Diagnostic Performance of Relative Apical Sparing Across Cardiac Diseases: A Multimodality Systematic Review and Meta-Analysis

Figures

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  Figure 1. Flow diagram illustrating the literature screening and study selection procedure following PRISMA guidelines. STE, speckle tracking echocardiography.

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  Figure 2. Representative bull’s-eye (polar) map illustrating the base-to-apex gradient of longitudinal strain in a patient with cardiac amyloidosis. The map demonstrates relatively preserved apical strain compared with reduced basal and mid-ventricular strain, consistent with the typical “apical sparing” pattern. Global longitudinal strain and segmental strain values are displayed.

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  Figure 3. Forest plot of standardized mean differences (SMDs) for relative apical sparing comparing cardiac amyloidosis and non-amyloid conditions. Results are stratified by imaging modality, including two-dimensional speckle-tracking echocardiography (2D-STE) and cardiac magnetic resonance feature tracking (CMR-FT). Squares represent individual study estimates, with size proportional to study weight, and horizontal lines indicate 95% confidence intervals. Diamonds denote pooled random-effects estimates for each subgroup and for the overall analysis. Between-study heterogeneity was quantified using the I2 statistic [17,19,20,21,30,32,33,35,36,40,41,42,43,44].

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  Figure 4. Pooled standardized mean differences for relative apical sparing pattern comparing cardiac amyloidosis and non-amyloid conditions, stratified by imaging modality. Diamonds represent random-effects estimates, and horizontal lines indicate 95% confidence intervals.

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  Figure 5. Assessment of publication bias for the association between cardiac amyloidosis and relative apical sparing using funnel plot analysis.

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  Figure 6. Representative 2D speckle-tracking echocardiography–derived left ventricular global longitudinal strain bull’s-eye maps in a healthy individual with mitral valve prolapse (A) and a patient with pectus excavatum (B). In both cases, the LV-GLS bull’s-eye maps demonstrate reduced basal segment deformation with relative preservation of apical strain, resulting in an apparent apical sparing pattern. These findings highlight the potential influence of thoracic morphology on regional myocardial deformation patterns independent of myocardial infiltration.