Interventionelle Perspektive der Trikuspidalinsuffizienz

Abstract

Tricuspid regurgitation (TR) is a frequent condition in patients with advanced stages of left heart valve or myocardial disease. Although TR has traditionally assumed a lower priority in treatment of cardiac disease as it is frequently secondary to tricuspid annular dilatation it has a major impact on functional status and long-term survival. For symptomatic TR, surgical correction is the only effective therapy and most repairs are done in the setting of other planned cardiac surgery. However, TV surgery in advanced stages of multivalvular heart disease as well as after previous cardiac surgery carry high mortality rates and is, therefore, not routinely offered to many patients. The recent advent of transcatheter treatment of structural heart disease has expanded the therapeutic options for many high-risk or nonsurgical patients. However, for therapy of TR no percutaneous approach is available in clinical practice. Considering the impact of TR on functional status and long-term survival and the increasing number of high-risk patients undergoing percutaneous therapy of left heart valve disease today, there is an increasing need for parallel transcatheter therapy for TR. Several concepts have been proposed and evaluated in preclinical investigation and first human application. This article discusses the clinical impact and current management of TR and examines the potentials and limitations of emerging transcatheter approaches from preclinical investigation to first patient application.

Kernaussagen

• Die Trikuspidalinsuffizienz entsteht überwiegend sekundär bei Dilatation des rechten Ventrikels infolge einer fortgeschrittenen linkskardialen Erkrankung.

• Trotz wesentlicher Fortschritte in der interventionellen Therapie von Herzklappenerkrankungen ist für die Therapie der Trikuspidalinsuffizienz weiterhin kein perkutanes Verfahren klinisch etabliert.

• Der perkutane orthotope Ersatz der Trikuspidalklappe konnte im Tiermodell erfolgreich durchgeführt werden. Als wesentliche Herausforderung des Verfahrens zeigte sich dabei die sichere Fixierung der perkutanen Klappenprothese im Bereich des Trikuspidalannulus. Dieser bietet aufgrund seiner elliptischen, sich dynamisch im Herzzyklus verändernden Form kaum Widerlager für die Verankerung mittels Radialkraft.

• Die heterotope Klappenimplantation in zentralvenöser Position wurde als einziges interventionelles Verfahren bereits erfolgreich zur Therapie der Trikuspidalinsuffizienz am Patienten durchgeführt. Das Verfahren ist technisch einfacher umsetzbar, zeigt aber wesentliche hämodynamische Limitationen. Obwohl durch den heterotopen Trikuspidalklappenersatz eine Reduktion des Rückstroms von Blut in die V. cava inferior erreicht werden kann, sind sowohl die damit zu erzielende Symptomverbesserung als auch die Langzeiteffekte unklar und erfordern weitere umfassende Untersuchungen.

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