Noninvasive Myocardial Work Assessment Using Echocardiography in Mixed Aortic Valve Disease

BackgroundMixed aortic valve disease (MAVD), defined by the coexistence of aortic stenosis (AS) and aortic regurgitation (AR), imposes combined pressure and volume overload on the left ventricle (LV). Conventional echocardiographic indices have limited ability to capture this complex hemodynamic burden. ObjectivesTo develop a novel, noninvasive integrated myocardial work index (iMWI) for characterization of LV workload and risk stratification in patients with MAVD. MethodsWe retrospectively studied 1,022 patients (median age 80 years, 60% women) with mild or greater AS and AR who underwent transthoracic echocardiography between 2015 and 2020. iMWI was defined as (systolic blood pressure + mean aortic gradient) x LV global longitudinal strain / E/e'. The primary endpoint was a composite of cardiovascular death, heart failure hospitalization, or aortic valve replacement. Prognostic performance was assessed with Kaplan-Meier analysis, Cox regression, and time-dependent ROC curves. ResultsiMWI values varied by MAVD phenotype, with progressive reductions in groups with [&ge;]moderate AS (p for trend = 0.022). Patients with both [&ge;]moderate AS and [&ge;]moderate AR had the lowest median iMWI (170; IQR 112-225). Lower iMWI was independently associated with higher risk of the composite endpoint (adjusted HR 1.05 per 10-unit decrease; 95% CI 1.02- 1.09; p = 0.001). The lowest tertile showed poorer event-free survival (log-rank p < 0.001). iMWI yielded moderate 3-year predictive accuracy (AUC 0.67; 95% CI 0.64-0.76), with consistent value even without severe MAVD. ConclusionsiMWI integrates afterload, preload, and myocardial deformation into a single noninvasive metric. It independently predicts adverse outcomes in MAVD and may enhance risk stratification, complementing conventional echocardiographic indices. CONDENSED ABSTRACTMixed aortic valve disease (MAVD), defined by the coexistence of aortic stenosis and regurgitation, imposes combined pressure and volume overload on the left ventricle. Conventional echocardiographic indices incompletely reflect this complex burden. Among 1,022 patients with MAVD, we developed a novel integrated myocardial work index (iMWI), incorporating afterload, preload, and myocardial deformation into a single noninvasive metric. Lower iMWI was independently associated with adverse outcomes, including cardiovascular death, heart failure hospitalization, and aortic valve replacement. iMWI may provide a simple and feasible tool to improve risk stratification in MAVD, complementing conventional echocardiographic parameters. Clinical PerspectiveO_ST_ABSCompetency in Medical KnowledgeC_ST_ABSMixed aortic valve disease (MAVD), characterized by the coexistence of aortic stenosis and regurgitation, imposes combined pressure and volume overload on the left ventricle. Conventional echocardiographic indices are limited in capturing this dual burden and the performance of the underlying myocardium. In this study, a novel integrated myocardial work index (iMWI), which incorporates afterload, preload, and myocardial deformation into a single noninvasive metric, was shown to independently predict adverse outcomes in a large cohort of patients with MAVD. Translational OutlookFurther studies are needed to validate iMWI prospectively and across diverse populations, and to assess its incremental value for guiding clinical decision-making, including timing of aortic valve intervention. Integration of iMWI into routine echocardiographic workflows may provide a practical tool for improving risk stratification in patients with complex valvular heart disease.