Kathetergestützter Aortenklappenersatz: Alternative zur offenen Chirurgie bei Hochrisikopatienten
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Zusammenfassung
Die Therapie der Wahl bei hochgradiger, symptomatischer Aortenstenose ist der prothetische Aortenklappenersatz mit Herz-Lungen-Maschine; das Risiko des Eingriffs liegt im Mittel bei 2–5 %. Bei einer Reihe von Patienten kann angesichts ihres Alters und erheblicher Komorbiditäten ein weitaus höheres Risiko vorliegen. Für diese Patienten stellen kathetergestützte Klappenersatzverfahren mittlerweile eine Alter native dar, die das Operationsrisiko senkt.
Zwischen Juli 2007 und November 2008 wurden insgesamt 182 Patienten mit einem mittleren Alter von 81,1 Jahren behandelt. Das prädizierte Operationsrisiko lag nach dem logistischen Euroscore im Mittel bei 22,5 %, nach dem STS-Score bei 23,5 %. Es wurden 145 CoreValve- und 37 Edwards- Sapien-Prothesen implantiert, der bevorzugte Zugang war bei 79 % der Patienten der transarterielle.
Die 30-Tages-Mortalität betrug im Gesamtkollektiv 10,9 %, nach einem Jahr lebten noch über 78 % der Patienten mit transarteriellem Zugang und 56 % der Patienten mit transapikalem Zugang. Die wesentlichen Komplikationen waren schrittmacherpflichtige AV-Blockierungen (21 %) und periphere vaskuläre Komplikationen (20 %).
Der kathetergestützte Aortenklappenersatz konnte als Routinealternativverfahren bei Patienten mit erhöhtem Operationsrisiko etabliert werden; die Mortalität ist angesichts des durch Scores prädizierten Risikos ausgesprochen zufriedenstellend. Die Optimierung des prozeduralen Managements und zu erwartende technische Modifikationen an Klappen und Kathetern lassen eine weitere Verbesserung der Ergebnisse erwarten.
Schlüsselwörter
Aortenstenose interventioneller Aorten klappenersatz Katheter CoreValve-Prothese Edwards-Sapien-ProtheseCatheter-based aortic valve replacement: Alternative to open surgery on high-risk patients
Abstract
Prosthetic aortic valve replacement with extracorporeal circulation is the therapy of choice for high-grade symptomatic aortic stenosis; the mean risk of the procedure is 2–5 %. Due to age and comorbidities, a number of patients can be at a far higher risk. Meanwhile, catheter-based valve replacement procedures constitute an alternative for these patients by minimizing the operative risk.
Between 7/2007 and 11/2008 a total of 182 patients with a mean age of 81.1 years were treated. According to the logistic Euroscore the predicted operative risk was at a mean of 22.5 % and according to STS score at 23.5 %. A total of 145 CoreValve and 37 Edwards-Sapien prostheses were implanted; transarterial access was preferred in 79 % of the patients. The 30-day mortality in the total collective was 10.9 %. After one year, over 78 % of patients with transarterial access and 56 % of patients with transapical access were still alive. Substantial complications were AV block requiring pacemaker implantation (21 %) and peripheral vascular complications (20 %).
Catheter-based aortic valve replacement could be established as a routine alternative procedure for patients with increased operative risk. Mortality is satisfactory, given the score-predicted risk. Further improvement of results can be expected through optimization of procedural management and technical modifications of valves and catheters.
Keywords
aortic stenosis interventional aortic valve replacement catheter CoreValve Edwards-SapienPreview
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