Right Ventricular Strain

See Article by Prihadi et al In clinical practice, tricuspid regurgitation (TR) occurs most frequently as a consequence to dilatation of the tricuspid annulus because of right ventricular (RV) volume or pressure overload.Chronic elevated left ventricular filling pressures caused by left heart valvular or myocardial disease lead to secondary pulmonary hypertension and RV failure.Both RV dysfunction and TR have been associated with poor prognosis in these clinical scenarios.Historically, TR has been an undervalued entity, especially when associated to left-side heart disease.A conservative approach to the tricuspid valve has been preferred under the belief that treatment of left heart disease would ultimately reverse pulmonary hypertension, leading to a reduction of RV size and improved tricuspid leaflet coaptation.However, not uncommonly, TR does not resolve following treatment of left-side heart disease. 1 Current guidelines for the management of valvular heart disease recommend surgical correction of secondary TR to be made early enough to avoid permanent RV dysfunction, which is often the watershed to patient's prognosis.2 Furthermore, once RV dysfunction is present, TR does not appear to be an independent marker of decreased survival, but rather an epiphenomenon of RV dysfunction.3 Perhaps, the most important challenge for selecting those patients who may benefit from tricuspid valve replacement or repair, even with the recent surge of percutaneous approaches, has been evaluating RV performance.The most widely available imaging technique, 2-dimensional echocardiography, remains limited by frequently suboptimal acoustic windows and the use of often incorrect geometric assumptions.RV visualization by 3-dimensional echocardiography is particularly difficult, especially when the chamber becomes enlarged.Although easy to implement and fairly reproducible, the evaluation of the tricuspid annulus systolic excursion can be severely influenced by the use of an improper imaging angle and takes mostly into account the function of the RV free wall basal segment.Cardiac magnetic resonance remains the gold standard method for RV evaluation because it is not influenced by the body habitus and relies on diastolic and systolic RV volumes quantification, resulting on a tridimensional ejection fraction.However, it is frequently impractical for many patients with heart failure because of their inability to stay supine for a prolonged time and sustain repetitive long breath holds.Many of them also have implanted devices that are not magnetic resonance imaging compatible or produce significant imaging artifacts.In the current issue of Circulation: Cardiovascular Imaging, Prihadi et al 4 address the limitations of most commonly used echocardiographic methods to assess RV function, comparing the prognostic value of longitudinal strain of the RV free wall measured by speckle tracking with tricuspid annulus systolic excursion and fractional area change on the detection of subtle and subclinical RV dysfunction in