A practical framework for the perioperative use of myocardial strain is provided by summarizing the current evidence, clarifying its methodological limitations, simplifying its acquisition and interpretation for non-expert users, distinguishing established clinical applications from future research directions, and identifying the key evidence gaps that must be addressed.
Abstract
Myocardial strain imaging, derived from speckle-tracking echocardiography (STE), has evolved from a research tool into a reproducible technique for detecting subclinical myocardial dysfunction. Recent advances in automated contouring and artificial intelligence have improved feasibility, reproducibility, and analysis speed, making multichamber strain assessment increasingly accessible in perioperative practice. Perioperative cardiovascular complications, including myocardial injury after non-cardiac surgery (MINS), postoperative atrial fibrillation (POAF), and heart failure, are associated with substantial postoperative morbidity and mortality. Conventional echocardiographic parameters, particularly left ventricular ejection fraction (LVEF), lack sensitivity for detecting early myocardial dysfunction. By quantifying myocardial deformation, strain imaging identifies subtle abnormalities in ventricular and atrial mechanics before conventional echocardiographic abnormalities become evident. Among available parameters, left ventricular global longitudinal strain (LV-GLS) and left atrial reservoir strain (LASr) provide the strongest evidence for perioperative risk stratification, with impaired values independently associated with MINS and POAF, respectively. Right ventricular strain (RV-GLS, RV-FWLS) and right atrial reservoir strain (RASr) remain promising but less standardized parameters supported mainly by observational data. Despite these advances, several barriers continue to limit widespread implementation, including vendor variability, the lack of standardized thresholds, and the absence of validated transesophageal echocardiography (TEE)-specific reference values. Importantly, current evidence supports myocardial strain primarily as a tool for risk stratification rather than for guiding therapy. No randomized trial has demonstrated that strain-guided perioperative management improves clinical outcomes, and its incremental value beyond established perioperative tools, including clinical risk scores, biomarkers, and conventional echocardiography, remains to be established. This review aims to provide a practical framework for the perioperative use of myocardial strain by summarizing the current evidence, clarifying its methodological limitations, simplifying its acquisition and interpretation for non-expert users, distinguishing established clinical applications from future research directions, and identifying the key evidence gaps that must be addressed before strain-guided strategies can be incorporated into routine perioperative care.
This review will provide methodology, normal reference values, and clinical applications of right ventricular global longitudinal strain, specifically for the Indian context, incorporating recent Indian studies across acute myocardial infarction, valvular heart disease, cardiac surgery, heart failure with preserved ejection fraction, and diabetes mellitus.
Parminder Sharma, Arghadip Bose, Basant Kumar· Indian Journal of Clinical C...· 0 citations
Nonischemic cardiomyopathy (NICM) carries significant morbidity and mortality. While left ventricular ejection fraction (LVEF) remains central to risk stratification, it may not fully capture the extent of myocardial impairment, and strain imaging can provide independent prognostic information beyond LVEF alone. Myocardial strain imaging may provide additional prognostic value, but its role in NICM remains incompletely defined. This scoping review, conducted per PRISMA-ScR guidelines, searched PubMed, Embase, and Cochrane Library from inception through October 25, 2025, to identify studies evaluating myocardial strain parameters, specifically left ventricular global longitudinal strain (LVGLS), left ventricular global circumferential strain, left ventricular global radial strain, and right ventricular global longitudinal strain, in adult NICM populations using speckle-tracking echocardiography or cardiac magnetic resonance feature tracking. Data were extracted by 2 independent reviewers and synthesized descriptively. From 1356 records, 36 studies (7903 patients) were included, with follow-up ranging from 9 months to 7.8 years. LVGLS was the most frequently assessed parameter. Across 21 studies evaluating major adverse cardiovascular events, worse baseline strain values were consistently associated with increased risk (hazard ratios 1.06-2.70 per unit decrease in strain magnitude). Two studies reported significant associations with ventricular arrhythmias, and 4 showed that more favorable baseline strain predicted a higher likelihood of left ventricular reverse remodeling. Strain parameters, particularly LVGLS, remained independently associated with outcomes in 34 of 36 studies after multivariable adjustment, often providing incremental value beyond LVEF and late gadolinium enhancement. These findings support strain imaging, especially LVGLS, as an adjunct to conventional risk stratification in diverse NICM populations. Standardized, multicenter prospective studies are needed to establish its role in clinical decision-making.
Dina Mohammed, Humza Saeed, Abdallah Rayyan et al.· Cardiology in Review· 0 citations
With aging societies, heart failure (HF) is a growing public health concern, particularly HF with a preserved left ventricular ejection fraction (HFpEF). Patients with atherosclerotic cardiovascular disease (ASCVD) are at an increased risk of incident HF, while the prediction of individual risk remains challenging. Speckle-tracking echocardiography enables an objective and quantitative assessment of subtle myocardial alterations that are undetectable with conventional echocardiography and has excellent feasibility and reproducibility. Left ventricular global longitudinal strain (LVGLS), a sensitive measure of LV systolic dysfunction, has been found to be an independent risk factor for the occurrence of HF. In addition, more than 50% of patients with HFpEF had impaired LVGLS. Recently, deformation imaging has been employed to assess left atrial (LA) performance, and impaired LA strain has been shown to predict unfavorable outcomes in various clinical settings. This review article presents the clinical relevance of subclinical left heart dysfunction in patients with ASCVD and describes its future perspectives.
K. Nakanishi· Journal of atherosclerosis a...· 0 citations
Ischemic cardiomyopathy (ICM) is characterized by profound left ventricular (LV) remodelling, impaired systolic function, and variable myocardial viability. Cardiac magnetic resonance feature tracking (CMR-FT) enables non-invasive quantification of myocardial deformation from standard cine sequences without dedicated tagging sequences. The present study aimed to evaluate the role of CMR-FT in the comprehensive assessment of myocardial function and viability in patients with ICM compared with healthy controls. Cases showed markedly elevated end-diastolic and end-systolic volumes with severely reduced ejection fraction (EF: 36.6 ± 16.9% vs. 64.1 ± 10.0%; p < 0.001). Stroke volume was preserved, reflecting Frank-Starling compensation. Wall motion abnormalities were concentrated in mid-cavity and apical territories. Apical segments demonstrated the highest transmural scar burden on LGE (apex 33.3%; apical inferior 35.3%). All three global strain parameters were profoundly impaired with large effect sizes (GRS Cohen’s d = 2.46; GCS d = 2.00; GLS d = 1.38). Segmental circumferential strain (SCS) and segmental radial strain (SRS) demonstrated statistically significant discriminative ability for non-viable myocardium (AUC 0.624–0.637); segmental longitudinal strain (SLS) reached significance uniquely for viable scar versus no scar (AUC 0.566). CMR-FT provides comprehensive, non-invasive assessment of myocardial deformation in ICM. A multi-strain approach—SCS and SRS for transmural scar identification, SLS for early subendocardial injury—offers clinically meaningful, contrast-independent viability information that complements LGE imaging and supports risk stratification in this population.
Yomna Abdulwahab Mohmamed Rihan, M. Bilal, A. Sultan et al.· The Egyptian Journal of Radi...· 0 citations
Heart failure with preserved ejection fraction (HFpEF) represents an increasingly prevalent clinical syndrome, driven by population ageing and the growing burden of cardiometabolic comorbidities, and is associated with significant morbidity and mortality. Due to its heterogeneous pathophysiology and the frequent absence of overt structural abnormalities, early diagnosis and accurate risk stratification remain challenging. In the current era of emerging disease-modifying therapies, the identification of sensitive imaging markers able to detect early myocardial dysfunction and refine patient characterization has become increasingly important. Speckle-tracking echocardiography has emerged as a valuable tool for the comprehensive evaluation of HFpEF, allowing the assessment of subclinical myocardial impairment beyond conventional parameters. Left ventricular global longitudinal strain (LV-GLS) identifies subtle systolic dysfunction despite preserved left ventricular ejection fraction (LVEF) and provides incremental diagnostic and prognostic information. Accordingly, LV-GLS has been incorporated into contemporary diagnostic algorithms and may represent a promising marker for monitoring disease progression and therapeutic response. Beyond the left ventricle (LV), left atrial (LA) strain has gained increasing relevance as a marker of atrial myopathy and elevated filling pressures. Left atrial reservoir strain (LARS) detects early atrial dysfunction before overt structural remodelling, improves the identification of HFpEF in patients with unexplained dyspnoea, and provides additional prognostic information, including prediction of atrial fibrillation and thromboembolic risk. Moreover, right ventricular free-wall longitudinal strain (RV-FWLS) allows early recognition of right ventricular involvement and has shown important prognostic implications, particularly in relation to pulmonary vascular dysfunction and exercise intolerance. Overall, a multi-chamber strain-based approach may improve HFpEF diagnosis, phenotyping, and risk stratification, supporting a transition toward a more personalized management strategy. Further prospective studies are needed to define the role of strain imaging in guiding therapeutic decisions and monitoring treatment response.
M. C. Pastore, Clarissa Carmona De Azevedo Bellagamba, A. Stefanini et al.· Journal of Clinical Medicine· 0 citations
Methodological heterogeneity, as well as limited reproducibility data and the relative scarcity of studies available suggest the need for standardized acquisition protocols and larger, well-designed studies to determine its clinical usefulness.
Nishan Kotian, A. Vasudeva, K. Nayak et al.· BMC Pregnancy and Childbirth· 0 citations