Qualität der chirurgischen Behandlung von Aortenklappenvitien

Zusammenfassung

Die Entwicklung neuer Hybridklappen legt eine aktuelle Bestandsaufnahme der konventionellen Verfahren nahe. Die chirurgische Therapie der Aortenvitien umfasst ein Spektrum an Verfahren, die mit geringem Risiko eingesetzt werden können. Der Euroscore überschätzt das Risiko erheblich, auch der STS-Score ist nicht immer zuverlässig. Es ist immer noch nicht bewiesen, ob der Einsatz von Hybridklappen das Letalitätsrisiko senkt. Die spezifischen Komplikationsraten (Schlaganfall, AV-Block, paravalvuläres Leck) sind höher als nach konventioneller Operation.

Trotz des Enthusiasmus um die Hybridklappen erscheint es als sinnvoll, ihren Einsatz auf echte Konstellationen mit erhöhtem Risikoprofil zu beschränken.

Summary

The current enthusiasm with the development of catheter-based aortic valve replacement suggests a critical appraisal of the quality of conventional techniques.

Currently surgical treatment of diseased aortic valves includes different methods that can be employed with a low risk. Risk prediction is difficult, the Euroscore largely overestimates mortality.

By comparison, there is no evidence that the risk of implantation is reduced by catheter-based implantation. Specific complications (stroke, AV-block, perivalvular leak) are more frequent compared to conventional replacement.

Despite the current enthusiasm over the feasibility of catheter-based implantation of hybrid aortic valves they should still be used cautiously.

Schlüsselwörter

Aortenklappenvitium - Herzchirurgie - Qualitätssicherung - Herzklappenrekonstruktion - Herzklappenersatz

Keywords

aortic valve disease - cardiac surgery - quality management - aortic valve repair - aortic valve implantation

Literatur

• 1 Aicher D, Fries R, Rodionycheva S, Schmidt K, Langer F, Schäfers H J. Aortic valve repair leads to a low incidence of valve-related complications.  Eur J Cardiothorac Surg. 2009 ;  , Jul 28 [Epub ahead of print]
• 2 Ambler G, Omar R Z, Royston P, Kinsman R, Keogh B E, Taylor K M. Generic, simple risk stratification model for heart valve surgery.  Circulation. 2005;  112 224-231
• 3 Astor B C, Kaczmarek R G, Hefflin B, Daley W R. Mortality after aortic valve replacement: results from a nationally representative database.  Ann Thorac Surg. 2000;  70 1939-1945
• 4 Banbury M K, Cosgrove 3rd D M, Thomas J D. et al . Hemodynamic stability during 17 years of the Carpentier-Edwards aortic pericardial bioprosthesis.  Ann Thorac Surg. 2002;  73 1460-1465
• 5 Blackstone E H, Cosgrove D M, Jamieson W R. et al . Prosthesis size and long-term survival after aortic valve replacement.  J Thorac Cardiovasc Surg. 2003;  126 783-796
• 6 Cabrol C, Cabrol A, Guiraudon G, Bertrand M. Le traitement de l’insuffisance aortique parannuloplastie aortique.  Arch Mal Coeur Vaiss. 1966;  59 1305-1322
• 7 Casselman F P, Gillinov A M, Akhrass R, Kasirajan V, Blackstone E H, Cosgrove D M. Intermediate-term durability of bicuspid aortic valve repair for prolapsing leaflet.  Eur J Cardiothorac Surg. 1999;  15 302-308
• 8 Clark R E. The Society of Thoracic Surgeons National Database status report.  Ann Thorac Surg. 1994;  57 20-26
• 9 Clavel M A, Fuchs C, Burwash I G. et al . Predictors of outcomes in low-flow, low-gradient aortic stenosis: results of the multicenter TOPAS Study.  Circulation. 2008;  118 S234-S242
• 10 Connolly H M, Oh J K, Orszulak T A. et al . Aortic valve replacement for aortic stenosis with severe left ventricular dysfunction. Prognostic indicators.  Circulation. 1997;  95 2395-2400
• 11 Connolly H M, Oh J K, Schaff H V. et al . Severe aortic stenosis with low transvalvular gradient and severe left ventricular dysfunction: result of aortic valve replacement in 52 patients.  Circulation. 2000;  101 1940-1946
• 12 Cosgrove D M, Rosenkranz E R, Hendren W G, Bartlett J C, Stewart W J. Valvuloplasty for aortic insufficiency.  J Thorac Cardiovasc Surg. 1991;  102 571-576
• 13 Cribier A, Eltchaninoff H, Tron C. et al . Treatment of calcific aortic stenosis with the percutaneous heart valve: mid-term follow-up from the initial feasibility studies: the French experience.  J Am Coll Cardiol. 2006;  47 1214-1223
• 14 David T E, Feindel C M. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta.  J Thorac Cardiovasc Surg. 1992;  103 617-621
• 15 Dewey T M, Brown D, Ryan W H, Herbert M A, Prince S L, Mack M J. Reliability of risk algorithms in predicting early and late operative outcomes in high-risk patients undergoing aortic valve replacement.  J Thorac Cardiovasc Surg. 2008;  135 180-187
• 16 Filsoufi F, Castillo J G, Rahmanian P B. et al . Epidemiology of deep sternal wound infection in cardiac surgery.  J Cardiothorac Vasc Anesth. 2009;  23 488-494
• 17 Filsoufi F, Rahmanian P B, Castillo J G, Bronster D, Adams D H. Incidence, imaging analysis, and early and late outcomes of stroke after cardiac valve operation.  Am J Cardiol. 2008;  101 1472-1478
• 18 Filsoufi F, Rahmanian P B, Castillo J G, Chikwe J, Silvay G, Adams D H. Excellent early and late outcomes of aortic valve replacement in people aged 80 and older.  J Am Geriatr Soc. 2008;  56 255-261
• 19 Grossi E A, Schwartz C F, Yu P J. et al . High-risk aortic valve replacement: are the outcomes as bad as predicted?.  Ann Thorac Surg. 2008;  85 102-106
• 20 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
• 21 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
• 22 Hammermeister K, Sethi G K, Henderson W G, Grover F L, Oprian C, Rahimtoola S H. Outcomes 15 years after valve replacement with a mechanical versus a bioprosthetic valve: final report of the Veterans Affairs randomized trial.  J Am Coll Cardiol. 2000;  36 1152-1158
• 23 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
• 24 Iung B, Baron G, Tornos P, Gohlke-Bärwolf C, Butchart E G, Vahanian A. Valvular heart disease in the community: a European experience.  Curr Probl Cardiol. 2007;  32 609-661
• 25 Levy F, Laurent M, Monin J L. et al . Aortic valve replacement for low-flow/low-gradient aortic stenosis operative risk stratification and long-term outcome: a European multicenter study.  J Am Coll Cardiol. 2008;  51 1466-1472
• 26 Melby S J, Zierer A, Kaiser S P. et al . Aortic valve replacement in octogenarians: risk factors for early and late mortality.  Ann Thorac Surg. 2007;  83 1651-1656
• 27 Michel P, Roques F, Nashef S A. EuroSCORE Project Group . Logistic or additive EuroSCORE for high-risk patients?.  Eur J Cardiothorac Surg. 2003;  23 684-687
• 28 Nashef S A, Roques F, Michel P, Gauducheau E, Lemeshow S, Salamon R. European system for cardiac operative risk evaluation (EuroSCORE).  Eur J Cardiothorac Surg. 1999;  16 9-13
• 29 Osswald B R, Gegouskov V, Badowski-Zyla D. et al . Overestimation of aortic valve replacement risk by EuroSCORE: implications for percutaneous valve replacement.  Eur Heart J. 2009;  30 74-80
• 30 Oxenham H, Bloomfield P, Wheatley D J. et al . Twenty year comparison of a Bjork-Shiley mechanical heart valve with porcine bioprostheses.  Heart. 2003;  89 715-721
• 31 Roques F, Michel P, Goldstone A R, Nashef S A. The logistic EuroSCORE.  Eur Heart J. 2003;  24 881-882
• 32 Ross D. Homograft replacement of the aortic valve.  Br J Surg. 1967;  54 842-843
• 33 Sarsam M A, Yacoub M. Remodeling of the aortic valve anulus.  J Thorac Cardiovasc Surg. 1993;  105 435-438
• 34 Takkenberg J J, Klieverik L M, Schoof P H. et al . The Ross procedure: a systematic review and meta-analysis.  Circulation. 2009;  119 222-228
• 35 Walther T, Simon P, Dewey T. et al . Transapical minimally invasive aortic valve implantation: multicenter experience.  Circulation. 2007;  116 I240-I245
• 36 Webb J G. Percutaneous aortic valve replacement will become a common treatment for aortic valve disease.  JACC Cardiovasc Interv. 2008;  1 122-126
• 37 Webb J G, Altwegg L, Boone R H. et al . Transcatheter aortic valve implantation. Impact on clinical and valve-related outcomes.  Circulation. 2009;  119 3009-3016
• 38 Zajarias A, Cribier A G. Outcomes and safety of percutaneous aortic valve replacement.  J Am Coll Cardiol. 2009;  53 1829-1836