Postsystolic strain patterns of the right ventricular (RV) wall may be useful to assess clinical improvement after treatment in patients with pulmonary artery hypertension (PAH) and RV dysfunction, according to a new study published in Cardiovascular Imaging Case Reports.

Rodríguez-Pérez and colleagues reported a case of a 37-year-old female presenting with exertional dyspnea and effort syncope 2 months following childbirth. An echocardiogram revealed RV dilatation with mid cavity and basal diameters of 43 mm and 42 mm, respectively, and an end-diastolic area of 30.1 cm^2.

She was diagnosed with mild RV dysfunction with a 31% fractional area change (FAC), a tricuspid annular plane systolic excursion (TAPSE) of 21 mm, and tissue Doppler systolic annular velocity (TDI S’) of 13 mm/sec, with a possible progressive uncoupling.

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Other findings suggested pressure overload, moderate tricuspid regurgitation, estimated pulmonary artery systolic pressure of 73 mmHg, and a nondilated and collapsible inferior vena cava of 1.6 cm. A right heart catheterization reported severe precapillary pulmonary hypertension, and bloodwork showed elevated natriuretic peptide (NT-proBNP) levels at 1754 ng/L.

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Findings in the physical examination, vital signs, liver, thyroid, kidney function blood tests, electrocardiogram, computed tomography angiography, and pulmonary ventilation/perfusion scan were normal, while tests for connective tissue disease, HIV, and hepatitis were negative. Due to these results, the healthcare team diagnosed the patient with idiopathic PAH and further ruled out pulmonary embolism, interatrial or interventricular communications, and parenchymal lung disease.

At the moment of the diagnosis, RV postsystolic pattern fell into a type 2 classification. After 6 months of treatment with ambrisentan (10 mg daily) and tadalafil (40 mg daily), the RV postsystolic pattern was a type 1, all echocardiographic parameters improved, the NT-proBNP decreased to normal values (118 ng/L), and her symptoms diminished (World Health Organization functional class 1).

“In the case that we present here, RV longitudinal shortening parameters such as TAPSE and TDI S’ were normal despite an impaired transversal shortening measured by FAC and [RV free-wall longitudinal strain], and in this context, finding a type II RV postsystolic strain pattern helped us to better understand and assess RV systolic dysfunction,” the authors wrote.

Given the reproducible characteristic of RV postsystolic patterns, classifying patients with PAH and RV dysfunction may represent an accessible and accurate method for predicting prognosis, assessing risk, and determining treatment response.


Rodríguez-Pérez Á, Bos L, Podzamczer I, Meseguer M, Mayos-Pérez M, Leta R. Right ventricular postsystolic strain curve morphology before and after vasodilator treatment in idiopathic pulmonary arterial hypertension. CASE. Published online April 22, 2022. doi:10.1016/