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Kathetergestützte Aortenklappenimplantation

Transcatheter Aortic Valve Implantation

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Zusammenfassung

Bedingt durch den demographischen Wandel und die fortschreitende Alterung der Bevölkerung kommt es zu einer kontinuierlichen Zunahme von Patienten mit hämodynamisch signifikanten Aortenklappenstenosen. Obwohl mit dem chirurgischen Aortenklappenersatz eine etablierte und erfolgreiche Behandlungsoption zur Verfügung steht, wird über ein Drittel aller Patienten mit symptomatischer Aortenklappenstenose nicht operiert, meist aufgrund höheren Patientenalters sowie aufgrund von Komorbiditäten. Für dieses Patientengut steht mittlerweile mit der kathetergestützten Aortenklappenimplantation eine minimalinvasive Therapiealternative zur Verfügung. Kathetertechnische Aortenklappenimplantationen erfolgen nach vorausgegangener Valvuloplastie der Aortenklappe über einen transfemoralen oder einen transapikalen Zugangsweg am schlagenden Herzen. Die ballonexpandierbare Edwards-SAPIEN-Prothese sowie die selbstexpandierende Medtronic-CoreValve-Prothese haben eine CE-Zulassung erhalten, insgesamt sind weltweit bereits über 10 000 Patienten therapiert worden.

Im bisher nahezu ausschließlich behandelten Hochrisikopatientengut ist die Implantation mit gutem Akuterfolg durchführbar. Die 30-Tage-Mortalität beträgt in verschiedenen Registern zwischen 8% und 15%. Größere randomisierte Studien müssen zukünftig die Wertigkeit des neuen Verfahrens gegenüber dem herkömmlichen Aortenklappenersatz oder der rein medikamentösen Therapie untersuchen.

Abstract

Degenerative aortic valve stenosis accounts for the majority of native valve diseases and the prognosis is poor for symptomatic patients if untreated. Owing to the progressive aging of the population, the incidence of symptomatic aortic stenoses will further increase. Surgical aortic valve replacement provides a valuable treatment option with a well-documented favorable long-term outcome. However, the risk of surgery increases especially in older patients with significant comorbidities. For this reason, one third of symptomatic patients is not considered suitable for surgery. Transcatheter off-pump aortic valve implantation, however, using a transfemoral or a transapical approach may be a suitable therapeutic option for these patients. The balloon-expandable Edwards-SAPIEN prosthesis and the self-expandable Medtronic Core- Valve system have received CE approval and more than 10,000 patients have been treated worldwide.

Both methods share the same main principles: after crossing the stenotic aortic valve, balloon valvuloplasty is performed during a short episode of rapid ventricular pacing to predilate the native valve. After careful positioning of the valve prosthesis using either transesophageal echocardiography or fluoroscopy or both, the valve is released.

30-day mortality ranges between 8% and 15% in different registries in higher-risk patients. Nonetheless, larger randomized trials are warranted in order to validate the safety and effectiveness of this new approach.

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Authors and Affiliations

  1. Kerckhoff-Klinik, Herz- und Thoraxzentrum Bad Nauheim, Bad Nauheim, Germany

    Helge Möllmann, Christian W. Hamm & Thomas Walther

  2. Herzzentrum Leipzig, Leipzig, Germany

    Jörg Kempfert

  3. Abteilung Kardiologie Kerckhoff-Klinik, Herz- und Thoraxzentrum, Benekestraße 2–8, 61231, Bad Nauheim, Germany

    Helge Möllmann

Authors
  1. Helge Möllmann
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  2. Jörg Kempfert
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  3. Christian W. Hamm
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  4. Thomas Walther
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Correspondence to Helge Möllmann.

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Möllmann, H., Kempfert, J., Hamm, C.W. et al. Kathetergestützte Aortenklappenimplantation. Herz 35, 62–68 (2010). https://doi.org/10.1007/s00059-010-3326-2

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