Abstract
Purpose of Review
Speckle-tracking echocardiography (STE) can assess myocardial motion in non-LV chambers—including assessment of left atrial (LA) and right ventricular (RV) strain. This review seeks to highlight the diagnostic, prognostic, and clinical significance of these parameters in heart failure, atrial fibrillation (AF), diastolic dysfunction, pulmonary hypertension (PH), tricuspid regurgitation, and heart transplant recipients.
Recent Findings
Impaired LA strain reflects worse LV diastolic function in individuals with and without HF, and this is associated with decreased exercise capacity. Initiating treatments targeting these functional aspects may enhance exercise capacity and potentially prevent heart failure (HF). Impaired LA strain also identifies patients with a high risk of AF, and this recognition may lead to preventive strategies. Impaired RV strain has significant clinical and prognostic implications across various clinical scenarios, including HF, PH, tricuspid regurgitation, or in heart transplant recipients.
Summary
STE should not be limited to the assessment of deformation of the LV myocardium. The use of LA and RV strain is supported by a substantial evidence base, and these parameters should be used more widely.
Similar content being viewed by others
Explore related subjects
Discover the latest articles, news and stories from top researchers in related subjects.Avoid common mistakes on your manuscript.
Introduction
Left ventricular (LV) strain is widely used in the detection of subclinical LV dysfunction (e.g., cancer treatment-related cardiac dysfunction), heart failure with preserved ejection fraction (HFpEF), the assessment of LV diastolic dysfunction, risk stratification in aortic stenosis and mitral regurgitation, and many other LV diseases [1,2,3,4]. However, the use of speckle-tracking echocardiography (STE) is not limited to the assessment of deformation of the LV myocardium and may be used to study myocardial motion in other chambers—including the assessment of left atrial (LA) and right ventricular (RV) strain. This review seeks to highlight the diagnostic, prognostic, and clinical significance of these parameters in various clinical conditions such as heart failure, atrial fibrillation, diastolic dysfunction, pulmonary hypertension, tricuspid regurgitation, and heart transplant recipients.
Left Atrial Strain
Physiology
Left atrial strain is a feasible and rapid speckle-tracking tool for assessing atrial function, which has been shown to have diagnostic and prognostic value. Each of the phases of atrial function can be measured with strain imaging, and there are normal ranges (Appendix Table 1) for reservoir function (which accommodates pulmonary venous return during ventricular systole), conduit function (which accommodates pulmonary venous return during early diastole), and contractile function (which facilitates ventricular filling during atrial systole) [5, 6] (Fig. 1). Nonetheless, it is important to appreciate that none of these parameters purely assess atrial function, because of the interplay between atrial and ventricular activity, preload, and afterload. Thus, reservoir function is determined by atrial compliance during ventricular systole, but is also governed by LV end-systolic volume and LV base descent during systole. Likewise, the LA and LV freely communicate during diastole, so conduit function is dependent on LV relaxation and stiffness (chamber compliance) and as well as on reservoir function and atrial compliance. The atrial booster pump (contractile strain) is mainly related to the effectiveness of atrial contractility but the quality of pump function depends on LV systolic reserve, atrial preload (degree of venous return), and atrial afterload (LV end-diastolic pressures) [5, 6].
Examples of LA strain curves. A Healthy subject; LA volume (53 mls) is normal, as are reservoir (S_R), conduit (S_CD), and contractile strain (S_CT). B Heart failure; in the presence of indeterminate left atrial pressure (normal LA volume, but borderline E/e’, and no tricuspid regurgitation jet), LA reservoir strain > 18% is reassuring that LA pressure is normal. More reassuring still would have been an LA contractile strain > 14% [15••]. C Risk of atrial fibrillation. LA volume is borderline. The reservoir strain (18%) is associated with a > sixfold increased hazard of developing AF, compared with people with a reservoir strain > 23%. In absolute risk terms, this would be a rate of > 4% per year vs. < 1% per year [50]
Techniques for Assessing LA Function
A number of imaging tools may be used for the assessment of LA size and function, but echocardiography remains the most accessible and least expensive [5]. While the assessment of LA size with either 2D or 3D measurement of LA volume indexed to body surface area (LAVI) is ubiquitous, volumetric analysis of the LA at multiple phases of the cardiac cycle is difficult. Measurement of LA volumes at their largest (at LV end-systole), smallest (at LV end-diastole), and immediately before atrial systole (at the onset of the P wave on the electrocardiogram) estimate the reservoir, conduit, and booster pump functions. Calculation of total, passive, and active emptying fractions, which pertain to the reservoir, conduit, and booster pump functions, is possible based on the given volumes [5, 6]. However, the volumetric approach is less feasible than STE for assessing LA function. Nonetheless, technical considerations are important for STE, including good image quality and an appropriate frame-rate (preferably 50–70 frames per second) (Fig. 1A). Potential technical challenges include limited endocardial resolution in the far field of apical views, thin atrial walls, and the existence of adjacent structures such as pulmonary veins or LA appendage.
Other imaging modalities for LA assessment include cardiac magnetic resonance (CMR) and cardiac computed tomography (CCT). In addition to LA anatomy and function, CMR is also able to assess LA fibrosis from late gadolinium enhancement (LGE) [7, 8]. CCT also permits the evaluation of pulmonary venous anatomy [9], estimation of risk of AF recurrence, and coronary artery disease [8].
LA Strain in the Assessment of LV Diastolic Function
Echocardiography remains the primary imaging technique for the assessment of LV diastolic dysfunction (DD), by determination of LV relaxation and compliance, and the estimation of LV filling pressure [10]. LA strain is significantly and negatively associated with the severity of LVDD [11,12,13], and conversely, the severity of DD is linked to the prevalence of abnormal LA strain values [12, 13]. LA strain will become in important adjunct in the estimation of LV filling pressure. In patients with a mitral E/A ratio from 0.8 to 2.0, LV filling pressure is likely raised when two of the three predictive features (average E/e’ > 14, peak TR velocity > 2.8 m/s, and LAVi > 34 ml/m2) are present. If one of the three criteria is absent and the remaining two provide conflicting results, LA reservoir strain can serve as the third parameter. The effectiveness of this approach was demonstrated in a recent multicenter study, which utilized invasive LV filling pressure as a reference point [14, 15••]; LA reservoir strain < 18% corresponded to an increased LV filling pressure. However, LA strain is more difficult to use in the assessment of LV filling pressure in AF.
LA contractile strain may be an even stronger correlate of LV filling pressure than LA reservoir strain. The associations of both LA reservoir and booster strains with LV filling pressure are modest in patients with normal LV ejection fraction. In such circumstances, high values of LA booster strain accurately identify non-elevated LV filling pressure [14]. However, the disadvantage of using LA contractile strain as a marker of high LV filling pressure is that low values may also reflect atrial stunning post-atrial arrhythmias. Lower velocities of septal and lateral a’ (which show mitral annular velocity during LA contraction), and reduced transmitral A wave (determined by atrial contraction and LV compliance), may be confirmatory of impaired LA function.
LAVi is a reliable parameter for assessing the long-term effect of increased LV filling pressure on the LA. However, it has been demonstrated that LAVi combined with LA strain significantly improves the detection rate of LV diastolic dysfunction and increased LV filling pressure compared to using only LAVi. This finding is relevant for patients with preserved ejection fraction, among whom elevated LV filling pressure is indicated by reductions in LA reservoir strain and LA pump strain [16]. Moreover, LA reservoir strain has a stronger association with invasive LV filling pressure than does LAVi [17, 18]. Importantly, the measurement of LA reservoir strain using STE has shown very high feasibility, with a rate of ~ 95% [14].
Prognostic Role of LA Strain in Heart Failure
Diastolic dysfunction and raised LV filling pressures are markers of adverse outcome in people with and without symptomatic heart failure. Left atrial strain delivers a practical and reliable diagnostic tool to identify elevated LA pressure both during rest and exercise in patients with HF or suspected HF (Fig. 1B). Moreover, LA strain demonstrates the highest prognostic value in patients with HF among the other non-invasive indices of filling pressure [19]. LA strain represents a robust approach for evaluating pulmonary artery wedge pressure (PAWP) at rest. Furthermore, it demonstrates consistent capability in detecting pathological increases in PAWP during exertion, even when resting pressures appear normal [19].
The progressive worsening of exercise capacity from stage A through stage B to stage C in HF is accompanied by a gradual impairment of LA reservoir and contractile strain and strain reserve. Individuals without HF with reduced resting LA reservoir strain and without the ability to increase LA reservoir strain after passive leg raise have been found to have a shorter 6-min walk distance than those with preserved atrial strain and strain reserve [20]. Peak VO2 is directly associated with LA compliance. LA structure and function are associated with non-specific HF symptoms in stages A and B, even after adjustment for comorbidities, risk factors, echocardiographic parameters of cardiac structure, and diastolic function.
In patients with heart failure with preserved ejection fraction (HFpEF), LA strain seems superior to LAVi for predicting adverse outcomes. Among patients with HFpEF, LA strain is more strongly associated with adverse outcomes than longitudinal LV and RV strain measurements [21]. Similarly, in patients with heart failure with reduced ejection fraction (HFrEF), reduced peak atrial longitudinal strain (PALS) was significantly associated with more advanced HF and greater impairment in both LV systolic and diastolic function indices. Impaired PALS strongly predicts adverse outcomes, independent of other clinical and echocardiographic factors used to assess prognosis. Moreover, PALS provides additional prognostic information concerning LAVi, LV filling pressures, and LV global longitudinal strain (GLS) [22].
While an increase in LAVi can indicate the chronic impact of elevated LV or LA filling pressures and be a predictor of adverse outcomes in patients with HFrEF [23], LA enlargement can also occur in patients with normal filling pressures, i.e., healthy athletes or individuals with lone arrhythmias. Therefore, measurements of LA dimensions may not always offer a dependable estimation of LA pressure or function [22].
Detection of Atriopathy and Prediction of AF with LA Strain
Cardiac output can be reduced by around 15–20% by loss of atrial contraction when atrial fibrillation occurs in the context of HF. Conversely, increase of the LA booster pump function may compensate for decreased early filling in patients with impaired LV relaxation. In this setting, the likely reason for increased LA contractility is increased LA volume (Frank-Starling’s law). However, prolonged exposure to increased LV filling pressure leads to extreme dilatation and exhaustion of the Frank-Starling response, with both impaired LA function and the risk of AF [24]. A significant evidence base has been gathered regarding the prediction of AF with LA strain (Appendix Table 2).
In HFpEF, patients who develop AF are characterized by reduced LA strain (Fig. 1C)—independent of older age, higher BNP, and creatinine levels, increased LAVi, LV mass, impaired diastolic function, as well as reduced exercise capacity. Peak atrial contractile strain (PACS), peak atrial longitudinal strain (PALS), and LAVi demonstrate the highest predictive value for AF (PACS and PALS were independent of clinical data, LAVi, and E/e’ ratio). These three parameters (PACS, PALS, and LAVi) identify three key predictors of atrial fibrillation, and their combination is able to effectively distinguish high and low AF risk in HFpEF. This high-risk subset demonstrated a 33-fold increase in hazard [25].
The recurrence of AF after ablation is an important problem. In patients in sinus rhythm, LA reservoir and LA conduit strain have been strongly associated with atrial fibrillation recurrence, independent of LAVi, BMI, and LA pressure. However, some evidence points toward left atrial appendage velocity (LAAV), obtained at transesophageal echocardiography, as the strongest independent predictor [26]. In patients with AF, LAVi has been proposed as the only independently associated risk factor for AF recurrence after ablation, and LA strain appears to be less useful.
LA strain may help identify a group of patients with a high risk of developing AF. The appropriate clinical response to this predictor needs further study. It seems likely that pre-emptive lifestyle intervention, including stopping alcohol intake, may reduce the risk of progression. Whether there is sufficient justification to initiate empirical anticoagulation in this setting also requires further study [27].
Right Ventricular Strain
Right Ventricular (RV) Physiology
The right ventricular ejection fraction (or its surrogates including RV fractional area change) is a crucial factor in assessing the prognosis of a variety of conditions [28]. The muscle fibers within the RV are arranged in two layers—a superficial layer arranged circumferentially and a deeper layer arranged longitudinally. This specific arrangement determines the contractile motion of the RV, which is typically characterized by longitudinal shortening rather than the twisting and torsional contraction observed in the LV. In comparison to the LV, the RV is relatively thinner and more influenced by external factors, particularly pulmonary vascular resistance (PVR). Even slight increases in PVR can lead to significant reductions in RV cardiac output. However, in cases of chronic pressure overload, such as pulmonary hypertension (PH), the RV undergoes remodeling and hypertrophy as an adaptive response before eventually thinning and progressing toward failure [29].
RV Strain vs. Other Parameters of RV Function
Multiple acoustic windows should be used to provide a precise evaluation of the RV. In routine clinical practice, RV strain appears more reliable than other, commonly used indices of RV longitudinal function, including tricuspid annular plane systolic excursion (TAPSE) and annular systolic velocity (s’) from Doppler tissue imaging (DTI). The principal problem with standard parameters of longitudinal function is that they may be influenced by tethering—i.e., passive motion of the RV by preserved LV function. In certain conditions such as regional RV dysfunction, severe pulmonary arterial hypertension, or following cardiac surgery, TAPSE may not provide accurate measurements. Despite its limitations, TAPSE remains widely utilized as an index for assessing RV performance due to its ease of measurement, reproducibility, and diagnostic and prognostic significance across various disease states [30]. Similar to TAPSE, s’ reflects the function of longitudinal fibers, which play a significant role in RV contraction. The advantages and limitations of s’ are comparable to those observed with TAPSE; however, s’ demonstrates a stronger correlation with RV ejection fraction measured by cardiac magnetic resonance imaging (CMR) than does TAPSE [31]. RV longitudinal and radial function are often not matched, so it is still helpful to assess fractional area change (FAC). FAC offers insights into both the longitudinal and radial aspects of RV contraction. Unlike other methods, it is not limited to a single type of motion. However, one significant limitation of this technique is the often poor visualization of the RV lateral wall.
In comparison to the abovementioned parameters, RV strain (percent change in myocardial length) reflects both global and regional systolic function (Fig. 2A), but is significantly affected by image quality. RV strain is a strong independent predictor of severe adverse events in chronic heart failure and probably outperforms other indices of RV systolic function [32].
Examples of RV strain curves. A Healthy subject; global strain (GS, lower limit of normal [LLN] − 17%) and free-wall strain (FWS, LLN − 19%) are normal [37••]. B Heart failure. C Pulmonary hypertension. D Tricuspid regurgitation. These patients with RV enlargement have both impaired GS and FWS, and this is prognostically meaningful
Right Ventricular Strain in the Assessment of RV/PA Coupling
The function of the RV, which involves adapting to increased afterload, plays a critical role in determining the progression and symptoms of all types of pulmonary hypertension (PH). Nevertheless, as afterload continues to rise, the initially adaptive response transforms into pathological maladaptive remodeling. The current gold-standard approach for evaluating RV-PA coupling involves invasive and technically complex procedures. There is a need for non-invasive techniques, primarily relying on echocardiography, to estimate RV-PA coupling [33]. The ratio of TAPSE and estimated pulmonary arterial systolic pressure (TAPSE/PASP) was among the earliest and most well-validated non-invasive Doppler echocardiography-derived substitutes for RV-PA coupling. Currently TAPSE is being replaced by diverse echocardiographic parameters of RV contractility, especially RV strain. Initially employed as a prognostic test in heart failure [34•], it has also been used to assess prognosis in precapillary PH [35]. It is also a predictor of critical endpoints in tricuspid regurgitation.
Right Ventricular Strain in Heart Failure (Appendix Table 3)
Approximately 20% of patients with HFpEF have RV dysfunction, and this prevalence may be as high as 30–50% [36]. There is a progressive decline in RV free wall longitudinal strain (RVFWLS) across different groups with varying degrees of LV diastolic dysfunction (Fig. 2B). RVGLS has a stronger correlation with CMR-derived RVEF than do other conventional echocardiographic parameters, making it a more accurate measure of RV function. RVGLS was more impaired in HFpEF patients when compared to asymptomatic patients with LV diastolic dysfunction. Furthermore, reduced RVGLS was significantly associated with worse NYHA functional class in HFpEF patients, and it is an independent predictor of both overall mortality and heart failure rehospitalization.
In HFrEF, RVGLS and RVFWLS have been independently associated with death, cardiovascular death, heart transplantation, and worsening HF. Impaired RVGLS has been linked to worsening NYHA class, increased LV volume, and worse LV diastolic function. Interestingly, RVFWLS demonstrates superior incremental value over RVGLS in HFrEF patients, perhaps because the septal contribution to RVGLS is already assessed in LV parameters. Both RVGLS and RVFWLS can be reduced, even if traditional parameters like TAPSE and s’ are within the normal range. Strain levels are related to the clinical status of stable HF patients, provide information about global RV systolic function, and enable the detection of subclinical RV dysfunction [37••].
In patients with acute HFrEF, RVFWLS is correlated with conventional RV function parameters (TAPSE, s’, RVFAC) [38]. In this group of patients, RVFWLS is an independent predictor of poor prognosis, offering incremental prognostic value beyond clinical, and standard echocardiographic parameters.
Right Ventricular Strain in Pulmonary Hypertension (Appendix Table 4)
Similar to HF patients, in pulmonary arterial hypertension (PAH), conventional RV systolic function parameters like TAPSE, FAC, s’, and RVEF may appear normal despite abnormal RV strain. This highlights the importance of using RV strain as it can detect subclinical RV dysfunction in the early stages of the disease [39]. RVFWLS (Fig. 2C) more accurately predicts cardiovascular events in PAH than do TAPSE, FAC, s’, and RV index of myocardial performance and is an independent predictor of adverse clinical events and mortality. Individuals with a significantly impaired RVFWLS showed a proportional worsening in functional class, shorter 6-min walk distance, and higher N-terminal pro-B-type natriuretic peptide level. Individuals who experience an improvement in RVFWLS in response to therapy have a 7 times lower mortality rate, confirming the better prognosis in patients with PAH if RV function improves during therapy [40]. Conversely, a relative reduction of RV longitudinal strain > 10% was identified as a significant and independent risk factor for adverse outcomes in patients with PH.
Right Ventricular Strain Assessment in Tricuspid Regurgitation (Appendix Table 5)
The reduction in RVFWLS is directly related to the severity of tricuspid regurgitation [41]. Decreased RVFWLS (Fig. 2D), TAPSE, and FAC have been identified as independent predictors of 2-year all-cause mortality, with RV strain showing the highest predictive value [42, 43]. RVFWLS is independently associated with 2.8-year all-cause mortality and provides additional prognostic information beyond FAC and TAPSE. Moreover, RVFWLS remains independently associated with outcome after adjusting for comorbidities (diabetes mellitus, chronic kidney disease, coronary artery disease) and New York Heart Association class III/IV, whereas FAC and TAPSE did not show independent predictive value. Patients with impaired CMR-derived RVFWLS exhibited significantly lower survival rates than those with preserved RVFWLS—even after accounting for clinical and imaging risk factors, including RV size and ejection fraction [44].
While data on RV strain in predicting survival after valvular “edge-to-edge” repair procedures is still being investigated, it holds promise as a useful parameter in patients with tricuspid regurgitation, and the body of evidence supporting its relevance continues to grow.
Ventricular Strain in Heart Transplant Recipients
After heart transplantation, RV failure stands as a crucial factor contributing to early cardiac morbidity and mortality. As previously mentioned, myocardial strain is sensitive to the detection of subclinical impairment of RV function, even when other conventional RV function parameters appear normal. In a study investigating heart transplant recipients using CMR-derived RVLS and RVEF, RVLS was decreased in recipients with adverse events compared to those without such events. Moreover, both RVEF and RVLS emerged as significant independent predictors in heart transplant recipients. Notably, the predictive value of RVLS was superior to that of RVEF [45]. In a separate study, it was demonstrated through multivariable and univariable analyses that RVGLS serves as a significant predictor of 6-year all-cause mortality. Additionally, the RV diastolic strain rate (the rate of change of strain over time, which is reduced when the rate of contraction is reduced) was found to be a reliable predictor for both all-cause mortality and post-heart transplantation complications. Interestingly, while novel strain parameters of myocardial function showed predictive value, traditional 2D and Doppler parameters of systolic and diastolic function did not exhibit significant differences between rejection score groups [46]. These findings suggest that strain assessment in patients after heart transplantation could serve as a valuable, noninvasive tool for identifying individuals with a poor prognosis. This approach has the potential to enable early optimization of treatment strategies.
In pediatric pulmonary hypertension, 3D echocardiographic RVEF, RVFWLS, and FAC have been demonstrated as predictors of outcomes [47]. Moreover, a recent meta-analysis revealed that RVGLS, assessed using both 3D and 2D echocardiography, was a survival predictor in patients with pulmonary hypertension [48]. Additionally, the inclusion of RV dyssynchrony (measured based on 2D echocardiographic longitudinal strain) in a multivariable model improved the prediction of peak oxygen uptake, even though the model already incorporated conventional parameters such as RV FAC [49]. These findings highlight the significance of RV strain in pulmonary hypertension management.
Conclusions
In individuals with and without HF, impaired left atrial function, absence of LA functional reserve, and worse LV diastolic function are linked to decreased submaximal exercise capacity. Initiating treatments targeting these functional aspects may enhance exercise capacity and potentially prevent the onset of heart failure. Early identification of patients with a high risk of AF may lead to preventive strategies and possibly even empirical anticoagulation.
RV function has significant clinical and prognostic implications across various clinical scenarios, including HF, PH, tricuspid regurgitation, or in heart transplant recipients. The introduction of RV (global and free wall) longitudinal strain as a novel echocardiographic parameter has enhanced the assessment of RV systolic function, enabling the detection of subclinical RV dysfunction. However, additional studies are necessary to fully establish its role in patient management.
Data Availability
No datasets were generated or analyzed during the current study.
Code Availability
Not applicable.
References
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Nagueh SF, Khan SU. Left atrial strain for assessment of left ventricular diastolic function: focus on populations with normal LVEF. JACC Cardiovasc Imaging. 2023;16(5):691–707.
Anastasiou V, et al. Shifting from left ventricular ejection fraction to strain imaging in aortic stenosis. Diagnostics (Basel). 2023;13(10):1756.
Bigg HF, et al. Prognostic utility of echocardiographically derived left ventricular strain in assessing neonatal enteroviral myocarditis outcome. Cardiol Young. 2023;33(5):704–9.
Ueyama H, et al. Prognostic value of left ventricular global longitudinal strain in mitral regurgitation: a systematic review. Heart Fail Rev. 2023;28(2):465–83.
Hoit BD. Left atrial size and function: role in prognosis. J Am Coll Cardiol. 2014;63(6):493–505.
Hoit BD. Left atrial reservoir strain: its time has come. JACC Cardiovasc Imaging. 2022;15(3):392–4.
Caudron J, et al. Evaluation of left ventricular diastolic function with cardiac MR imaging. Radiographics. 2011;31(1):239–59.
Beltrami M, Dei LL, Milli M. The role of the left atrium: From multimodality imaging to clinical practice: a review. Life (Basel). 2022;12(8):1191.
To AC, et al. Clinical utility of multimodality LA imaging: assessment of size, function, and structure. JACC Cardiovasc Imaging. 2011;4(7):788–98.
Silbiger JJ. Pathophysiology and echocardiographic diagnosis of left ventricular diastolic dysfunction. J Am Soc Echocardiogr. 2019;32(2):216-232.e2.
Galderisi M, et al. Standardization of adult transthoracic echocardiography reporting in agreement with recent chamber quantification, diastolic function, and heart valve disease recommendations: an expert consensus document of the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2017;18(12):1301–10.
Frydas A, et al. Left atrial strain as sensitive marker of left ventricular diastolic dysfunction in heart failure. ESC Heart Fail. 2020;7(4):1956–65.
Potter EL, et al. Association of asymptomatic diastolic dysfunction assessed by left atrial strain with incident heart failure. JACC Cardiovasc Imaging. 2020;13(11):2316–26.
Inoue K, et al. Determinants of left atrial reservoir and pump strain and use of atrial strain for evaluation of left ventricular filling pressure. Eur Heart J Cardiovasc Imaging. 2021;23(1):61–70.
•• Smiseth OA, et al. Multimodality imaging in patients with heart failure and preserved ejection fraction: an expert consensus document of the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2022;23(2):e34–61. This important document integrates LA strain with the existing guideline for diastolic assessment. It shows how incorporation of reservoir strain can be an important means of reclassifying indeterminate data.
Morris DA, et al. Potential usefulness and clinical relevance of adding left atrial strain to left atrial volume index in the detection of left ventricular diastolic dysfunction. JACC Cardiovasc Imaging. 2018;11(10):1405–15.
Cameli M, et al. Correlation of left atrial strain and doppler measurements with invasive measurement of left ventricular end-diastolic pressure in patients stratified for different values of ejection fraction. Echocardiography. 2016;33(3):398–405.
Kurt M, et al. Relation of left ventricular end-diastolic pressure and N-terminal pro-brain natriuretic peptide level with left atrial deformation parameters. Eur Heart J Cardiovasc Imaging. 2012;13(6):524–30.
Lundberg A, et al. Left atrial strain improves estimation of filling pressures in heart failure: a simultaneous echocardiographic and invasive haemodynamic study. Clin Res Cardiol. 2019;108(6):703–15.
Patel RB, et al. Associations of cardiac mechanics with exercise capacity: the multi-ethnic study of atherosclerosis. J Am Coll Cardiol. 2021;78(3):245–57.
Freed BH, et al. Prognostic utility and clinical significance of cardiac mechanics in heart failure with preserved ejection fraction: importance of left atrial strain. Circ Cardio Imaging. 2016;9(3). https://doi.org/10.1161/CIRCIMAGING.115.003754.
Carluccio E, et al. Left atrial reservoir function and outcome in heart failure with reduced ejection fraction. Circ Cardiovasc Imaging. 2018;11(11): e007696.
Tamura H, et al. Increased left atrial volume index predicts a poor prognosis in patients with heart failure. J Card Fail. 2011;17(3):210–6.
Stefanadis C, Dernellis J, Toutouzas P. A clinical appraisal of left atrial function. Eur Heart J. 2001;22(1):22–36.
Jasic-Szpak E, et al. Prediction of AF in heart failure with preserved ejection fraction: incremental value of left atrial strain. JACC Cardiovasc Imaging. 2021;14(1):131–44.
Kiliszek M, et al. Value of left atrial strain in predicting recurrence after atrial fibrillation ablation. J Clin Med. 2023;12(12):4034.
Kosmala W. Heart failure with preserved ejection fraction and atrial fibrillation: how to fight allied enemies. J Am Coll Cardiol. 2020;76(9):1065–7.
Ghio S, et al. Prognostic relevance of the echocardiographic assessment of right ventricular function in patients with idiopathic pulmonary arterial hypertension. Int J Cardiol. 2010;140(3):272–8.
van der Bruggen CEE, et al. RV pressure overload: from hypertrophy to failure. Cardiovasc Res. 2017;113(12):1423–32.
Smolarek D, Gruchała M, Sobiczewski W. Echocardiographic evaluation of right ventricular systolic function: the traditional and innovative approach. Cardiol J. 2017;24(5):563–72.
Wang Z, et al. Association between echocardiography derived right ventricular function parameters with cardiac magnetic resonance derived right ventricular ejection fraction and 6-minute walk distance in pulmonary hypertension patients. Zhonghua Xin Xue Guan Bing Za Zhi. 2014;42(9):748–52.
Guendouz S, et al. Prognostic significance and normal values of 2D strain to assess right ventricular systolic function in chronic heart failure. Circ J. 2012;76(1):127–36.
Rako ZA, et al. Adaptive versus maladaptive right ventricular remodelling. ESC Heart Fail. 2023;10(2):762–75.
• Guazzi M, et al. Tricuspid annular plane systolic excursion and pulmonary arterial systolic pressure relationship in heart failure: an index of right ventricular contractile function and prognosis. Am J Physiol Heart Circ Physiol. 2013;305(9):H1373–81. This paper emphasizes the rationale and prognostic implications of assessing RV function in the context of afterload.
Tello K, et al. Relevance of the TAPSE/PASP ratio in pulmonary arterial hypertension. Int J Cardiol. 2018;266:229–35.
Nguyen KL, Hu P, Finn JP. Cardiac magnetic resonance quantification of structure-function relationships in heart failure. Heart Fail Clin. 2021;17(1):9–24.
•• Morris DA, et al. Normal range and usefulness of right ventricular systolic strain to detect subtle right ventricular systolic abnormalities in patients with heart failure: a multicentre study. Eur Heart J Cardiovasc Imaging. 2017;18(2):212–23. Important study that defines normal ranges for the clinical application of RV global and free-wall strain.
Borovac JA, et al. Right ventricular free wall strain and congestive hepatopathy in patients with acute worsening of chronic heart failure: a CATSTAT-HF echo substudy. J Clin Med. 2020;9(5):1317.
van Kessel M, et al. Prognostic value of right ventricular free wall strain in pulmonary hypertension patients with pseudo-normalized tricuspid annular plane systolic excursion values. Int J Cardiovasc Imaging. 2016;32(6):905–12.
Hardegree EL, et al. Role of serial quantitative assessment of right ventricular function by strain in pulmonary arterial hypertension. Am J Cardiol. 2013;111(1):143–8.
Hirasawa K, et al. Comparison of the usefulness of strain imaging by echocardiography versus computed tomography to detect right ventricular systolic dysfunction in patients with significant secondary tricuspid regurgitation. Am J Cardiol. 2020;134:116–22.
Lurz P, et al. Assessment of acute changes in ventricular volumes, function, and strain after interventional edge-to-edge repair of mitral regurgitation using cardiac magnetic resonance imaging. Eur Heart J Cardiovasc Imaging. 2015;16(12):1399–404.
Bannehr M, et al. Right ventricular longitudinal strain predicts survival in patients with functional tricuspid regurgitation. Can J Cardiol. 2021;37(7):1086–93.
Romano S, et al. Prognostic value of feature-tracking right ventricular longitudinal strain in severe functional tricuspid regurgitation: a multicenter study. JACC Cardiovasc Imaging. 2021;14(8):1561–8.
Sun W, et al. Prognostic value of feature-tracking right ventricular longitudinal strain in heart transplant recipients. Eur Radiol. 2023;33(6):3878–88.
Chamberlain R, et al. Prognostic value of left and right ventricular deformation strain analysis on acute cellular rejection in heart transplant recipients: a 6-year outcome study. Int J Cardiovasc Imaging. 2022;38(11):2271–81.
Jone PN, et al. 3D echocardiographic evaluation of right ventricular function and strain: a prognostic study in paediatric pulmonary hypertension. Eur Heart J Cardiovasc Imaging. 2018;19(9):1026–33.
Hulshof HG, et al. Prognostic value of right ventricular longitudinal strain in patients with pulmonary hypertension: a systematic review and meta-analysis. Eur Heart J Cardiovasc Imaging. 2019;20(4):475–84.
Badagliacca R, et al. Right ventricular dyssynchrony and exercise capacity in idiopathic pulmonary arterial hypertension. Eur Respir J. 2017;49(6):1601419.
Hauser R, et al. Left atrial strain predicts incident atrial fibrillation in the general population: the Copenhagen City Heart Study. Eur Heart J Cardiovasc Imaging. 2021;23(1):52–60.
Funding
Dr. Marwick is supported by an Investigator grant (2008129) from the National Health and Medical Research Council (NHMRC0, Canberra, Australia). No other funds were used for this project.
Author information
Authors and Affiliations
Contributions
AS searched the literature and created the first draft. WK assisted with selecting content and revised the paper based on his knowledge of the field. THM designed the paper, assisted with selecting content, and revised the paper based on his knowledge of the field.
Corresponding author
Ethics declarations
Conflict of Interest
None of the authors have any relevant disclosures or conflicts of interest to report.
Human and Animal Rights and Informed Consent
No animal or human subjects by the authors were used in this study.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary Information
Below is the link to the electronic supplementary material.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
Serafin, A., Kosmala, W. & Marwick, T.H. Evolving Applications of Echocardiography in the Evaluation of Left Atrial and Right Ventricular Strain. Curr Cardiol Rep 26, 593–600 (2024). https://doi.org/10.1007/s11886-024-02058-x
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11886-024-02058-x