Echocardiographic strain as an ally in the evaluation of congenital heart disease: a narrative review

Introduction: Congenital heart diseases (CHDs) are the most common congenital malformations in newborns and are associated with significant long-term cardiac morbidity. Conventional echocardiographic parameters such as ejection fraction often fail to detect subclinical myocardial dysfunction. Myocardial strain analysis, primarily through speckle-tracking echocardiography (STE), has emerged as a sensitive, non-invasive technique to assess myocardial deformation and guide clinical decision-making in pediatric patients with CHDs. Methods: This narrative review was conducted through a comprehensive search of PubMed, Embase, and Scopus databases, covering literature from 2009 to 2025. Search terms included "global longitudinal strain," "congenital heart disease," and pediatric age-related keywords. A total of 119 records were screened, and 40 studies were selected based on relevance and methodological quality. Articles were included regardless of language but ultimately analyzed in English or Spanish. Results: The reviewed studies confirm the clinical utility of strain imaging in detecting early myocardial dysfunction, monitoring surgical outcomes, and predicting prognosis across various CHDs, including atrial and ventricular septal defects, Tetralogy of Fallot, single-ventricle physiology, and transposition of the great arteries. RV longitudinal strain and atrial strain have shown prognostic value in early dysfunction and adverse outcomes. Additionally, fetal myocardial strain imaging has demonstrated utility in prenatal diagnosis and individualized care planning. Conclusion: Myocardial strain imaging is a powerful adjunct to conventional echocardiography, offering enhanced sensitivity for identifying subclinical myocardial dysfunction. Its integration into routine practice enhances risk stratification, informs therapeutic decisions, and contributes to personalized care in CHD across all stages of life, including the fetal period. Its systematic use is strongly recommended in pediatric cardiology centers specializing in CHD.