Additional Role of Myocardial Work in Prognostic Stratification of Patients with Severe Aortic Regurgitation Undergoing Aortic Valve Surgery

Background/Objectives: The optimal timing for surgery in severe aortic regurgitation (AR) remains challenging. Current recommendations are based on symptoms, LV size and ejection fraction (LVEF), yet subclinical dysfunction may occur earlier. Myocardial work (MW), derived from LV longitudinal strain (GLS) and systemic systolic arterial pressure, provides a sensitive load-adjusted assessment of myocardial performance. The aim of this study was to evaluate the prognostic role of preoperative MW indices in patients with severe AR undergoing cardiac surgery. Methods: This retrospective, single-center observational study included 83 consecutive patients with severe AR referred for surgery. All patients underwent preoperative echocardiography with speckle-tracking and MW analysis. The primary composite endpoint was all-cause mortality or unplanned hospitalization for heart failure. Median follow-up was 25 months. Results: Compared with reference values, our patients showed significantly reduced global work index (GWI) (1580 ± 568 vs. 1896 ± 308 mmHg%, p < 0.001) and global work efficiency (GWE) (86% vs. 96%, p < 0.001) and markedly increased global wasted work (GWW) (328 ± 182 vs. 78.5 ± 51.26 mmHg%, p < 0.001), reflecting impaired myocardial efficiency. Patients reaching the primary endpoint exhibited significantly higher GWW (432 ± 224 vs. 295 ± 154 mmHg%, p = 0.017) and lower GWE (82% vs. 88%, p = 0.013). On univariate analysis, higher GWE was associated with a lower risk of the composite endpoint (HR 0.939, 95% CI 0.888–0.993, p = 0.028). A GWE cut-off value of 85.5% provided optimal prognostic stratification, with higher values associated with improved event-free survival. The accuracy for outcome prediction of GWE increased when combined with other echocardiographic parameters, such as LVEF. Conclusions: In patients with severe AR, MW analysis—particularly GWE—offers incremental prognostic value, allowing the identification of subclinical ventricular dysfunction. This could lead to better risk stratification and earlier surgical intervention, particularly when combined with other conventional echocardiographic parameters.