Zusammenfassung
Die kalzifzierte Aortenklappenstenose ist der häufigste
erworbene Herzklappenfehler. Die Betroffenen sind ältere
Menschen in der 8. und 9. Lebensdekade, die häufig zusätzlich
Komorbiditäten wie linskventrikuläre Dysfunktion,
eingeschränkte Nierenfunktion und pulmonale Hypertonie
sowie weitere Begleiterkrankungen (Diabetes mellitus, Schlaganfall,
COPD) aufweisen. Bei bis zu 30 % dieser Patienten
sind operative Morbidität und Letalität so hoch,
dass der chirurgische Aortenklappenersatz nicht durchgeführt
werden kann. Andererseits ist die Prognose der Aortenklappenstenose äußerst
schlecht, sind die typischen Symptome wie Belastungsdyspnoe, Synkope
und Angina pectoris erst einmal aufgetreten. Für diese
Patientengruppe kommt die kathetergestützte Aortenklappenimplantation
(transcatheter aortic valve implantation, TAVI) als eine neue Behandlungsmethode
in Betracht. Die Aortenklappenbioprothese besteht aus einem ballonexpandierbaren
oder selbstexpandierenden Stent, in den eine Herzklappe aus Rinder-
oder Schweineperikard fixiert ist. Die Implantation erfolgt über
einen retrograden, transarteriellen Zugang (über die Arteria
femoralis oder die Arteria subclavia). Die ballonexpandierbare Klappenprothese
kann auch transapikal eingebracht werden. Neuere Studien (z. B.
PARTNER-Studie) zeigen eine hohe Erfolgsrate in der Implantation
und ein besseres Überleben im Vergleich zur konservativen
Therapie, weisen aber auch zerebrovaskuläre und peripher
vaskuläre Komplikationen auf. Die weitere Verkleinerung
der derzeitigen Applikationssysteme und neue Prothesentypen, die
sich im experimentellen Stadium oder bereits in der klinischen Prüfung
befinden, tragen dieser Entwicklung Rechnung.
Abstract
The calcified aortic stenosis is the dominating valve disease.
Patients affected are most common elderly people in the 8th or
9th decade of their life who often show associated comorbidities
like reduced left ventricular function, impaired renal function,
pulmonary hypertension, and further diseases (Diabetes mellitus,
stroke, COPD). In many cases perioperative morbidity and mortality are
too high for surgical valve replacement and up to 30 % of
patients are rejected. Nevertheless, prognosis of aortic stenosis
is worse if the typical symptoms like dyspnea on exertion, syncope, and
angina occur. The transcatheter aortic valve implantation is a new
method treating this particular group of patients. The aortic valve
bioprothesis consists of a balloon-expandable stent or a self-expandable
frame, in which a valve of bovine or porcine pericardium is incorporated.
The implantation is performed by retrograde access via the femoral
or subclavian artery; the balloon-expandable prosthesis can also
be implanted by transapical approach. Recently, the PARTNER trial and
other studies demonstrate a high implantation success rate and better
survival in comparison to standard therapy but exhibit also cerebral
vascular and peripheral vascular complications. A further reduction
of the available delivery systems and new types of valves which
are under experimental tests and clinical evaluation contribute
to this development.
Schlüsselwörter
Aortenklappenstenose - Aortenklappenersatz - perkutane Aortenklappenimplantation - Valvuloplastie, Ballondilatation - Kathetergestützte Aortenklappenimplantation
(TAVI) - Herzklappe
Keywords
aortic valve stenosis - aortic valve replacement - percutaneous aortic valve implantation - valvuloplasty - balloon dilatation - trancatheter aortic valve implantation (TAVI) - heart valve
Literatur
1
Bellamy, MF, Pellikka P A, Klarich K W. et al .
Association
of cholesterol levels, hydroxymethylglutaryl coenzyme-A reductase
inhibitor treatment, and progression of aortic stenosis in the community.
J Am Coll Cardiol.
2002;
40
1723-1730
2
Bonow R O, Carabello B, Kanu C. et al .
ACC/AHA 2006 guidelines for the
management of patients with valvular heart disease: a report of
the American College of Cardiology/American Heart Association
Task Force on Practice Guidelines (writing committee to revise the
1998 Guidelines for the Management of Patients With Valvular Heart
Disease): developed in collaboration with the Society of Anethesiologists:
endorsed by the Society of Cardiovascular Angiography and Interventions
and the Society of Thoracic Surgeons.
Circulation.
2006;
114
e84-231
3
Cosmi J E, Kort S, Tunick P A. et al .
The risk of the development of aortic stenosis
in patients with „benign” aortic valve thickening.
Arch Intern Med.
2002;
162
2345-2347
4
Cowell S J, Newby D E, Prescott R J. et al, Scottish Aortic Stenosis and Lipid Lowering
Trial, Impact on Regression (SALTIRE) Investigators .
A
randomized trial of intensive lipid-lowering therapy in calicfied
aortic stenosis.
N Engl J Med.
2005;
352
2389-2397
5
Cribier A, Savin T, Berland T. et al .
Percutaneous transluminal valvuloplasty
in acquired aortic stenosis in elderly patients: An alternative
to valve replacement?.
Lancet.
1986;
1
63-67
6
Cribier A, Savin T, Berland J. et al .
Percutaneous trasluminal balloon valvuloplasty
of adult aortic stenosis: Report of 92 cases.
J Am Coll
Cardiol.
1987;
9
381-386
7
Cribier A, Eltchaninoff H, Bash A. et al .
Percutaneous transcatheter implantation
of an aortic valve prosthesis for calcified aortic stenosis. First
human case description.
Circulation.
2002;
106
3006-3008
8
Figulla R, Cremer J, Wather T. et al .
Positionspapier zur kathetergeführten
Aortenklappenintervention.
Kardiologe.
2009;
3
199-206
9
Feldman T.
Proceedinngs of the TCT: Balloon aortic valvuloplasty appropriate
for elderly valve patients.
J Interven Cardiol.
2006;
19
276-279
10
Freeman R V, Otto C M.
Spectrum of calcific
aortic valve disease: pathogenesis, disease progression, and treatment
strategies.
Circulation.
2005;
111
3316-3326
11
Grube E, Schuler G, Buellesfeld L. et al .
Percutaneous aortic valve replacement for
severe aortic stenosis in high-risk patients using the second- and
current third-generation self-expanding CoreValve prosthesis: device
success and 30-day clinical outcome.
J Am Coll Cardiol.
2007;
50
69-76
12
Iung B, Baron G, Butchart E G. et al .
A prospective survey of patients with valvular
heart disease in Europe: The Euro Heart Survey on valvular heart
disease.
Eur Heart J.
2003;
24
1231-1243
13
Kahlert P, Eggebrecht H, Erbel R, Sack S.
A modified „preclosure” technique
after percutaneous aortic valve replacement.
Catheter
Cardiovasc Interv.
2008;
72
877-884
14
Kahlert P, Al-Rashid F, Weber M. et al .
Vasculer access site complications after
percutaneous transfemoral aortic valve implantation.
Herz.
2009;
34
398-408
15
Lefèvre T, Kappetein A P, Wolner E. et al .
One year follow-up of the multi-centre
European PARTNER transcatheter heart valve study.
Eur
Heart J.
2011;
32
148-157
16
Leon M B, Smith C R, Mack M. et al, for the PARTNER trial investigators .
Transcatheter
aortic-valve implantation for aortic stenosis in patients who cannot
undergo surgery.
N Engl J Med.
2010;
363
1597-1607
17
Leon M B, Piazza N, Nikolsky E. et al .
Standardized endpoint definitions for transcatheter
aortic valve implantation clinical trials: a consensus report from
the Valve Academic Research Consortium.
Eur Heart J.
2011;
32
205-217
18
Lindroos M, Kupari M, Heikkila J, Tilvis R.
Prevalence of aortic
valve abnormalities in the elderly: an echocardiographic study of
a random population sample.
J Am Coll Cardiol.
1993;
21
1220-1225
19
Melby S J, Zierer A, Kaiser S P. et al .
Aortic valve replacement in octogenerians.
Risk factors for early and late mortality.
Ann Thorac
Surg.
2007;
83
1651-1656
20 National Adult Cardiac Surgical
Database Report 1999–2000. The United Kingdom Cardiac Surgical
Register. http://www.scts.org/file/NACSDreport2000ukcsr.pdf .Accessed 10 May 2006.
21
OŽKeefe Jr J H, Vlietstra R E, Bailey K R. et al .
Natural
history of candidates for balloon aortic valvuloplasty.
Mayo
Clin Proc.
1987;
62
986-991
22
Ross Jr I J, Braunwald E.
Aortic
stenosis.
Circulation.
1968;
37
(SupplV)
V61-V67
23
Sack S, Naber C, Kahlert P. et
al .
Die perkutane Herzklappenimplantation.
Herz.
2005;
30
433-437
24
Sack S, Kahlert P, Khandanpour S. et al .
Revival of an old method with new techniques:
balloon aortic valvuloplasty of the calcified aortic stenosis in
the elderly.
Clin Res Cardiol.
2008;
97
288-297
25
Sack S, Schofer J.
Die kathetergestützte
Implantation einer Aortenklappenprothese. Aktueller Stand und zukünftige
Technologien.
Herz.
2009;
34
357-366
26
Shareghi S, Rasouli L, Shavelle D M. et al .
Current results of balloon aortic valvuloplasty
in high-risk patients.
J Invasive Cardiol.
2007;
19
1-5
27 STS national database: STS
U.S. cardiac surgery database: 1997 Aortic valve replacement patients:
preoperative risk variables. Chicago: Society
of Thoracic Surgeons; 2000 http://www.ctsnet.org/doc/3031 Accessed
10 May 2006
28
Vahanian A, Baumgartner H, Bax J, Butchart E, Dion R, Filippatos G. et al .
Guidelines
on the management of valvular heart disease: The Task Force on the
Management of Valvular Heart Disease of the European Society of
Cardiology.
Eur Heart J.
2007;
28
230-268
29
Vahanian A, Alfieri O, Al-Attar N. et al .
Transcatheter valve implantation for patients
with aortic stenosis: a position statement from the European Association
of Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology
(ESC), in collaboration with the European Association of Percutaneous
Cardiovascular Interventions (EAPCI).
Eur Heart J.
2008;
29
1463-1470
30
Walther T, Simon P, Dewey T. et
al .
Transapical minimally invasive aortic valve implantation:
multicenter experience.
Circulation.
2007;
116
(Suppl)
I240-I245
31
Webb J G, Pasupati S, Humphries K, Thompson C. et al .
Percutaneous
transarterial aortic valve replacement in selected high-risk patients
with aortic stenosis.
Circulation.
2007;
116
755-763
32
Zahn R, Gerckens U, Grube E. et
al, on behalf of the German TAVI-Registry Investigators .
Transcatheter
aortic valve implantation: first results from a multi-centre real-world
registry.
Eur Heart J.
2011;
32
198-204
33
Zimpfer D, Czerny M, Kilo J. et
al .
Cognitive deficit after aortic valve replacement.
Ann Thorac Surg.
2002;
74
407-412
Prof. Dr. med. Stefan Sack
Klinik für Kardiologie, Pneumologie, Internistische
Intensivmedizin und Zentrale Notaufnahme, Sektion Innere
Medizin Klinikum Schwabing Städtisches
Klinikum München GmbH
Kölner Platz 1
80804 München
Telefon: 089/3068-2525
Fax: 089/3068-3905
eMail: stefan.sack@klinikum-muenchen.de