Diagnostik und Therapie der Rechtsherzinsuffizienz

Abstract

Right heart failure may be due to increased afterload caused by pulmonary hypertension, increased volume load as in valvular incompetence, myocardial ischemia, and cardiomyopathy. The clinical consequences of those various disease entities are rather homogenous, venous congestion being the key symptom. The diagnosis is based on clinical findings and echocardiography. Right ventricular Tei-index and TAPSE (tricuspid annular plane systolic excursion) are easily obtained measures of right ventricular contractile function. Brain natriuretic peptide is helpful to follow changes in right ventricular dysfunction during therapy. Treatment of right heart failure aims at the correction of the underlying condition, especially if underlying pulmonary disease can be improved. Unifying principles are reduction of excessive pre- and afterload, improved myocardial oxygen delivery and correction of hypercapnia and acidosis, e.g. by ventilatory support. Diuretic therapy must avoid volume depletion resulting in renal failure, whereas volume substitution should be done cautiously. Specific pulmonary vasodilators are indicated only in pulmonary arterial hypertension (PAH) and in inoperable chronic thromboembolic pulmonary hypertension (CTEPH). The standard medical treatment of left heart failure is not generally suitable for right heart dysfunction, except if secondary to left heart disease. In many instances, an interdisciplinary approach to right heart failure is needed, involving the expertise both of the cardiologist and the pulmonologist.

Kernaussagen

• Pathophysiologie, Ätiologie und Klinik der Rechtsherzinsuffizienz unterscheiden sich wesentlich von der Linksherzinsuffizienz.

• Die Echokardiografie ist für die Diagnostik der Rechtsherzinsuffizienz unersetzlich, wobei auf spezifische Parameter (Dimensionen, TAPSE, Tei-Index, PA-Druck) geachtet werden muss. NT-proBNP ist ein weiterer wichtiger Parameter.

• Die evidenzbasierte Therapie der Linksherzinsuffizienz ist bei der isolierten Rechtsherzinsuffizienz meist nicht angezeigt.

• Die spezifische Therapie der pulmonal-arteriellen Hypertonie ist für andere Formen des Cor pulmonale in der Regel nicht angezeigt.

• Ist eine Lungenerkrankung die Ursache der Rechtsherzinsuffizienz, so sind an erster Stelle Störungen der Atemmechanik, Hypoxie, Hyperkapnie und Azidose zu behandeln.

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