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Diagnostik der Mitralinsuffizienz

Wie viel und welche Quantifizierung brauchen wir?

Evaluation of mitral regurgitation

How much quantification do we need?

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Zusammenfassung

Eine hochgradige Mitralinsuffizienz (MI) ist mit erhöhter Morbidität und Mortalität vergesellschaftet. Die korrekte Evaluation von Ätiologie, Pathomechanismus und Schweregrad ist entsprechend entscheidend für eine optimale Behandlung. Die Echokardiographie ist die wesentliche Diagnosemodalität im klinischen Alltag; sie ermöglicht die Bestimmung des Schweregrads häufig bereits mittels einfach zu erhebender, qualitativer Parameter. Ergänzend bietet sie verschiedene Verfahren, um die hämodynamische Bedeutung der MI zu quantifizieren. Der am besten mit klinischen Ereignissen korrelierte quantitative Parameter ist die EROA („effective regurgitant orifice area“); ihre Berechnung wird in amerikanischen und europäischen Leitlinien empfohlen. Gleichwohl besteht Uneinigkeit über die Grenzwerte für eine hochgradige, sekundäre MI. Die Evaluation einer MI muss immer auch die Beurteilung der angrenzenden Herzhöhlen beinhalten – einerseits, um die Auswirkung der MI auf Größe und Funktion beurteilen zu können, andererseits auch, weil die Bedeutung der quantitativen Parameter von Ventrikelgröße und Auswurfvolumen abhängig ist. Neue 3‑D-echokardiographische Ansätze zur Quantifizierung der MI haben in Studien überzeugende Ergebnisse gezeigt, ihre Parameter sind allerdings noch nicht hinreichend klinisch validiert. Als Alternative zur Echokardiographie hat sich für ausgewählte Indikationen die kardiale Magnetresonanztomographie (MRT) als systematische und untersucherunabhängige Methode zur Quantifizierung der MI bewährt.

Abstract

Severe mitral regurgitation (MR) is associated with increased morbidity and mortality. Thus, the correct evaluation of the underlying etiology, pathomechanism and severity is crucial for optimal treatment. Echocardiography is the predominant diagnostic modality in the clinical routine as it enables grading of mitral regurgitation, which can frequently be achieved by readily available qualitative parameters. Additionally, echocardiography provides several methods to quantify the hemodynamic significance of MR. The effective regurgitation orifice area (EROA) is the quantitative parameter best correlated with clinical events. American and European imaging guidelines both recommend the use of quantitative parameters even though they disagree on the cut-off values for secondary MR. The evaluation of MR should always include an assessment of the adjacent heart chambers in order to be able to assess the impact of volume overload on size and function of the left ventricle and left atrium. The final interpretation of the quantitative parameters requires knowledge of left ventricular volume and ejection fraction. Newer 3D-echocardiographic approaches to quantify MR are less dependent on mathematical assumptions and have shown convincing results in several studies but still lack sufficient clinical validation. As an alternative to echocardiography, for specific indications cardiac magnetic resonance imaging (MRI) has proven to be a systematic and observer-independent method for quantification of MR.

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Abbreviations

EROA:

Effektive Regurgitationsöffnungsfläche

LVEDV:

Linksventrikuläres enddiastolisches Volumen

LVEF:

Linksventrikuläre Ejektionsfraktion

LVESV:

Linksventrikuläres endsystolisches Volumen

MI:

Mitralinsuffizienz

PISA:

„Proximal isovelocity surface area“

RF:

Regurgitationsfraktion

RVol:

Regurgitationsvolumen

SV:

Schlagvolumen

TEE:

Transösophageale Echokardiographie

TSV:

Totales Schlagvolumen

TTE:

Transthorakale Echokardiographie

VCA:

Vena-contracta-Fläche

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Authors and Affiliations

  1. Department of Cardiology, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland

    F. Kreidel, T. Ruf, A. Tamm, M. Geyer & R. S. von Bardeleben

  2. Klinik für Radiologie der Universitätsmedizin Main, Mainz, Deutschland

    T. Emrich

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  1. F. Kreidel
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  2. T. Ruf
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  3. A. Tamm
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  4. M. Geyer
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  6. R. S. von Bardeleben
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Correspondence to F. Kreidel.

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Interessenkonflikt

F. Kreidel, T. Ruf, A. Tamm, M. Geyer, T. Emrich und R.S. von Bardeleben geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Kreidel, F., Ruf, T., Tamm, A. et al. Diagnostik der Mitralinsuffizienz. Herz 44, 574–585 (2019). https://doi.org/10.1007/s00059-019-04857-3

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