What does this research mean for the field?

In patients with severe primary mitral regurgitation undergoing surgery, impaired pre-operative left ventricular global work index (LVGWI) is independently associated with higher all-cause mortality. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

March 29, 2025Open Access

Prognostic impact of left ventricular myocardial work in patients undergoing surgery for primary mitral regurgitation

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Severe, primary mitral regurgitation (n=306). Intervention: Impaired left ventricular global myocardial work index (LVGWI ≤ 1900 mmHg%) vs. Preserved LVGWI (> 1900 mmHg%). Primary outcome: All-cause mortality (HR 2.94, 95% CI 1.23-7.06, p=0.016).

Key Result

In patients with severe primary mitral regurgitation undergoing surgery, impaired pre-operative left ventricular global work index was independently associated with higher all-cause mortality (HR 2.94).

Study Design

Type

Cohort (n=306)

Multicenter

Structured PICO

Does impaired pre-operative left ventricular global myocardial work index (LVGWI ≤ 1900 mmHg%) predict increased all-cause mortality in patients undergoing surgery for severe primary mitral regurgitation?

Population

306 patients with severe, primary mitral regurgitation (MR) who underwent mitral valve surgery, mean age 63, 68% male, single-center (The Netherlands). Exclusions: hypertrophic cardiomyopathy, previous cardiac surgery, significant aortic valve disease, concomitant aortic valve surgery, mitral valve replacement, suboptimal echocardiographic images, and no blood pressure measurement on the same day.

Intervention

Pre-operative assessment showing impaired left ventricular global myocardial work index (LVGWI ≤ 1900 mmHg%) measured via transthoracic echocardiography.

Comparator

Pre-operative assessment showing preserved left ventricular global myocardial work index (LVGWI > 1900 mmHg%).

Outcome

All-cause mortality after mitral valve surgery at a median follow-up of 5.0 years.hard clinical

Impaired pre-operative left ventricular global myocardial work index (≤ 1900 mmHg%) is independently associated with higher all-cause mortality in patients undergoing surgery for severe primary mitral regurgitation.

Main Result

Effect estimate: HR 2.94 (95% CI 1.23-7.06)

p-value: p=0.016

Limitations

Retrospective, single-center, observational design
Follow-up time is limited to the medium term
Unable to assess all cardiac events including heart failure hospitalization
Limited number of events prevented adjusting for all variables
Non-invasive LVMW calculated by a single vendor only
Blood pressure measurement not standardized
Unable to discriminate cardiac from non-cardiac death

Abstract

PURPOSE: Echocardiography-based, left ventricular myocardial work (LVMW) can assess LV function by incorporating LV afterload. This study aims to evaluate the prognostic value of LVMW indices in patients with primary mitral regurgitation (MR) undergoing mitral valve surgery. METHODS AND RESULTS: A total of 306 patients (mean age 63 ± 12 years, 68% male) with severe, primary MR who underwent surgery, were included. All patients underwent transthoracic echocardiography and LVMW indices were assessed with commercially available ultrasound equipment before surgery. The mean LV global work index (LVGWI) was 1979 ± 537 mmHg% and 130 (42%) patients had impaired LVGWI (≤ 1900 mmHg%). During a median follow-up of 5.0 years (interquartile range, 2.5-8.9), 27 (8.8%) patients died after mitral valve surgery. Patients with impaired LVGWI or LV global longitudinal strain (LVGLS) (≤ 20%) had lower survival rates compared to the group with preserved (p < 0.01 and p = 0.02, respectively). While the likelihood ratio test suggests that LVGWI ≤ 1900 mmHg% provides additional prognostic information beyond the model including LVGLS (p < 0.05) for all-cause mortality, no significant improvement was observed in area under the curve, the C-index, or net-reclassification index. CONCLUSIONS: In patients with severe, primary MR who underwent surgery, impaired pre-operative LVGWI was associated with a higher mortality risk, and may have incremental value beyond LVGLS, but requires further study for validation.

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