Additional role of myocardial work in prognostic stratification of patients with severe aortic regurgitation

Abstract Background aortic regurgitation (AR) is the fourth most common heart valve disease in general population. Surgical indications include severe AR with left ventricular (LV) remodelling in terms of dilatation and reduction of ejection fraction (LVEF) even if a subclinical LV disfunction can occur earlier hopefully at a reversible stage. Speckle Tracking-derived myocardial work (MW) is a relatively novel technique integrating LV global longitudinal strain (GLS) with its afterload estimated by brachial arterial blood pressure (BP). Poor data is available regarding MW in AR, especially for prognostic purposes. Aim to assess possible correlation of pre-operatory MW indices with outcome in a population of patients with severe AR undergoing surgery. Methods we screened consecutive patients with severe AR undergoing surgery at our Hospital between January 2020 and July 2024, with available BP at the time of preoperatory echocardiography. We excluded patients with mixed aortic valve disease or combined more than mild regurgitation or stenosis, active infective endocarditis; acute aortic syndromes; presence of prosthetic valve or ring; atrial fibrillation during examination; and absent informed consent. All patients underwent complete echocardiographic exams, including GLS and MW analysis. The primary endpoint was a composite of all-cause mortality and unplanned hospitalization for heart failure (HF). Secondary endpoints included each of these as individual outcomes—as well as New York Heart Association (NYHA) functional class at follow-up. Results a population of 83 patients was finally included (age 71 [62-78] years, 74% men). Most patients were symptomatic (NYHA II-IV) at time of echo evaluation (57, 69%), with preserved EF (> 50%) (66, 80%), with a median value of 55 [50-57]%. Patients were divided according to the primary endpoint occurrence (20 events in a median follow up of 25 [15-33] months). Among echocardiographic indices, estimated systemic pulmonary pressure was higher in subjects with events, similar to global wasted work (GWW), while global work efficiency (GWE) was lower; other MW parameters did not show significant differences. At Cox regression analysis, GWE was significantly associated with the primary endpoint (HR 0.939, p=0.028). At ROC curve analysis, the combination of LVEF and GWE showed the higher specificity and sensitivity in predicting events (see Figure 1). Patients with GWE ≤85.5% had a worse mid-term outcome at Kaplan Maier curves (see Figure 2). Conclusions the use of MW in addition to LVEF can implement prognostic stratification in patients with AR, with a possible role in the anticipation of surgical indication in moderate-to-severe stages of disease.