Integrative Assessment of Left Ventricular Myocardial Work: Prognostic Utility and Clinical Application Across Cardiovascular Pathologies

Figures

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  Figure 1. Schematic representation of the left ventricular pressure–volume loop in normal conditions. The loop illustrates the sequential mechanical events of a single cardiac cycle, including pressure rise at constant volume (isovolumetric contraction), systolic blood ejection into the arterial circulation, pressure decline at unchanged volume (isovolumetric relaxation), and diastolic ventricular filling preceding the next contraction. Different colors indicate the distinct phases of the cardiac cycle, and arrows denote their sequential progression.

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  Figure 2. Conceptual framework and noninvasive assessment of myocardial work [16,17,18,19,20,21,22]. The figure illustrates the conceptual progression from invasive to noninvasive assessment of cardiac mechanics and myocardial work. The upper panels depict the historical development of pressure–volume analysis, beginning with Otto Frank’s description of ventricular pressure–volume relationships (1895) [16] and later advances by Suga and Sagawa (1974) [17], who introduced instantaneous pressure–volume relationships and the end-systolic pressure–volume relationship (ESPVR) to characterize ventricular energetics. The middle panels show the development of a noninvasive approach to MW estimation, based on an empirically derived left ventricular pressure curve adjusted to valvular event timing and arterial blood pressure, as proposed by Russell et al. (2012) [21]. The lower panels demonstrate the integration of speckle-tracking-derived myocardial strain with the estimated left ventricular pressure curve to generate pressure–strain loops, whose enclosed area provides a surrogate measure of regional myocardial work. This framework preserves the physiological coupling between loading conditions and…

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  Figure 3. Myocardial work assessment includes two-dimensional grayscale imaging in apical two-, three-, and four-chamber views, followed by global longitudinal strain and left ventricular bull’s-eye analysis. Activation of the myocardial work module allows input of brachial blood pressure and determination of valvular timing. The output includes regional and global myocardial work indices, pressure–strain loops, and derived parameters such as global constructive and wasted work. ANT_SEPT, antero-septal; ANT, anterior; LAT, lateral; POST, posterior; INF, inferior; SEPT, septal; GS, global strain; AVO, aortic valve opening; AVC, aortic valve closure; MVO, mitral valve opening; MVC, mitral valve closure; V, apical view orientation marker.

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  Figure 4. Myocardial work analysis in a patient with acute anterior myocardial infarction. Global reductions in GWI, GCW and GWE, together with impaired GLS, indicate marked myocardial dysfunction. These findings suggest a higher risk of adverse outcomes and highlight the potential of MW indices to provide additional prognostic information beyond conventional measures. GLS, global longitudinal strain; EF, ejection fraction; GWI, global work index; GCW, global constructive work; GWW, global wasted work; GWE, global work efficiency; BP, blood pressure. Red line represents the left ventricular pressure–strain loop. In the bull’s-eye plot, green indicates normal myocardial work, while blue highlights areas of negative work in the anteroseptal segments, suggesting impaired myocardial function in those regions.

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  Figure 5. Myocardial work analysis in a patient with severe mitral regurgitation. (A) Parasternal long-axis view showing posterior mitral valve prolapse. (B) Apical 2-chamber view with color Doppler demonstrating severe mitral regurgitation with posteriorly directed jet. (C) Speckle-tracking analysis identifying preserved LV function (GLS −19.8%, LVEF 60%). (D) Myocardial work analysis showing preserved GWI, GCW and GWE, but very low wasted work (GWW = 33 mmHg%), suggesting minimal energy loss. Patients with extremely low GWW, even with preserved LVEF and GLS, may be at higher risk of adverse outcomes [38], including progression of heart failure or complications from severe mitral regurgitation. In this context, MW could help identify patients who might benefit from earlier or more aggressive management, such as closer follow-up, optimization of afterload-reducing therapy, or consideration for mitral valve intervention. In the panel (C), red shades indicate negative strain values, while blue indicates positive strain values. In panel (D), the myocardial work bull’s-eye shows green for normal/constructive myocardial work and blue for negative/wasted work. GS/GLS, global longitudinal strain;…

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  Figure 6. Echocardiographic assessment of a patient with severe aortic stenosis before TAVR. (A) Continuous-wave Doppler across the aortic valve demonstrates high velocities consistent with elevated gradients. (B) Bullseye plot from speckle-tracking shows severely reduced GLS (−5.5%) and LVEF (31%), indicating profound systolic impairment. (C) Myocardial work analysis reveals markedly reduced GWI and GCW, with the bullseye predominantly blue, indicating minimal or negative work across all LV segments. These results highlight limited contractile LV reserve, suggesting high risk for adverse outcomes. The right-shifted pressure-strain loop (red line) in this patient essentially reflects impaired contractility under high afterload. GS, global longitudinal strain; EF, ejection fraction; GWI, global work index; GCW, global constructive work; GWW, global wasted work; GWE, global work efficiency; BP, blood pressure; V, apical view orientation marker.

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  Figure 7. MW analysis in a patient with hypertrophic cardiomyopathy. (a) Parasternal long-axis view demonstrates severe ventricular hypertrophy. (b) Global longitudinal strain bull’s-eye plot shows impaired longitudinal deformation in hypertrophied antero-lateral segments, with a GLS of −11.4%. (c) The pressure–strain loop displays a reduced enclosed area and a rightward shift, indicating marked impairment of myocardial work. (d) The myocardial work index bull’s-eye plot demonstrates reduced myocardial work in the basal antero-lateral segment (light-blue shaded) and increased work in the inferior segment (red shaded). These findings indicate significant regional myocardial dysfunction and heterogeneity, which are associated with higher risk of adverse clinical events, highlighting the potential prognostic value of MW indices in hypertrophic cardiomyopathy. GS, global longitudinal strain; ANT, anterior; LAT, lateral; POST, posterior; ANT SEPT, antero-septal; INF, inferior; SEPT, septal; V, apical view orientation marker.

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  Figure 8. Myocardial work analysis in a patient with heart failure and mildly reduced EF. (A) Bullseye plot from speckle-tracking echocardiography showing a GLS of −15.5%, indicating moderately reduced systolic function. (B) Myocardial work analysis plot indicates largely preserved contractile efficiency with minimal wasted work. GWI has a value of 1246 mmHg%, indicating a reduced risk of hospitalization for heart failure. GS, global longitudinal strain; ANT, anterior; LAT, lateral; POST, posterior; ANT SEPT, antero-septal, INF, inferior; SEPT, septal.