Background: Left ventricular hypertrophy (LVH) is a common cardiac phenotype rather than a single disease entity. Increased left ventricular wall thickness may result from a broad spectrum of pathological conditions, including inherited cardiomyopathies, infiltrative disorders, pressure-overload states, and metabolic diseases. Although transthoracic echocardiography remains the first-line imaging modality for detecting LVH, considerable overlap in morphological appearance frequently limits accurate etiological diagnosis.

Cardiac magnetic resonance (CMR) has emerged as the reference standard for comprehensive myocardial evaluation by integrating ventricular morphology, function, and advanced myocardial tissue characterization. Multiparametric CMR integrates ventricular morphology, function, native T1 mapping and late gadolinium enhancement, providing disease-specific imaging biomarkers for accurate etiological diagnosis of LVH.

Aim: To demonstrate how multiparametric CMR differentiates various causes of left ventricular hypertrophy using representative comparative clinical cases.

Methods: We retrospectively reviewed four representative patients referred for evaluation of unexplained left ventricular hypertrophy who underwent multiparametric cardiac magnetic resonance imaging on a 3.0-T scanner. Clinical presentation, electrocardiographic and echocardiographic findings, together with CMR morphology and tissue characterization, were integrated to establish the final diagnosis. In one patient, genetic testing was performed to confirm the suspected diagnosis of mitochondrial cardiomyopathy. Representative cases were selected to illustrate the distinctive imaging features of different etiologies of left ventricular hypertrophy.

Discussion: Although all patients presented with left ventricular hypertrophy, multiparametric CMR demonstrated distinct disease-specific imaging signatures that enabled accurate etiological differentiation. Integration of ventricular morphology, native T1 mapping, and late gadolinium enhancement substantially improved diagnostic confidence beyond wall thickness assessment alone. In one patient, the diagnosis was further confirmed by genetic testing, highlighting the complementary role of multimodality evaluation in selected cases.

Conclusion: Multiparametric CMR is a comprehensive non-invasive imaging technique for the etiological evaluation of left ventricular hypertrophy. By combining ventricular morphology with myocardial tissue characterization, it enables accurate differentiation of diverse LVH phenotypes and facilitates timely disease-specific management. These representative cases emphasize that left ventricular hypertrophy is a phenotype rather than a diagnosis, and that multiparametric CMR provides disease-specific imaging signatures essential for accurate diagnosis and appropriate patient management.

To be updated