Operative Strategien bei terminaler Herzinsuffizienz

Zusammenfassung

In fast allen westlichen industrialisierten Ländern betrifft die terminale Herzinsuffizienz immer mehr Menschen. Nach wie vor ist die orthotope Herztransplantation dabei die „chirurgische“ Therapie der Wahl. Der Mangel an Spenderorganen und der technische Fortschritt führten in den letzten 20 Jahren zu chirurgischen organerhaltenden Strategien und Therapien, mit denen eine anstehende Herztransplantation hinausgezögert oder sogar vermieden werden kann. Heute können bestimmte Patienten mit ischämischer Kardiomyopathie oder Mitralklappeninsuffizienz trotz deutlich reduzierter Ventrikelfunktion mit einem akzeptablen Risiko operiert werden. Zusätzlich ist der Mitraclip für diese Patienten eine weitere therapeutische Alternative. Außerdem wurden Rekonstruktionsverfahren des linken Ventrikels in großen klinischen Studien wie RESTORE oder STICH untersucht – und werden kontrovers diskutiert. Weiterentwickelte Herzunterstützungssysteme werden nicht nur als Überbrückungssysteme zur Herztransplantation angewendet, sondern auch als Dauertherapie bei terminaler Herzinsuffizienz. In der vorliegenden Übersichtsarbeit werden die verschiedenen Verfahren, insbesondere deren Anwendung, Differenzialindikation und Komplikationen erläutert.

Abstract

Throughout almost all western industrialized nations an increasing number of patients are affected by terminal heart failure. Cardiac transplantation still remains the gold standard for the treatment of end-stage patients. However, motivated by an ever increasing organ donor shortage and supported by technical progress and innovations in cardiac surgery, a number of new innovative approaches such as resyncronisation and organ sparing strategies have been further developed to delay or finally avoid the need of heart transplantation. Therefore, a considerable number of patients suffering from ischemic cardiomyopathy or mitral valve regurgitation can nowadays be treated with conventional heart surgery, consisting of myocardial revascularization associated with surgical ventricular restoration and correction of mitral valve regurgitation at an acceptable operative risk. In addition Mitraclip represents an alternative therapeutic option for these patients. Left ventricular reconstruction techniques have been evaluated in recent multicenter trials such as RESTORE or STICH and since its publication, data have started a controversial discussion. Technical advances in handling and durability of the newer generation of ventricular assist devices have expanded their use from a “bridge to transplantation” therapy to destination therapy. This article will provide an overview of current therapeutic options in end-stage heart failure and will also give a short outlook on future perspectives.

Schlüsselwörter

Kardiomyopathie - Herztransplantation - Assistsysteme - Mitralklappenchirurgie - Koronarrevaskularisation - linksventrikuläre Ventrikelreduktion

Key words

cardiomyopathy - cardiac transplantation - ventricular assist device - myocardial revascularization - left ventricular reconstruction - destination therapy

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