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Heart transplantation (HT) is a standard therapy for end-stage heart failure. Acute allograft rejection (AAR) is a common problem in the first year after HT and it should be diagnosed as soon as possible (preferably at a subclinical level). At present right ventricular endomyocardial biopsy remains the gold standard in diagnosing AAR. Potentially, deformation parameters are independent of overall cardiac motion and could be sensitive in detecting regional functional abnormalities induced by AAR.Objective: To assess the potential role of strain measured by speckle tracking to identify AAR proven by endomyocardial biopsy (EMB).Methods: We included 14 consecutive patients who were transplanted during the last year in our centre. Ten echocardiograms per patient were done the same day of EMB. We recorded images of the 4 and 2-chamber apical views as well as short axis views. We analyzed 12 individual segments for the assessment of longitudinal (long S), circunferencial (circ S) and radial (rad S) strain and strain rate (SR).Results: We analized 3024 segments, 5% of the segments were non-interpretable. According to the International Society of Heart and Lung Transplantation criteria, 84 biopsies had grade 0R AAR, 21 IR, and 4 IIR. Strain results are shown in the table. The only independent predictor of AAR among strain values was long R. A cut-off value of long S lower than -14% resulted in a sensitivity of 71.0%, a specificity of 70.0%, a predictive positive value of 50% and a negative predictive value of 84.4% for AAR diagnosis (AUC 0,70 CI 95% 0,54-0,80. RR 3.2, 95% CI 1.5-6.9, p 0.01).Conclusion: All modalities of global strain were decreased in AAR group. Longitudinal global strain is the best parameter for the diagnosis probably because longitudinal fibers may be more affected at initial phases of AAR. Strain 2D imaging could be of clinical value in monitoring and diagnosing AAR and could improve patient management by reducing the number of biopsies performed.