Management von Herzklappenpatienten 2008

Zusammenfassung

Degenerative Aortenklappenstenosen und Mitralinsuffizienzen sind die häufigsten Herzklappenfehler in Mitteleuropa; ihre Prävalenz steigt mit Zunahme der Lebenserwartung stetig an. Trotz Zunahme des mittleren Patientenalters zum Interventionszeitpunkt sowie der Co-Morbidität ist die perioperative Sterblichkeit mit ca. 3,5 % in Deutschland konstant niedrig. Die Beschwerdesymptomatik ist für die Wahl des Interventionszeitpunktes wenig geeignet. Die Beurteilung der myokardialen Lastadaptation gelingt derzeit mit prognostischer Relevanz am besten durch Bestimmung der myokardialen Kontraktilitätsreserve. Durch fehlerhafte Beurteilung der myokardialen Adaptation erfolgen Klappeninterventionen auch heute noch oft zu spät, so dass die postoperative Prognose – insbesondere für Patienten mit Mitralinsuffizienz – eingeschränkt ist. Für viele Patienten mit Herzklappenfehlern und für alle Patienten nach Kunstklappenersatz besteht die Indikation zur Behandlung mit Vitamin-K-Antagonisten. Die Stabilität einer oralen Antikoagulation bestimmt weitgehend das Risiko von Embolien und Blutungen. Bei der Mehrzahl der Patienten ist eine Ziel-INR von 2,5 optimal. Das INR-Selbstmanagement senkt das Komplikationsrisiko um ca. 30 %.

Abstract

In Central Europe, the vast majority of patients with valvar heart disease today suffer from degenerative aortic valve stenosis or mitral regurgitation. Due to the aging population, the prevalence of both diseases is rapidly increasing. Despite older age at the time of intervention and more co-morbidities, perioperative mortality has been constantly low (about 3.5 % in Germany). Clinical symptoms reported by patients are often inappropriate to chose the optimal time for intervention. Myocardial contractility reserve is yet the most appropriate measure to assess myocardial adaption to the chronic pressure and/or volume overload. Awaiting myocardial maladaption is hampered by a significant worsening in prognosis. This is especially true for mitral regurgitation, where imaging techniques regularly fail to assess LV pump function due to the low left ventricular impedance. For patients with valvar heart disease requiring therapy with vitamin K antagonists, stability of oral anticoagulation therapy is essential to avoid thromboembolic as well as bleeding complications. For the majority of these patients, a target INR of 2.5 is optimal. INR point of care self management results in a more than 30 % reduction of adverse events.

Schüsselwörter

Herzklappenfehler - Aortenstenose - Mitralinsuffizienz - Herzklappenersatz - Antikoagulation

Key words

valvar heart diseases - aortic valve stenosis - mitral regurgitation - heart valve replacement - anticoagulation

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