Mitralklappen- Stenose - Universitätsklinikum Münster

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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:
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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
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Mitralklappen-Stenose
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Ätiologie
meist rheumatisch
(rheumatisches Fieber)
Facies mitralis
Mitralklappenstenose
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Mitralklappen-Stenose
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Mitralklappen-Stenose
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Mitralklappen-Stenose
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Echokardiographie
Thorax - Röntgen
RV
Ao
LV
LA
Mitralklappen-Stenose
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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,
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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
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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
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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
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Mitralklappen-Insuffizienz
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Mitralinsuffizienz
•
•
Oft über viele Jahre asymptomatisch
•
Palpitationen (Rhythmusstörungen /
Vorhofflimmern)
•
•
•
Manifeste Linksherzinsuffizienz
Belastungsdyspnoe
Leistungseinschränkung
Spätstadium: Rechtsdekompensation
Hochfrequentes Holosystolikum Apex
Mitralklappen-Insuffizienz
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Thorax-Röntgen
Mitralklappen-Insuffizienz
Echokardiographie
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Mitralklappen-Insuffizienz
Echokardiographie
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Mitralklappen-Insuffizienz
MITRALINSUFFIZIENZ QUANTIFIZIERUNG
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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
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Endovascular CVRS for Edge to Edge Mitral Repair
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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
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Herzklappenfehler
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Perkutane Ring-Prothesen
Annuloplastie
Herzklappenersatz
Cardiac Dimensions
Herzklappenersatz
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Prothesentyp
+ Generation
Starr-Edwards Lillehei-Kaster
Björk-Shiley
Omniscience
Björk-Shiley MS
Omnicarbon
St. Jude Medical
Duromedics
Carpentier-Edw.
Perimount
Klappenersatz und Embolierisiko
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Risiken der fehlenden Antikoagulation
Thromboembolische Komplikationen
• Prothesenthrombose
• Periphere Embolien
• Zerebrale Embolien
Thromboembolie-Risiko
Antikoagulation
Therapeutisches Fenster
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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