Prognostic Value of Non-Invasive Global Myocardial Work in Asymptomatic Aortic Stenosis

Abstract

This study aimed to evaluate the modification of non-invasive myocardial work (MW) indices related to aortic stenosis (AS) stages of cardiac damage and their prognostic value. The echocardiographic and outcome data of 170 patients, with asymptomatic moderate-to-severe AS and left ventricular ejection fraction (LVEF) ≥50%, and 50 age- and sex-comparable healthy controls were analysed. Primary endpoints were the occurrence of all-cause and cardiovascular death. Increased values of the global work index (GWI), global constructive work (GCW), and global wasted work (GWW) were observed in AS patients compared to controls (GWI: 2528 ± 521 vs. 2005 ± 302 mmHg%, GCW: 2948 ± 598 vs. 2360 ± 353 mmHg%, p < 0.001; GWW: 139 ± 90 vs. 90 ± 49 mmHg%, p = 0.005), with no changes in the global work efficiency. When patients were stratified according to the stages of cardiac damage, the GWI showed lower values in Stage 3–4 as compared to Stage 0 and Stage 2 (p = 0.024). During a mean follow-up of 30 months, 27 patients died. In multivariable Cox-regression analysis, adjusted for confounders, GWI (HR: 0.998, CI: 0.997–1.000; p = 0.034) and GCW (HR:0.998, CI: 0.997–0.999; p = 0.003) were significantly associated with excess mortality. When used as categorical variables, a GWI £ 1951 mmHg% and a GCW £ 2475 mmHg% accurately predicted all-cause and cardiovascular death at 4-year follow-up. In conclusion, in asymptomatic patients with moderate-to-severe AS, reduced values of GWI and GCW are associated with increased mortality. Therefore, the evaluation of MW indices may allow for a better identification of asymptomatic patients with moderate to severe AS and preserved LVEF whom are at increased risk of worse prognosis during follow-up.

Myocardial Work in Echocardiography

“…Reduced GWI and GCW at follow-up are associated with increased mortality. 82 GWI and GCW positively correlate with aortic regurgitation severity in patients with normal LVEF. 84 GWI threshold of 1285 mm Hg% is a predictor of LV reverse remodeling.…”

“…74 De Rosa et al 81 also found that low-flow, low-gradient AS patients had no improvement in GWI post-TAVR. 81 Lastly, Ilardi et al 82 recently studied the prognostic value of myocardial work in AS patients. They showed increased GWI, GCW, and GWW in AS patients compared with controls and also reported that reduced GWI (hazard ratio [HR], 0.998 [95% CI, 0.997–1.000]; P =0.034) and GCW (HR, 0.998 [95% CI, 0.997–0.999]; P =0.003) measurements after follow-up were significantly associated with excess mortality.…”

Prognostic Relevance of Global Myocardial Work Index in Patients with Moderate Aortic Valve Stenosis

“…The GWI has been reported to be a useful diagnostic tool in patients with severe aortic stenosis [9,10]. In a previous 2 of 11 study by Ilardi et al, a GWI ≤ 1951 mmHg% was associated with a higher mortality in moderate-to-severe AS [11]. In addition, the GWI showed an independent association with symptoms in patients with severe AS [12].…”

Echocardiographic Evaluation after Transcatheter Aortic Valve Implantation: A Comprehensive Review

“…Recently, noninvasive measurement of LV myocardial work (MW) has proven to be a valuable method for estimating myocardial performance in AS patients undergoing TAVI [ 24 ]. This tool incorporates echocardiographic strain data, cardiac events timing (from aortic and mitral valve opening and closure), and estimation of LV pressure (derived from systolic blood pressure) in order to derive global work index (GWI), global constructive work (GCW), global wasted work (GWW) and global work efficiency (GWE).…”

“…However, global work indices remained abnormal after the procedure, suggesting an incomplete recovery of the LV function after TAVI [ 25 ] ( Figure 1 ). Moreover, lower values of GCW and GWI at baseline in AS patients have been associated with advanced stages of myocardial disease and with a worse prognosis even after aortic valve replacement [ 24 ].…”