Prognostic value of right ventricular longitudinal strain assessed by multimodal imaging in amyloidosis: systematic review and meta-analysis

Aims Amyloidosis is a progressive and often fatal disease, with right ventricular (RV) involvement emerging as critical determinant of outcomes. This meta-analysis sought to evaluate the prognostic significance of RV longitudinal strain parameters in patients with amyloidosis. Methods and results Eligible studies reporting on the association between RV free-wall longitudinal strain (RV-FWLS) and RV global longitudinal strain (RV-GLS) assessed by echocardiography or cardiac magnetic resonance (CMR) with adverse outcomes were included. Using an inversely weighted random-effects meta-analysis, pooled hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated for all-cause mortality and a composite endpoint of all-cause death or heart failure hospitalization per 1% lower RV strain values. Eighteen studies with low-to-moderate risk of bias (Newcastle-Ottawa scale) and encompassing 1772 patients [mean age 68.8 ± 8.8 years; 57.3% with light-chain amyloidosis (AL)], were analysed. 210 patients experienced the composite outcome (median [inter-quartile range] follow-up: 1.5 [0.6] years) and 628 died [median follow-up: 2.6 (1.6) years]. 2D speckle-tracking RV-FWLS was associated with all-cause mortality (HR: 1.10; 95% CI: 1.07-1.13; I² = 8.6%) and the composite outcome (HR: 1.06; 95% CI: 1.02-1.10; I² = 0%). Similarly, 2D speckle-tracking RV-GLS was associated with all-cause mortality (HR: 1.10; 95% CI: 1.07-1.13; I² = 8.6%). Subgroup and meta-regression analysis confirmed consistency across amyloid subtypes, study design, presence of cardiac involvement, follow-up duration, and strain analysis software. In AL amyloidosis, CMR-based RV-GLS also predicted all-cause mortality (HR: 1.06; 95% CI: 1.03-1.09; I² = 0%). Conclusion RV longitudinal strain parameters are powerful and robust predictors of adverse outcomes in amyloidosis.