Recent studies have shown that myocardial constructive work (CW) assessed by pressure strain loops (PSLs) is an independent predictor of the volumetric response to cardiac resynchronization therapy (CRT).

To assess if CW has an additive value in the prediction of long-term outcome of patients undergoing CRT, in addition to the assessment of volumetric CRT response.

2D-standard and speckle-tracking echocardiography were performed in 166 CRT candidates (mean age: 66±10 years, males: 69%, QRS duration: 165±19ms) before CRT implantation and at 6-month follow-up. left-ventricular CW was assessed by PSLs. Volumetric response to CRT was defined by a>15% reduction in LV end-systolic volume at 6-month follow-up and was observed in 48 (29%) patients.

After a median 4-year FU (range: 1.3–5 years), cardiac death occurred in 14 patients (8%). At multivariable Cox-regression analysis, CW and age were the only prognostic predictors of cardiac death, independently from septal flash and CRT-response. At ROC curve analysis, CW≤888mmHg % was the best cut-off to predict cardiac mortality (AUC 0.71, P=0.007).

Among CRT responders, the presence of CW≤888mmHg was associated with a dismal prognosis (log-rank test P=0.004). The concomitance of CW≤888mmHg and absence volumetric response to CRT identified patients with the worst prognosis (log-rank test P<0.0001).

left-ventricular CW assessed by PSLs allows the prediction of cardiac death in CRT candidates. A CW≤888mmHg is associated with a increased cardiac mortality in both CRT responders and non-responders.