Myocardial work indices outperform GLS for early reverse remodeling after Myval-TAVI

Background

Transcatheter aortic valve implantation (TAVI) provides afterload relief in patients with severe aortic stenosis (AS). While global longitudinal strain (GLS) is considered a sensitive marker of LV systolic function, myocardial work (MW) indices, may provide a more robust measure of myocardial performance.

Purpose

We aimed to assess early changes in myocardial deformation, left atrial reservoir strain (LARS), and MW indices following TAVI with the Myval balloon-expandable valve, and to evaluate their association with functional improvement.

Methods

We prospectively studied 31 consecutive patients with symptomatic severe AS undergoing TAVI with MyVAL. Comprehensive echocardiography, including LV and RV GLS, and LARS, was performed at baseline and 30-day follow-up. MW indices [global work index (GWI), global constructive work (GCW), global wasted work (GWW), global work efficiency (GWE)] were computed. Clinical status and major adverse cardiac events were assessed at 30 days.

Results

Procedural success was 100%. At 30 days, a ≥1-class NYHA improvement occurred in 97% of patients. Aortic valve mean gradient decreased significantly (Δ−32.8 mmHg, p<0.001). When assessing myocardial deformation, LV GLS paradoxically became less negative following TAVI, with mean values moving from −14.7±3.7% at baseline to −13.4±3.5% at 30 days (p=0.028). RV global strain remained unchanged (−17.6±5.2% vs. −17.1±5.5%, p=0.46). By contrast, left atrial performance showed a favorable trajectory, with LARS increasing from 20.9±7.5% to 22.9±8.2% (p=0.079),

GWW decreased substantially from 287±118 mmHg% at baseline to 210±93 mmHg% at follow-up (p<0.001), indicating a significant reduction in energy loss due to dyssynchronous or ineffective myocardial contraction. In parallel, GWI improved markedly, rising from 91.0±4.1% to 95.9±3.8% (p<0.001), reflecting the more favorable redistribution of energy toward effective ejection. GCW also increased significantly, from 1996±570 mmHg% to 2120±545 mmHg% (p=0.039), suggesting that TAVI enhances the ability of the LV to perform useful systolic work once the afterload burden is alleviated. GWI demonstrated a modest but consistent upward shift, from 2094±534 to 2178±488 mmHg% (p=0.051), a change consistent with improved overall stroke work while accounting for normalized loading conditions. At 30-day follow-up, one death was reported (3%).

Conclusions

In patients with severe AS undergoing Myval-TAVI, GLS demonstrated only modest attenuation at 30 days, whereas MW indices consistently improved, with reduced wasted work, increased constructive work, and higher efficiency, indicating enhanced myocardial performance once afterload was normalized. LARS also showed early improvement, suggesting beneficial effects on atrial function. MW indices and atrial strain are more sensitive and physiologically meaningful markers of early reverse remodeling after TAVI than GLS alone.