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Perkutane Aortenklappenimplantation (TAVI)

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Transcatheter aortic valve implantation (TAVI)

Current perspectives

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Zusammenfassung

Der perkutane Aortenklappenersatz (TAVI) hat sich als Standardtherapie der hochgradigen Aortenklappenstenose bei älteren Patienten mit einem hohen operativen Risiko etabliert. Deutschlandweit werden inzwischen über 10.000 TAVI pro Jahr implantiert. Die TAVI zeigt sich nicht nur dem konservativen Procedere bei inoperablen Patienten klar überlegen, sondern ist in Hinblick auf das Outcome mit dem chirurgischen Aortenklappenersatz bei Patienten mit hohem perioperativen Risiko vergleichbar.

In den letzten Jahren haben sich durch die Weiterentwicklung der Technologien aber auch durch die Lernkurve der Operateure und eine sorgfältigere präoperative Diagnostik des Vitiums die Komplikationsraten deutlich reduziert, so dass in den neueren Studien eine Nicht-Unterlegenheit der TAVI gegenüber dem konventionellen Aortenklappenersatz auch bei Patienten mit mittlerem Operationsrisiko gezeigt werden konnte. Dennoch bestehen weiterhin spezifische prozedurbezogene Herausforderungen wie die paravalvuläre Aortenklappeninsuffizienz, postoperative AV-Überleitungsstörungen oder Blutungskomplikationen, auf die besonderes Augenmerk gelegt werden muss. Daher ist eine individuelle Evaluierung jedes Patienten mit Berücksichtigung des operativen Risikos, der Komorbiditäten und der klinischen Gesamtsituation im interdisziplinären Heart-Team essentiell, um im weiteren Verlauf eine optimale Therapie zu garantieren.

Weitere randomisierte Studien werden benötigt, um zu untersuchen, ob durch die rapiden Weiterentwicklungen und somit Verbesserungen der Ergebnisse die TAVI in Zukunft auch bei Patienten mit geringerem operativen Risiko eine Alternative zu dem chirurgischen Aortenklappenersatz darstellt.

Abstract

Transcatheter aortic valve implantation (TAVI) has evolved as the treatment modality of choice for elderly patients with symptomatic severe aortic stenosis who are at high risk for surgery. More than 10,000 TAVI procedures were undertaken in Germany during 2014.

A mortality benefit has been shown for TAVI compared with conservative treatment in patients deemed inoperable, and the procedure was proven to be at least non-inferior to surgical aortic valve replacement in high-risk patients. Through improvements in preprocedural imaging and in valve technology as well as increasing operator and surgical team experience, TAVI has developed rapidly in the past few years. Complication rates declinded considerably and the latest study results even suggest a superiority of TAVI to surgical valve replacement in patients at intermediate operative risk. Nevertheless, the challenge to avoid procedure-specific complications influencing the outcome still remains. Therefore, making an individual decision about the approach and the valve prosthesis in an interdisciplinary heart team consisting of a cardiologist and a cardiac surgeon is indispensable for guaranteeing the best therapy for the patient.

Considering the rapid developments and procedural improvements in this field, randomized trials are required to assess whether the indication for TAVI may be extended to patients at lower perioperative risk in the future.

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  1. Abteilung Kardiologie, Kerckhoff-Klinik Bad Nauheim, Benekestrasse 2–8, 61231, Bad Nauheim, Deutschland

    Luise Gaede &  Helge Möllmann

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  1. Luise Gaede
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Correspondence to Helge Möllmann.

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L. Gaede gibt an, dass kein Interessenkonflikt besteht. H. Möllmann: Abbott, Boston Scientific, Edwards Lifesciences, St. Jude Medikcal, Symetis SA Proktor- und/oder Referentenhonorar

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Gaede, L., Möllmann, H. Perkutane Aortenklappenimplantation (TAVI). Herz 40, 742–751 (2015). https://doi.org/10.1007/s00059-015-4328-x

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