Gosia Wamil: Assistant Professor and Guide Heart specialist, Mayo Clinic Healthcare, London, UK; Guide Heart specialist, Nice Western Hospital NHS Belief, Swindon, UK; Honorary Analysis Fellow, Deep Drugs, College of Oxford, UK
Quotation: EMJ Cardiol. 2026; https://doi.org/10.33590/emjcardiol/Q54YF209
You’ve got spent greater than 20 years in cardiology and now lead multimodality cardiac imaging providers within the NHS and at Mayo Clinic Healthcare in London, UK. Trying again, what have been the pivotal moments that satisfied you imaging might be greater than a diagnostic device and grow to be a driver of medical decision-making?
For a lot of my early coaching, imaging was offered as a confirmatory check: you shaped a medical impression after which ordered a scan to help it. What modified my pondering was seeing cardiovascular magnetic resonance (CMR) repeatedly overturn diagnoses that had appeared clinically convincing. A affected person thought to have a non-specific cardiomyopathy may present a sample of fibrosis that fully adjustments their analysis, prognosis, and administration. Upon getting seen imaging redirect all the course of a affected person’s care, you cease pondering of it as the ultimate step and begin seeing it as the purpose the place lots of an important medical choices start.
The instances which have stayed with me are these by which no single imaging modality offered the reply. A affected person with unexplained left ventricular hypertrophy might initially seem to have hypertrophic cardiomyopathy (HCM) on echocardiography. Nevertheless, when CMR demonstrates diffuse infiltration moderately than sarcomeric illness, the analysis adjustments to cardiac amyloidosis, with completely completely different therapy choices and prognosis. These are the moments that satisfied me that multimodality imaging shouldn’t be about performing extra exams; it’s about asking the subsequent query that can change administration.
That philosophy has formed my profession. Somewhat than pondering of echocardiography, CT, or CMR as separate disciplines, I’ve more and more considered them as complementary instruments, every addressing a distinct medical query. The aim isn’t to supply probably the most complete imaging report; it’s to offer the data that permits the multidisciplinary group to make the proper determination for the affected person. That, to me, is the place imaging turns into way over a diagnostic device and turns into a driver of personalised care.
As each cardiovascular imaging and cardiomyopathy care grow to be more and more multidisciplinary, a shift formalised by the 2023 European Society of Cardiology (ESC) Pointers on the administration of cardiomyopathies, what classes have you ever realized about collaboration throughout specialties, and the way has this formed your method to affected person care and analysis?
One of many largest adjustments over the previous decade has been recognising that no single specialist has all of the solutions in cardiomyopathy. These are complicated ailments that sit on the intersection of imaging, genetics, electrophysiology, coronary heart failure, and more and more medical pharmacology. The very best choices are not often made in isolation.
Working in multidisciplinary groups has taught me that the worth of imaging shouldn’t be merely in producing an correct report, however in offering the data that every specialist must reply a selected medical query. The electrophysiologist could also be targeted on arrhythmic danger, the geneticist on whether or not a phenotype helps the interpretation of a genetic variant, and the center failure specialist on whether or not imaging suggests a probably treatable trigger. The identical scan can subsequently imply very various things relying on the medical context.
That’s the reason I consider a number of the most respected work occurs across the multidisciplinary assembly desk. Reviewing pictures collectively, discussing uncertainty brazenly, and mixing completely different views virtually at all times results in higher choices than anyone speciality may attain alone.
The identical philosophy has formed my analysis. Essentially the most fascinating questions usually come up on the boundaries between disciplines, the place imaging meets genetics, coronary heart failure, electrophysiology, or cardiometabolic medication. In the end, multidisciplinary care shouldn’t be about having extra consultants concerned; it’s about guaranteeing that each affected person advantages from the mixed experience of the entire group. That, in my expertise, is how imaging has its best impression.
Your experience spans echocardiography, cardiac CT, and CMR at a time when cardiovascular imaging is turning into more and more subspecialised. How have you ever navigated these quickly evolving applied sciences whereas sustaining a patient-centred method to care?
The problem of contemporary cardiovascular imaging shouldn’t be maintaining with know-how; it’s understanding when that know-how genuinely advantages the affected person. As imaging has grow to be more and more specialised, there’s a danger of turning into an skilled in a modality moderately than an skilled in fixing medical issues.
I’ve at all times loved working throughout echocardiography, cardiac CT, and CMR as a result of every provides a distinct perspective. Echocardiography excels at physiology and haemodynamics, CT gives unparalleled evaluation of coronary anatomy and atherosclerosis, and CMR provides distinctive insights into myocardial tissue and illness mechanisms. The true worth lies not in mastering every method individually, however in understanding how they complement each other.
On the similar time, a patient-centred method generally means recognising that the most effective investigation is not any additional investigation in any respect. Each scan carries prices, potential dangers, and the opportunity of incidental findings which will create extra uncertainty than readability. Some of the vital abilities an skilled imager develops is understanding when sufficient info has been obtained to make a assured medical determination.
In the end, I see know-how as an enabler moderately than the vacation spot. Sufferers not often keep in mind which imaging modality they underwent; they keep in mind whether or not they acquired a transparent analysis, an applicable therapy plan, and confidence that the choices being made have been the proper ones. That perspective has helped me embrace new applied sciences whereas holding the main focus the place it belongs: on the particular person moderately than the scan.
Many clinicians nonetheless consider imaging modalities in silos. All through your profession, you’ve championed a genuinely multimodal method. Are you able to share an instance the place integrating a number of imaging strategies basically modified a analysis, danger evaluation, or administration technique?
One instance that has stayed with me comes from a affected person with longstanding Sort 2 diabetes who offered with progressive exertional breathlessness regardless of a preserved ejection fraction. If we had relied on a single imaging modality, we might virtually actually have missed the underlying analysis.
Coronary CT angiography excluded vital coronary artery illness, permitting us to maneuver past an ischaemic clarification. Echocardiography then demonstrated impaired world longitudinal pressure with proof of raised filling pressures, suggesting early myocardial dysfunction regardless of a traditional ejection fraction. Lastly, CMR revealed diffuse growth of the extracellular quantity with out focal scar, per diffuse interstitial fibrosis.
Taken collectively, these findings recognized early diabetic cardiomyopathy, a analysis that no particular person imaging check may have established with the identical degree of confidence. Extra importantly, it modified administration. Somewhat than pursuing additional investigations, we targeted on aggressive cardiometabolic optimisation, together with initiation of sodium-glucose cotransporter 2 (SGLT2) inhibition and intensive risk-factor modification.
For me, that’s the essence of multi-modality imaging. It isn’t about performing extra scans; it’s about combining complementary info to reply questions that no single method can reply alone. When imaging strikes past describing anatomy and begins altering analysis, therapy, and prognosis, it turns into a real associate in medical decision-making.
As a member of the European Affiliation of Cardiovascular Imaging (EACVI) Scientific Committee, you’ve an uncommon vantage level on developments throughout European cardiovascular imaging. Which rising tendencies or analysis areas do you consider are presently under-appreciated, however have the potential to considerably affect follow within the coming years?
Three areas stand out to me. First, imaging is shifting from analysis in the direction of precision danger prediction. We already purchase huge quantities of imaging information, however the subsequent step is integrating quantitative imaging biomarkers into medical danger fashions that genuinely enhance decision-making, moderately than reporting them in isolation. The problem is now not buying higher pictures however extracting clinically significant info.
Second, I consider imaging as a marker of therapy response remains to be under-appreciated. As disease-modifying therapies emerge for situations corresponding to HCM, amyloidosis, and coronary heart failure, imaging will more and more be used to detect early reverse remodelling and information therapy escalation or de-escalation, moderately than merely confirming a analysis.
Lastly, the least glamorous however maybe most vital space is information standardisation. If we wish imaging biomarkers to grow to be a part of routine care, they should be reproducible throughout distributors, centres, and healthcare methods. Harmonised acquisition protocols, structured reporting, and inter-operability are important if we’re to mix imaging with genomics, biomarkers, and digital well being data at scale.
From my perspective on the EACVI Scientific Committee, there may be large innovation throughout Europe. The chance now’s to translate that innovation into strong proof and sensible workflows. In the end, the most important advances over the subsequent decade might not come from a brand new imaging modality, however from making the data we already purchase extra quantitative, reproducible, and actionable for on a regular basis medical follow.
HCM has undergone a outstanding transformation, with new imaging strategies, risk-stratification instruments, and therapeutic choices now obtainable. Which advances have had the best impression on affected person care, and what do you take into account probably the most urgent unanswered questions within the discipline immediately?
HCM is without doubt one of the few areas in cardiology the place we’ve seen simultaneous advances in imaging, danger prediction, and disease-specific remedy. Collectively, they’ve basically modified affected person care.
From an imaging perspective, CMR has had the best impression. Past refining the analysis, late gadolinium enhancement has grow to be central to sudden cardiac loss of life danger evaluation, notably in sufferers whose standard danger estimates sit within the gray zone. It has moved us away from relying solely on wall thickness and household historical past in the direction of a extra personalised understanding of arrhythmic danger.
Therapeutically, the introduction of cardiac myosin inhibitors represents a real paradigm shift. For the primary time, we have now therapies that concentrate on the underlying pathophysiology of obstructive HCM moderately than merely assuaging signs. They’ve additionally modified the function of the imaging heart specialist, with serial echocardiography now guiding therapy initiation, dose titration, and long-term monitoring.
Regardless of this progress, vital questions stay. Sudden cardiac loss of life danger prediction remains to be imperfect, and we want extra exact fashions that combine imaging, genetics, and medical information to higher determine the sufferers who really profit from an implantable cardioverter defibrillator. We additionally want to know whether or not myosin inhibitors alter the pure historical past of the illness by stopping fibrosis and hostile remodelling, moderately than merely bettering haemodynamics and signs.
Lastly, I believe the best unmet want is in non-obstructive HCM and genotype-positive, phenotype-negative people. These are sometimes probably the most difficult conversations within the clinic as a result of sufferers wish to know not solely what their analysis is immediately, however what their future is more likely to appear to be. Serving to us reply that query is the place the subsequent technology of imaging analysis ought to focus.
Cardiac MRI has grow to be more and more central to HCM evaluation, notably for tissue characterisation and danger stratification. How do you see its function evolving, and are we approaching the purpose at which imaging biomarkers may affect therapy choices as a lot as conventional medical parameters?
I believe we’ve already crossed the purpose the place CMR is now not an adjunct; it’s a core part of HCM evaluation. Echocardiography stays the first-line investigation, however CMR gives info that merely can’t be obtained another method, notably round myocardial fibrosis and tissue characterisation. That info more and more influences a number of the most vital choices we make, particularly round sudden cardiac loss of life danger and implantable cardioverter defibrillator implantation.
Late gadolinium enhancement is the clearest instance. We now have strong proof that the extent of fibrosis gives incremental prognostic worth past conventional medical danger elements, notably in sufferers who sit within the intermediate-risk class. Equally vital, the absence of serious fibrosis will be reassuring and helps help a extra conservative administration technique. In that sense, imaging biomarkers are already influencing therapy choices alongside standard medical parameters.
Trying forward, I believe the subsequent frontier is shifting past alternative fibrosis in the direction of earlier markers of illness exercise. Native T1 mapping, extracellular quantity quantification, and different quantitative CMR biomarkers might permit us to determine myocardial remodelling earlier than irreversible scar develops. As disease-modifying therapies grow to be extra broadly obtainable, these biomarkers may assist determine sufferers who would profit from earlier intervention and supply goal measures of therapy response.
That stated, imaging biomarkers ought to complement, not change, medical judgement. Their best worth lies in integrating imaging with genetics, signs, rhythm evaluation, and household historical past to ship genuinely personalised care. Reaching that can require continued standardisation of quantitative CMR throughout centres, which I see as one of many key priorities for our discipline over the subsequent decade.
AI is more and more being built-in into cardiovascular imaging workflows. Out of your expertise, the place is AI already including real medical worth, and the place do you suppose expectations presently exceed actuality?
AI is already including real worth, however maybe not within the areas that appeal to probably the most headlines. Its best impression immediately is in automating repetitive, measurement-intensive duties corresponding to chamber quantification, ejection fraction, pressure evaluation, picture segmentation, and high quality management. These functions enhance reproducibility, scale back reporting time, and permit clinicians to spend extra time deciphering research and discussing administration with sufferers. In busy imaging departments, that consistency is an actual benefit.
The place I believe expectations presently exceed actuality is in absolutely autonomous analysis and danger prediction. Many AI fashions carry out extraordinarily nicely in analysis datasets however are far much less convincing when utilized throughout completely different scanners, establishments, and affected person populations. Earlier than we depend on these instruments for main medical choices, we want strong potential validation demonstrating not simply technical accuracy, however improved affected person outcomes.
Trying forward, I consider the best alternative for AI shouldn’t be changing imaging specialists however serving to us combine more and more complicated info. Fashionable cardiovascular imaging generates an unlimited quantity of information, and AI may help mix imaging with medical variables, genomics, biomarkers, and digital well being data to ship extra personalised danger evaluation and therapy suggestions.
In the end, the way forward for AI in cardiovascular imaging is unlikely to be about changing human experience. It is going to be about making clinicians extra environment friendly, extra constant, and, most significantly, enabling better-informed choices for particular person sufferers.
Alongside your medical and analysis roles, you might be closely concerned in training and customary setting by means of the EACVI and the British Society of Echocardiography (BSE). What abilities will the subsequent technology of cardiac imagers and advisor cardiologists want as a way to achieve an more and more technology-driven discipline?
Know-how will undoubtedly change how we practise, however I don’t suppose it adjustments what makes a superb heart specialist. The subsequent technology will must be comfy working throughout imaging modalities and perceive how you can use AI and quantitative instruments, however know-how ought to help medical judgement, not change it.
The talent I worth most is the flexibility to ask the proper medical query earlier than selecting the imaging check. An impressive imager shouldn’t be the one who performs probably the most subtle scan, however the one who understands what info will change administration and selects the proper modality to reply that query.
Equally vital is the flexibility to combine info. Fashionable cardiologists must deliver collectively echocardiography, CT, CMR, genetics, biomarkers, and medical historical past right into a single, coherent evaluation. Sufferers don’t expertise their illness in silos, and neither ought to we.
Lastly, I hope we proceed to stress communication and curiosity. Imaging studies ought to inform choices, not merely describe findings, and we should have the ability to clarify uncertainty to each colleagues and sufferers. On the similar time, the sector is evolving so quickly that steady studying is now not non-obligatory, it’s a part of the job.
By way of my work with the EACVI, one in every of my priorities has been to assist develop coaching and requirements that put together cardiologists not only for immediately’s follow, however for the applied sciences and therapies they are going to be utilizing 10 years from now. For my part, the most effective cardiac imagers of the longer term will mix technical excellence with medical perception, mental curiosity, and a dedication to lifelong studying.
As somebody who combines medical follow, analysis, society management, and training throughout two well being methods, what has been probably the most rewarding facet of your profession to this point, and what continues to inspire you immediately?
What has been probably the most rewarding is seeing how imaging can genuinely change a affected person’s journey. Generally meaning making a tough analysis that had beforehand been missed; generally it means giving somebody reassurance that they don’t want an invasive process or machine. These conversations stick with you far longer than any publication or presentation as a result of you may see the quick impression on the affected person and their household.
Past particular person sufferers, I’ve discovered monumental satisfaction in serving to form the sector by means of analysis, training, {and professional} societies. Whether or not contributing to medical pointers, creating imaging requirements by means of the EACVI and the BSE, or mentoring trainees, there’s a multiplier impact. In case you assist one clinician make higher choices all through their profession, the profit extends to 1000’s of sufferers.
What continues to inspire me is that cardiovascular imaging stays some of the dynamic areas of drugs. We’re coming into an period the place superior imaging, genetics, AI, and novel therapies are converging to ship more and more personalised care. It’s a privilege to be a part of that transformation.
Above all, I stay pushed by curiosity. Each affected person teaches us one thing new, and each scientific advance raises one other query. That mixture of medical follow, analysis, and training implies that no 2 days are the identical. If, over the course of my profession, I can contribute to higher proof, higher imaging, and higher coaching for the subsequent technology of cardiologists, I’ll really feel I’ve made a significant distinction.
Lastly, if we have been to reconvene 10 years from now, what main adjustments do you suppose we might see within the analysis and administration of cardiomyopathies, and what function do you hope imaging will play in that future?
I believe the most important change will likely be that we cease serious about cardiomyopathies as ailments outlined by how the center seems and as a substitute classify them by their underlying biology. Imaging, genetics, biomarkers, and medical information will likely be built-in to determine the precise illness mechanism in every affected person, permitting us to maneuver from a ‘one-size-fits-all’ method to really personalised care.
In that future, imaging will now not be used merely to substantiate a analysis. It is going to assist determine illness at a a lot earlier stage, refine particular person danger, information therapy choice, and monitor response to remedy over time. As extra disease-modifying therapies grow to be obtainable, imaging will more and more act as a biomarker, permitting us to find out whether or not a remedy is genuinely altering the pure historical past of illness moderately than merely bettering signs.
I additionally hope that AI may have matured past immediately’s pleasure. Somewhat than being considered as a separate know-how, it ought to grow to be an invisible a part of on a regular basis follow, bettering workflow, integrating complicated information, and supporting medical choices, whereas leaving clinicians free to deal with the affected person in entrance of them.
In the end, I hope that in 10 years’ time we will likely be diagnosing cardiomyopathies earlier, treating them extra exactly, and stopping extra instances of coronary heart failure and sudden cardiac loss of life than we do immediately. If imaging evolves from producing stunning photos to turning into a central device for personalised decision-making all through the affected person’s journey, I believe we may have achieved one thing really transformative.
