Right ventricular global wasted work: employing myocardial energetics for risk assessment and outcome prediction in pulmonary hypertension

Right ventricular (RV) failure is the principal determinant of outcome in pulmonary arterial hypertension (PAH), yet contemporary risk stratification consider limited echocardiographic information.1 In this context, the recent study by Feloukidis et al. in EHJ–Cardiovascular Imaging provides important insights by identifying right ventricular global wasted work (RVGWW) as a marker of haemodynamic severity and clinical risk.2 By integrating myocardial work analysis with the 2022 ESC/ERS risk stratification framework, the authors highlight the energetic dimension of RV maladaptation, demonstrating that RVGWW correlates with invasive haemodynamics and increases stepwise across risk categories. A key strength of the study is the elegant use of spline-derived cut-offs to identify high-risk patients, with RVGWW outperforming established non-invasive indices such as right atrial area and the TAPSE/PASP ratio. These findings suggest that RVGWW captures clinically meaningful information not fully reflected by conventional echocardiographic markers. Mechanistically, elevated RVGWW reflects post-systolic shortening and septal dyssynchrony, which are hallmarks of ventriculoarterial uncoupling and inefficient myocardial energy use. Hence, RVGWW represents the energetic footprint of maladaptive RV–pulmonary arterial interaction that integrates deformation, afterload, and mechanical inefficiency into a single parameter. This may explain why it tracks clinical risk more closely than measures of systolic excursion or area change alone.