Role of Imaging Techniques in Monitoring Atrial Cardiomyopathy and Atrial Failure: A Scientific Statement

Abstract Atrial cardiomyopathy (AtCM) is increasingly recognized as a distinct pathological entity characterized by structural, functional and electrical abnormalities that may predispose to atrial fibrillation, heart failure and other adverse cardiovascular outcomes. Early identification and longitudinal monitoring of atrial remodelling are therefore crucial to improve risk stratification, guide therapeutic decisions, and assess treatment response. However, clinical evaluation alone is often insufficient to capture the complexity and temporal evolution of atrial disease. Multimodality cardiac imaging plays a central role in the detection, characterization and surveillance of AtCM and atrial failure, the latter representing the advanced stage of this continuum. This scientific statement synthesizes the current evidence supporting the use of imaging techniques for monitoring AtCM across diverse clinical scenarios. The strengths and limitations of echocardiography, cardiac magnetic resonance, cardiac computed tomography and nuclear imaging are discussed with respect to atrial size, function, tissue characterization and substrate assessment, with particular emphasis on advanced imaging markers. Furthermore, pragmatic imaging-based algorithms are proposed for the evaluation and follow-up of AtCM in preclinical and overt heart failure, atrial fibrillation, cardiomyopathies, valvular heart disease, and peri-procedural settings. Knowledge gaps, unmet clinical needs and future research priorities are also highlighted. By integrating available evidence into a structured framework, this document aims to support a more standardized - yet personalized - approach to imaging-guided management of AtCM in clinical practice.