Aortenvitien – chirurgische Therapie

Zusammenfassung

Der Aortenklappenersatz (AKE) ist ein Standardeingriff mit geringem Letalitäts- und Morbiditätsrisiko. Zum Ersatz der Klappe werden traditionell mechanische Prothesen implantiert. In den letzten Jahren geht der Trend zu modernen Bioprothesen, die meist ab dem 60.–65. Lebensjahr eingesetzt werden. Die Eingriffe erfolgen standardisiert über eine komplette oder eine partielle Sternotomie. Im Langzeitverlauf spielen die klappenassoziierten Komplikationen eine relevante Rolle. Die Rekonstruktion der Aortenklappe ist dagegen mit wenigen Langzeitkomplikationen behaftet. Für ältere Patienten mit Nebenerkrankungen und somit erheblich erhöhtem Risiko stehen neuerdings minimalinvasive Verfahren durch kathetertechnische Aortenklappenimplantation (transfemoral oder transapikal) zur Verfügung. Daten zur Langzeithaltbarkeit der Implantate liegen noch nicht vor. Für die meisten Patienten bleibt die konventionelle Operation aufgrund der guten Ergebnisse die Therapie der Wahl.

Abstract

Current status: Aortic valve replacement has been the standard to treat aortic stenosis and regurgitation for decades. The same applies to aortic replacement in presence of aneurysm. The increasing number of elderly patients with relevant comorbidities has led to an increasing use of xenografts; in parallel aortic valve repair has been developed, and an increasing number of patients are treated by transcatheter techniques. Indications for surgery/intervention: Clear criteria exist for operation or intervention. Asymptomatic patients may require a critical assessment. Young patients with connective tissue disease may benefit from early prophylactic surgery. Choice of prosthesis: Mechanical prostheses appear ideal due to their durability, but require long-term anticoagulation and exhibit relevant valve-related complications. Biologic substitutes require only temporary anticoagulation and appear suitable for patients > 60 years. Transcatheter aortic valve implantation: This approach is gaining importance for older patients with increased operative risk. Postinterventional mortality remains substantial at present, and due to some limitations including the rate of perivalvular leaks this approach should be reserved for high risk individuals. Sutureless valves: These new implants have not yet shown proven advantages over conventional prostheses. Ross-Operation: This procedure is increasingly applied in young patients without dilatation of the aortoventricular junction. Aortic valve repair: Repair has become an attractive alternative to replacement in aortic regurgitation. Thus anticoagulation can be avoided, and the risk of valve-related complications is low.

Schlüsselwörter

Aortenklappenstenose - Aortenklappeninsuffizienz - Aortenaneurysma - mechanischer Klappenersatz - biologischer Klappenersatz - Aortenklappenrekonstruktion - kathetertechnische Klappen

Key words

aortic valve stenosis - aortic valve regurgitation - aortic aneurysm - mechanical valve replacement - biologic valve replacement - aortic valve repair - transcatheter aortic valves

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