How should we interpret excessive left ventricular trabeculation? Update on controversies from the cardiac imaging perspective

There are well-established and widely accepted criteria for determining the presence of excessive myocardial trabeculation (ET) in the left ventricle in patients undergoing cardiac imaging studies. ET has been documented in healthy individuals, as well as in patients with cardiomyopathies. It is also associated with clinical conditions that increase preload and afterload, as well as various neuromuscular and systemic diseases. There is sufficient scientific evidence demonstrating that the development of ET is not due to an embryologic interruption in myocardial compaction. Therefore, the term "ventricular non-compaction" is now outdated, and its classification as an independent cardiomyopathy is discouraged. However, significant controversy remains regarding the clinical relevance of this phenotypic trait and its implications for the management of patients with suspected or diagnosed cardiovascular disease. This review aims to provide a comprehensive and updated overview of current knowledge on myocardial trabeculation, including diagnostic criteria, prognostic implications, and its associations with other conditions, with a particular focus on differences between adult and pediatric populations. Furthermore, it discusses the potential adverse cardiovascular events linked to ET and highlights the importance of differential diagnosis to distinguish myocardial ET from other mimicking conditions. CRITICAL RELEVANCE STATEMENT: This review critically appraises current knowledge on myocardial trabeculation, integrating imaging and clinical perspectives, to clarify diagnostic criteria, highlight differential diagnoses, and improve diagnostic accuracy and clinical decision-making. KEY POINTS: ET does not necessarily represent a pathological imaging finding and may be related to a normal phenotypic trait. Hemodynamic stressors may trigger excessive trabeculation, though its cause and clinical significance remain unclear. Excessive trabeculation imaging must combine with clinical and genetic information for accurate prognostic stratification.