Four-Dimensional Cine Cinematic Rendering of Structural Heart and Mechanical Circulatory Support Devices: An Illustrative Technical Experience.

Patients with implanted cardiac devices are a rapidly growing imaging population, and electrocardiogram-gated cardiac computed tomography (CT) is increasingly used to characterize device geometry, multi-device relationships, and dynamic behavior across the cardiac cycle. Cinematic rendering (CR) is a photorealistic three-dimensional (3D) visualization technique for cardiac CT whose established contribution in this population is communicative: it conveys 3D device geometry and material distinctions within a single rendered volume. We describe a demonstrative case series extending CR across the cardiac cycle-time-resolved "4D cine" CR-to depict dynamic device behavior and time-resolved multi-device interaction in a single volume; this is an illustrative technical experience rather than a systematic evaluation of diagnostic performance. Illustrative examples include an EVOQUE transcatheter tricuspid valve rendered together with concurrent surgical mitral and transcatheter aortic valves, a left atrial appendage occlusion device, a normally positioned Impella catheter, and a HeartMate 3 left ventricular assist device (LVAD). Across cases, 4D cine CR feasibility scaled inversely with metallic burden-the aggregate volume and radiodensity of metallic device components within the scan field-with renderings informative for low-metal nitinol and catheter devices but substantially degraded by streak artifact in high-metal LVAD housings. This relationship was observed qualitatively in a small selected series and is offered as an initial observation rather than an established characteristic of the technique. We discuss current limitations and emerging directions such as photon-counting detector CT, metal artifact reduction, and artificial-intelligence-assisted post-processing that may extend 4D cine CR in this population.