Integrated Strain–Flow Analysis for Early Assessment of Right Ventricular Dysfunction in Pulmonary Arterial Hypertension

PURPOSE: Early detection of right ventricular (RV) dysfunction is essential in pulmonary arterial hypertension (PAH) but remains challenging using conventional echocardiography. This study investigates the feasibility of a noninvasive, physics-based framework using three-dimensional (3D) echocardiography that integrates myocardial strain and volumetric flow analysis to characterize RV mechanical performance across stages of PAH. METHODS: A prospective pilot study (N = 15) enrolled healthy controls, PAH patients with preserved RV size, and PAH patients with RV dysfunction. Deformation was evaluated by principal strain analysis and by conventional (longitudinal, circumferential) components. Hemodynamic metrics included hemodynamic forces and energetic properties that were derived using a physics-informed volumetric echocardiographic particle image velocimetry (V-Echo-PIV) method applied to contrast-enhanced acquisitions. RESULTS: Deformation analysis revealed that longitudinal strain was significantly reduced even in PAH patients with preserved RV dimensions, while second principal (secondary) strain showed a distinctive sign reversal, indicating a paradoxical systolic lengthening, early in the disease. The analysis of hemodynamic forces showed a marked reduction in systolic propulsion across all PAH stages. In contrast, energetic abnormalities were predominantly observed at later stage of the disease. CONCLUSIONS: The integration of 3D myocardial strain with fluid dynamics provides a comprehensive physiological assessment of RV remodeling. While strain and systolic propulsion appear as sensitive markers for early dysfunction, diastolic energetics may support disease staging. This noninvasive framework shows promise for early detection and longitudinal monitoring of PAH patients.