Myocardial Strain in Perioperative Medicine: A Practical Review for Anesthesiologists

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.