Multimodality imaging assessment of right ventricular longitudinal strain for prognostic stratification in cardiac amyloidosis: a systematic review and meta-analysis
J Herrera, R W M Vernooij, A K Gosh, A Wechalekar, R K Cheng, K Keramida, M Anguita, P L Sanchez, C Perez del Villar, I Cruz, C HerreraAbstract
Background
Amyloidosis is a progressive disorder frequently associated with cardiac involvement and poor prognosis. While left ventricular and atrial strain parameters have been extensively linked to adverse events in amyloidosis, the prognostic implications of right ventricular (RV) longitudinal deformation parameters remain less clearly defined.
Objective
To determine the prognostic value of RV global longitudinal strain (RV-GLS) and RV free-wall longitudinal strain (RV-FWLS) assessed by multimodal imaging in relation to mortality and heart failure–related hospitalization in patients with amyloidosis.
Methods
A detailed search of PubMed, EMBASE, and Cochrane databases was conducted through the end of 2025 in accordance with PRISMA and MOOSE recommendations. Prospective and retrospective studies evaluating the association between RV-GLS or RV-FWLS and clinical outcomes were included. Study selection, data extraction, and quality assessment (Newcastle–Ottawa scale) were performed independently. Pooled hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated using inverse-variance weighted random-effects models, estimating risk per 1% absolute worsening in RV strain. Outcomes included all-cause mortality and a composite of death or HF hospitalization.
Results
Eighteen studies comprising 1,772 patients (mean age 68.8 ± 8.8 years; 57.3% AL amyloidosis, remainder predominantly ATTR) were analyzed (Table 1), with overall low-to-moderate risk of bias and minimal statistical heterogeneity. During follow-up [median follow-up: 2.6 (1.6) years], 628 patients died and 210 experienced the composite endpoint (median [inter-quartile range] follow-up: 1.5 [0.6] years). RV-FWLS by 2D speckle-tracking was significantly associated with all-cause mortality (HR: 1.10; 95% CI: 1.07–1.13; I² = 8.6%) and with the composite endpoint (HR: 1.06; 95% CI: 1.02–1.10; I² = 0%). Similarly, RV-GLS was linked to higher mortality risk (HR: 1.10; 95% CI: 1.07–1.13; I² = 8.6%). In AL amyloidosis, CMR-derived RV-GLS also independently predicted all-cause mortality (HR: 1.06; 95% CI: 1.03–1.09; I² = 0%).
Conclusions
Across imaging modalities and amyloidosis, RV longitudinal strain parameters provide robust and independent prognostic information. These findings support the potential integration of RV deformation analysis into routine risk stratification of patients with amyloidosis.