{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,7]],"date-time":"2026-05-07T20:38:51Z","timestamp":1778186331657,"version":"3.51.4"},"reference-count":127,"publisher":"MDPI AG","issue":"2","license":[{"start":{"date-parts":[[2026,1,7]],"date-time":"2026-01-07T00:00:00Z","timestamp":1767744000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Diagnostics"],"abstract":"<jats:p>Left ventricular (LV) apical obliteration represents a convergent imaging phenotype arising from diverse cardiac conditions, including thrombotic, hypertrophic, infiltrative, congenital, and neoplastic diseases. These conditions, despite sharing overlapping morphological features, require profoundly different management strategies. In this context, an accurate characterization of the LV apex is a cornerstone point, and can be performed through various techniques. Advances in multimodality imaging have substantially improved diagnostic precision, allowing clinicians to differentiate true obliteration from mimicking conditions such as hypertrabeculation, apical hypertrophy, or subendocardial fibrosis. This review provides a comprehensive overview of the anatomical variability of the LV apex and its implications for imaging interpretation. We appraise the role of echocardiography, including contrast-enhanced and speckle-tracking studies\u2014alongside cardiac magnetic resonance (CMR), computed tomography (CT), and selective nuclear imaging in the evaluation of apical pathology. For each principal cause of apical obliteration\u2014LV thrombus, apical hypertrophic cardiomyopathy, left ventricular non-compaction, endomyocardial fibrosis, cardiac amyloidosis, and intracardiac tumors\u2014we outline key diagnostic clues, imaging red flags, and distinguishing tissue characteristics. Special emphasis is given to the incremental value of CMR for tissue characterization, thrombus detection, and fibrosis mapping, as well as to the interpretative challenges posed by apical foreshortening, near-field artefacts, and suboptimal acoustic windows. A practical, stepwise imaging framework is proposed to guide clinicians through the differential diagnosis of apical obliteration using an integrated multimodality approach. Future directions include the incorporation of 4D flow, advanced mapping techniques, and artificial intelligence-powered analysis to refine apical phenotyping and identify early disease signatures. Recognizing the full spectrum of apical pathology and its imaging manifestations is essential to prevent misdiagnosis, enable timely therapeutic decisions, and improve risk stratification.<\/jats:p>","DOI":"10.3390\/diagnostics16020184","type":"journal-article","created":{"date-parts":[[2026,1,7]],"date-time":"2026-01-07T08:26:56Z","timestamp":1767774416000},"page":"184","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Unmasking the Apex: Multimodality Imaging for the Evaluation of Left Ventricular Apical Obliteration"],"prefix":"10.3390","volume":"16","author":[{"given":"Ilaria","family":"Dentamaro","sequence":"first","affiliation":[{"name":"University Cardiology Unit, Interdisciplinary Department of Medicine, Polyclinic University Hospital, University of Bari \u201cAldo Moro\u201d, 70124 Bari, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-4865-2522","authenticated-orcid":false,"given":"Marco Maria","family":"Dicorato","sequence":"additional","affiliation":[{"name":"University Cardiology Unit, Interdisciplinary Department of Medicine, Polyclinic University Hospital, University of Bari \u201cAldo Moro\u201d, 70124 Bari, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Paolo","family":"Basile","sequence":"additional","affiliation":[{"name":"University Cardiology Unit, Interdisciplinary Department of Medicine, Polyclinic University Hospital, University of Bari \u201cAldo Moro\u201d, 70124 Bari, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Maria Cristina","family":"Carella","sequence":"additional","affiliation":[{"name":"University Cardiology Unit, Interdisciplinary Department of Medicine, Polyclinic University Hospital, University of Bari \u201cAldo Moro\u201d, 70124 Bari, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3767-7595","authenticated-orcid":false,"given":"Francesco","family":"Mangini","sequence":"additional","affiliation":[{"name":"Cardiology Division, Miulli Hospital, 70021 Acquaviva delle Fonti, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rita","family":"Musci","sequence":"additional","affiliation":[{"name":"University Cardiology Unit, Interdisciplinary Department of Medicine, Polyclinic University Hospital, University of Bari \u201cAldo Moro\u201d, 70124 Bari, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Roberta","family":"Ruggieri","sequence":"additional","affiliation":[{"name":"UOC Cardiologia, Ospedale Di Venere, Asl Bari, 70124 Bari, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0458-1469","authenticated-orcid":false,"given":"Eduardo","family":"Urgesi","sequence":"additional","affiliation":[{"name":"University Cardiology Unit, Interdisciplinary Department of Medicine, Polyclinic University Hospital, University of Bari \u201cAldo Moro\u201d, 70124 Bari, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3918-8680","authenticated-orcid":false,"given":"Laura","family":"Piscitelli","sequence":"additional","affiliation":[{"name":"Cardiology Unit, A. Perrino Hospital, 72100 Brindisi, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sergio","family":"Dentamaro","sequence":"additional","affiliation":[{"name":"Vascular Surgery, Polyclinic University Hospital, University of Bari \u201cAldo Moro\u201d, 70124 Bari, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Gianluca","family":"Pontone","sequence":"additional","affiliation":[{"name":"Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9452-4037","authenticated-orcid":false,"given":"Cinzia","family":"Forleo","sequence":"additional","affiliation":[{"name":"University Cardiology Unit, Interdisciplinary Department of Medicine, Polyclinic University Hospital, University of Bari \u201cAldo Moro\u201d, 70124 Bari, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Marco Matteo","family":"Ciccone","sequence":"additional","affiliation":[{"name":"University Cardiology Unit, Interdisciplinary Department of Medicine, Polyclinic University Hospital, University of Bari \u201cAldo Moro\u201d, 70124 Bari, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7133-4401","authenticated-orcid":false,"given":"Andrea Igoren","family":"Guaricci","sequence":"additional","affiliation":[{"name":"University Cardiology Unit, Interdisciplinary Department of Medicine, Polyclinic University Hospital, University of Bari \u201cAldo Moro\u201d, 70124 Bari, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2026,1,7]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"471","DOI":"10.1007\/s13244-011-0091-6","article-title":"Left ventricular apical diseases","volume":"2","author":"Cisneros","year":"2011","journal-title":"Insights Imaging"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1404","DOI":"10.1016\/j.jcmg.2016.12.006","article-title":"Timing of Cardiac Magnetic Resonance Imaging Impacts on the Detection Rate of Left Ventricular Thrombus After Myocardial Infarction","volume":"10","author":"Gellen","year":"2017","journal-title":"JACC Cardiovasc. 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