Einführung in die chirurgische Therapie von Aortenklappenerkrankungen

Aortenklappenerkrankungen werden mit steigender Zahl chirurgisch behandelt. Von offenen chirurgischen Aortenklappenersatzverfahren und rekonstruktiven Maßnahmen profitieren immer mehr jüngere Patienten mit Aortenklappeninsuffizienz oder prothetischen Aortenklappen. Indikationen, Techniken und Ergebnisse der chirurgischen Möglichkeiten und auch die Therapie der Aortenklappenendokarditis oder Prothesenendokarditis werden im Folgenden beleuchtet.

Kernaussagen

• Insuffizienz der Aortenklappe kann in sehr vielen Fällen mit einer haltbaren Rekonstruktion der Klappe behandelt werden.

• Bei der viel häufigeren Aortenklappenstenose ist fast immer ein Ersatz der Klappe notwendig.

• Als Klappenprothesen gibt es neben den klassischen mechanischen und biologischen Prothesen auch neue biologische Herzklappenprothesen.

• Neue biologische Prothesen sind entweder sehr schnell und minimalinvasiv einsetzbar oder verfügen durch eine Oberflächenbehandlung über besonders lange Haltbarkeit.

• Für ältere oder Risikopatienten ist die Behandlung mit einer kathetergestützten Aortenklappe (TAVI) eine segensreiche und minimalinvasive Prozedur.

• TAVI-Prothesen können auch in nicht mehr funktionsfähige biologische Herzklappenprothesen implantiert werden.

• Eine individuelle Auswahl des am besten geeigneten Verfahrens für den jeweiligen Patienten kann im Heart Team in geeigneten Zentren mit Expertise in allen Bereichen der Aortenklappenbehandlung geleistet werden.

Schlüsselwörter

Aortenklappe - Insuffizienz - Klappenersatz - Bioprothesen - TAVI - Operation - Rekonstruktion

Publication History

Article published online:
14 September 2021

• Literatur

• 1 Beckmann A, Meyer R, Lewandowski J. et al. German Heart Surgery Report 2019: The Annual Updated Registry of the German Society for Thoracic and Cardiovascular Surgery. Thorac Cardiovasc Surg 2020; 68 (04) 263-276
• 2 Baumgartner H, Hung J, Bermejo J. et al. Recommendations on the echocardiographic assessment of aortic valve stenosis: A focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. Eur Heart J Cardiovasc Imaging 2017; 18 (03) 254-275
• 3 Clavel MA, Dumesnil JG, Capoulade R. et al. Outcome of patients with aortic stenosis, small valve area, and low-flow, low-gradient despite preserved left ventricular ejection fraction. J Am Coll Cardiol 2012; 60 (14) 1259-1267
• 4 Falk V, Baumgartner H, Bax JJ, De Bonis M. et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur J Cardiothorac Surg 2017; 52 (04) 616-664
• 5 Généreux P, Stone GW, OʼGara PT. et al. Natural History, Diagnostic Approaches, and Therapeutic Strategies for Patients with Asymptomatic Severe Aortic Stenosis. J Thorac Cardiovasc Surg 2016; 67: 2263-2288
• 6 Kuck K-H, Bleiziffer S, Eggebrecht H. et al. Konsensuspapier der Deutschen Gesellschaft für Kardiologie (DGK) und der Deutschen Gesellschaft für Thorax-, Herz- und Gefäßchirurgie (DGTHG) zur kathetergestützten Aortenklappenimplantation (TAVI) 2020. Kardiologe 2020; 14 (03) 182-204
• 7 Mack MJ, Leon MB, Thourani VH. Et al. Transcatheter Aortic-Valve Replacement with a Balloon-Expandable Valve in Low-Risk Patients. N Engl J Med 2019; 380 (18) 1695-1705
• 8 Popma JJ, Deeb GM, Yakubov SJ. et al. Transcatheter Aortic-Valve Replacement with a Self-Expanding Valve in Low-Risk Patients. N Engl J Med 2019; 380 (18) 1706-1715
• 9 Harken DE, Taylor WJ, Lefemine AA. et al. Aortic valve replacement with a gaged ball valve. Am J Cardiol 1962; 9 (02) 292-299
• 10 Cosgrove 3rd DM, Sabik JF. Minimally Invasive Approach for Aortic Valve Operations. Ann Thorac Surg 1996; 62 (02) 596-597
• 11 Gundry SR. Aortic Valve Replacement By Mini-Sternotomy. Oper Tech Card Thorac Surg 1998; 3 (01) 47-53
• 12 Svensson LG. Minimal-access “J” or “j” sternotomy for valvular, aortic, and coronary operations or reoperations. Ann Thorac Surg 1997; 64 (05) 1501-1503
• 13 Tam RKW, Almeida AA. Minimally invasive aortic valve replacement via partial sternotomy. Ann Thorac Surg 1998; 65 (01) 275-276
• 14 Bonacchi M, Prifti E, Giunti G. et al. Does ministernotomy improve postoperative outcome in aortic valve operation? A prospective randomized study. Ann Thorac Surg 2002; 73 (02) 460-465
• 15 Neely RC, Boskovski MT, Gosev I. et al. Minimally invasive aortic valve replacement versus aortic valve replacement through full sternotomy: the Brigham and Womenʼs Hospital experience. Ann Cardiothorac Surg 2015; 4 (01) 38-48
• 16 Kort S, Applebaum RM, Grossi EA. et al. Minimally invasive aortic valve replacement: Echocardiographic and clinical results. Am Heart J 2001; 142 (03) 476-481
• 17 Glauber M, Miceli A, Gilmanov D. et al. Right anterior minithoracotomy versus conventional aortic valve replacement: A propensity score matched study. J Thorac Cardiovasc Surg 2013; 145 (05) 1222-1226
• 18 Miceli A, Murzi M, Gilmanov D. et al. Minimally invasive aortic valve replacement using right minithoracotomy is associated with better outcomes than ministernotomy. J Thorac Cardiovasc Surg 2014; 148 (01) 133-137
• 19 Dunning J, Gao H, Chambers J. et al. Aortic valve surgery: Marked increases in volume and significant decreases in mechanical valve use – An analysis of 41,227 patients over 5 years from the Society for Cardiothoracic Surgery in Great Britain and Ireland National database. J Thorac Cardiovasc Surg 2011; 142 (04) 776-782
• 20 Hammermeister K, Sethi GK, Henderson WG. et al. 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 (04) 1152-1158
• 21 Oxenham H, Bloomfield P, Wheatley DJ. et al. Twenty year comparison of a Bjork-Shiley mechanical heart valve with porcine bioprostheses. Heart 2003; 89 (07) 715-721
• 22 Stassano P, Di Tommaso L, Monaco M. et al. Aortic Valve Replacement. A Prospective Randomized Evaluation of Mechanical Versus Biological Valves in Patients Ages 55 to 70 Years. J Am Coll Cardiol 2009; 54 (20) 1862-1868
• 23 Chiang YP, Chikwe J, Moskowitz AJ. et al. Survival and long-term outcomes following bioprosthetic vs. mechanical aortic valve replacement in patients aged 50 to 69 years. JAMA 2014; 312 (13) 1323-1329
• 24 Glaser N, Jackson V, Holzmann MJ. et al. Aortic valve replacement with mechanical vs. biological prostheses in patients aged 50–69 years. Eur Heart J 2016; 37 (34) 2658-2667
• 25 Williams ML, Bavaria JE, Acker MA. et al. Valve Selection in End-Stage Renal Disease: Should It Always Be Biological?. Ann Thorac Surg 2016; 102 (05) 1531-1535
• 26 Klieverik LMA, Yacoub MH, Edwards S. et al. Surgical Treatment of Active Native Aortic Valve Endocarditis With Allografts and Mechanical Prostheses. Ann Thorac Surg 2009; 88 (06) 1814-1821
• 27 Heneghan C, Ward A, Perera R. Self-monitoring of oral anticoagulation: Systematic review and meta-analysis of individual patient data. Lancet 2012; 379(9813): 322-334
• 28 Pache G, Schoechlin S, Blanke P. et al. Early hypo-attenuated leaflet thickening in balloon-expandable transcatheter aortic heart valves. Eur Heart J 2016; 37 (28) 2263-2271
• 29 Tuzcu EM, Kapadia SR, Vemulapalli S. et al. Transcatheter Aortic Valve Replacement of Failed Surgically Implanted Bioprostheses: The STS/ACC Registry. J Am Coll Cardiol 2018; 72 (04) 370-382
• 30 Pechlivanidis K, Onorati F, Petrilli G. et al. In which patients is transcatheter aortic valve replacement potentially better indicated than surgery for redo aortic valve disease? Long-term results of a 10-year surgical experience. J Thorac Cardiovasc Surg 2014; 148 (02) 500-508
• 31 Ibrahim M, Spelde AE, Carter TI. et al. The Ross Operation in the Adult: What, Why, and When?. J Cardiothorac Vasc Anesth 2018; 32 (04) 1885-1891
• 32 Laufer G, Haverich A, Andreas M. et al. Long-term outcomes of a rapid deployment aortic valve: data up to 5 years. Eur J Cardiothorac Surg 2017; 52 (02) 281-287
• 33 Meuris B, Flameng WJ, Laborde F. et al. Five-year results of the pilot trial of a sutureless valve. J Thorac Cardiovasc Surg 2015; 150 (01) 84-88
• 34 Della Barbera M, Basso C, Valente M. et al. Pre-implantation collapse in the Sorin Perceval S Sutureless prosthesis does not affect pericardial graft structure. Cardiovasc Pathol 2013; 22 (03) e43
• 35 Boodhwani M, de Kerchove L, Glineur D et al.Repair-oriented classification of aortic insufficiency: impact on surgical techniques and clinical outcomes. J Thorac Cardiovasc Surg 2009; 137 (02) 286-294
• 36 David TE, Feindel CM. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1992; 103 (04) 617-621 discussion 622
• 37 Sarsam MA, Yacoub M. Remodeling of the aortic valve anulus. J Thorac Cardiovasc Surg 1993; 105 (03) 435-438
• 38 Kari FA, Doll KN, Hemmer W. et al. Survival and freedom from aortic valve-related reoperation after valve-sparing aortic root replacement in 1015 patients. Interact Cardiovasc Thorac Surg 2016; 22 (04) 431-438
• 39 David TE, Armstrong S, Manlhiot C. et al. Long-term results of aortic root repair using the reimplantation technique. J Thorac Cardiovasc Surg 2013; 145 (3 Suppl): S22-S25
• 40 Miyahara S, Abe N, Matsueda T. et al. Impact of positional relationship of commissures on cusp function after valve-sparing root replacement for regurgitant bicuspid aortic valve. Eur J Cardiothorac Surg 2016; 50 (01) 75-81
• 41 Nezhad ZM, De Kerchove L, Hechadi J. et al. Aortic valve repair with patch in non-rheumatic disease: Indication, techniques and durability. Eur J Cardiothorac Surg 2014; 46 (06) 997-1005
• 42 Sievers HH, Schmidtke C. A classification system for the bicuspid aortic valve from 304 surgical specimens. J Thorac Cardiovasc Surg 2007; 133 (05) 1226-1233
• 43 Ozaki S, Kawase I, Yamashita H. et al. Midterm outcomes after aortic valve neocuspidization with glutaraldehyde-treated autologous pericardium. J Thorac Cardiovasc Surg 2018; 155 (06) 2379-2387
• 44 Li JS, Sexton DJ, Mick N. et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis 2000; 30 (04) 633-638