Vol 27, No 6 (2020)
Original Article
Published online: 2018-09-13

open access

Page views 1393
Article views/downloads 1128
Get Citation

Connect on Social Media

Connect on Social Media

Predictors of syncope in patients with severe aortic stenosis: The role of orthostatic unload test

Paweł Kleczyński1, Paweł Petkow Dimitrow1, Artur Dziewierz1, Agata Wiktorowicz1, Tomasz Rakowski1, Andrzej Surdacki1, Dariusz Dudek1
Pubmed: 30234894
Cardiol J 2020;27(6):749-755.

Abstract

Background: There is a paucity of data regarding response of cerebral blood flow to the postural unloading maneuver and its impact on the risk of syncope in patients with aortic stenosis (AS). The aim of the present study was to assess effects of orthostatic stress test on changes in carotid and vertebral artery blood flow and its association with syncope in patients with severe AS.

Methods: 108 patients were enrolled (72 with and 36 patients without syncope) with severe isolated severe AS. Peak systolic blood-flow velocity (PSV) and end-diastolic velocity in the carotid arteries and vertebral arteries were measured by duplex ultrasound in the supine position and at 1–2 min after the assumption of the standing position.

Results: The orthostatic stress test induced a significant decrease in carotid and vertebral arterial flow velocities in all examined arteries (p < 0.001). The median (interquartile range) of mean change in PSV for carotid arteries was higher for patients with syncope (syncope [–] vs. syncope [+]: –0.6 cm/s [–1.8, 1.0] vs. –7.3 cm/s [–9.5, –2.0]; p < 0.001) and similarly for vertebral arteries (–0.5 cm/s [–2.0, 0.5] vs. –4.8 cm/s [–6.5, –1.3]; p < 0.001, respectively). Age, aortic valve area, and mean change in PSV for carotid arteries were independently associated with syncope.

Conclusions: In patients with AS, a decrease in carotid and vertebral arterial flow velocities in the standing position was observed and was associated with syncope. The present findings may support the value of an orthostatic test in identifying patients with severe AS and a high risk of syncope.

Article available in PDF format

View PDF Download PDF file

References

  1. Falk V, Baumgartner H, Bax JJ, et al. ESC Scientific Document Group, ESC Scientific Document Group. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2017; 38(36): 2739–2791.
  2. Dimitrow PP, Sorysz D. Orthostatic stress echocardiography as a useful test to measure variability of transvalvular pressure gradients in aortic stenosis. Cardiovasc Ultrasound. 2013; 11: 15.
  3. Dimitrow PP, Bober M, Michałowska J, et al. Left ventricular outflow tract gradient provoked by upright position or exercise in treated patients with hypertrophic cardiomyopathy without obstruction at rest. Echocardiography. 2009; 26(5): 513–520.
  4. Dimitrow PP, Cheng TO. Standing position alone or in combination with exercise as a stress test to provoke left ventricular outflow tract gradient in hypertrophic cardiomyopathy and other conditions. Int J Cardiol. 2010; 143(3): 219–222.
  5. Mason DT, Braunwald E, Ross J. Effects of changes in body position on the severity of obstruction to left ventricular outflow in idiopathic hypertrophic subaortic stenosis. Circulation. 1966; 33(3): 374–382.
  6. Kleczyński P, Petkow Dimitrow P, Dziewierz A, et al. Decreased carotid and vertebral arterial blood-flow velocity in response to orthostatic unload in patients with severe aortic stenosis. Cardiol J. 2016; 23(4): 393–401.
  7. Ross J. Jr, Braunwald E. Aortic stenosis Circulation. 1968; 38: 61–67.
  8. Schwartz LS, Goldfischer J, Sprague GJ, et al. Syncope and sudden death in aortic stenosis. Am J Cardiol. 1969; 23(5): 647–658.
  9. Satoh M, Saeki M, Yamazoe M, et al. Syncope in aortic stenosis during continuous electrocardiographic monitoring. A case report. Jpn Circ J. 1988; 52(12): 1415–1418.
  10. Omran H, Fehske W, Rabahieh R, et al. Valvular aortic stenosis: risk of syncope. J Heart Valve Dis. 1996; 5(1): 31–34.
  11. Orłowska-Baranowska E, Baranowski R, Hryniewiecki T. Incidence of syncope and cardiac arrest in patients with severe aortic stenosis. Pol Arch Med Wewn. 2014; 124(6): 306–312.
  12. Sorgato A, Faggiano P, Aurigemma GP, et al. Ventricular arrhythmias in adult aortic stenosis: prevalence, mechanisms, and clinical relevance. Chest. 1998; 113(2): 482–491.
  13. Batur MK, Açil T, Onalan O, et al. Is ventricular repolarization heterogeneity a cause of serious ventricular tachyarrhythmias in aortic valve stenosis? Clin Cardiol. 2000; 23(6): 449–452.
  14. Koşar F, Tandoğan I, Hisar I, et al. QTc dispersion measurement for risk of syncope in patients with aortic stenosis. Angiology. 2001; 52(4): 259–265.
  15. Tsai JP, Lee PY, Wang KT, et al. Torsade de pointes in severe aortic stenosis: case report. J Heart Valve Dis. 2007; 16(5): 504–507.
  16. Sato K, Fisher J, Seifert T, et al. Blood flow in internal carotid and vertebral arteries during orthostatic stress. Exp Physiol . 2012; 97(12): 1272–1280.
  17. Ogoh S, Sato K, Okazaki K, et al. Blood flow in internal carotid and vertebral arteries during graded lower body negative pressure in humans. Exp Physiol. 2015; 100(3): 259–266.
  18. Kleczyński P, Petkow Dimitrow P, Dziewierz A, et al. Transcatheter aortic valve implantation improves carotid and vertebral arterial blood flow in patients with severe aortic stenosis: practical role of orthostatic stress test. Clin Cardiol. 2017; 40(7): 492–497.
  19. Cammalleri V, Romeo F, Marchei M, et al. Carotid Doppler sonography: additional tool to assess hemodynamic improvement after transcatheter aortic valve implantation. J Cardiovasc Med (Hagerstown). 2018; 19(3): 113–119.