1 Department of Mechanical Engineering, Gina Cody School of Engineering, Concordia University, Montreal, QC H3G 1M8, Canada.
2 Department of Mechanical Engineering, York University, Toronto, ON M3J 1P3, Canada.
3 Section of Cardiovascular Medicine, Department of Medicine, Yale University, New Haven, CT 06519, USA.
4 Department of Medicine, Weill Cornell Medicine, New York, NY 10021, USA.
5 Dalio Institute of Cardiovascular Imaging, Department of Radiology, Weill Cornell Medicine, New York, NY 10021, USA.

Background: Image-guided navigation has revolutionized precision cardiac interventions, yet current technologies face critical limitations in real-time guidance and procedural accuracy. Method: Here, we comprehensively evaluate state-of-the-art imaging modalities, from conventional fluoroscopy to emerging hybrid systems, analyzing their applications across coronary, structural, and electrophysiological interventions. Results: We demonstrate that novel approaches combining optical coherence tomography with near-infrared spectroscopy or fluorescence achieve unprecedented plaque characterization and procedural guidance through simultaneous structural and molecular imaging. Our analysis reveals key challenges, including imaging artifacts and resolution constraints, while highlighting recent technological solutions incorporating artificial intelligence and robotics. We show that non-imaging alternatives, such as fiber optic real-shape sensing and electromagnetic tracking, complement traditional techniques by providing real-time navigation without radiation exposure. This paper also discusses the integration of image-guided navigation techniques into augmented reality systems and patient-specific modeling, highlighting initial clinical studies that demonstrate their significant promise in reducing procedural times and improving accuracy. These findings establish a framework for next-generation cardiac interventions, emphasizing the critical role of multimodal imaging platforms enhanced by AI-driven decision support. Conclusions: We conclude that continued innovation in hybrid imaging systems, coupled with advances in automation, will be essential for optimizing procedural outcomes and expanding access to complex cardiac interventions.