Background The current study aims to validate the accuracy of 3-dimensional speckle-tracking echocardiography (3D-STE) in evaluating biventricular functions against the accuracy of cardiac magnetic resonance (CMR) and to explore the comprehensive characteristics and normal values for 3D-biventricular functions in transplanted hearts. Methods and Results A cohort of 35 heart transplant (HT) patients underwent both 3D echocardiography and CMR examination to validate the accuracy of 3D-STE in evaluating biventricular functions (Protocol 1). Then, 3D-STE derived biventricular functions were compared between 46 HT patients and 46 non-HT controls (Protocol 2). Protocol 1, validated that 3D-STE showed excellent accuracy in evaluating biventricular functions of transplanted hearts against CMR. Protocol 2, revealed lower (normal range) 3D-biventricular ejection fractions in HT patients than in controls (P<0.001). 3D-left ventricular global longitudinal strain, left ventricular-global circumferential strain, left ventricular-global radial strain, left ventricular-global performance index and right ventricular free-wall longitudinal strain were all lower in the HT patients than in healthy controls (P<0.001). Further, these strain values were all good for differentiating between groups (areas under the curve: 0.80-0.94, P<0.001). Moreover, left ventricular-lateral-wall radial displacement was higher and septal-wall radial displacement was lower in the HT group than in control group (P<0.001). Conclusions Compared with cardiac magnetic resonance, 3D-STE can evaluate biventricular functions of transplanted hearts accurately; 3D-biventricular mechanical functions are reduced even in clinically well HT patients. The provided characteristics and appropriate normal values of biventricular functions can be the basis for detection of ventricular dysfunction during follow-ups and further studies on transplanted hearts.

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