Dokument: Gegenüberstellung der Erfolgsraten zwischen Aortenklappenstenosesubtypen nach Aortenklappenvalvuloplastie als mögliches Überbrückungsverfahren

Titel:	Gegenüberstellung der Erfolgsraten zwischen Aortenklappenstenosesubtypen nach Aortenklappenvalvuloplastie als mögliches Überbrückungsverfahren
Weiterer Titel:	Comparison of success rates between aortic valve stenosis subtypes after aortic valvuloplasty as a possible bridging procedure
URL für Lesezeichen:	https://docserv.uni-duesseldorf.de/servlets/DocumentServlet?id=65051
URN (NBN):	urn:nbn:de:hbz:061-20240320-104655-8
Kollektion:	Dissertationen
Sprache:	Deutsch
Dokumententyp:	Wissenschaftliche Abschlussarbeiten » Dissertation
Medientyp:	Text
Autor:	Wimmer, Anna Christina [Autor]
Dateien:	[Dateien anzeigen] Adobe PDF [Details] 1,66 MB in einer Datei [ZIP-Datei erzeugen] Dateien vom 24.02.2024 / geändert 24.02.2024
Beitragende:	Prof. Dr. med. Zeus, Tobias [Gutachter] Prof. Dr. med. Albert, Alexander [Gutachter]
Dewey Dezimal-Klassifikation:	600 Technik, Medizin, angewandte Wissenschaften » 610 Medizin und Gesundheit
Beschreibungen:	Die Aortenklappenstenose ist das am häufigsten auftretende Herzklappenvitium in der westlichen Welt. Als therapeutische Option stehen der chirurgische Aortenklappenersatz, die Transkatheter-Aortenklappenimplantation (TAVI) und die Aortenklappensprengung (BAV) zur Verfügung. Die BAV ist hierbei aufgrund rascher Restenosierung nicht als kuratives Verfahren anzusehen. Durch die BAV können jedoch auch Hochrisikopatienten und Patienten mit für eine TAVI temporären Kontraindikationen behandelt und somit einer definitiven Therapie zugeführt werden. Seit 2017 wird nach den Leitlinien der European Society of Cardiology die schwere Aortenklappenstenose in verschiedene Flussprofile eingeteilt. Hierbei erfolgt in Abhängigkeit von den Flussgradienten über der Aortenklappe eine Unterteilung in Low-Gradient- (LG-AS) und High-Gradient-Aortenklappenstenose (HG-AS). Bei Vorliegen einer LG-AS kann in der Regel eine weitere Subtypisierung mittels Ejektionsfraktion in classical-Low-Flow-Low-Gradient- (cLFLG-AS) und paradoxical-Low-Flow-Low-Gradient-Aortenklappenstenose (pLFLG-AS) stattfinden. In zahlreichen Studien wurde untersucht, ob die Flussprofile in unterschiedlichem Maß von den erwähnten Interventionen profitieren. Hieraus geht hervor, dass der chirurgische Klappenersatz höhere Erfolgsraten bei HG-AS Patienten zeigt als bei Patienten mit cLFLG-AS und pLFLG-AS. Die TAVI ergab vergleichbare Erfolgs- und Komplikationsraten in allen Flussprofilen. Ob die Langzeitmortalität der Flussprofile sich nach TAVI unterscheidet, ist nach aktueller Studienlage nicht klar zu beantworten. Studien zur BAV mit Differenzierung in die beschriebenen Flussprofile liegen bislang nicht vor. Ziel der Arbeit ist es zu ermitteln, ob die Erfolgsraten durch BAV bzw. BAV + TAVI sich in den verschiedenen Flussprofilen voneinander unterscheiden. Als Hypothese wurde angenommen, dass die HG-AS stärker von den Interventionen profitiert als die anderen Flussprofile. In dieser klinisch-retrospektiven Studie wurden Daten von 174 Patienten analysiert, die zwischen 2008 und 2018 eine BAV bzw. BAV + TAVI in der Abteilung für Kardiologie des Universitätsklinikums Düsseldorf erhalten haben. Die prä-, inter- und postprozeduralen Daten wurden aus den elektronischen Patientenakten gewonnen und durch Daten von externen Krankenhäusern, Praxen und Standesämtern erweitert. In der Auswertung ergab sich, dass die Studienpopulation insgesamt mehr Risikofaktoren und Vorerkrankungen aufwies als in vergleichbarer Literatur. Die cLFLG-AS zeigte, auch im Vergleich zu den anderen Flussprofilen, eine höhere Rate an Vorerkrankungen. Dennoch konnte die Hämodynamik sowohl durch die BAV als auch durch die TAVI in allen Gruppen signifikant verbessert werden. Es ergaben sich keine bedeutenden Unterschiede bei den Komplikationsraten. Der Vergleich zwischen den Flussprofilen ergab nach BAV bzw. BAV + TAVI keinen signifikanten Unterschied in der Überlebenszeit nach einem Jahr. Unsere Studienpopulation war im Gegensatz zu Vergleichsstudien nicht für eine primäre TAVI geeignet, was den vom Flussprofil unabhängigen schlechteren Gesundheitszustand erklärt. Die BAV zeigte sich in dieser Population als ein geeignetes Verfahren, um Patienten aller Flussprofile hämodynamisch zu stabilisieren. Nichtdestotrotz ist eine Folgeintervention mit TAVI anzustreben, um eine geringere Ein-Jahresmortalität im Vergleich zur alleinigen BAV zu erreichen. Aortic valve stenosis is the most common heart valve condition in the Western world. Therapeutic options include surgical aortic valve replacement, transcatheter aortic valve implantation (TAVI), and balloon aortic valvuloplasty (BAV). BAV is not considered a curative procedure due to rapid restenosis. However, BAV can treat high-risk patients and patients with temporary contraindications to TAVI and thus provide definitive therapy. Since 2017, severe aortic valve stenosis is classified into different flow profiles according to the guidelines of the European Society of Cardiology. Depending on the flow gradients across the aortic valve, it is divided into low-gradient (LG-AS) and high-gradient aortic valve stenosis (HG-AS). In the case of LG-AS, further subtyping by ejection fraction into classical-low-flow-low-gradient (cLFLG-AS) and paradoxical-low-flow-low-gradient aortic valve stenosis (pLFLG-AS) can be applied. Numerous studies have investigated whether the different flow profiles benefit from the aforementioned interventions to different degrees. They indicate that surgical valve replacement shows higher success rates in HG-AS patients than in patients with cLFLG-AS and pLFLG-AS. TAVI showed comparable success and complication rates in all flow profiles. Whether long-term mortality differs between flow profiles after TAVI cannot be clearly answered based on current studies. Studies on BAV with differentiation into the described flow profiles are not yet available. The aim of this work is to determine whether the success rates by BAV or BAV + TAVI differ in different flow profiles. It was hypothesized that HG-AS would benefit more from the interventions than other flow profiles. In this clinical retrospective study, data from 174 patients who received BAV or BAV + TAVI in the Department of Cardiology at the University Hospital Düsseldorf between 2008 and 2018 were analyzed. Pre-, inter-, and postprocedural data were obtained from electronic patient records and augmented with data from external hospitals, outpatient visits and registries. The analysis revealed that the study population had more risk factors and pre-existing comorbidities overall than in comparable literature. The cLFLG-AS also showed a higher rate of pre-existing disease compared with the other flow profiles. Nevertheless, hemodynamics were significantly improved by both BAV and TAVI in all groups. There were no significant differences in complication rates. A comparison between flow profiles after BAV or BAV + TAVI showed no significant difference in survival at one year. In contrast to comparative studies, our study population was not suitable for primary TAVI, which explains the poorer health status independent of flow profile. In this population, BAV was shown to be an appropriate procedure to hemodynamically stabilize patients of all flow profiles. Nonetheless, follow-up intervention with TAVI should be sought to achieve lower one-year mortality in comparison to a single BAV intervention.
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