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DOI: 10.1055/s-0031-1280746
© Georg Thieme Verlag Stuttgart · New York
Herzinsuffizienz – Technische Möglichkeiten und Grenzen der mechanischen Kreislaufunterstützung
Technical possibilities and limitations of mechanical circulatory supportPublication History
Publication Date:
17 June 2011 (online)
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Zusammenfassung
Mit Kunstherzsystemen (VAD) können der linke (LVAD), rechte (RVAD) bzw. beide Ventrikel des Herzens (BVAD) unterstützt werden. Traditional werden VAD-Systeme als Überbrückung bis zur Herztransplantation (BTT) implantiert; allerdings steigen in den letzten Jahren die Zahlen der permanenten Kreislaufunterstützung (DT) an. Eine Explantation eines VAD-Systems als „bridge to recovery“ (BTR) kommt nur für wenige Patienten in Fragen. Patientenselektion, prä- und intraoperatives Management sowie der Zeitpunkt der VAD-Implantation bestimmen den Erfolg dieser Therapie.
Abstract
Ventricular assist devices (VAD) to support the left (LVAD), the right (RVAD) or both ventricles (BVAD) have emerged as one standard of care for advanced heart failure patients. Initially used to bridge patients to transplantation (BTT) they are now more frequently implanted as permanent support (destination therapy, DT). Bridge to recovery (BTR) is a valid option for only a small number of patients. Although there are different devices available, patient selection, preoperative and intraoperative management, and the timing of VAD implantation are the elements critical to successful circulatory support.
Schlüsselwörter:
Herzinsuffizienz - LVAD - BVAD - permanente Kreislaufunterstützung - Überbrückung bis Herztransplantation
Keywords:
end-stage heart failure - LVAD - BVAD - destination therapy - bridge to transplantation - bridge to recovery
Kernaussagen
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Mit einem mechanischen Kreislaufunterstützungssystem können Patienten bis zu einer Herztransplantation überbrückt (bridge to transplantation), permanent unterstützt (destination therapy) bzw. bis zu einer Myokarderholung versorgt werden (bridge to recovery).
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Die mechanische Kreislaufunterstützung ist die Therapie der Wahl bei akutem therapierefraktärem Herzversagen sowie (neben der Herztransplantation) bei terminaler Herzinsuffizienz.
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In den letzten Jahren hat der Anteil an BVAD-Implantationen im Vergleich zu LVAD-Implantationen abgenommen und liegt nur noch bei ungefähr 25 %.
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Nach VAD-Implantation ist eine präzise Antikoagulation erforderlich. Diese richtet sich im Wesentlichen am INR aus. Vorzugsweise kommen Coumadin oder Warfarin sowie Thrombozytenaggregationshemmer zur Anwendung.
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Hauptkomplikationen im Langzeitverlauf der VAD-Therapie sind Infektionen ausgehend vom perkutanen Steuerkabel, Thrombembolien und Blutungen.
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Langfristig soll dem Patienten am VAD ein selbstbestimmtes Leben in häuslicher Umgebung, die Möglichkeit der aktiven Freizeitgestaltung undin einzelnen Fällen auch die Integrierung in den Arbeitsprozess ermöglicht werden.
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Der Einsatz von VAD zur permanenten Unterstützung des Kreislaufs nimmt kontinuierlich zu.
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Thomas Krabatsch
Martin Schweiger
Alexander Stepanenko
Thorsten Drews
Evgenij Potapov
Juliane Vierecke
Beate Jurmann
Miralem Pasic
Yu-Guo Weng
Michael Huebler
Roland Hetzer