops after pericardiocentesis, and it is associated with poor survival in cancer patients. Several clinical signs, imaging, and laboratory findings suggestive of pericardial inflammation and/or direct malignant pericardial invasion are frequently observed and could be used as predictors of CP development.

Usefulness of Diastolic Function Score as a Predictor of Long-Term Prognosis in Patients With Acute Myocardial Infarction.

Background: Left ventricular diastolic function (LVDF) evaluation using a combination of several echocardiographic parameters is an important predictor of adverse events in patients with acute myocardial infarction (AMI). To date, the clinical impact of each individual LVDF marker is well-known, but the clinical significance of the sum of the abnormal diastolic function markers and the long-term clinical outcome are not well-known. This study aimed to investigate the usefulness of LVDF score in predicting clinical outcomes of patients with AMI. Methods: LVDF scores were measured in a 2,030 patients with AMI who underwent successful percutaneous coronary intervention from 2012 to 2015. Four LVDF parameters (septal e' ≥ 7 cm/s, septal E/e' ≤ 15, TR velocity ≤ 2.8 m/s, and LAVI ≤ 34 ml/m2) were used for LVDF scoring. The presence of each abnormal LVDF parameter was scored as 1, and the total LVDF score ranged from 0 to 4. Mortality and hospitalization due to heart failure (HHF) in relation to LVDF score were evaluated. To compare the predictive ability of LVDF scores and left ventricular ejection fraction (LVEF) for mortality and HHF, receiver operating characteristic (ROC) curve and landmark analyses were performed. Results: Over the 3-year clinical follow-up, all-cause mortality occurred in 278 patients (13.7%), while 91 patients (4.5%) developed HHF. All-cause mortality and HHF significantly increased as LVDF scores increased (all-cause mortality-LVDF score 0: 2.3%, score 1: 8.8%, score 2: 16.7%, score 3: 31.8%, and score 4: 44.5%, p < 0.001; HHF-LVDF score 0: 0.6%, score 1: 1.8%, score 2: 6.3%, score 3: 10.3%, and score 4: 18.2%, p < 0.001). In multivariate analysis, a higher LVDF score was associated with significantly higher adjusted hazard ratios for all-cause mortality and HHF. In landmark analysis, LVDF score was a better predictor of long-term mortality than LVEF (area under the ROC curve: 0.739 vs. 0.640, p < 0.001). Conclusion: The present study demonstrated that LVDF score was a significant predictor of mortality and HHF in patients with AMI. LVDF scores are useful for risk stratification of patients with AMI; therefore, careful monitoring and management should be performed for patients with AMI with higher LVDF scores.

Epidemiology of Venous Thromboembolism and Treatment Pattern of Oral Anticoagulation in Korea, 2009-2016: a Nationwide Study Based on the National Health Insurance Service Database.

BACKGROUND: The annual incidence of venous thromboembolism (VTE) is increasing, and the treatment pattern of oral anticoagulants (OACs) has changed with introduction of new oral anticoagulants (NOACs). The aims of this study were to assess the annual incidence of VTE in a Korean population and the change of treatment pattern with availability of NOACs using a population-based database. METHODS: Using the Korean National Health Insurance Services database, we identified patients diagnosed with VTE between 2009 and 2016. The annual prevalence of VTE and clinical characteristics and treatment pattern were investigated. The annual incidence of VTE was calculated using direct and indirect methods using the estimated Korean population in 2009 as the reference. RESULTS: The annual incidence of VTE in Korean has increased yearly from 23.9 per 100,000 in 2009 to 42.2 in 2016. The overall rate of OAC prescription for VTE treatment increased from 55.9% to 68% in the same time period. The rate of initiation of NOAC treatment greatly increased, particularly from 2013 onwards, with a 20-fold increase from 2009 to 2016 (2.1% vs. 54.3%). CONCLUSIONS: The annual incidence of VTE in Korea increased by almost two-fold from 2009 to 2016. The rate of initiation of NOAC treatment has increased substantially since 2013, and these agents have surpassed VKAs as the anticoagulant of choice for VTE. This temporal pattern of OAC prescription is consistent with the current clinical guidelines, which indicate NOACs over the warfarin in patients with VTE.

Gender Difference of Cardiac Remodeling in University Athletes: Results from 2015 Gwangju Summer Universiade.

BACKGROUND AND OBJECTIVES: There is little data about cardiac geometry in highly trained young athletes, especially female specific changes. We investigated gender difference on exercise induced cardiac remodeling (EICR) in highly trained university athletes. METHODS: A total of 1,185 university athletes divided into 2 groups; female (n=497, 22.0±2.3 years) vs. male (n=688, 22.6±2.4 years). Remodeling of the left ventricle (LV), left atrium (LA), right ventricle (RV), and any cardiac chamber were compared. RESULTS: LV, LA, RV, and any remodeling was found in 156 (13.2%), 206 (17.4%), 82 (6.9%), and 379 athletes (31.9%), respectively. LV, LA, and any remodeling were more common in male than female athletes (n=53, 12.1% vs. n=103, 15.5%, p=0.065), (n=65, 13.1% vs. n=141, 20.5%, p<0.001), (n=144, 30.0% vs. n=235, 34.2%, p=0.058), respectively, whereas RV remodeling was significantly more common in female than male athletes (n=56, 11.3% vs. n=26, 3.8%, p<0.001). Interestingly, the development of LV, LA, and RV remodeling were not overlapped in many of athletes, suggesting different mechanism of EICR according to cardiac chamber. Various predictors including sports type, heart rate, muscle mass, fat mass, body surface area, and training time were differently involved in cardiac remodeling, and there were gender differences of these predictors for cardiac remodeling. CONCLUSIONS: EICR was common in both sex and was independently developed among cardiac chambers in highly trained university athletes. LV and LA remodeling were common in males, whereas RV remodeling was significantly more common in females demonstrating gender difference in EICR. The present study also demonstrated gender difference in the predictors of EICR.

Multimodality cardiovascular imaging in pulmonary embolism.

Acute pulmonary embolism (APE) is one of the leading causes of cardiovascular (CV) morbidity and mortality. To select appropriate therapeutic strategy and/or to minimize the mortality and morbidity, rapid and correct identification of life-threatening APE is very important. Also, right ventricular (RV) failure usually precedes acute hemodynamic compromise or death, and thus the identification of RV failure is another important step in risk stratification or treatment of APE. With advances in diagnosis and treatment, the prognosis of APE has been dramatically improving in most cases, but inadequate therapy or recurrent episodes of pulmonary embolism (PE) may result in negative outcomes or, so called, chronic thromboembolic pulmonary hypertension (CTEPH). CTEPH is a condition characterized by remaining chronic thromboembolic material in the pulmonary vasculature and subsequent chronic pulmonary hypertension. Various imaging modalities include chest computed tomography pulmonary angiography (CTPA), echocardiography, magnetic resonance imaging, and nuclear imaging and each are used for the assessment of varying status of PE. Assessment of thromboembolic burden by chest CTPA is the first step in the diagnosis of PE. Hemodynamic assessment can be achieved by echocardiography and also by chest CTPA. Nuclear imaging is useful in discriminating CTEPH from APE. Better perspectives on diagnosis, risk stratification and decision making in PE can be provided by combining multimodality CV imaging. Here, the advantages or pitfalls of each imaging modality in diagnosis, risk stratification, or management of PE will be discussed.