Heart valve reconstruction

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As a heart valve repair is called the restoration of form and therefore of a natural malfunctioning heart valve . Depending on the position ( aortic valve , mitral valve , pulmonary valve or tricuspid valve ) and the type or cause of the functional disorder, different procedures are used.

history

Even before the development of heart valve prostheses , the French surgeon Théodore Tuffier performed the first rupture of a narrowed aortic valve to treat aortic stenosis . The American surgeon Elliot Cutler carried out the first demolition of a narrowed mitral valve in 1923, the English surgeon Henry Souttar , who succeeded in digitally demolishing the mitral stenosis , followed in 1926. From today's perspective, the first attempts were experimental.

The first artificial heart valve with a ball prosthesis was implanted in 1961 by the two Americans Albert Starr and Lowell Edwards .

indication

The indication for surgery depends on clinical symptoms and objective criteria. The primary goal is to improve life expectancy through causal treatment of acute or chronic heart failure , and secondarily to improve symptoms. Reconstruction is an alternative treatment to heart valve replacement , which is often unavoidable due to the severe destruction of the valve.

Various procedures are available for heart valve replacement depending on the age of the patient. What they all have in common is that long-term complications of valve replacement are unavoidable with varying degrees of probability. These include clot formation (thromboembolism) on the valve prosthesis, bleeding under the inhibition of blood clotting , the wear and tear of biological prostheses and sensitivity to inflammation (prosthetic endocarditis).

After the heart valve reconstruction, other results emerge, which also differ between the various heart valves. What all heart valves have in common is that after a reconstruction the risk of clot formation is minimal, inhibition of blood coagulation is usually not necessary and there is no bleeding. The likelihood of heart valve inflammation is significantly lower than after a replacement.

Replacement remains the best procedure for many diseased heart valves. In the past 30 years, however, reconstruction procedures have been developed and become routine for various heart valve defects. This is particularly true for aortic valve insufficiency, mitral valve insufficiency and triscupid valve insufficiency. Reconstruction is often possible with congenital aortic stenosis, but practically not with acquired aortic stenosis. Rheumatic mitral stenosis and tricuspid valve stenosis can also often be treated with reconstruction. Not every valve defect should be operated on automatically; reconstruction is also one of the operations. We regularly check when an operation makes sense. The following list gives a simplified overview of the indications :

Aortic valve stenosis with little or no calcification of the valve

  • severe aortic valve stenosis with symptoms
  • Severe aortic valve stenosis without symptoms with reduced pump function ( EF - ejection fraction <50%) or pathological stress test or rapid progression

Aortic regurgitation

  • severe aortic regurgitation and symptoms
  • Severe aortic valve insufficiency without symptoms with reduced pump function (EF <50%) or end-systolic diameter of the left ventricle> 50 mm
  • Aneurysm of the ascending aorta (ascending aorta) with risk of bursting

Mitral valve stenosis with little or no calcification of the valve

Mitral valve regurgitation

  • severe mitral regurgitation and symptoms and EF> 30%
  • severe mitral regurgitation and a high probability of a reconstruction being successful
  • Severe mitral regurgitation without symptoms with EF <60% or new atrial fibrillation or systolic pulmonary arterial pressure> 50 mmHg

Tricuspid regurgitation

Surgical technique

The surgical technique varies between mitral valve reconstruction , aortic valve reconstruction , pulmonary valve reconstruction and tricuspid valve reconstruction . Details should be found under the respective key words. All operations have in common that the result should be checked intraoperatively by echocardiography. Once the indication has been established, examinations are carried out to assess the risk of surgery and anesthesia. These include e.g. B. a pulmonary function test and a cardiac catheter examination. More recently, it has also been possible to visualize the coronary vessels using an ECG-triggered CT. If coronary artery disease is diagnosed, the creation of coronary artery bypasses is usually recommended, which can be done in one session with the valve replacement.

Minimally invasive procedures

In addition to the open surgical technique with opening of the chest, minimally invasive techniques have been developed. Here, too, there are considerable differences between the various heart valves, so that reference should be made to the individual heart valve defects.

Aftercare

Anticoagulation

In contrast to valve replacement, no inhibition of blood coagulation ( anticoagulation ) is required after the reconstruction . Only the occurrence of an irregular heartbeat ( atrial fibrillation ) may require anticoagulation to prevent clots from forming in the left atrium.

Endocarditis prophylaxis

After heart valve replacement , lifelong endocarditis prophylaxis is usually carried out for all interventions in the oropharynx (e.g. dental surgery, tonsillectomy). It is unclear whether this is also necessary after a heart valve reconstruction.

literature

  • Martin Steiner: Assessment of biological and mechanical heart valve prostheses using time-resolved methods (dissertation). VVB Laufersweiler Verlag, Giessen 2005, ISBN 3-89687-053-X , p. 319.
  • Michael J. Eichler: In vitro cavitation studies on mechanical heart valve prostheses (dissertation). Logos Verlag, Berlin 2003, ISBN 3-8325-0398-6 , p. 175.

Individual evidence

  1. ^ L. Wi Stephenson: History of Cardiac Surgery . In: LH Cohn, LH Edmunds Jr. (Eds.): Cardiac Surgery in the Adult . McGraw-Hill, New York 2003, pp. 3-29.
  2. ↑ a b c A. Vahanian, O. Alfieri et al .: Guidelines on the management of valvular heart disease (version 2012). In: Eur Heart J. Volume 33, No. 19, October 2012, pp. 2451-2496.
  3. ↑ a b Hans-Joachim Schäfers : Clinical basics of cardiac and thoracic surgery . 1st edition. ABW Wissenschaftsverlagsgesellschaft, 2003
  4. ↑ a b Hans-Joachim Schäfers: Current Treatment of Mitral Regurgitation . 2010 (english)
  5. ↑ a b Hans-Joachim Schäfers: Current treatment of aortic regurgitation . UNI-MED Science, 2013 (English)