Ein wichtiger Prädiktor - Stellenwert der pulmonal-venösen Hypertonie bei der chronischen Herzinsuffizienz

Zusammenfassung

Die pulmonal-venöse Hypertonie ist ein wichtiger Prädiktor der Mortalität bei Patienten mit schwerer linksventrikulärer Dysfunktion. Der pulmonal-arterielle Druck korreliert hierbei linear mit dem kapillären Verschlussdruck und schützt so einerseits den linken Ventrikel vor einer Volumenüberladung, erhöht jedoch andererseits die rechtsventrikuläre Nachlast. Letztendlich ist die Entwicklung einer pulmonal-venösen Hypertonie bei chronischer Herzinsuffizienz auf die ansteigenden linksventrikulären Füllungsdrucke aufgrund der zunehmenden linksventrikulären Dysfunktion zurückzuführen. Von prognostischer Bedeutung scheinen - insbesondere zumindest bei Patienten mit schwerst eingeschränkter linksventrikulärer Dysfunktion - rechtsventrikuläre Parameter zu sein. Im Zentrum der therapeutischen Strategie steht die Optimierung der linksventrikulären Vorlast und des linksventrikulären Füllungsdruckes. Dazu eignen sich zum Beispiel operative Maßnahmen an Herzklappen und Koronarsystem - insbesondere aber auch eine Behandlung mit Diuretika und ACE-Hemmern, mit dem Ziel, die Vor- und Nachlast des Herzens zu optimieren.

Summary

Pulmonary venous hypertension is a major predictor of mortality in patients with severe left ventricular dysfunction. The pulmonary arterial pressure correlated linearly with the capillary occlusion pressure, thus protecting the left ventricle on the one hand while increasing the right ventricular afterload on the other. In the last resort, development of pulmonary venous hypertension in patients with chronic cardiac insufficiency is due to the increasing left ventricular filling pressures resulting from progressive left ventricular dysfunction. Especially the right ventricular ejection fraction would appear to be of particular importance. At the centre of the therapeutic strategy is the optimisation of the left ventricular preload and left ventricular filling pressure. Suitable methods for achieving this are, for example, surgical procedures on the cardiac valves and coronaries, but in particular also treatment with diuretic agents and ACE-inhibitors with the aim of optimising preload and afterload.

Key Words

left ventricular dysfunction - pulmonary endothelial dysfunction - pulmonary venous hypertension - right ventricular dysfunction - transpulmonary gradient - echocardiographic quantification - risk stratification - therapeutic options

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1 flolan international randomized survival trial

2 endothelin antagonist bosentan for lowering cardiac events in heart failure

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