Interventionelle Therapie bei Trikuspidalklappenerkrankungen

 

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Neben der konservativen medikamentösen Therapie, die meist zu einer Verbesserung der NYHA-Klasse führt, stellt die Operation die einzig derzeit etablierte Therapie der hochgradigen symptomatischen Trikuspidalinsuffizienz (TI) dar. Jedoch sind die in der Literatur veröffentlichten Ergebnisse chirurgischer Trikuspidalklappeneingriffe uneinheitlich. Meist wird eine 30-Tage-Mortalität zwischen 8–12 % berichtet, die damit 3- bis 4-fach höher im Vergleich zu anderen Herzklappeneingriffe liegt. Bei interventionellen Verfahren wird prinzipiell zwischen Rekonstruktion und Ersatz unterschieden. Die „Rekonstruktion“ mit Katheterverfahren stellt bei Patienten mit funktioneller Insuffizienz ein vielversprechendes Konzept dar, da die Funktion der nativen Klappe ohne Verankerung eines Implantats wieder hergestellt werden kann. Ein Ersatz der Trikuspidalklappe erfolgt entweder orthotop oder heterotop, wobei der heterotope bzw. cavale Klappenersatz (CAVI) technisch einfacher durchzuführen ist und nach bisheriger Erfahrung zu einer Reduktion der zentralvenösen Stauung der rechtskardialen Stauungssymptomatik führt. Im Gegensatz zur Trikuspidalinduffizienz ist die Trikuspidalstenose in den Industrieländern eine extrem seltene Erkrankung. Ensprechend der mangelhaften Datenlage sind Empfehlungen zur interventionellen Therapie nur begrenzt möglich. Die Leitlinien empfehlen zunächst einen interventionellen Behandlungsversuch.

Apart from conservative drug-based therapy, which in most cases leads to an improvement in NYHA class, surgery is the only currently established therapy for high-grade symptomatic tricuspid insufficiency (TI). However, the results of surgical tricuspid valve interventions, as published in the literature, are inconsistent. In most cases, a 30-day mortality of 8–12 % is reported, which is 3 to 4 times higher compared to other heart valve interventions. With interventional procedures, a distinction is made between reconstruction and replacement. “Reconstruction” procedures using catheters are promising for patients with functional insufficiency, as the functioning of the native valve can be restored without the insertion of an implant. A replacement of the tricuspid valve is either orthotopic or heterotopic; of the two, heterotopic or caval valve replacement (CAVI) is technically easier to perform, and experience demonstrates that it leads to a reduction of right-sided cardiac congestive symptoms in the central venous congestion.

In contrast to tricuspid insufficiency, tricuspid stenosis is an extremely rare disease in industrialized countries. Given the insufficiency of data, recommendations for interventional therapy are only possible to a limited extent. Initially, the guidelines recommend an interventional treatment trial.

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