Zusammenfassung
Die Mitralklappeninsuffizienz (MI) ist die zweithäufigste Klappenerkrankung in Europa. Grundsätzlich ist zwischen einer primären und sekundären bzw. funktionellen MI zu unterscheiden. Bei einer primären MI liegt die Ursache in einem morphologischen Defekt der Mitralklappe, der zur Volumenbelastung, linksventrikulären Dilatation und schließlich zur Einschränkung der linksventrikulären systolischen Funktion führt. Bei Patienten mit primärer MI ist eine frühzeitige operative Korrektur in Form einer Mitralklappenrekonstruktion oder eines Mitralklappenersatzes Therapie der Wahl.
Bei einer sekundären bzw. funktionellen MI ist die Klappenmorphologie typischerweise unauffällig. Die MI resultiert aus einer Klappenringerweiterung und/oder einer Verlagerung der Papillarmuskel infolge einer veränderten Ventrikelgeometrie, die z.B. durch einen Myokardinfarkt oder eine dilatative Kardiomyopathie bedingt sein kann. Bei Patienten mit sekundärer MI steht die medikamentöse Therapie der Herzinsuffizienz im Vordergrund. Zusätzlich ist im Fall persistierender Beschwerden eine kardiale Resynchronisationstherapie bei geeigneten Patienten indiziert. Der Stellenwert eines chirurgischen Vorgehens ist aufgrund einer kontroversen und unklaren Studienlage im Vergleich zur primären MI weniger präzise definiert. Aus diesem Grund sollte eine Mitralklappenrekonstruktion nur bei Patienten in Erwägung gezogen werden, die trotz optimaler Therapie weiterhin schwer symptomatisch sind.
Abstract
Mitral regurgitation (MR) is the second most frequent valve disease in Europe. In addressing the current therapy for MR, it is useful to distinguish primary from secondary or functional MR. In primary MR, there is derangement of the mitral valve itself causing left ventricular volume overload and left ventricular dysfunction. By contrast, in secondary MR, the valve and its components are typically normal and MR is related to changes of annular size (dilatation) and papillary muscle displacement due to left ventricular damage caused by myocardial infarction or dilated cardiomyopathy.
In primary MR, mitral valve repair or replacement is the first-line therapy. In secondary MR, the best management includes standard medical therapy for heart failure and cardiac resynchronization therapy in selected patients. Since there is no evidence from randomized studies that surgery improves mortality, this approach may only be considered in patients who remain symptomatic despite optimal medical therapy or in patients undergoing coronary revascularization.
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Schaefer, A. Sekundär-funktionelle Mitralinsuffizienz bei Herzinsuffizienz: Tabletten oder Messer?. Herz 34, 118–123 (2009). https://doi.org/10.1007/s00059-009-3198-5
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DOI: https://doi.org/10.1007/s00059-009-3198-5