Multimodality imaging in valvular heart disease: how to use state-of-the-art technology in daily practice Anna Reid 1, Philipp Blanke 1, Jeroen J. Bax 2, and Jonathon Leipsic 1* 1 Department of Radiology and Cardiology, Center for Heart Lung Innovation, St. Paul’s Hospital, University of British Columbia, 1081 Burrard Street, Vancouver V6Z1Y6, BC, Canada; and 2 Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands *Corresponding author. Tel: (604) 806-8026, Email: [email protected] Our understanding of the complexities of valvular heart disease (VHD) has evolved in recent years, primarily because of the increased use of multimodality imaging (MMI). Whilst echocardiography remains the primary imaging technique, the contemporary evaluation of patients with VHD requires comprehensive analysis of the mechanism of valvular dysfunction, accurate quantification of severity, and active exclusion extravalvular consequences. Furthermore, advances in surgical and percutaneous therapies have driven the need for meticulous multimodality imaging to aid in patient and procedural selection. Fundamental decision-making regarding whom, when, and how to treat patients with VHD has become more complex. There has been rapid technological advancement in MMI; many techniques are now available in routine clinical practice, and their integration into has the potential to truly individualize management strategies. This review provides an overview of the current evidence for the use of MMI in VHD, and how various techniques within each modality can be used practically to answer clinical conundrums. Keywords Valvular heart disease • Aortic stenosis • Mitral regurgitation • PET • CT • CMR Change in aortic valve computed tomography calcium score and 18F-sodium fluoride positron emission tomography activity after 1 year. (A and B) Coaxial short-axis views of the aortic valve from two patients with mild aortic stenosis (top and bottom). On baseline computed tomography scans (left) established regions of macrocalcification appear white. Baseline fused 18F-sodium fluoride positron emission tomography and computed tomography scans (middle) show intense 18F-sodium fluoride uptake (red, yellow regions) both overlying and adjacent to existing calcium deposits on the computed tomography. One-year follow-up computed tomography scans (right) demonstrate increased calcium accumulation in much the same distribution as the baseline positron emission tomography activity. Reproduced with permission from Dweck et al.11 Copyright 2014, Wolters Kluwer.