Herzchirurgie bei betagten Patienten

Zusammenfassung

Aufgrund der altersabhängigen Prävalenz kardialer Erkrankungen nimmt die Anzahl herzchirurgischer Eingriffe auch bei betagten Patienten zu. Durch die Herzoperation kann eine der Allgemeinbevölkerung vergleichbar hohe Lebensqualität und Lebenserwartung erreicht werden. Der Effekt der herzchirurgischen Therapie hält über Jahrzehnte an. So profitieren auch ältere Patienten von der kompletten Revaskularisation der Herzkranzgefäße und vom Aortenklappenersatz mit Bioprothesen, deren Degenerationsrate im Alter vernachlässigbar gering wird. Ein Nachteil der herzchirurgischen Therapie ist das chirurgische Trauma. Zukunftsweisend sind neue schonende Operationsmethoden wie z. B. die Bypass-Operation am schlagenden Herzen ohne Manipulation an der Aorta. Hier lässt sich die perioperative Schlaganfallrate auf weit < 1 % senken.

Die Indikation zur Herzoperation wird altersunabhängig und basierend auf den Evidenz-basierten Richtlinien gestellt. Die Entscheidung für die Operation erfolgt nach Einschätzung des zu erwartenden Operationsrisikos, das bei Älteren häufig durch die Begleiterkrankungen und weniger durch das Alter per se bestimmt wird. Es lässt sich basierend auf Risiko-Scores und/oder Klinik-spezifischen Daten kalkulieren. Die Erwartungen des Patienten an die Operation und sein Wille, die damit verbundenen Strapazen durchzustehen, sind sorgfältig zu prüfen. Die Operation sollte möglichst elektiv und frühzeitig erfolgen. Mitentscheidend für die Prognose sind ein guter Ernährungszustand und eine präoperative Optimierung der Organfunktionen. Der Blutzuckerwert sollte eingestellt, Schilddrüsen-Dysfunktionen, (stumme) Infekte, Anämie und depressive Störungen sollten im Vorfeld ausgeschlossen bzw. behandelt werden. Ein entsprechendes Screening durch den Hausarzt wird empfohlen. Postoperativ sind ältere Patienten anfälliger für Komplikationen (insbesondere Low-Output-Syndrome, Nierenversagen, respiratorische Insuffizienzen, Schlaganfälle) und benötigen daher eine intensivere Versorgung.

Summary

Caused by the age-dependent prevalence of cardiac diseases, the number of cardiac surgical interventions to geriatric patients is increasing. High life quality and life expectancy can be reached by cardiac operations. The advantage of cardiac surgical interventions is the decade’s long positive effect. Accordingly also elderly benefit from complete revascularisation and from aortic valve replacement with biological prosthesis, which rarely degenerate in old age. A weak point is the surgical trauma, which can be reduced by less-invasive methods, such as OPCAB with aortic non-touch-technique, resulting in less than 1 % stroke.

The indications for heart operations will be based on age-independent evidence-based guidelines. The decision for surgery is influenced by the expectation of the risk. This is defined by the co-morbidities and to lesser extent by the age per se. The operation risk can be calculated by risk-scores and hospital-specific data. The patient’s expectations from the operation and his ability to overcome the accompanying stress must be thoroughly assessed. The operation must take place electively and at the right time. A good nutritional status and preoperative optimization of the organ functions are decisive for the prognosis. The blood-sugar-level must be optimized; thyroid function, (hidden) infections, anaemia and depression must be excluded or treated. The required screening tests should have been done already by the family doctor. The elderly are postoperatively susceptible to complications; especially low cardiac output, renal failure, respiratory insufficiency and stroke. Subsequently they need more intensive care.

Schlüsselwörter

Herzchirurgie - Mitralklappenchirurgie - Bypassoperation - Aortenklappenersatz - Altersmedizin

Key words

cardiac surgery - mitral valve surgery - coronary bypass surgery - aortic valve replacement - geriatrics

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