Die kathetergeführte Aortenklappenimplantation

Abstract

Degenerative aortic valve stenosis is the most common form of adult valvular heart disease with an increasing prevalence in the aging population. Prognosis is poor once typical symptoms (dyspnea at exertion, angina pectoris, syncope) occur, even with optimal medical management. Surgical aortic valve replacement is the treatment of choice and can be performed at low risk in suitable candidates. However, approximately one third of patients with indication to surgical aortic valve replacement is rejected from surgery due to an increased operative risk as a result of old age and preexisting comorbidities. Transcatheter aortic valve implantation (TAVI) using stent-based bioprothesis has recently emerged as a viable and widely accepted treatment option for these high-risk patients showing promising short- and mid-term results. Though TAVI is currently restricted to patients older than 75 years and a logistic EuroSCORE > 20 % or an STS-Score > 10 %, it has opened new horizons in the treatment of aortic valve stenosis and further expansion of its clinical application is anticipated with proven long-term safety and further technological refinements. This review gives an overview of the current state of this innovative technology.

Kernaussagen

Die degenerative, kalzifizierte Aortenklappenstenose ist der häufigste erworbene Herzklappenfehler des Erwachsenen und hat mit Beginn des Auftretens klinischer Symptome eine extrem schlechte Prognose.

Trotz klarer Indikation wird aktuell bei einem Drittel der über 75-jährigen Patienten aufgrund des erhöhten Lebensalters und bestehender Komorbiditäten kein chirurgischer Aortenklappenersatz durchgeführt.

Mit der perkutanen, kathetergeführten Aortenklappenimplantation steht heute eine neue Therapieoption zur Behandlung „inoperabler” Hochrisikopatienten zur Verfügung. Solche Patienten sind insbesondere:

• ältere Patienten (> 75 Jahre) mit Komorbiditäten oder mit degenerierter Bioprothese

• voroperierte Patienten

• Patienten mit Porzellanaorta

• Patienten mit schweren Malformationen des Thorax oder mit starken Thoraxverwachsungen infolge Radiatio.

Die Indikationsstellung und Durchführung dieses neuen Verfahrens erfordern eine intensive vorbereitende Diagnostik und enge Kooperation von Kardiologen, Kardiochirurgen und Kardioanästhesisten, um einen optimalen Implantationserfolg mit bestmöglichem Komplikationsmanagement zu gewährleisten.

Im aktuellen Kollektiv von Hochrisikopatienten kann die kathetergeführte Aortenklappenimplantation heute in 95 % der Fälle erfolgreich mit einer zufriedenstellenden peri- und postinterventionellen Komplikationsrate und einer 30-Tages-Letalität von ca. 10 % durchgeführt werden.

Literatur

• 1 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
• 2 Iung B, Cachier A, Baron G. et al . Decision-making in elderly patients with severe aortic stenosis: why are so many denied surgery?.  Eur Heart J. 2005;  26 2714-2720
• 3 Frank S, Johnson A, Ross Jr J. Natural history of valvular aortic stenosis.  Br Heart J. 1973;  35 41-46
• 4 Talano J V, Melek B. Aortic Stenosis.  eMedicine Journal. 2002;  3
• 5 Schwarz F, Baumann P, Manthey J. The effect of aortic valve replacement on survival.  Circulation. 1982;  66 1105-1110
• 6 Kolh P, Kerzmann A, Lahaye L. et al . Cardiac surgery in octogenarians; peri-operative outcome and long-term results.  Eur Heart J. 2001;  22 1235-1243
• 7 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
• 8 Bonow R O, Carabello B A, Chatterjee K. et al . 2008 Focused update incorporated into the 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): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.  Circulation. 2008;  118 e523-e661
• 9 Kapoor N, Varadajan P, Pai R. Survival patterns in conservatively treated patients with severe aortic stenosis: Prognostic variables in 457 patients.  Circulation. 2004;  110 (Suppl III) 548
• 10 Cribier A, Savin T, Saoudi N. et al . Percutaneous transluminal valvuloplasty of acquired aortic stenosis in elderly patients: an alternative to valve replacement?.  Lancet. 1986;  1 63-67
• 11 NHLBI Balloon Valvuloplasty Registry participants. Percutaneous balloon aortic valvuloplasty. Acute and 30-day follow-up results in 674 patients from the NHLBI Balloon Valvuloplasty Registry.  Circulation. 1991;  84 2383-2397
• 12 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
• 13 Andersen H R, Knudsen L L, Hasenkam J M. Transluminal implantation of artificial heart valves. Description of a new expandable aortic valve and initial results with implantation by catheter technique in closed chest pigs.  Eur Heart J. 1992;  13 704-708
• 14 Bonhoeffer P, Boudjemline Y, Saliba Z. et al . Percutaneous replacement of pulmonary valve in a right-ventricle to pulmonary-artery prosthetic conduit with valve dysfunction.  Lancet. 2000;  356 1403-1405
• 15 Cribier A, Eltchaninoff H, Bash A. et al . Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis: first human case description.  Circulation. 2002;  106 3006-3008
• 16 Hanzel G S, Harrity P J, Schreiber T L, O’Neill W W. Retrograde percutaneous aortic valve implantation for critical aortic stenosis.  Catheter Cardiovasc Interv. 2005;  64 322-326
• 17 Webb J G, Chandavimol M, Thompson C R. et al . Percutaneous aortic valve implantation retrograde from the femoral artery.  Circulation. 2006;  113 842-850
• 18 Lichtenstein S V, Cheung A, Ye J. et al . Transapical transcatheter aortic valve implantation in humans: initial clinical experience.  Circulation. 2006;  114 591-596
• 19 Walther T, Simon P, Dewey T. et al . Transapical minimally invasive aortic valve implantation: multicenter experience.  Circulation. 2007;  116 I240-I245
• 20 Bergmann L, Kottenberg E, Heine T. et al . Anesthesia with transfemoral and transapical aortic valve implantation. Periinterventional management and hemodynamic observations.  Herz. 2009;  34 381-387
• 21 Kahlert P, Eggebrecht H, Erbel R, Sack S. A modified „Preclosure” technique after percutaneous aortic valve replacement.  Catheter Cardiovasc Interv. 2008;  72 877-884
• 22 Kahlert P, Al-Rashid F, Weber M. et al . Vascular access site complications after percutaneous transfemoral aortic valve implantation.  Herz. 2009;  34 398-408
• 23 Janosi R A, Kahlert P, Plicht B. et al . Guidance of percutaneous transcatheter aortic valve implantation by real-time three-dimensional transesophageal echocardiography – A single-center experience.  Minim Invasive Ther Allied Technol. 2009;  18 3; 142-148
• 24 Thielmann M, Eggebrecht H, Wendt D. et al . New techniques for the treatment of valvular aortic stenosis – transcatheter aortic valve implantation with the SAPIEN heart valve.  Minim Invasive Ther Allied Technol. 2009;  18 3; 131-141
• 25 Wendt D, Eggebrecht H, Kahlert P. et al . Experience and learning curve with transapical aortic valve implantation.  Herz. 2009;  34 388-397
• 26 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
• 27 Rosengart T K, Feldman T, Borger M A. et al . Percutaneous and minimally invasive valve procedures: a scientific statement from the American Heart Association Council on Cardiovascular Surgery and Anesthesia, Council on Clinical Cardiology, Functional Genomics and Translational Biology Interdisciplinary Working Group, and Quality of Care and Outcomes Research Interdisciplinary Working Group.  Circulation. 2008;  117 1750-1767
• 28 Figulla H R, Cremer J, Walther T. et al . Positionspapier zur kathetergeführten Aortenklappenintervention.  Kardiologe. 2009;  199-206
• 29 Webb J G, Pasupati S, Humphries K. et al . Percutaneous transarterial aortic valve replacement in selected high-risk patients with aortic stenosis.  Circulation. 2007;  116 755-763
• 30 Grube E, Laborde J C, Gerckens U. et al . Percutaneous implantation of the CoreValve self-expanding valve prosthesis in high-risk patients with aortic valve disease: the Siegburg first-in-man study.  Circulation. 2006;  114 1616-1624