Two-dimensional ultrasound is optimal for screening; RT-3DE shows highest consistency with cardiovascular magnetic resonance for precise diagnosis, and 3DE-LACI has demonstrated independent prognostic value in cardiac amyloidosis.
Abstract
Background The Left Atrioventricular Coupling Index (LACI) is an emerging echocardiographic parameter for assessing left atrial and ventricular diastolic function. While accumulating evidence supports its prognostic value, technical standardization for clinical implementation remains lacking. Methods This narrative review compares four LACI measurement approaches: two-dimensional echocardiography (2DE), real-time three-dimensional echocardiography (RT-3DE), speckle-tracking echocardiography (STE), and artificial intelligence (AI)-assisted analysis. We evaluate technical characteristics, standardization challenges, and evidence gaps. Results Two-dimensional ultrasound is optimal for screening; RT-3DE shows highest consistency with cardiovascular magnetic resonance for precise diagnosis, and 3DE-LACI has demonstrated independent prognostic value in cardiac amyloidosis. STE aids mechanistic exploration but requires algorithmic standardization. AI demonstrates potential but needs multicenter validation. Key limitations include absent cross-platform calibration, fragmented reference values, and lack of externally validated cutoffs. Conclusion LACI is a promising marker of diastolic function with proven prognostic value; however, technical heterogeneity and inconsistent thresholds have hindered its clinical application. Future efforts should focus on cross-manufacturer standardization, the establishment of reference values for specific populations, and randomized controlled trials evaluating LACI as a guide for treatment.
Background Movement of the mitral annulus toward the left ventricular (LV) apex during systole, termed atrioventricular plane displacement or mitral annular plane systolic excursion (MAPSE), was first observed by Leonardo da Vinci in the 15th century. MAPSE, a measure of longitudinal movement, shows good agreement between transthoracic echocardiography and cardiovascular magnetic resonance imaging and can also be measured by transesophageal echocardiography and cardiac computed tomography. Measurement is fast, simple, and easily automated. However, no major imaging guidelines advise routine measurement. Methods We present a systematic review of studies appraising the diagnostic and prognostic performance of MAPSE from PubMed, Medline, Google Scholar, and Embase until September 2025 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses statement. Studies assessing MAPSE in adult populations were included, and non‐English publications, abstracts, and studies of congenital heart disease were excluded. Newcastle–Ottawa Scale assessed study quality. Correlation coefficients between MAPSE and markers of systolic function were pooled using Hunter–Schmidt meta‐analysis. Heterogeneous diagnostic and prognostic outcomes were synthesized narratively. Results The review included 92 studies. MAPSE correlated with LV ejection fraction (r=0.64 [95% CI, 0.54–0.74]) and global longitudinal strain (r=0.53 [95% CI, 0.45–0.63]), showing a modest association with systolic function, particularly useful in patients with poor echocardiographic windows. MAPSE was frequently reduced despite preserved LV ejection fraction across multiple pathologies, enabling earlier detection of systolic impairment. MAPSE also demonstrated strong prognostic value, outperforming LVEF and global longitudinal strain in predicting adverse events in several studies. Conclusions Overall, MAPSE has a clinically important role meriting integration into routine cardiac imaging and care.
Debbie Falconer, F. Fröjdh, N. Wyeth et al.· Journal of the American Hear...· 1 citation
Background Although the reproducibility of individual echocardiographic measurements has been previously investigated, evidence evaluating a comprehensive panel of routinely used left- and right-sided parameters within standardized real-world clinical workflows from Latin American centers remains limited. We aimed to evaluate the reproducibility of routine echocardiographic measurements, including intraobserver and interobserver variability, and to examine their agreement with cardiac magnetic resonance (CMR). Methods Two cohorts of adult participants were included between 2022 and 2023: a clinical cohort consisting of patients referred for transthoracic echocardiography because of cardiovascular symptoms or routine cardiovascular evaluation, and a healthy reference group with no history of cardiovascular disease or self-reported systemic illness. Left- and right-sided echocardiographic measurements, including ventricular, atrial, and left ventricular outflow tract (LVOT) indices, were analyzed. CMR was used to assess left ventricular volumes and ejection fraction. Reproducibility was assessed by two echocardiographers using intraclass correlation coefficients and Bland–Altman analysis. Results Sixty-three participants were included, 20 in the healthy reference group and 43 in the clinical cohort. Left ventricular measurements showed excellent reproducibility, whereas right-sided indices showed overall good reproducibility. LVOT diameter showed the lowest concordance. Compared with CMR, echocardiography underestimated left ventricular volumes, while agreement for left ventricular ejection fraction remained excellent. Conclusions In routine clinical practice, standard echocardiographic measurements showed overall good reproducibility, with the strongest performance for left ventricular indices. Greater variability was observed for selected right ventricular measurements and LVOT diameter, whereas agreement with CMR was excellent for left ventricular ejection fraction despite underestimation of ventricular volumes.
Raúl Reyes-Toledo, D. G. David-Pardo, G. Lemus-Barrios et al.· Frontiers in Cardiovascular...· 0 citations
Right ventricular function has historically received less attention than left ventricular function. Yet, emerging evidence highlights its crucial prognostic role in various cardiovascular diseases, including acute myocardial infarction, pulmonary hypertension, pulmonary embolism, and congenital heart disease. Advances in echocardiography, particularly two-dimensional speckle-tracking echocardiography, have enabled quantitative assessment of right ventricular global longitudinal strain and right ventricular free-wall longitudinal strain, providing greater sensitivity for detecting subclinical right ventricular dysfunction than conventional indices, such as tricuspid annular plane systolic excursion or fractional area change. This review will provide methodology, normal reference values, and clinical applications of right ventricular global longitudinal strain, specifically for the Indian context. It incorporates recent Indian studies across acute myocardial infarction, valvular heart disease, cardiac surgery, heart failure with preserved ejection fraction, and diabetes mellitus. International data provide a comparative context, revealing significant gaps in population-specific normative data for India. Technical challenges, including vendor variability, load dependency, and imaging quality limitations, are discussed alongside emerging technologies such as 3D speckle-tracking, artificial intelligence integration, and telemedicine applications. The review concludes with recommendations for establishing India-specific reference ranges, developing comprehensive training programs, and conducting large-scale prospective outcome studies to facilitate routine clinical integration of right ventricular strain imaging across India’s diverse healthcare landscape.
Parminder Sharma, Arghadip Bose, Basant Kumar· Indian Journal of Clinical C...· 0 citations
BACKGROUND
Right atrioventricular coupling index (RACI), defined as the ratio of right atrial (RA) to right ventricular end-diastolic volume on cardiac magnetic resonance, is a novel parameter that reflects RA-right ventricular (RV) hemodynamic interplay. Its prognostic value in functional tricuspid regurgitation (TR) is unknown.
METHODS
This study included 633 consecutive patients with moderate or greater functional TR undergoing cardiac magnetic resonance. Patients were stratified into 2 groups based on the optimal cutoff by the Youden index (normal: RACI<0.62 versus high: RACI≥0.62). The primary outcome was all-cause mortality.
RESULTS
Patients with high RACI (n=147) were older (74.1±10.7 years versus 60.6±16.1 years, P<0.001) with larger RA volumes (RV end-systolic volume index: 96.7 [interquartile range, 77.5-121.2] mL/m2 versus 55.4 [interquartile range, 42.6-69.0] mL/m2; P<0.001), smaller RV size (RV end-diastolic volume index: 106.2±33.5 versus 114.8±37.2 mL/m2; P=0.012), and no difference in RV function (RV ejection fraction: 46.3±9.8% versus 45.4±12.7%; P=0.43). Over a median follow-up of 2.9 years (interquartile range, 0.7-6.9), a high RACI was associated with increased mortality risk (25% versus 15%; hazard ratio, 2.06 [95% CI, 1.47-2.90]; P<0.001). In multivariable Cox regression analysis adjusting for age, right and left heart size and function, and clinical markers of right-sided congestion (glomerular filtration rate <30, total bilirubin), RACI remained an independent predictor of all-cause mortality (adjusted hazard ratio, 1.16 per 0.10 increase, 95% CI, 1.03-1.32, P=0.014). In addition, RACI provided incremental prognostic value for predicting the primary outcome over conventional right heart indices (RA and RV volumes, RV ejection fraction, TR severity), improving model performance (χ2 increased from 28.5 to 37.6; P=0.003).
CONCLUSIONS
RACI is a novel parameter that effectively integrates RA and RV remodeling, and independently predicts all-cause mortality in functional TR. Incorporating RACI into clinical assessment may help with improving risk stratification and guiding the timing of intervention in patients with functional TR.
Robert S. Zhang, G. Falco, E. Li et al.· Circulation Cardiovascular I...· 0 citations
Background: Atrial stiffness can be estimated non-invasively using speckle-tracking echocardiography (STE) and has recently emerged as an outcome predictor. We aimed to assess left atrial (LA) and right atrial (RA) phasic function; the LA stiffness index (LASI), the RA stiffness index (RASI) and their sum; and the biatrial stiffness index (BASI) in dilated cardiomyopathy (DCM), and to test whether combining the two atria adds prognostic information over either index alone. Methods: A total of 121 patients with non-ischaemic DCM in sinus rhythm were followed prospectively for a composite endpoint of all-cause death, non-fatal cardiac arrest, or hospitalisation for heart failure decompensation. LASI was defined as the mitral E/e′ ratio divided by LA reservoir strain, RASI as the tricuspid Et/e′t ratio divided by RA reservoir strain, and BASI as the sum of the two. Cox models were adjusted for NYHA class, LV ejection fraction (LVEF), maximal LA volume (LAVmax) and pulmonary artery systolic pressure (PASP). Results: After 19 ± 11 months, 55 patients reached the endpoint. LA reservoir and contraction strain, all three components of RA strain and all three stiffness indices were significantly impaired in patients with events. All stiffness indices were independent outcome predictors in multivariable Cox regression (HR 2.79 [95% CI, 1.35–5.75], p = 0.006 for LASI, HR 1.84 [95% CI, 1.02–3.29], p = 0.04 for RASI and HR 2.74 [95% CI, 1.36–5.51], p = 0.005 for BASI). BASI showed the greatest increase in risk prediction (Δ likelihood ratio χ2 test = 10.3, p = 0.001) over NYHA class, left ventricular ejection fraction, LA maximal volume and pulmonary artery systolic pressure. BASI showed the highest discrimination (AUC = 0.73); however, it was not significantly better than LASI or RASI alone. Conclusions: Left and right atrial stiffness are both associated with adverse outcome in DCM and add prognostic information to an LV-centred risk model. Their unweighted sum performs at least as well as either component and offers a single parsimonious measure, whose incremental clinical value remains to be established in larger, externally validated cohorts.
A. Vijiiac, I. Petre, S. Onciul et al.· Journal of Clinical Medicine· 0 citations
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.
C. Beyls, F. Gonzalez, E. Donal et al.· Journal of Clinical Medicine· 0 citations