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Introduction: Stress echocardiography can predict major cardiac events after heart transplantation. Strain imaging can detect subclinical anomalies in the myocard before decrease of left ventricular ejection fraction or regional contraction abnormalities are observed. We wanted to investigate whether strain during stress echo is related to adverse events.Methods: We have included 42 HTx patients, (aged 58±14), who underwent stress echocardiography (during check-up at 6±4 yrs after HTx). Apical 2-, 4-, 3- chamber views were recorded in convential two-dimensional and color tissue Doppler at baseline, each step of stress and during recovery. Longitudinal strain and strain rate (SR) were calculated from color Doppler velocity data.Following adverse points were recorded during 6±2 yrs follow-up: death, need for revascularization and need for retransplantation. Two patients were excluded from the follow-up because after stress echocardiography an indication of surgical revascularization and heart retransplantation was directly formed.Results: During follow-up 9 HTx patients died (2 had cardiac related death, 1 secondary to hypoglycemia, 2 related to infections and 4 secondary to neoplasia). Survivors in comparison with non-survivors, presented with higher peak end systolic strain (-18.9±3.4 vs. -14.4±4.2, p=0.002) and higer peak SR (-2.1±0.5 vs. -1.7±0.7, p=0.06). Four cardiac events were noted during follow-up (2 patients needed coronary stenting and 2 patients died of cardiac causes). Patients who had cardiac events in comparison with the rest of the group had lower strain at rest and abnormal strain response to stres (Table 1).Conclusions: Longitudinal strain is a predictor of cardiac events and mortality in HTx patients. Decreased strain at rest, which does not increase at peak exercise, predicts cardiac adverse events.