Myocardial work in severe aortic stenosis as a predictor of cardiovascular symptoms and outcomes: a single-center cohort study

Background Aortic stenosis (AS) is the most prevalent valvular disease, with incidence increasing with age. Optimal timing of intervention remains challenging, as it traditionally relies on overt symptoms or markers of advanced disease. Although the 2025 ESC/EACTS Guidelines expand indications for early treatment in asymptomatic patients, symptom status remains central to decision-making. Notably, up to 25% of patients remain asymptomatic, and when present, symptoms are often subtle and nonspecific, particularly in the elderly. Left ventricular myocardial work (LVMW) is an emerging echocardiographic tool that integrates afterload into strain analysis, providing a load-adjusted assessment of systolic performance. In this setting, LVMW may serve as an early marker of myocardial damage and symptom development in severe AS. Purpose To investigate the association of LVMW indices with symptoms, risk of surgery and outcomes in patients with severe AS. Methods A single-center retrospective cohort study was conducted including consecutive patients with severe AS evaluated between January and December 2022. Severe AS was defined as a mean transvalvular gradient ≥40 mmHg or <40 mmHg with an aortic valve area <1.0 cm². Patients were followed for one year from the index transthoracic echocardiogram. Those with insufficient image quality or incomplete data were excluded. Symptom status was classified according to the New York Heart Association (NYHA) functional class. Clinical variables and outcomes were obtained from electronic medical records. LVMW indices were derived from non-invasive pressure–strain analysis and adjusted for the mean transvalvular gradient. Results During the study period, 94 TTEs were screened; 15 were excluded, leaving 79 for LVMW analysis. The mean age was 77.3 years, and 51% were women. Clinical characteristics, echocardiographic features, and outcomes are shown in Table 1. The Global Work Index (GWI) was significantly associated with the presence of symptoms (p=0.026). ROC analysis identified an optimal cut-off of 1638 mmHg% based on the maximum Youden index. Patients below 1638 mmHg% had a markedly higher likelihood of symptoms, and this association remained independent after adjustment for age, atrial fibrillation, prior coronary artery disease, and diuretic use (adjusted OR 5.0, 95% CI 1.46–17.11, p=0.010). In secondary survival analysis for the composite endpoint of cardiac death, heart failure hospitalization, and valve replacement, Global Work Efficiency ≤90% was identified as a predictor, as demonstrated by Kaplan–Meier analysis in Figure 1 (log-rank p=0.0009). Conclusion(s) In patients with severe AS, LVMW indices were associated with symptom status and adverse clinical outcomes. Myocardial work assessment may provide incremental information to support clinical decision-making in this population. Prospective studies are warranted to validate its role in guiding the timing of intervention.