Prognostic Value of Right Ventricular Global Wasted Work in Precapillary Pulmonary Hypertension: A 3D Echocardiographic Study

ABSTRACT Aim Right ventricular (RV) function determines symptom burden and clinical outcomes in pulmonary hypertension (PH). Global wasted work (GWW) quantifies mechanical inefficiencies in RV performance associated with elevated afterload, but is inadequately characterized in precapillary PH. We assessed the association of GWW with echocardiographic indices of RV remodeling, RV–PA coupling and invasive hemodynamics, and evaluated its prognostic significance in precapillary PH. Methods and Results Myocardial work indices were measured by 3D echocardiography in patients with well‐defined precapillary PH who underwent right heart catheterization within 24 hours. Patients with poor image quality, significant valvular lesions and associated left heart disease were excluded. Among 61 patients, those with GWW ≥ 38 mmHg/% ( n = 31) exhibited larger RV end‐systolic volume (60 [42–71] vs. 42 [35–46] mL/m 2 , p = 0.009), lower TAPSE (17 [16–20] vs. 20 [17–23] mm, p = 0.04), higher E a (1.32[0.98–1.57] vs. 0.92 [0.64–1.29] mmHg/mL, p = 0.02) and higher pulmonary vascular resistance (11.1 [8.1–14.2] vs. 5.4 [3.4–8.7]WU, p = 0.002). GWW decreased as RV longitudinal strain and RV—PA coupling improved and increased with lower cardiac index and higher pulmonary vascular resistance. GWW outperformed conventional right ventricular indices in identifying patients at risk of death or transplantation (HR: 2.5 [1.1–5.7], p = 0.02). Conclusions Elevated GWW is associated with RV remodeling, worsening RV function and reduced survival in precapillary PH. Our results suggest that GWW may offer incremental prognostic value over conventional RV metrics, with potential implications for risk stratification and therapy management. Larger studies are warranted to validate these findings.