Barriers to cardiovascular magnetic resonance across Europe: a 46-country EACVI observatory study

Abstract Aims Cardiovascular magnetic resonance (CMR) is established in guidelines, yet utilization remains inconsistent across Europe and beyond. This study aimed to identify barriers to CMR practice and reporting across European Society of Cardiology (ESC) member and affiliate countries. Methods and results This study was conducted between January and September 2025. A sequential exploratory mixed methods design was used, comprising two phases: qualitative interviews and a quantitative survey. Countries were grouped into five ESC subregions (Northern, Western, Southern, and Eastern Europe, and Central Asia/Caucasus) based on the United Nations regional classification system. Quantitative data were analysed using chi-square tests for regional differences. Qualitative responses were synthesized using thematic analysis and integrated through triangulation. Among 283 respondents from 46 countries, inadequate reimbursement (46%), insufficient training (38%), and limited scanner capacity (29%) were the main barriers. Eastern European countries reported four-fold higher training deficits than Northern and Southern Europe (56% vs. 14%, P < 0.001). Country-level analyses showed substantial heterogeneity in drivers of limited CMR access, ranging from workforce and efficiency constraints in mature systems to financial and governance restrictions. Qualitative findings enriched these results, identifying structural inefficiencies, interdepartmental barriers, and emerging adaptive strategies such as remote supervision and reading, and regional collaboration networks to support capacity building in resource-limited settings. Conclusion Across ESC member and affiliated countries, CMR delivery remains constrained by infrastructure, training, and reimbursement limitations. Targeted investment in standardized education, harmonized reimbursement frameworks, and collaborative service models is essential to promote equitable and sustainable access to CMR across Europe.