Prophylaxe und Therapie des postoperativen Vorhofflimmerns bei thoraxchirurgischen Eingriffen

Zusammenfassung

Postoperatives Vorhofflimmern (VHF) tritt bei 12–44 % aller Patienten nach thoraxchirurgischen Eingriffen auf und ist mit einer erhöhten Komplikationsrate und Mortalität assoziiert. Die US-amerikanische Gesellschaft für Thoraxchirurgie hat 2011 eine Leitlinie zur Prophylaxe und Therapie des perioperativen VHF herausgegeben. Eine ausreichend hohe Evidenz besteht für die Fortführung einer zuvor bestehenden β-Blocker-Therapie trotz der bekannten negativ inotropen Wirkung. Als Alternative bei nicht etablierter β-Blocker-Therapie ist der Kalziumantagonist Diltiazem oder auch Amiodaron bei nicht pneumonektomierten Patienten Mittel der Wahl. Zur Frequenzkontrolle des postoperativ neu aufgetretenen VHF können bei hämodynamischer Stabilität selektive β₁-Blocker, Kalziumantagonisten und ggf. Magnesium wie auch Digoxin eingesetzt werden. Amiodaron, β₁-Blocker und Flecainid können unter Beachtung der Nebenwirkungen und Kontraindikationen zur medikamentösen Rhythmuskontrolle bei hämodynamischer Stabilität eingesetzt werden, bei hämodynamischer Instabilität empfiehlt sich eine elektrische Kardioversion. Bei Persistenz des VHFs > 48 Stunden wird eine Antikoagulation abhängig von klinischer Gesamtkonstellation und vom CHADS2-Score empfohlen. Die vorliegende Übersichtsarbeit diskutiert die aktuelle Evidenz für die einzelnen Medikamente und Maßnahmen.

Abstract

Following thoracic surgery atrial fibrillation (AF) frequently occurs in 12 to 44 % of cases postoperatively and is related to an increased morbidity and mortality. In 2011, the Society of Thoracic Surgeons of the United States published guidelines for the prophylaxis and treatment of postoperative AF. High evidence levels are provided for continuing β-blocker treatment despite its known negative inotropic effects. Alternatively, the calcium channel blocker diltiazem, or amiodarone for patients without pneumonectomy are recommended for prophylactic therapy. For rate control of AF occurring post surgery, not only selective β1-blockers, calcium channel blockers, but also magnesium or digoxin are suitable in haemodynamically stable patients. Amiodarone, β₁-blockers and flecainide are preferred for rhythm control in case of haemodynamic stability in regard to possible side effects and contraindications. In contrast, electrical cardioversion is indicated in those patients with haemodynamic instability. Persistent AF of > 48 hours is a target for anticoagulation treatment depending on the individual aspects of the patient and in accordance to the CHADS2 score. The present review article further discusses the evidence for the recommended medical therapy and treatment strategies.

Schlüsselwörter

Vorhofflimmern - Thoraxchirurgie - β-Blocker - Amiodaron - Kardioversion - Diltiazem

Key words

atrial fibrillation - general thoracic surgery - β-blocker - amiodarone - cardioversion - diltiazem

• Literatur

• 1 Roselli EE, Murthy SC, Rice TW et al. Atrial fibrillation complicating lung cancer resection. J Thorac Cardiovasc Surg 2005; 130: 438-444
• 2 Irshad K, Feldman LS, Chu VF et al. Causes of increased length of hospitalization on a general thoracic surgery service: a prospective observational study. Can J Surg 2002; 45: 264-268
• 3 Harpole DH, Liptay MJ, DeCamp jr. MM et al. Prospective analysis of pneumonectomy: risk factors for major morbidity and cardiac dysrhythmias. Ann Thorac Surg 1996; 61: 977-982
• 4 Nielsen TD, Bahnson T, Davis RD et al. Atrial fibrillation after pulmonary transplant. Chest 2004; 126: 496-500
• 5 Vaporciyan AA, Correa AM, Rice DC et al. Risk factors associated with atrial fibrillation after noncardiac thoracic surgery: analysis of 2588 patients. J Thorac Cardiovasc Surg 2004; 127: 779-786
• 6 Onaitis M, DʼAmico T, Zhao Y et al. Risk factors for atrial fibrillation after lung cancer surgery: analysis of the Society of Thoracic Surgeons general thoracic surgery database. Ann Thorac Surg 2010; 90: 368-374
• 7 McKenna jr. RJ, Houck W, Fuller CB. Video-assisted thoracic surgery lobectomy: experience with 1,100 cases. Ann Thorac Surg 2006; 81: 421-425
• 8 Paul S, Altorki NK, Sheng S et al. Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: a propensity-matched analysis from the STS database. J Thorac Cardiovasc Surg 2010; 139: 366-378
• 9 Onaitis MW, Petersen RP, Balderson SS et al. Thoracoscopic lobectomy is a safe and versatile procedure: experience with 500 consecutive patients. Ann Surg 2006; 244: 420-425
• 10 Burgess DC, Kilborn MJ, Keech AC. Interventions for prevention of post-operative atrial fibrillation and its complications after cardiac surgery: a meta-analysis. Eur Heart J 2006; 27: 2846-2857
• 11 Mentz RJ, Wojdyla D, Fiuzat M. Association of beta-blocker use and selectivity with outcomes in patients with heart failure and chronic obstructive pulmonary disease (from OPTIMIZE-HF). Am J Cardiol 2013; 111: 582-587
• 12 van Gestel YR, Hoeks SE, Sin DD et al. Impact of cardioselective beta-blockers on mortality in patients with chronic obstructive pulmonary disease and atherosclerosis. Am J Respir Crit Care Med 2008; 178: 695-700
• 13 Salpeter S, Ormiston T, Salpeter E. Cardioselective beta-blockers for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2005; (4) CD003566
• 14 Sedrakyan A, Treasure T, Browne J et al. Pharmacologic prophylaxis for postoperative atrial tachyarrhythmia in general thoracic surgery: evidence from randomized clinical trials. J Thorac Cardiovasc Surg 2005; 129: 997-1005
• 15 Van Mieghem W, Coolen L, Malysse I et al. Amiodarone and the development of ARDS after lung surgery. Chest 1994; 105: 1642-1645
• 16 Tisdale JE, Wroblewski HA, Wall DS et al. A randomized trial evaluating amiodarone for prevention of atrial fibrillation after pulmonary resection. Ann Thorac Surg 2009; 88: 886-893
• 17 Rena O, Papalia E, Oliaro A et al. Supraventricular arrhythmias after resection surgery of the lung. Eur J Cardiothorac Surg 2001; 20: 688-693
• 18 Hohnloser SH, Kuck KH, Lilienthal J. Rhythm or rate control in atrial fibrillation–Pharmacological Intervention in Atrial Fibrillation (PIAF): a randomised trial. Lancet 2000; 356: 1789-1794
• 19 Van Gelder IC, Hagens VE, Bosker HA et al. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med 2002; 347: 1834-1840
• 20 Camm AJ, Lip GY, De Caterina R et al. Guidelines ESCCfP: 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J 2012; 33: 2719-2747
• 21 Hilleman DE, Spinler SA. Conversion of recent-onset atrial fibrillation with intravenous amiodarone: a meta-analysis of randomized controlled trials. Pharmacotherapy 2002; 22: 66-74
• 22 Izhar U, Ad N, Rudis E. When should we discontinue antiarrhythmic therapy for atrial fibrillation after coronary artery bypass grafting? A prospective randomized study. J Thorac Cardiovasc Surg 2005; 129: 401-406
• 23 Gage BF, Waterman AD, Shannon W et al. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA 2001; 285: 2864-2870