JACC: Cardiovascular Imaging
SyncopeThe Underestimated Threat in Severe Aortic Stenosis
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Author + information
- Georg Goliasch, MD, PhDa,
- Andreas A. Kammerlander, MDa,
- Christian Nitsche, MDa,
- Carolina Donaa,
- Laurin Schachnera,
- Begüm Öztürka,
- Christina Binder, MDa,
- Franz Duca, MDa,
- Stefan Aschauer, MDa,
- Günther Laufer, MDb,
- Christian Hengstenberg, MDa,
- Diana Bonderman, MDa and
- Julia Mascherbauer, MDa,∗ (julia.mascherbauer{at}meduniwien.ac.at)
- aDepartment of Internal Medicine II, Medical University of Vienna, Vienna, Austria
- bDepartment of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
- ↵∗Address for correspondence:
Dr. Julia Mascherbauer, Medical University of Vienna, Department of Internal Medicine II, Waehringer Guertel 18-20, A-1090 Vienna, Austria.
Graphical abstract
Abstract
Objectives Decision making in severe aortic stenosis (AS) requires a comprehensive pre-operative evaluation of the risk-to-benefit ratio. The aim of this study was to assess whether certain pre-operative symptoms are associated with outcome after surgical aortic valve replacement (SAVR).
Background The cardinal symptoms of AS indicating a need for intervention are angina, symptoms of heart failure, and syncope. Nevertheless, it remains unknown whether the presence of these more advanced symptoms conveys an increased risk after SAVR and whether the detection of early symptoms in patients with asymptomatic AS should be emphasized more in routine clinical practice.
Methods A total of 625 patients with isolated severe AS undergoing elective SAVR were prospectively enrolled in this long-term observational study.
Results Patients experiencing syncope had significantly smaller left ventricular diameters (p = 0.02), left atrial diameters (p = 0.043), right ventricular diameters (p = 0.04), and right atrial diameters (p = 0.001), smaller aortic valve areas (p = 0.048), and lower indexed stroke volumes (p = 0.043) compared with patients without syncope. Syncope conveyed an increased risk for mortality after SAVR that persisted after multivariate adjustment for a bootstrap-selected confounder model, with an adjusted hazard ratio of 2.27 (95% confidence interval: 1.04 to 4.95; p = 0.04) for 1-year short-term mortality and an adjusted hazard ratio of 2.11 (95% confidence interval: 1.39 to 3.21; p < 0.001) for 10-year long-term mortality. In contrast, pre-operative dyspnea, angina, and reduced left ventricular function were not significantly associated with outcomes.
Conclusions This long-term observational study in a large contemporary cohort of patients with AS for the first time demonstrates that syncope represents an underestimated threat in aortic stenosis, associated with poor prognosis after SAVR. Importantly, other primary indications for SAVR (i.e., dyspnea, angina, and decreased left ventricular function) were associated with significantly better post-operative outcomes than syncope. Patients experiencing syncope displayed a specific pathophysiologic phenotype characterized by a smaller aortic valve area, smaller cardiac cavities, and lower stroke volumes.
Footnotes
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received June 1, 2018.
- Revision received September 17, 2018.
- Accepted September 19, 2018.
- 2019 American College of Cardiology Foundation
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