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Syncope is one of the most serious symptoms of aortic valve stenosis (AS). For the past 50 years, syncope was considered the terminal state of AS.1 Unexpectedly, however, only a few studies have investigated syncope in patients with AS.2–4 Furthermore, AS severity is usually defined on the basis of valve-specific factors such as aortic valve area and mean transaortic pressure gradient.5–7 However, recent studies8,9 revealed that AS is not an isolated disease limited to the aortic valve but rather a concomitant disease influenced by global hemodynamic afterload imposed on the left ventricle. Briand et al8 recently proposed valvuloarterial impedance (Zva), which estimates global left ventricular (LV) hemodynamic load as the sum of valvular and arterial loads. This global LV afterload causes LV impairments such as changes in LV geometry and myocardial damage, inducing LV diastolic and systolic dysfunction.9–11 Clinical Perspective on p 1031 Considering the complex relationship between the patho-physiology and clinical manifestations of AS, we hypothesized that Zva assessment could provide more information on syn-cope development. In this study, therefore, we assessed the effect of clinical and echocardiographic parameters, including Zva, on syncope in patients with AS

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