Subscribe to RSS
DOI: 10.1055/s-0030-1257055
© Georg Thieme Verlag KG Stuttgart · New York
Interventionelle Perspektive der Trikuspidalinsuffizienz
Publication History
Publication Date:
02 February 2012 (online)
![](https://www.thieme-connect.de/media/kardiologie-u2d/201104/lookinside/thumbnails/10.1055-s-0030-1257055-1.jpg)
Abstract
Tricuspid regurgitation (TR) is a frequent condition in patients with advanced stages of left heart valve or myocardial disease. Although TR has traditionally assumed a lower priority in treatment of cardiac disease as it is frequently secondary to tricuspid annular dilatation it has a major impact on functional status and long-term survival. For symptomatic TR, surgical correction is the only effective therapy and most repairs are done in the setting of other planned cardiac surgery. However, TV surgery in advanced stages of multivalvular heart disease as well as after previous cardiac surgery carry high mortality rates and is, therefore, not routinely offered to many patients. The recent advent of transcatheter treatment of structural heart disease has expanded the therapeutic options for many high-risk or nonsurgical patients. However, for therapy of TR no percutaneous approach is available in clinical practice. Considering the impact of TR on functional status and long-term survival and the increasing number of high-risk patients undergoing percutaneous therapy of left heart valve disease today, there is an increasing need for parallel transcatheter therapy for TR. Several concepts have been proposed and evaluated in preclinical investigation and first human application. This article discusses the clinical impact and current management of TR and examines the potentials and limitations of emerging transcatheter approaches from preclinical investigation to first patient application.
Kernaussagen
-
Die Trikuspidalinsuffizienz entsteht überwiegend sekundär bei Dilatation des rechten Ventrikels infolge einer fortgeschrittenen linkskardialen Erkrankung.
-
Trotz wesentlicher Fortschritte in der interventionellen Therapie von Herzklappenerkrankungen ist für die Therapie der Trikuspidalinsuffizienz weiterhin kein perkutanes Verfahren klinisch etabliert.
-
Der perkutane orthotope Ersatz der Trikuspidalklappe konnte im Tiermodell erfolgreich durchgeführt werden. Als wesentliche Herausforderung des Verfahrens zeigte sich dabei die sichere Fixierung der perkutanen Klappenprothese im Bereich des Trikuspidalannulus. Dieser bietet aufgrund seiner elliptischen, sich dynamisch im Herzzyklus verändernden Form kaum Widerlager für die Verankerung mittels Radialkraft.
-
Die heterotope Klappenimplantation in zentralvenöser Position wurde als einziges interventionelles Verfahren bereits erfolgreich zur Therapie der Trikuspidalinsuffizienz am Patienten durchgeführt. Das Verfahren ist technisch einfacher umsetzbar, zeigt aber wesentliche hämodynamische Limitationen. Obwohl durch den heterotopen Trikuspidalklappenersatz eine Reduktion des Rückstroms von Blut in die V. cava inferior erreicht werden kann, sind sowohl die damit zu erzielende Symptomverbesserung als auch die Langzeiteffekte unklar und erfordern weitere umfassende Untersuchungen.
Literatur
- 1 Simon R, Oelert H, Borst H G, Lichtlen P R. Influence of mitral valve surgery on tricuspid incompetence concomitant with mitral valve disease. Circulation. 1980; 62 152-157
- 2 King R M, Schaff H V, Danielson G K et al. Surgery for tricuspid regurgitation late after mitral valve replacement. Circulation. 1984; 70 193-197
- 3 Wahlers T, Albes J, Pethig K et al. Valve reconstruction or replacement for long-term biopsy-induced tricuspid regurgitation following heart transplantation. Transpl Int. 1996; 9(Suppl 1) 247-248
- 4 Chares M, Lamm P, Leischik R et al. Highly acute course of ruptured papillary muscle of the tricuspid valve in a case of blunt chest trauma. Thorac Cardiovasc Surg. 1993; 41 325-327
- 5 Dounis G, Matsakas E, Poularas J et al. Traumatic tricuspid insufficiency: a case report with a review of the literature. Eur J Emerg Med. 2002; 9 258-261
- 6 Nath J, Foster E, Heidenreich P A. Impact of tricuspid regurgitation on long-term survival. J Am Coll Cardiol. 2004; 43 405-409
- 7 Bruce C J, Connolly H M. Right-sided valve disease deserves a little more respect. Circulation. 2009; 119 2726-2734
- 8 Rogers J H. Functional Tricuspid Regurgitation and New Percutaneous Concepts. TCT; 2008 available at http://www.tctmd.com
- 9 Duran C M, Pomar J L, Colman T et al. Is tricuspid valve repair necessary?. J Thorac Cardiovasc Surg. 1980; 80 849-860
- 10 Braunwald N S, Ross J, Morrow A G. Conservative management of tricuspid regurgitation in patients undergoing mitral valve replacement. Circulation. 1967; 35 63-69
- 11 Dreyfus G D, Corbi P J, Chan K M, Bahrami T. Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair?. Ann Thorac Surg. 2005; 79 127-132
- 12 Boyaci A, Gokce V, Topaloglu S et al. Outcome of significant functional tricuspid regurgitation late after mitral valve replacement for predominant rheumatic mitral stenosis. Angiology. 2007; 58 336-342
- 13 Izumi C, Iga K, Konishi T. Progression of isolated tricuspid regurgitation late after mitral valve surgery for rheumatic mitral valve disease. J Heart Valve Dis. 2002; 11 353-356
- 14 Raja S G, Dreyfus G D. Surgery for functional tricuspid regurgitation: current techniques, outcomes and emerging concepts. Expert Rev Cardiovasc Ther. 2009; 7 73-84
- 15 Vahanian A, Baumgartner H, Bax J 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
- 16 Bonow R O, Carabello B A, Chatterjee K 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 Cardiovascular Anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. J Am Coll Cardiol. 2006; 48 1-148
- 17 Shiran A, Sagie A. Tricuspid regurgitation in mitral valve disease incidence, prognostic implications, mechanism, and management. J Am Coll Cardiol. 2009; 53 401-408
- 18 Singh S K, Tang G H, Maganti M D et al. Midterm outcomes of tricuspid valve repair versus replacement for organic tricuspid disease. Ann Thorac Surg. 2006; 82 1735-1741 ; discussion 1741
- 19 Tang G H, David T E, Singh S K et al. Tricuspid valve repair with an annuloplasty ring results in improved long-term outcomes. Circulation. 2006; 114 577-581
- 20 Gummert J F, Funkat A, Beckmann A et al. Cardiac Surgery in Germany during 2007: A Report on Behalf of the German Society for Thoracic and Cardiovascular Surgery. Thorac Cardiovasc Surg. 2008; 56 328-336
- 21 Gummert J F, Funkat A K, Beckmann A et al. Cardiac Surgery in Germany during 2010: A Report on Behalf of the German Society for Thoracic and Cardiovascular Surgery. Thorac Cardiovasc Surg. ;
- 22 Lauten A, Figulla H R, Willich C et al. Percutaneous caval stent valve implantation: investigation of an interventional approach for treatment of tricuspid regurgitation. Eur Heart J. ; 31 1274-1281
- 23 Boudjemline Y, Agnoletti G, Bonnet D et al. Steps toward the percutaneous replacement of atrioventricular valves an experimental study. J Am Coll Cardiol. 2005; 46 360-365
- 24 Zegdi R, Khabbaz Z, Borenstein N, Fabiani J N. A repositionable valved stent for endovascular treatment of deteriorated bioprostheses. J Am Coll Cardiol. 2006; 48 1365-1368
- 25 Lauten A, Ferrari M, Hekmat K et al. Heterotopic transcatheter tricuspid valve implantation: first-in-man application of a novel approach to tricuspid regurgitation. Eur Heart J. ; 32 1207-1213
Dr. med. Alexander Lauten
Klinik für Innere Medizin I
Universitätsherzzentrum Jena
Erlanger Allee 101
07740 Jena
Email: Alexander.Lauten@med.uni-jena.de