Multidimensional cardiac functional phenotyping beyond ejection fraction: a multimodality imaging framework for cardiovascular care

Cardiac functional assessment has traditionally relied on left ventricular ejection fraction (LVEF), but this single volumetric index cannot fully capture the complexity of cardiac physiology. Contemporary multimodality imaging enables cardiac function to be evaluated across five interrelated domains: pump function, myocardial deformation, diastolic function, flow dynamics, and tissue characterization. Integrating biomarkers across these domains may provide a more pathophysiologically grounded interpretation of cardiac dysfunction than LVEF alone. Clinically, multidimensional functional phenotyping may refine disease characterization and risk stratification in conditions such as heart failure with preserved ejection fraction, cardiomyopathies, and valvular heart disease. This review proposes a five-dimensional, phenotype-oriented multimodality imaging framework for cardiovascular care and emphasizes a selective stepwise escalation strategy from standard echocardiography to advanced echocardiographic analysis, cardiac magnetic resonance, computed tomography, nuclear imaging, and selected flow-based assessment, particularly 4D flow cardiovascular magnetic resonance, when clinically indicated. The framework is intended to support clinically actionable interpretation rather than indiscriminate use of multiple imaging modalities. We also discuss practical barriers to implementation, including cost-effectiveness, workflow burden, vendor variability, limited standardization of 4D flow cardiovascular magnetic resonance, and the need for interpretable and externally validated artificial intelligence-based integration.