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Der „asymptomatische“ Patient mit chronischem Herzklappenfehler

The “asymptomatic” patient with chronic acquired heart valve disease

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Zusammenfassung

Bei symptomatischen Patienten mit chronischen erworbenen Herzklappenfehlern kann eine Intervention indiziert sein, um Beschwerden und die Lebensqualität zu verbessern. Interventionsziel bei asymptomatischen Patienten ist die Prognoseverbesserung durch Prävention typischer Komplikationen, insbesondere von Herzinsuffizienz und Arrhythmien. Leitliniengerecht ist es unerlässlich, Symptome zuverlässig zu erfassen und u. a. mithilfe der Spiroergometrie zu objektivieren. Bei zweifelsfrei asymptomatischen Patienten mit hämodynamisch fortgeschrittenen Klappenfehlern muss zudem geprüft werden, ob das Myokard an die chronische Druck- und/oder Volumenbelastung auch unter Belastungsbedingungen adaptiert ist (Kontraktilitätsreserve). Nach den klassischen Symptomen der diastolischen und systolischen Herzinsuffizienz zu fragen, ist dabei nicht ausreichend, da die Leitlinien ein abwartendes Vorgehen nur für Patienten empfehlen, die frei von jedweder kausalen Symptomatik sind. Bei allen anderen Patienten ist grundsätzlich die Intervention indiziert. In Anbetracht des zunehmend älteren Patientenkollektivs mit Herzklappenfehlern – insbesondere mit degenerativer Aortenklappenstenose – gilt es zu berücksichtigen, dass der Lebensstil der Patienten oftmals durch die Vermeidung körperlicher Belastungen charakterisiert ist. Dementsprechend sind Fragen zur Belastungsintoleranz oft wenig hilfreich. Bei einer erschöpften myokardialen Kontraktilitätsreserve ist eine Klappenintervention auch indiziert, wenn der Patient im Alltagsleben asymptomatisch ist.

Abstract

An intervention for chronic acquired valvular heart disease may either be indicated in symptomatic patients to relieve symptoms and improve quality of life or in asymptomatic patients to improve long-term prognosis, e.g., by preventing disease-related complications like chronic heart failure or arrhythmias. For proper action according to current guidelines, the systematic evaluation of symptoms related to the underlying valve disease is of utmost importance. If a discrepancy between symptoms reported or not reported by the patients and the severity of the valve disease is supposed, true absence of symptoms and exercise tolerance should be verified by spiroergometry. In the truly asymptomatic patient with a severe valvular lesion, preservation of myocardial adaption to the chronic volume or pressure overload should be tested utilizing appropriate imaging techniques like radionuclide ventriculography under exercise conditions. The proper evaluation of the functional status is of growing importance in our aging population with its sedentary lifestyle. In this context, the results of a survey should be kept in mind, which indicated that a significant proportion of patients still have interventions too late during the natural history of their valve disease with symptoms of congestive heart failure, arrhythmias, and the risk of sudden cardiac death persisting after a primarily successful valve repair or replacement.

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  1. Kardiologische Klinik, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Deutschland

    D. Horstkotte, C. Prinz & C. Piper

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  1. D. Horstkotte
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  2. C. Prinz
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  3. C. Piper
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Correspondence to D. Horstkotte.

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Horstkotte, D., Prinz, C. & Piper, C. Der „asymptomatische“ Patient mit chronischem Herzklappenfehler. Internist 54, 7–17 (2013). https://doi.org/10.1007/s00108-012-3092-8

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