The Role of Speckle-Tracking Echocardiography in Predicting Mortality and Morbidity in Patients with Congenital Heart Disease: A Systematic Review and Meta-analysis.

The Role of Speckle-Tracking Echocardiography in Predicting Mortality and Morbidity in Patients with Congenital Heart Disease: A Systematic Review and Meta-analysis.

Dorobantu DM, Amir NH, Wadey CA, Sharma C, Stuart AG, Williams CA, Pieles GE.J Am Soc Echocardiogr. 2024 Feb;37(2):216-225. doi: 10.1016/j.echo.2023.11.003. Epub 2023 Nov 14.PMID: 37972793 Free article.

Take-home Points:

  • Ventricular strain is associated with outcomes in CHDs
  • STE recommendations should be disease specific
  • STE has added prognostic value to conventional risk factors in CHD.
Dr Timothy Roberts

Commentary by Dr. Timothy Roberts (Melbourne, Australia), section editor of ACHD Journal Watch:

Introduction:

Speckle-tracking echocardiography (STE) is well established in a range of acquired heart disease pathologies including heart failure, ischemic heart disease, valvulopathies, cardiomyopathies and chemotherapy surveillance. The applicability of STE, however, for disease-specific subtypes and risk stratification in congenital heart disease (CHD) remains unclear, with ESC and ACC/AHA guidelines not offering disease-specific recommendations on the use of STE. The aim of this study was to investigate current data available on ventricular STE in outcome prognosis for patients with CHD.

Study Design:

A systematic review was performed to evaluate the prognostic value of STE in patients with CHD, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Search terms related to “morbidity, mortality, outcomes,” “congenital heart disease,” “speckle tracking,” and “echocardiography” were entered into EMBASE, Medline, Web of Science, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) databases from inception to January 2023.

Inclusion criteria were (1) any diagnosis of CHD; (2) two-dimensional STE with measurements of ventricular systolic function; (3) clinical outcomes; (4) a research question assessing the association between STE and MACE.

Studies were grouped by disease: (1) atrial switch TGA (asTGA) or congenitally corrected TGA (ccTGA); (2) repaired tetralogy of Fallot (ToF), BAV or congenital aortic stenosis (cAS); (3) hypoplastic left heart syndrome (HLHS) at varying time points; (4) SV after Fontan operation; (5) Ebstein’s anomaly; and (6) coarctation of the aorta (CoA).

Key Findings

A total of 33 studies were included, comprising 4,261 patients across six diagnosis groups. The most reported STE parameters overall were RV/SV longitudinal strain (Sl; n = 20) and LV Sl (n = 15), RV/SV radial strain rates (SRl; n = 10), RV/SV circumferential strain (Sc; n = 7), RV/SV circumferential strain rate (SRc; n = 6), and n = 1 each for LV SRl, LV Sc, LV radial strain (Sr), and RV Sr.

Systemic RV: asTGA and ccTGA:  RV Sl was associated with MACE, with an increase of MACE probability of 10 – 12% for each 1% worsening of RV Sl, independent of other conventional parameters.

HLHS and other SV:  SV/RV strain was found to be associated with outcomes in all studies reporting interstage and post-Glenn assessments. Strain rate was consistently associated with outcomes when measured interstage and seemingly outperformed strain. Only 3 studies reported STE after Fontan operation with discrepant results, although the larger of the 3 studies showed a positive association of dominant ventricle strain to outcome.

Tetralogy of Fallot:  All studies reported at least 1 STE parameter associated with at least 1 definition of MACE. The meta-analysis showed both RV Sl and LV Sl to be prognostic of MACE, independent of other conventional parameters such as QRS duration.

Bicuspid aortic valve and cAS: LV strain was prognostic of MACE, while there was no evidence to support the use of LV STE as a predictor of outcomes related to BAV aortopathy.

Strengths:

  • Large dataset of 33 studies and 4,261 patients included
  • Robust methodology used to compile the systematic review including consideration of risk of bias in the included studies

Limitations:

  • Heterogeneity within congenital heart disease cohorts can affect the interpretation of results in a meta-analysis
  • Significant variation noted in the performance and reporting of STE measurements
  • Definition of MACE was broad, and used less commonly in most pediatric CHD studies
  • Presumption of reporting bias favoring positive results

Discussion: The authors advocate for:

Encouraging clinical use of STE in CHD and improving the quality of the evidence available, to allow for future disease-specific recommendations to be improved.

Conclusion:

STE measurements are associated with outcomes in a variety of CHDs, with potential for added value over conventional imaging and clinical parameters. Further research, and continued advances in STE technology, should enable the gap in practice between CHD and other areas of heart failure to be closed, and incorporate STE into future disease-specific CHD guidelines.