Mitralklappen- Stenose

Transkript

1 Erworbene Herzklappenfehler 2. Teil Mitralklappen- Stenose Westfälische Wilhelms-Universität Münster Univ.-Prof. Dr. Helmut Baumgartner Kardiologisches Zentrum für angeborene (EMAH) und erworbene Herzfehler Universitätsklinikum Münster Mitralstenose: Pathophysiologie: Obstruktion der linksventrikulären Füllung Zunahme des linksatrialen Drucks, des pulmonalvenösen Drucks und in weiterer Folge des pulmonalarteriellen Drucks Der Druckanstieg ist Abhängig von Schweregrad der MS Fluss über der Klappe Diastolischer Füllungsdauer Faktoren wie Tachykardie, Belastung, Fieber, Schwangerschaft oder Vorhofflimmern führen oft zu einer symptomatischen Verschlechterung Erste Symptome: Dyspnoe, (Lungenödem), Leistungsschwäche, Palpitationen (atriale Arrhythmien), Embolie Spät: Rechtsdekompensation Ätiologie meist rheumatisch (rheumatisches Fieber) Facies mitralis

2 Mitralklappenstenose Thorax - Röntgen Echokardiographie RV LV Ao LA Echokardiographie Mitralstenose Planimetrie der Mitralöffnungsfläche

3 Quantifizierung der Mitralstenose Pressure Half-Time (PT 1/2 ) peak V 2 PT 1/2 MVA: 220 PT 1/2 Severe MS: Valve area 1.0cm 2, mgradient 10mmHg Konservative Therapie Körperliche Schonung NaCl- und Volumen-Bilanz Medikation: β-blocker (HF-Senkung) Diuretikum Vorlastsenker Erhalt des Sinusrhythmus Antikoagulation bei AF Mitralstenose: Indikation zur Intervention Gradient 25 5 mmhg MÖF 0,9 2,3 cm2 HZV 4,1 4,8 l/min Beschwerden trotz Therapie (Pulmonale Hypertension) (Pat. nicht im Sinusrhythmus zu halten) Früher, wenn Valvuloplastie möglich (<NYHA III) Später, wenn nur Klappenersatz möglich ( NYHA III) LA Druckgradient Mitralklappe LV vor Valvuloplastie LA LV nach Valvuloplastie Indications for Percutaneous Mitral Commissurotomy in Symptomatic Mitral Stenosis with Valve Area < 1.5 Cm² Indications for Percutaneous Mitral Commissurotomy in Asymptomatic Mitral Stenosis with Valve Area < 1.5 Cm² Symptomatic patients with favourable characteristics for percutaneous mitral commissurotomy Symptomatic patients with contra-indication or high risk for surgery Class IB Asymptomatic patients with favourable characteristics and high thromboembolic risk or high risk of haemodynamic decompensation: - previous history of embolism - dense spontaneous contrast in the left atrium As initial treatment in symptomatic patients with unfavourable anatomy but otherwise favourable clinical characteristics - recent or paroxysmal atrial fibrillation - systolic pulmonary pressure > 50 mmhg at rest - need for major non-cardiac surgery - desire of pregnancy

4 Suitability for Percutaneous Mitral Commissurotomy Favourable characteristics can be defined by the absence of several of the following unfavourable characteristics: Clinical characteristics: old age, history of commissurotomy, NYHA class IV, atrial fibrillation, severe pulmonary hypertension, Anatomic characteristics: echo score >8, Cormier score of 3 (Calcification of mitral valve of any extent, as assessed by fluoroscopy), very small mitral valve area, severe tricuspid regurgitation. Contraindications to Percutaneous Mitral Commissurotomy Mitral valve area > 1.5 cm² Left atrial thrombus More than mild mitral regurgitation Severe- or bicommissural calcification Absence of commissural fusion Severe concomitant aortic valve disease, or severe combined tricuspid stenosis and regurgitation Concomitant coronary artery disease requiring bypass surgery Mitralklappenfehler Mitralklappen- Insuffizienz Mitralinsuffizienz: ÄTIOLOGIE Primäre Klappenerkrankung Degenerative MI Postrheumatische MI Infektiöse Endokarditis Andere entzündliche Erkrankungen Papillarmuskelabriss (Myokardinfarkt) Congenital Sekundäre Mitralinsuffizienz Koronare Herzkrankheit Cardiomyopathien Mitralinsuffizienz: Ätiologie Mitral Regurgitation RV LV Ao LA DEGENERATIVE MI (Prolaps, Sehnenfadenabriss, myxomatöse Degeneration, fibroelast. Defizienz) Levine, R. A. N Engl J Med 2004;351:

5 Mitralklappen-Insuffizienz Mitralinsuffizienz Oft über viele Jahre asymptomatisch Palpitationen (Rhythmusstörungen / Vorhofflimmern) Manifeste Linksherzinsuffizienz Belastungsdyspnoe Leistungseinschränkung Spätstadium: Rechtsdekompensation Hochfrequentes Holosystolikum Apex Mitralklappen-Insuffizienz Thorax-Röntgen Mitralklappen-Insuffizienz Echokardiographie Mitralklappen-Insuffizienz Echokardiographie

6 Mitralklappen-Insuffizienz MITRALINSUFFIZIENZ QUANTIFIZIERUNG Proximale Jetbreite Vena Contracta effective regurgitant orifice Proximaler Konvergenzstrom Proximal Isovelocity Surface Area KLAPPENINSUFFIZIENZ QUANTIFIZIERUNG Integrative Vorgangsweise Semiquantifizierung (leicht - mittel - schwer) aus Zusammenschau mehrer Parameter in Kenntnis ihrer individuellen Limitationen: Jet - v.a. prox. Jetbreite / Vena contracta Größe des Konvergenzstromkegels CW-Spektrum - Form und Dichte Fluss in Lungenvenen bzw. Aorta asc. Klappenmorphologie (Teilabriss) Clinical Outcome of Severe Mitral Regurgitation (Flail Leaflet N = 229) LV Volumsbelastung (chron.) Ling LH et al NEJM 1996;335:1417 Incidence (5%) Surgery or Death 90±3% 82±4% 63±8% 40 - Surgery CHF 30±12% 20 - AFib after diagnosis Mitral Regurgitation: Pre-operative EF and Post-op. Survival Mitral Regurgitation: Impact of Pre-op. EF on Survival Survival (%) Ejection Fraction: <.40 Survival (%) EF 60% 73% EF 50-60% 53% 32% EF <50% of Follow-up Philips et al Am J Cardiol 1981 Follow-up () Enriquez-Sarano et al. Circulation 1994;90:

7 Mitral Regurgitation: Impact of Pre-op. Symptoms on Survival Mitral Regurgitation Impact of Pre-op. LVESD on Post-op. EF Survival (%) EF 60% EF < 60% NYHA I-II NYHA I-II NYHA III-IV NYHA III-IV Postoperative EF r = p = P = P = n = 478 Tribouilloy C et al. Circulation 1999;99:400 Pre-operative LV end-syst. diameter Enriquez-Sarano et al. J Am Coll Cardiol 1994;24: Mitral - Rekonstruktion Early Surgery in Degenerative MR (Flail Leaflet) Survival from diagnosis (%) P = Conservative Treatment Early Surgery Retrospective study Determinants of mortality: age, symptoms, EF Ling L et al. Circulation 1997;96:1819 Predictive Value of Effective Regurgitant Orifice Area (ERO) in Asympt. MR Asymptomatic Severe Mitral Regurgitation Survival - Watchful Waiting Strategy Survival (%) P < 0.01 ERO < 20 mm 2 ERO mm 2 ERO 40 mm 2 Survival (%) 8 Deaths 3 prior to surgery - 3 unrelated to MR 3 in pts who had refused surgery - 1 SD in 80 yr-old - 1 unknown - 1 cancer All patients 2 Late postoperative deaths Patients with flail leaflet - 1 stroke Expected survival - 1 myocardial infarction P = n.s. Prospective Enriquez-Sarano, M. et al. N Engl J Med 2005;352: Rosenhek et al. Circulation 2006;113:2238

8 Asymptomatic Severe Mitral Regurgitation Event-free Survival - Watchful Waiting Chronic Severe Mitral Regurgitation Recommendations Event-free Survival (%) 92% 78% 65% 55% Rosenhek et al. Circulation 2006;113:2238 Indications for surgery: Symptoms (NYHA class II) Asymptomatic patients develop: LV-enlargement (LVESD 45mm / 40mm) (I) Impairment of LV-function (EF <.60) (I) Pulmonary hypertension (spap > 50 mmhg) (IIa) New onset atrial fibrillation (IIa) Normal LVF and high likelihood of repair (IIb / IIa*) * 90% repair * Low op. mortality ESC 2006 Guidelines: Eur Heart J 2007 (in press) ACC/AHA 2006 Guidelines: Circulation / JACC 2006 Indications for Surgery in Severe Chronic Organic Mitral Regurgitation Symptomatic patients with LV EF >30% and ESD < 55 mm* Asymptomatic patients with LV dysfunction (ESD > 45 mm* and /or LV EF 60%) Asymptomatic patients with preserved LV function and AF or pulmonary hypertension (spap >50 mmhg at rest) Patients with severe LV dysfunction (LV EF < 30% and/or ESD > 55 mm*) refractory to medical therapy with high likelihood of durable repair and low comorbidity Asymptomatic patients with preserved LV function, high likelihood of durable repair, and low risk for surgery Patients with severe LV dysfunction (LV EF < 30% and/or ESD > 55 mm*) refractory to medical therapy with low likelihood of repair and low comorbidity * Lower values can be considered for patients of small stature. Class IB IIbB IIbC Management of Asymptomatic Severe Chronic Organic Mitral Regurgitation Atrial fibrillation or spap > 50 mmhg at rest No Follow-up* Severe asymptomatic organic MR Yes LVEF > 60% and LVESD < 45 mm Yes No * valve repair can be considered when there is a high likelihood of durable valve repair at a low risk Surgery (repair whenever possible) Mitralklappenfehler Mitralklappenfehler P. Block Perkutane Verfahren der Raffung Cardiovascular Valve Repair System Endovascular CVRS for Edge to Edge Mitral Repair FannJI, St GoarFG, Komtebedde J, Oz MC, Block PC, Foster E, ButanyJ, Feldman T, Burdon TA: Beating heart catheter-basededge-to-edge mitral valve procedure in a porcine model; efficacy and healing response. Circulation 110: , 2004 Perkutane Verfahren der Raffung Bow-tie = Fliege (Kleidung)

9 Mitralklappenfehler Herzklappenfehler Perkutane Ring-Prothesen Annuloplastie Herzklappenersatz Cardiac Dimensions Herzklappenersatz Klappenersatz und Embolierisiko Prothesentyp + Generation Starr-Edwards Lillehei-Kaster Björk-Shiley Omniscience Björk-Shiley MS Omnicarbon St. Jude Medical Duromedics Carpentier-Edw. Perimount Risiken der fehlenden Antikoagulation Thromboembolische Komplikationen Prothesenthrombose Periphere Embolien Zerebrale Embolien Thromboembolie-Risiko Antikoagulation Therapeutisches Fenster Optimal riskbenefit ratio Choice of the Prosthesis: In Favour of Mechanical Prosthesis The decision is based on the integration of several of the following factors Desire of the informed patient and absence of contraindication for longterm anticoagulation Patients at risk of accelerated structural valve deterioration* Patient already on anticoagulation because of other mechanical prosthesis Patients already on anticoagulation because at high risk for thromboembolism Age< and long life expectancy** Patients for whom future redo valve surgery would be at high risk (LV dysfunction, previous CABG, multiple valve prosthesis) * young age, hyperparathyroidism ** according to age, gender, the presence of comorbidity, and country-specific life expectancy Class

10 Choice of the Prosthesis: In Favour of Bioprosthesis The decision is based on the integration of several of the following factors Desire of the informed patient Unavailability of good quality anticoagulation (contraindication or high risk, unwillingness, compliance problems, life style, occupation) Re-operation for mechanical valve thrombosis in a patient with proven poor anticoagulant control Patient for whom future redo valve surgery would be at low risk Limited life expectancy*, severe comorbidity, or age > Young woman contemplating pregnancy Class IIbC Management after Valve Replacement Complete baseline assessment 6 to 12 weeks after surgery (clinical assessment, chest X-ray, ECG, TTE, blood testing) Antithrombotic therapy Adapted to prothesis- and patient-related risk factors Lifelong for all mechanical prostheses During the first 3 post-operative months for bioprostheses Detection of complications Prosthetic thrombosis Bioprosthetic failure Haemolysis and paravalvular leak Heart failure * according to age, gender, the presence of comorbidity, and country-specific life expectancy Risk Factors for Thromboembolism Prosthesis thrombogenicity Low : Carbomedics (aortic position), Medtronic Hall, St. Jude Medical (without Silzone) Medium : Bjork-Shiley, other bileaflet valves High : Lillehei-Kaster, Omniscience, Starr-Edwards Patient-related risk factors - mitral, tricuspid, or pulmonary valve replacement - previous thromboembolism - atrial fibrillation - left atrial diameter > 50 mm - left atrial dense spontaneous contrast - mitral stenosis of any degree - left ventricular ejection fraction < 35% - hypercoagulable state Target INR Prosthesis thrombogenicity Low Medium High Antithrombotic Therapy of Mechanical Prostheses Patient-related risk factors No risk factor Association of antiplatelet drugs 1 risk factor Coronary artery disease or other atherosclerotic disease Recurrent embolism despite adequate INR