Advertisement

Der Internist

, Volume 59, Issue 12, pp 1279–1290 | Cite as

Diagnose und Therapie der Aortenklappenstenose

  • A. VogelgesangEmail author
  • G. Hasenfuß
  • C. Jacobshagen
CME
  • 1.7k Downloads

Zusammenfassung

Die Aortenklappenstenose (AS) ist die häufigste Herzklappenerkrankung. Wird sie symptomatisch, steigt ihre Letalität rapide an. Der diagnostische Goldstandard ist die transthorakale Echokardiographie. Nach Bestimmung der maximalen Flussgeschwindigkeit, des mittleren Druckgradienten über der Klappe und der Aortenklappenöffnungsfläche erfolgt die Einteilung in ihre Unterformen. Unterschieden werden High-gradient-AS, Low-flow-low-gradient-AS mit reduzierter Pumpfunktion (<50 %) und „paradoxe“ Low-flow-low-gradient-AS mit erhaltener Pumpfunktion (≥50 %). Gegebenenfalls ist weitere Diagnostik mittels Dobutamin-Stressechokardiographie, transösophagealer Echokardiographie oder Kardio-CT notwendig. Die Therapie wird individualisiert festgelegt. Bei Indikation zum Klappenersatz entscheidet das multidisziplinäre „Herz-Team“ nach Patientenalter und Einschätzung des individuellen Eingriffsrisikos, ob ein offen-chirurgisches Vorgehen oder eine Transkatheter-Aortenklappenimplantation indiziert ist.

Schlüsselwörter

Transthorakale Echokardiographie Low-flow-low-gradient-Aortenklappenstenose Risikofaktoren Chirurgischer Aortenklappenersatz Transkatheter-Aortenklappenimplantation 

Diagnosis and treatment of aortic valve stenosis

Abstract

Aortic valve stenosis (AS) is the most frequently observed valvular heart disease. Once it is symptomatic the mortality rapidly increases. The diagnostic gold standard is transthoracic echocardiography. By measuring the maximum transvalvular velocity, mean transaortic pressure gradient and aortic valve opening area, classification of the type of stenosis can be defined. A differentiation is made between high-gradient AS, low-flow low gradient AS with reduced ventricular ejection fraction (<50%) and the paradoxical low-flow low-gradient AS with preserved ventricular function (≥50%). In some cases, additional diagnostic tools are necessary using dobutamine stress echocardiography, transesophageal echocardiography and cardiac computed tomography. The treatment follows an individualized approach. In cases of indications for valve replacement the multidisciplinary heart team takes into account the patient’s age and individual risk for deciding whether an open surgical approach or transcatheter aortic valve implantation is indicated.

Keywords

Transthoracic echocardiography Low-flow-low-gradient aortic stenosis Risk factors Surgical aortic valve replacement Transcatheter aortic valve replacement 

Notes

Einhaltung ethischer Richtlinien

Interessenkonflikt

C. Jacobshagen hat Vortragshonorare und Reisekostenerstattungen von den Firmen Edwards Lifesciences, Medtronic und Abbott erhalten. A. Vogelgesang und G. Hasenfuß geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

Literatur

  1. 1.
    Eveborn GW, Schirmer H, Heggelund G et al (2013) The evolving epidemiology of valvular aortic stenosis. The Tromso study. Heart 99:396–400CrossRefGoogle Scholar
  2. 2.
    Otto CM (2000) Timing of aortic valve surgery. Heart 84:211–218CrossRefGoogle Scholar
  3. 3.
    Park SJ, Enriquez-Sarano M, Chang SA et al (2013) Hemodynamic patterns for symptomatic presentations of severe aortic stenosis. JACC Cardiovasc Imaging 6:137–146CrossRefGoogle Scholar
  4. 4.
    Baumgartner H, Falk V, Bax JJ et al (2017) ESC/EACTS Guidelines for the management of valvular heart disease: The Task Force for the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 38(36):2739–2791.  https://doi.org/10.1093/eurheartj/ehx391 CrossRefGoogle Scholar
  5. 5.
    Nishimura RA, Otto CM, Bonow RO et al (2014) 2014 AHA/ACC guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Thorac Cardiovasc Surg 148:e1–e132CrossRefGoogle Scholar
  6. 6.
    Baumgartner HC, Hung JC-C, Bermejo J et al (2017) 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 18:254–275CrossRefGoogle Scholar
  7. 7.
    Minners J, Allgeier M, Gohlke-Baerwolf C et al (2008) Inconsistencies of echocardiographic criteria for the grading of aortic valve stenosis. Eur Heart J 29:1043–1048CrossRefGoogle Scholar
  8. 8.
    Defilippi CR, Willett DL, Brickner ME et al (1995) Usefulness of dobutamine echocardiography in distinguishing severe from nonsevere valvular aortic stenosis in patients with depressed left ventricular function and low transvalvular gradients. Am J Cardiol 75:191–194CrossRefGoogle Scholar
  9. 9.
    Pellikka PA, Nagueh SF, Elhendy AA et al (2007) American Society of Echocardiography recommendations for performance, interpretation, and application of stress echocardiography. J Am Soc Echocardiogr 20:1021–1041CrossRefGoogle Scholar
  10. 10.
    Cueff C, Serfaty JM, Cimadevilla C et al (2011) Measurement of aortic valve calcification using multislice computed tomography: Correlation with haemodynamic severity of aortic stenosis and clinical implication for patients with low ejection fraction. Heart 97:721–726CrossRefGoogle Scholar
  11. 11.
    Clavel MA, Messika-Zeitoun D, Pibarot P et al (2013) The complex nature of discordant severe calcified aortic valve disease grading: New insights from combined Doppler echocardiographic and computed tomographic study. J Am Coll Cardiol 62:2329–2338CrossRefGoogle Scholar
  12. 12.
    Hachicha Z, Dumesnil JG, Bogaty P et al (2007) Paradoxical low-flow, low-gradient severe aortic stenosis despite preserved ejection fraction is associated with higher afterload and reduced survival. Circulation 115:2856–2864CrossRefGoogle Scholar
  13. 13.
    Eleid MF, Nishimura RA, Sorajja P et al (2013) Systemic hypertension in low-gradient severe aortic stenosis with preserved ejection fraction. Circulation 128:1349–1353CrossRefGoogle Scholar
  14. 14.
    Clavel MA, Ennezat PV, Marechaux S et al (2013) Stress echocardiography to assess stenosis severity and predict outcome in patients with paradoxical low-flow, low-gradient aortic stenosis and preserved LVEF. JACC Cardiovasc Imaging 6:175–183CrossRefGoogle Scholar
  15. 15.
    Vogelgesang A, Hasenfuss G, Jacobshagen C (2017) Low-flow/low-gradient aortic stenosis-Still a diagnostic and therapeutic challenge. Clin Cardiol 40(9):654–659.  https://doi.org/10.1002/clc.22728 CrossRefPubMedGoogle Scholar
  16. 16.
    Herrmann HC, Pibarot P, Hueter I et al (2013) Predictors of mortality and outcomes of therapy in low-flow severe aortic stenosis: A Placement of Aortic Transcatheter Valves (PARTNER) trial analysis. Circulation 127:2316–2326CrossRefGoogle Scholar
  17. 17.
    Tribouilloy C, Levy F, Rusinaru D et al (2009) Outcome after aortic valve replacement for low-flow/low-gradient aortic stenosis without contractile reserve on dobutamine stress echocardiography. J Am Coll Cardiol 53:1865–1873CrossRefGoogle Scholar
  18. 18.
    Monin JL, Quere JP, Monchi M et al (2003) Low-gradient aortic stenosis: Operative risk stratification and predictors for long-term outcome: a multicenter study using dobutamine stress hemodynamics. Circulation 108:319–324CrossRefGoogle Scholar
  19. 19.
    Osnabrugge RL, Speir AM, Head SJ et al (2014) Performance of EuroSCORE II in a large US database: Implications for transcatheter aortic valve implantation. Eur J Cardiothorac Surg 46:400–408 (discussion 408)CrossRefGoogle Scholar
  20. 20.
    Leon MB, Smith CR, Mack MJ et al (2016) Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med 374:1609–1620CrossRefGoogle Scholar
  21. 21.
    Reardon MJ, Van Mieghem NM, Popma JJ et al (2017) Surgical or Transcatheter aortic-valve replacement in intermediate-risk patients. N Engl J Med 376:1321–1331CrossRefGoogle Scholar
  22. 22.
    Cahill TJ, Chen M, Hayashida K et al (2018) Transcatheter aortic valve implantation: Current status and future perspectives. Eur Heart J 39:2625–2634CrossRefGoogle Scholar
  23. 23.
    Hamm CW, Arsalan M, Mack MJ (2016) The future of transcatheter aortic valve implantation. Eur Heart J 37:803–810CrossRefGoogle Scholar

Copyright information

© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2018

Authors and Affiliations

  1. 1.Herzzentrum – Kardiologie und PneumologieUniversitätsmedizin GöttingenGöttingenDeutschland

Personalised recommendations