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Trikuspidaklappenoperation

Indikationen und Techniken

Tricuspid valve regurgitation

Indications and operative techniques

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Zusammenfassung

Bei 75 % der Patienten mit Trikuspidalklappeninsuffizienz handelt es sich um eine funktionelle Klappeninsuffizienz, der in der Regel eine Erkrankung des linken Herzens (z. B. Mitralinsuffizienz/-stenose) zugrunde liegt. Ohne chirurgische Behandlung beträgt die 3‑Jahres-Überlebenswahrscheinlichkeit bei mittel bis hochgradiger Insuffizienz 40 %. Bei 80–90 % der Patienten erfolgt die Trikuspidalklappenoperation in Kombination mit einem Mitral- und/oder Aortenklappeneingriff. Isolierte Trikuspidalklappenoperationen sind selten. Die Operation ist indiziert bei hochgradiger Klappeninsuffizienz, wenn die Indikation für einen zusätzlichen Eingriff an der Aorten- und/oder Mitralklappe gegeben ist. Eine Operationsindikation besteht auch bei symptomatischen Patienten mit hochgradiger, isolierter primärer Insuffizienz, wenn keine schwere rechtsventrikuläre Dysfunktion vorliegt. Neuere Untersuchungen belegen den Vorteil einer früheren Indikationsstellung unabhängig vom Schweregrad der Klappeninsuffizienz, wenn eine Ringdilatation (≥40 mm oder >21 mm/m2) vorliegt. Die Klappenrekonstruktion ist die Therapie der Wahl. Ein Klappenersatz ist selten erforderlich. Die Klappenrekonstruktion mit Implantation eines Anuloplastierings ist der Nahtanuloraphie in Hinblick auf das funktionelle Ergebnis und die Reoperationsinzidenz überlegen. Mit neuen konturierten Anuloplastieringen konnten sehr vielversprechende Resultate erzielt werden. Langzeitergebnisse liegen noch nicht vor. Der Schweregrad der Herzinsuffizienz und die Komorbidität (Niereninsuffizienz/Leberdysfunktion) sind die wesentlichen Determinanten der operativen Letalität und des Langzeitüberlebens. Reoperationen an der Trikuspidalklappe sind selten erforderlich, allerdings mit einer hohen Letalität verbunden.

Abstract

Functional tricuspid valve (TV) regurgitation secondary to left heart disease (e.g. mitral insufficiency and stenosis) is observed in 75% of the patients with TV regurgitation and is thus the most common etiology; therefore, the majority of patients who require TV surgery, undergo concomitant mitral and/or aortic valve surgery. Uncorrected moderate and severe TV regurgitation may persist or even worsen after mitral valve surgery, leading to progressive heart failure and death. Patients with moderate to severe TV regurgitation show a 3-year survival rate of 40%. Surgery is indicated in patients with severe TV regurgitation undergoing left-sided valve surgery and in patients with severe isolated primary regurgitation without severe right ventricular (RV) dysfunction. For patients requiring mitral valve surgery, tricuspid valve annuloplasty should be considered even in the absence of significant regurgitation, when severe annular dilatation (≥40 mm or >21 mm/m2) is present. Functional TV regurgitation is primarily treated with valve reconstruction which carries a lower perioperative risk than valve replacement. Valve replacement is rarely required. Tricuspid valve repair with ring annuloplasty is associated with better survival and a lower reoperation rate than suture annuloplasty. Long-term results are not available. The severity of the heart insufficiency and comorbidities (e.g. renal failure and liver dysfunction) are the essential determinants of operative mortality and long-term survival. Tricuspid valve reoperations are rarely necessary and associated with a considerable mortality.

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Author information

Authors and Affiliations

  1. Klinik für Herz- und Gefäßchirurgie, Deutsches Herzzentrum München, Technische Universität München, Lazarettstr. 36, 80636, München, Deutschland

    R. Lange &  T. Günther

  2. Standort München, Munich Heart Alliance, Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), München, Deutschland

    R. Lange &  T. Günther

  3. Department of Interventional Cardiology, McGill University Health Centre, Montreal, Quebec, Kanada

    N. Piazza MD, PhD

Authors
  1. R. Lange
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  3. T. Günther
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Correspondence to T. Günther.

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Interessenkonflikt

R. Lange ist Berater für Medtronic Inc. N. Piazza ist klinischer Proktor und Berater für, hat Forschungsförderung erhalten von und ist Mitglied im advisory board und steering committee von Medtronic Inc. T. Günther gibt an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Lange, R., Piazza, N. & Günther, T. Trikuspidaklappenoperation. Herz 42, 653–661 (2017). https://doi.org/10.1007/s00059-017-4603-0

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  • DOI: https://doi.org/10.1007/s00059-017-4603-0

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