Skip to main content
. 2024 Sep 27;60(10):1586. doi: 10.3390/medicina60101586

Table 1.

Summary of the reviewed clinical studies (listed from older to the most recently published).

First Author (Published Year) [Ref.] Type of Study Clinical Scenario Type of Strain Used Number of Patients in Each Group/Arm PE (+/− Other) Control Main Results (Regarding PE-Related Findings)
Kjaergaard et al. (2004) [21] Prospective, consecutive patients Sub-massive PE before and after thrombolysis and at 2 months follow-up RVLS of the RV free wall 3 − Middle part of RV-FW had low or positive strain that normalized after thrombolysis (apical and basal segments had unaffected strain)
Park et al. (2007) [22] Prospective, non-consecutive patients PE before and after treatment (anticoagulation +/− thrombolysis) PSS of the RV free wall 24 − PSS of middle and apex part of RV-FW were impaired at the baseline and both improved after treatment (changes were more pronounced in the middle part)
Sugiura et al. (2009) [23] Prospective, non-consecutive patients Massive or sub-massive PE before and after primary treatment Ɨ vs. control group (age- and sex-matched healthy subjects) Global and regional RV PSS 23 23

  1. PSS was reduced in all segments except for the basal and middle septum (accordingly, global RV PSS was also reduced), in comparison to the control group *

  2. After treatment PSS improved in all initially affected segments except for the basal RV lateral wall, which in conjunction with the still impaired middle RV lateral and basal septum segments led to a reduced global RV PSS (however, it improved compared to the global RV PSS before treatment administration) *
Park et al. (2010) [24] Retrospective, non-consecutive Acute CP due to massive PE vs. patients with chronic CP due to severe COPD Regional RV PSS 24 (28 COPD) -

  1. PSS of the middle segment of RV-FW was diminished in patients with acute CP compared to those with chronic CP due to severe COPD *

  2. Values of PSS of the middle segment of the RV free wall > −12.2% could predict acute CP (sensitivity 83.3%, specificity: 78.6%)
Takamura et al. (2011) [25] Prospective, consecutive patients Massive or sub-massive PE before and after primary treatment Ɨ vs. control group (age- and sex-matched healthy subjects) Global and regional LV PSS in the three contractile directions 25 25

  1. Global and regional radial PSS were reduced in patients with PE on admission and did not recover to normal values after treatment compared to the control group *

  2. Global and regional longitudinal PSS, apart from the basal lateral wall, were reduced in the setting of PE. After treatment: PSS in the basal and middle inferoseptum were still reduced, while PSS improvement of the apical segments and middle lateral wall led to a global PSS comparable to that of the control group *

  3. Global and regional circumferential PSS were diminished upon admission and restored to values comparable to those of the control group after treatment *
Platz et al. (2012) [26] Retrospective, non-consecutive patients PE vs. control group (age- and sex-matched subjects with no evidence of structural or valvular heart disease on echocardiography) Global and regional RVLS 75 30

  1. Global RV-FW and septal strain was affected in the PE subjects compared to the control group

  2. Except for the apical septum, regional RVLS was significantly reduced in all the other RV segments *

  3. All three segments of the RV-FW had significantly affected strain rates *

  4. Global RVLS did not differ between patients with and without McConnell sign
Ichikawa et al. (2013) [27] Retrospective, non-consecutive patients PE or CPAH vs. control group (age-matched normal subjects) Global and regional RV and LV PSS 37 (36 CPAH) 33

  1. Both groups showed a significant reduction in global RV longitudinal PSS compared to the control group

  2. The reduction in the PSS of the basal and middle part of the RV-FW was greater in PE *

  3. In the PE group, global PSS of the LV was reduced in comparison to the other 2 groups in almost all directions (longitudinal, radial, and circumferential), with only the PSS of the basal parts of the longitudinal axis being unaffected compared to the control group

  4. In the CPAH group, global PSS was maintained only in the longitudinal axis due to the intact PSS in the apical and lateral LV segments compared to the control group *
Vitarelli et al. (2014) [28] Prospective, non-consecutive patients Intermediate-risk PE at the onset of the acute episode and after median follow-up periods of 1 and 6 months vs. control group (sex- and age-matched healthy subjects) RVGLS and RVFWS 66 66

  1. Patients diagnosed with PE had lower RVGLS and lower RVLS in all RV-FW segments, with the mid-part being the most affected *

  2. Among 3D-RVEF, RVSP, and mid-FW wall RVLS, the latter showed a statistically significant reversal at 1-month follow-up, earlier than the others *

  3. Besides 3D-RVEF, mid-free-wall RVLS showed a statistically significant correlation with 6-month adverse outcomes ¥

  4. Mid-FW RVLS using a cut-off value > −12% could predict adverse outcomes ¥ at 6 months (sensitivity, 84%; specificity, 74%) *
Khemasuwan et al. (2015) [29] Retrospective, non-consecutive patients Patients with PE admitted to the ICU at some point during their hospitalization Global and regional RVLS 110 out of a total of 211 - Global and regional RVLS were not associated with short-term (during hospitalization) or long-term mortality but were associated with the need of mechanical ventilation during the ICU stay
Wright et al. (2016) [30] Retrospective, non-consecutive patients Non-high-risk PE vs. control group (divided into two groups, one unmatched and the other matched for age, sex, and PASP) RVLS of the free wall 45 161 with CPAH (45 matched and 116 unmatched)

  1. Patients with PE had RVLS reduced in all segments of the RV-FW *

  2. Those with and without McConnell sign had similar apical RVFWS

  3. RVFWS, using a cut-off value of −17.9%, can discriminate patients with PE from those with PAH (sensitivity: 88%, specificity: 63%)

  1. RVFWS seemed to abolish its discriminative power when assessed in subjects with normal or mildly reduced FAC
Ramberg et al. (2016) [31] Retrospective, non-consecutive patients PE vs. control group (age-matched healthy subjects) Global and regional RVLS and RV PSS 26 (13 had central and 13 had peripherally located PE) 10

  1. Both RVLS and PSS of the basal and middle part of the RV-FW were reduced compared to the control group *

  2. Among patients with central or peripheral PE, no statistically significant differences were observed regarding the RVLS
Dahhan et al. (2016) [32] Retrospective, non-consecutive patients Patients with PE followed up for 1 month after the index event Global and regional RVLS 69;
55 were still alive at 1 month		 -

  1. Patients who died in the 1st month had significantly affected RVGLS *

  2. RVFWS was also reduced in the non-survivor group (p = 0.05), with a significant proportion having >−12.5%
Lee et al. (2019) [33] Prospective, non-consecutive patients Non-high-risk PE RVGLS and RVFWS 144 -

  1. RVGLS and RVFWS were independently associated with in-hospital events ₴ *

  2. RVFWS ≥ −15.85% could predict in-hospital events ₴ (sensitivity: 66.7%, specificity: 66.7%, and NPV: 95.4%)

  3. RVGLS ≥ −18.95% could predict in-hospital events ₴ (sensitivity: 80%, specificity: 64.3%, and NPV: 96.5%)
Kanar et al. (2019) [34] Prospective, non-consecutive patients PE at the time of the index event and at 1-year follow-up PSS of the RV free wall and Global LV PSS 147 −

  1. Patients who died during follow-up had lower RV-FW PSS, LV global PSS, and a higher RV PSSD index compared to those who survived *

  2. Among the survivors, RV-FW PSS, LV global PSS, RV PSSD index, and time difference to PSS between RV-FW and LV lateral wall were all improved at the end of follow-up *

  3. Difference in time to PSS between RV-FW and LV lateral wall > 46 msec predicted mortality with a NPV of 93.3%
Trivedi et al. (2020) [35] Retrospective, non-consecutive patients Patients with PE (at the time of index event) vs. control group (sex-matched healthy subjects) RVFWS 84 66

  1. Patients with PE had reduced RVLS in all segments of the RV-FW *

  2. Adding RVFWS to traditional TTE indices increases sensitivity and specificity for the diagnosis of PE *
Mazur et al. (2020) [36] Cross-sectional, non-consecutive patients Patients diagnosed with PE or RVMI Global and regional RVLS 53 PE, 23 McConnell sign + (30 patients with RVMI, 16 McConnell sign +) -

  1. Patients with PE and McConnell sign had lower global RVLS, mainly due to the more altered RVFWS *, while IVS strain did not differ (compared to those without McConnell sign)

  2. Patients with McConnell sign had a mean value of AR 1.7× greater than those without it

  3. RVFWS and IVS strain showed a strong negative relationship
Li et al. (2022) [37] Case-control, non-consecutive patients PE before and after thrombolysis vs. control group (sex- and age-matched healthy subjects) Global and regional RV PSS 73
39—no PH
34 with PH		 40

  1. Before treatment and compared to the control group, irrespective of the presence of PH or not, patients with APE had lower global and regional RV PSS values *

  2. After treatment, those with PE but without PH had global and segmental RV PSS values similar to that of the control group

  3. After treatment, for those with PE and PH, despite being improved, global and regional RV PSS were still impaired compared to the control group *
Wilinski et al. (2023) [38] Prospective, cross-sectional, non-consecutive patients Patients referred for CTPA due to high clinical probability of PE. Comparison was made between those diagnosed vs. those who were not diagnosed with PE, while 30-day all-cause mortality was reported Global and regional RVLS 88 79 patients without PE

  1. Mid-RVFWS, both indexed to BSA and unindexed, was reduced in patients diagnosed with PE *

  2. Unindexed to BSA RVLS of both basal segments was reduced in patients with PE who passed away *

  3. Concerning the 30-day all-cause mortality, AUC of all the above indices ranged from 0.60 to 0.70 *
Ballas et al. (2023) [13] Prospective, consecutive patients Patients diagnosed with PE RVFWS 73 -

  1. Patients with conventional echocardiographic signs of PE (such as McConnell sign, 60/60 sign, etc.) had a median RFWS of −11.7, whereas those without had a median RFWS of −19.5 *

  2. Patients with sPESI score ≥ 1 had lower RVFWS than those with score 0 *

  3. In a small group of patients with non-high-risk PE, RVFWS was increased at day 5 after the index event (in comparison to day 1) *

Abbreviations: AR = apical ratio, calculated as the quotient of apical IVS strain divided by the RVFWS; AUC = area under the curve; BSA = body surface area; CI = confidence interval; COPD = chronic obstructive pulmonary disease; CP = cor pulmonale; CPAH = chronic pulmonary artery hypertension; FAC = fractional area change; FW = free wall; HR = hazard ratio; ICU = intensive care unit; IVS = interventricular septum; LV = left ventricle; NPV = negative predictive value; PASP = pulmonary artery systolic pressure; PE = pulmonary embolism; PH = pulmonary hypertension; PSS = peak systolic strain; PSSD = peak systolic strain dyssynchrony; RV = right ventricle; RVEF = right ventricular ejection fraction; RVFWS = right ventricle free-wall strain; RVGLS = right ventricular global longitudinal strain; RVLS = right ventricle longitudinal strain; RVMI = right ventricular myocardial infarction; RVSP = right ventricular systolic pressure; sPESI = simplified pulmonary embolism severity index; TTE = transthoracic echocardiography. * = For the above comparisons, p-value was calculated as <0.05. Ɨ = Primary treatment could be thrombolysis, catheter-based pulmonary embolectomy, and/or anticoagulation therapy (they all received continuous i.v. heparin infusions). ¥ = Adverse outcomes were defined as death, cardiopulmonary resuscitation, and acute PE recurrence. ₴ = In-hospital events were defined as in-hospital PE-related death, need of additive treatments, such as thrombolysis or pulmonary artery thromboembolectomy, and need of inotropes due to unstable vital signs.