Abstract
Tricuspid regurgitation (TR) is a frequent condition in patients with advanced stages
of left heart valve or myocardial disease. Although TR has traditionally assumed a
lower priority in treatment of cardiac disease as it is frequently secondary to tricuspid
annular dilatation it has a major impact on functional status and long-term survival.
For symptomatic TR, surgical correction is the only effective therapy and most repairs
are done in the setting of other planned cardiac surgery. However, TV surgery in advanced
stages of multivalvular heart disease as well as after previous cardiac surgery carry
high mortality rates and is, therefore, not routinely offered to many patients. The
recent advent of transcatheter treatment of structural heart disease has expanded
the therapeutic options for many high-risk or nonsurgical patients. However, for therapy
of TR no percutaneous approach is available in clinical practice. Considering the
impact of TR on functional status and long-term survival and the increasing number
of high-risk patients undergoing percutaneous therapy of left heart valve disease
today, there is an increasing need for parallel transcatheter therapy for TR. Several
concepts have been proposed and evaluated in preclinical investigation and first human
application. This article discusses the clinical impact and current management of
TR and examines the potentials and limitations of emerging transcatheter approaches
from preclinical investigation to first patient application.
Kernaussagen
-
Die Trikuspidalinsuffizienz entsteht überwiegend sekundär bei Dilatation des rechten
Ventrikels infolge einer fortgeschrittenen linkskardialen Erkrankung.
-
Trotz wesentlicher Fortschritte in der interventionellen Therapie von Herzklappenerkrankungen
ist für die Therapie der Trikuspidalinsuffizienz weiterhin kein perkutanes Verfahren
klinisch etabliert.
-
Der perkutane orthotope Ersatz der Trikuspidalklappe konnte im Tiermodell erfolgreich
durchgeführt werden. Als wesentliche Herausforderung des Verfahrens zeigte sich dabei
die sichere Fixierung der perkutanen Klappenprothese im Bereich des Trikuspidalannulus.
Dieser bietet aufgrund seiner elliptischen, sich dynamisch im Herzzyklus verändernden
Form kaum Widerlager für die Verankerung mittels Radialkraft.
-
Die heterotope Klappenimplantation in zentralvenöser Position wurde als einziges interventionelles
Verfahren bereits erfolgreich zur Therapie der Trikuspidalinsuffizienz am Patienten
durchgeführt. Das Verfahren ist technisch einfacher umsetzbar, zeigt aber wesentliche
hämodynamische Limitationen. Obwohl durch den heterotopen Trikuspidalklappenersatz
eine Reduktion des Rückstroms von Blut in die V. cava inferior erreicht werden kann,
sind sowohl die damit zu erzielende Symptomverbesserung als auch die Langzeiteffekte
unklar und erfordern weitere umfassende Untersuchungen.
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Dr. med. Alexander Lauten
Klinik für Innere Medizin I
Universitätsherzzentrum Jena
Erlanger Allee 101
07740 Jena
eMail: Alexander.Lauten@med.uni-jena.de
