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Die Nachsorge von Patienten nach MitraClip®-Implantation

Aftercare of patients after MitraClip® implantation

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Zusammenfassung

Viele Patienten mit mittel- bis hochgradiger Mitralklappeninsuffizienz kommen aufgrund ihrer Multimorbidität für eine operative Therapie nicht mehr in Frage. Für sie stellt das MitraClip®-Verfahren eine therapeutische Alternative dar.

Ziel des vorliegenden Artikels ist es, Empfehlungen für die Nachbehandlung einer MitraClip®-Versorgung aufzuzeigen. Hierfür wurde eine selektive Literaturübersicht anhand der aktuellen Veröffentlichungen unter besonderer Beachtung der nationalen und internationalen Leitlinien durchgeführt.

Bei Patienten nach MitraClip®-Behandlung ist wegen der zugrunde liegenden Herzinsuffizienz und nach der Herzklappenbehandlung eine Rehabilitationsmaßnahme indiziert. Neben einer Optimierung der medikamentösen Therapie erfolgen die Durchführung einer standardisierten Herzinsuffizienzschulung, die Initiierung eines Kraft- und Ausdauertrainings und eine psychosoziale Betreuung. Die Betroffenen werden außerdem über die Endokarditisprophylaxe für mindestens sechs Monate aufgeklärt. Weiterhin gilt es, die leitliniengerechte, medikamentöse Therapie mit ACE-Hemmern, Betablockern und Aldosteronantagonisten zu optimieren. Eine Besonderheit stellt die Gerinnungshemmung dar, die derzeit nur empirisch belegt ist und bei Sinusrhythmus typischerweise für vier Wochen mit dualer Thrombozytenaggregationshemmung (ASS + Clopidogrel), gefolgt von einer Monotherapie mit ASS, durchgeführt wird. Bei Vorhofflimmern wird eine lebenslange orale Antikoagulation für vier Wochen mit einem Thrombozytenaggregationshemmer kombiniert.

Bei den in der Rehabilitationsklinik und dem niedergelassenen Kardiologen durchzuführenden echokardiographischen Kontrollen muss das Augenmerk insbesondere auf einen residualen Vorhofseptumdefekt, den transmitralen Gradienten sowie eine Restinsuffizienz gelegt werden.

Abstract

Many patients with moderate to severe mitral regurgitation cannot be subjected to surgical therapy due to their multimorbidity. For these patients, MitraClip® implantation is a therapeutic alternative.

The aim of this article is to present recommendations for treatment after a MitraClip® procedure. For this purpose, a selective literature review has been carried out based on the current literature, notably on national and international guidelines.

After a MitraClip® procedure, rehabilitation is indicated because of the underlying heart failure as well as the treatment of a heart valve. Here, optimization of drug therapy, implementation of standardized heart failure training, the initiation of strength and endurance training and psychosocial support are initiated. Patients will be briefed on endocarditis prophylaxis lasting for at least six months. Furthermore, according to current guidelines, treatment with ACE inhibitors, beta-blockers and aldosterone antagonists are optimized. A special feature is anticoagulation, which is currently empirically accounted for and performed in sinus rhythm typically for four weeks of dual antiplatelet therapy (aspirin and clopidogrel) followed by a monotherapy with aspirin. In atrial fibrillation, lifelong oral anticoagulation is indicated combined with a platelet aggregation inhibitor for four weeks.

In particular, echocardiographic control in the rehabilitation clinic and by cardiologists has to be focused on a residual atrial septal defect, the transmitral gradient and a residual mitral regurgitation.

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Authors and Affiliations

  1. Paracelsus-Harz-Klinik Bad Suderode, Paracelsusstr. 1, 06485, Quedlinburg, Deutschland

    A. Schlitt

  2. Medizinische Fakultät, Martin Luther-Universität Halle-Wittenberg, Halle-Wittenberg, Deutschland

    A. Schlitt & H. Schmidt

  3. Klinik für Allgemeine und Interventionelle Kardiologie, Universitäres Herzzentrum Hamburg, Hamburg, Deutschland

    E. Lubos

  4. Reha-Klinik am Sendesaal, Bremen, Deutschland

    M. Guha

  5. Kardiologisch-Angiologische Praxis, Herzzentrum Bremen, Bremen, Deutschland

    C. Hegeler-Molkewehrum

  6. Klinik für Kardiologie und Diabetologie, Klinikum Magdeburg gGmbH, Magdeburg, Deutschland

    M. Sudau & H. Schmidt

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Correspondence to A. Schlitt.

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Interessenkonflikt

A. Schlitt wurde honoriert für Beratertätigkeit (Advisory Board) von den Firmen Boehringer Ingelheim und Astra Zeneca. Er bekam Vortragshonorare und erhielt Kongressgebühren- und Reisekostenerstattung von den Firmen Sanofi-Aventis, BMS, Pfizer, Novartis, Servier, Boehringer Ingelheim, MSD, Bayer AG, u.a. Studienunterstützung (Drittmittel) wurde ihm zuteil von den Firmen GSK, Sanofi-Aventis, Mitsubishi, Endotis, Bayer AG, Boehringer Ingelheim, Novartis, Actelion, BMS, u. a. E. Lubos erhielt Vortragshonorare, Studienunterstützung und Reisekosten von Abbott. C. Hegeler-Molkewehrum erhilet Vortragshonorare von Berlin Chemie sowie Kongressgebühr-, Hotel- und Reisekostenerstattung von Medtronic, Boston, Occlutech und Bayer AG. M. Guha, M. Sudau und H. Schmidt geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Schlitt, A., Lubos, E., Guha, M. et al. Die Nachsorge von Patienten nach MitraClip®-Implantation. Herz 42, 176–185 (2017). https://doi.org/10.1007/s00059-016-4448-y

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