Mitralklappen- Stenose - Universitätsklinikum Münster
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Mitralklappen- Stenose - Universitätsklinikum Münster
WWU Münster Erworbene Herzklappenfehler 2. Teil MitralklappenStenose Univ.-Prof. Dr. Helmut Baumgartner Westfälische Wilhelms-Universität Münster Kardiologisches Zentrum für angeborene (EMAH) und erworbene Herzfehler Universitätsklinikum Münster Mitralstenose: WWU Münster 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 Mitralklappen-Stenose WWU Münster Mitralklappen-Stenose WWU Münster Ätiologie meist rheumatisch (rheumatisches Fieber) Facies mitralis Mitralklappenstenose WWU Münster Mitralklappen-Stenose WWU Münster Mitralklappen-Stenose WWU Münster Mitralklappen-Stenose WWU Münster Echokardiographie Thorax - Röntgen RV Ao LV LA Mitralklappen-Stenose WWU Münster Mitralstenose Echokardiographie Planimetrie der Mitralöffnungsfläche Mitralklappen-Stenose Quantifizierung der Mitralstenose Konservative Therapie Pressure Half-Time (PT1/2) peak V √ 2 MVA: 220 PT1/2 PT1/2 Severe MS: Valve area ≤ 1.0cm2, WWU Münster mGradient ≥ 10mmHg • Körperliche Schonung • NaCl- und Volumen-Bilanz • Medikation: • β-Blocker (HF-Senkung) • Diuretikum • Vorlastsenker • Erhalt des Sinusrhythmus • Antikoagulation bei AF Mitralklappen-Stenose Mitralstenose: Indikation zur Intervention Gradient 25 5 mmHg MÖF 0,9 2,3 cm 2 WWU Münster HZV 4,1 4,8 l/min • Beschwerden trotz Therapie • (Pulmonale Hypertension) LA • (Pat. nicht im Sinusrhythmus zu halten) Druckgradient Mitralklappe • Früher, wenn Valvuloplastie möglich (<NYHA III) LA LV • Später, wenn nur Klappenersatz möglich (≥NYHA III) LV nach Valvuloplastie vor Valvuloplastie Indications for Percutaneous Mitral Commissurotomy in Symptomatic Mitral Stenosis with Valve Area < 1.5 Cm² Class Symptomatic patients with favourable characteristics for percutaneous mitral commissurotomy IB Symptomatic patients with contra-indication or high risk for surgery IC As initial treatment in symptomatic patients with unfavourable anatomy but otherwise favourable clinical characteristics IIaC ESC Guidelines Eur Heart J 2007 Indications for Percutaneous Mitral Commissurotomy in Asymptomatic Mitral Stenosis with Valve Area < 1.5 Cm² Asymptomatic patients with favourable characteristics and high thromboembolic risk or high risk of haemodynamic decompensation: - previous history of embolism IIaC - dense spontaneous contrast in the left atrium IIaC - recent or paroxysmal atrial fibrillation IIaC - systolic pulmonary pressure > 50 mmHg at rest IIaC - need for major non-cardiac surgery IIaC - desire of pregnancy IIaC ESC Guidelines Eur Heart J 2007 Suitability for Percutaneous Mitral Commissurotomy Contraindications to 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. • 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 ESC Guidelines Eur Heart J 2007 Mitralklappenfehler WWU Münster ESC Guidelines Eur Heart J 2007 Mitralinsuffizienz: ÄTIOLOGIE Primäre Klappenerkrankung MitralklappenInsuffizienz • 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;351:1681-1684 WWU Münster Mitralklappen-Insuffizienz WWU Münster Mitralinsuffizienz • • Oft über viele Jahre asymptomatisch • Palpitationen (Rhythmusstörungen / Vorhofflimmern) • • • Manifeste Linksherzinsuffizienz Belastungsdyspnoe Leistungseinschränkung Spätstadium: Rechtsdekompensation Hochfrequentes Holosystolikum Apex Mitralklappen-Insuffizienz WWU Münster Thorax-Röntgen Mitralklappen-Insuffizienz Echokardiographie WWU Münster Mitralklappen-Insuffizienz Echokardiographie WWU Münster Mitralklappen-Insuffizienz MITRALINSUFFIZIENZ QUANTIFIZIERUNG WWU Münster Proximale Jetbreite Vena Contracta effective regurgitant orifice KLAPPENINSUFFIZIENZ QUANTIFIZIERUNG Clinical Outcome of Severe Mitral Regurgitation (Flail Leaflet N = 229) 100 - aus Zusammenschau mehrer Parameter in Kenntnis ihrer individuellen Limitationen: • Jet - v.a. prox. Jetbreite / Vena contracta • Größe des Konvergenzstromkegels • CW-Spektrum - Form und Dichte Incidence (5%) Integrative Vorgangsweise • Semiquantifizierung (leicht - mittel - schwer) 90±3% 82±4% Surgery or Death 80 - 63±8% 60 - Surgery 40 - CHF 30±12% 20 - AFib • Fluss in Lungenvenen bzw. Aorta asc. 00 1 2 3 4 5 6 7 8 9 10 Years after diagnosis • Klappenmorphologie (Teilabriss) Ling LH et al NEJM 1996;335:1417 • LV Volumsbelastung (chron.) Mitral Regurgitation: Pre-operative EF and Post-op. Survival 100 - Mitral Regurgitation: Impact of Pre-op. EF on Survival EF ≥ 60% 60 - Ejection Fraction: ≥ .50 .40-.49 < .40 40 - 20 - 01 2 3 Years of Follow-up 4 5 Philips et al Am J Cardiol 1981 Survival (%) 80 - Survival (%) Proximaler Konvergenzstrom Proximal Isovelocity Surface Area 73% EF 50-60% 53% EF <50% 32% Follow-up (Years) Enriquez-Sarano et al. Circulation 1994;90:830-837 Mitral Regurgitation: Impact of Pre-op. Symptoms on Survival EF ≥ 60% EF < 60% NYHA I-II NYHA I-II NYHA III-IV r = -0.63 p = 0.0001 Postoperative EF Survival (%) Mitral Regurgitation Impact of Pre-op. LVESD on Post-op. EF NYHA III-IV P = 0.0001 P = 0.0003 Pre-operative LV end-syst. diameter Years Years n = 478 Enriquez-Sarano et al. J Am Coll Cardiol 1994;24:1536-1543 Tribouilloy C et al. Circulation 1999;99:400 Early Surgery in Degenerative MR (Flail Leaflet) Survival from diagnosis (%) Mitral Rekonstruktion Early Surgery P = 0.028 Conservative Treatment Retrospective study Determinants of mortality: age, symptoms, EF Years 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 8 Deaths • 3 prior to surgery - 3 unrelated to MR • 3 in pts who had refused surgery ERO < 20 mm 2 Survival (%) Survival (%) ERO 20-39 mm2 ERO ≥ 40 mm 2 P < 0.01 Years Prospective Enriquez-Sarano, M. et al. N Engl J Med 2005;352:875-883 - 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. Years Rosenhek et al. Circulation 2006;113:2238 Chronic Severe Mitral Regurgitation Event-free Survival (%) Asymptomatic Severe Mitral Regurgitation Event-free Survival - Watchful Waiting 92% Recommendations Indications for surgery: 78% – Symptoms (NYHA class ≥II) 65% – Asymptomatic patients develop: 55% • 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*) Years Rosenhek et al. Circulation 2006;113:2238 Indications for Surgery in Severe Chronic Organic Mitral Regurgitation Class Symptomatic patients with LV EF >30% and ESD < 55 mm* Asymptomatic patients with LV dysfunction (ESD > 45 mm* and /or LV EF ≤ 60%) * 90% repair * Low op. mortality ESC 2006 Guidelines: Eur Heart J 2007 (in press) ACC/AHA 2006 Guidelines: Circulation / JACC 2006 Management of Asymptomatic Severe Chronic Organic Mitral Regurgitation * valve repair can be considered when there is a high likelihood of durable valve repair at a low risk Severe asymptomatic organic MR LVEF > 60% and LVESD < 45 mm IB IC Asymptomatic patients with preserved LV function and AF or pulmonary hypertension (sPAP >50 mmHg at rest) IIaC 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 IIaC Asymptomatic patients with preserved LV function, high likelihood of durable repair, and low risk for surgery IIbB 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 IIbC Yes No Atrial fibrillation or sPAP > 50 mmHg at rest No Follow-up* Yes Surgery (repair whenever possible) * Lower values can be considered for patients of small stature. ESC Guidelines Eur Heart J 2007 ESC Guidelines Eur Heart J 2007 Perkutane Verfahren der Raffung Cardiovascular Valve Repair System P. Block Mitralklappenfehler WWU Münster Endovascular CVRS for Edge to Edge Mitral Repair WWU Münster Perkutane Verfahren der Raffung 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 110:988-993, 2004 Mitralklappenfehler Bow-tie = Fliege (Kleidung) Mitralklappenfehler WWU Münster Herzklappenfehler WWU Münster Perkutane Ring-Prothesen Annuloplastie Herzklappenersatz Cardiac Dimensions Herzklappenersatz WWU Münster Prothesentyp + Generation Starr-Edwards Lillehei-Kaster Björk-Shiley Omniscience Björk-Shiley MS Omnicarbon St. Jude Medical Duromedics Carpentier-Edw. Perimount Klappenersatz und Embolierisiko WWU Münster Risiken der fehlenden Antikoagulation Thromboembolische Komplikationen • Prothesenthrombose • Periphere Embolien • Zerebrale Embolien Thromboembolie-Risiko Antikoagulation Therapeutisches Fenster WWU Münster Choice of the Prosthesis: In Favour of Mechanical Prosthesis The decision is based on the integration of several of the following factors Class Optimal riskbenefit ratio Desire of the informed patient and absence of contraindication for longterm anticoagulation IC Patients at risk of accelerated structural valve deterioration* IC Patient already on anticoagulation because of other mechanical prosthesis IC Patients already on anticoagulation because at high risk for thromboembolism IIaC Age< 65-70 and long life expectancy** IIaC Patients for whom future redo valve surgery would be at high risk (LV dysfunction, previous CABG, multiple valve prosthesis) IIaC * young age, hyperparathyroidism ** according to age, gender, the presence of comorbidity, and country-specific life expectancy ESC Guidelines Eur Heart J 2007 Choice of the Prosthesis: In Favour of Bioprosthesis Management after Valve Replacement The decision is based on the integration of several of the following factors • Complete baseline assessment 6 to 12 weeks after surgery (clinical assessment, chest X-ray, ECG, TTE, blood testing) • Antithrombotic therapy Class Desire of the informed patient IC Unavailability of good quality anticoagulation (contraindication or high risk, unwillingness, compliance problems, life style, occupation) IC Re-operation for mechanical valve thrombosis in a patient with proven poor anticoagulant control IC Patient for whom future redo valve surgery would be at low risk IIaC Limited life expectancy*, severe comorbidity, or age > 65-70 IIaC Young woman contemplating pregnancy IIbC – 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 ESC Guidelines Eur Heart J 2007 ESC Guidelines Eur Heart J 2007 Antithrombotic Therapy of Mechanical Prostheses 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 ESC Guidelines Eur Heart J 2007 • Target INR Prosthesis thrombogenicity Patient-related risk factors No risk factor ≥ 1 risk factor Low 2.5 3.0 Medium 3.0 3.5 High 3.5 4.0 • Association of antiplatelet drugs – Coronary artery disease or other atherosclerotic disease – Recurrent embolism despite adequate INR ESC Guidelines Eur Heart J 2007
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