Zusammenfassung
Die bisherige Standardtherapie der fortgeschrittenen Mitralklappeninsuffizienz besteht in der herzchirurgischen Mitralklappenrekonstruktion mit Implantation eines Rings und ggf. Kürzung eines Segels zur Annäherung des posterioren und des anterioren Mitralklappensegels. In diesem Patientenkollektiv besteht jedoch häufig eine hohe Komorbidität, so dass neue, weniger belastende katheterbasierte Techniken entwickelt werden. Die EVOLUTION-I-Studie mit Implantation des MONARC®-Systems der Firma Edwards Lifesciences in den Koronarvenensinus zur indirekten Mitralklappenanuloplastie bei Patienten mit funktioneller Mitralklappeninsuffizienz zeigte nach 12 Monaten eine Reduktion der Mitralinsuffizienz von 2,48 auf 1,78. Eine direkte Anuloplastie bei funktioneller Mitralinsuffizienz ist mittels des MPAS® der Firma Mitralign möglich. Hierbei wird durch Insertion von drei Fäden in den posterioren Mitralklappenanulus und folgende Plikation eine verbesserte Koadaptation der Mitralklappensegel erreicht. Der MitraClip® der Firma Evalve bedient sich des Prinzips der „edge-toedge“- Technik. Hierbei werden das posteriore und das anteriore Segel durch Implantation einer Klammer zusammengefügt, so dass eine Reduktion der Mitralinsuffizienz mit diastolisch zwei Öffnungen resultiert.
Die bisherigen Resultate zeigen, dass katheterbasierte Techniken zur Behandlung der Mitralklappeninsuffizienz mit z.T. guten Ergebnissen bei Hochrisikopatienten möglich sind, so dass zukünftig möglicherweise eine echte Alternative zur konventionellen Herzchirurgie zur Verfügung steht.
Abstract
Standard therapy of advanced mitral valve regurgitation currently consists of mitral valve reconstruction through heart surgery including heart-lung machine employment. Typically, a ring is implanted and a leaflet reduced, if necessary, to approximate the posterior and anterior mitral valve leaflets to each other. Because of high comorbidity among this patient population, new and less burdening catheter-based techniques have been developed. Clinical etiology of mitral valve regurgitation is divided into two categories: “structural” versus “functional”.
The MONARC® system of the Edwards Lifesciences company consists of three components – distal stent, bridge with bioabsorbing coating, proximal stent – and is implanted into the coronary sinus. The underlying principle is an indirect annuloplasty of the mitral valve annulus resulting from resorption of the bridge coating and leading to a reduction and indirect tightening of the mitral valve annulus. The EVOLUTION I (EV I) study in patients suffering from functional mitral regurgitation to a degree between 2+ and 4+ revealed – 12 months after the MONARC® implantation – a mitral valve regurgitation reduction from 2.48 to 1.78. The EV I study found interaction of the foreshortening bridge with the coronary arteries in some patients. This problem is most widely excluded by previous computed tomographic or angiographic examinations in the ongoing follow-up study EV II.
Direct annuloplasty is made possible in case of functional mitral regurgitation by using the Mitralign Percutaneous Annuloplasty System® (MPAS®) of the Mitralign company. In doing so, an improved coadaptation of the mitral valve leaflet is achieved by inserting three sutures into the posterior mitral valve annulus and subsequent plicating.
The MitraClip® of the Evalve company uses the principle of the edge-to-edge technique. In doing so, the posterior and anterior leaflets are joined by implanting a clip, resulting in a reduction of mitral regurgitation with two diastolic orifices. In contrast to strukthe other two procedures, the MitraClip® can be used for both functional and structural mitral valve regurgitation. The EVEREST I study and the EVEREST II study, as far as it has already been published, show that this procedure is secure and its results are very positive.
The previous results of all three procedures show that catheter-based techniques for treating high-risk patients suffering from mitral valve regurgitation arrive at positive results in part, so that possibly a real alternative to conventional heart surgery will be available in the future.
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Frerker, C., Schäfer, U., Schewel, D. et al. Die perkutane Mitralklappenintervention bei Mitralklappeninsuffizienz – eine Alternative zur konventionellen Herzchirurgie?. Herz 34, 444–450 (2009). https://doi.org/10.1007/s00059-009-3280-z
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DOI: https://doi.org/10.1007/s00059-009-3280-z