Aortenklappenstenosen

 

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Zusammenfassung

Die kalzifzierte Aortenklappenstenose ist der häufigste erworbene Herzklappenfehler. Die Betroffenen sind ältere Menschen in der 8. und 9. Lebensdekade, die häufig zusätzlich Komorbiditäten wie linskventrikuläre Dysfunktion, eingeschränkte Nierenfunktion und pulmonale Hypertonie sowie weitere Begleiterkrankungen (Diabetes mellitus, Schlaganfall, COPD) aufweisen. Bei bis zu 30 % dieser Patienten sind operative Morbidität und Letalität so hoch, dass der chirurgische Aortenklappenersatz nicht durchgeführt werden kann. Andererseits ist die Prognose der Aortenklappenstenose äußerst schlecht, sind die typischen Symptome wie Belastungsdyspnoe, Synkope und Angina pectoris erst einmal aufgetreten. Für diese Patientengruppe kommt die kathetergestützte Aortenklappenimplantation (transcatheter aortic valve implantation, TAVI) als eine neue Behandlungsmethode in Betracht. Die Aortenklappenbioprothese besteht aus einem ballonexpandierbaren oder selbstexpandierenden Stent, in den eine Herzklappe aus Rinder- oder Schweineperikard fixiert ist. Die Implantation erfolgt über einen retrograden, transarteriellen Zugang (über die Arteria femoralis oder die Arteria subclavia). Die ballonexpandierbare Klappenprothese kann auch transapikal eingebracht werden. Neuere Studien (z. B. PARTNER-Studie) zeigen eine hohe Erfolgsrate in der Implantation und ein besseres Überleben im Vergleich zur konservativen Therapie, weisen aber auch zerebrovaskuläre und peripher vaskuläre Komplikationen auf. Die weitere Verkleinerung der derzeitigen Applikationssysteme und neue Prothesentypen, die sich im experimentellen Stadium oder bereits in der klinischen Prüfung befinden, tragen dieser Entwicklung Rechnung.

Abstract

The calcified aortic stenosis is the dominating valve disease. Patients affected are most common elderly people in the 8^th or 9^th decade of their life who often show associated comorbidities like reduced left ventricular function, impaired renal function, pulmonary hypertension, and further diseases (Diabetes mellitus, stroke, COPD). In many cases perioperative morbidity and mortality are too high for surgical valve replacement and up to 30 % of patients are rejected. Nevertheless, prognosis of aortic stenosis is worse if the typical symptoms like dyspnea on exertion, syncope, and angina occur. The transcatheter aortic valve implantation is a new method treating this particular group of patients. The aortic valve bioprothesis consists of a balloon-expandable stent or a self-expandable frame, in which a valve of bovine or porcine pericardium is incorporated. The implantation is performed by retrograde access via the femoral or subclavian artery; the balloon-expandable prosthesis can also be implanted by transapical approach. Recently, the PARTNER trial and other studies demonstrate a high implantation success rate and better survival in comparison to standard therapy but exhibit also cerebral vascular and peripheral vascular complications. A further reduction of the available delivery systems and new types of valves which are under experimental tests and clinical evaluation contribute to this development.

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Prof. Dr. med. Stefan Sack

Klinik für Kardiologie, Pneumologie, Internistische Intensivmedizin und Zentrale Notaufnahme,
Sektion Innere Medizin
Klinikum Schwabing
Städtisches Klinikum München GmbH

Kölner Platz 1

80804 München

Phone: 089/3068-2525

Fax: 089/3068-3905

Email: stefan.sack@klinikum-muenchen.de