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Kardiologie up2date 2013; 09(01): 37-56
DOI: 10.1055/s-0032-1326192
Herzinsuffizienz
© Georg Thieme Verlag KG Stuttgart · New York

Elektrische Therapie der Herzinsuffizienz

Jürgen Kuschyk
,
Martin Borggrefe
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Publication Date:
28 March 2013 (online)

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Abstract

Heart failure affects approximately 1 – 2 % of the adult population in developed countries with the prevalence rising to ≥ 10 % among persons 70 years of age or older. Based on optimal medical treatment, additional electrical therapy might be beneficial for selected patients. For symptomatic patients with systolic dysfunction, wide QRS complex and left bundle brunch block Cardiac Resynchronization Therapy has a class I recommendation. For patients with a normal QRS duration Cardiac Contractility Modulation has been proven to be effective. Recently, there is raising attention on autonomous modulation for heart failure to restore sympathetic-parasympathetic balance.

Kernaussagen

  • Die symptomatische Herzinsuffizienz ist die führende Todesursache und einer der Hauptgründe für Hospitalisierungen in der westlichen Welt mit weitreichenden sozioökonomischen Implikationen.

  • Die Basistherapie besteht in der leitliniengerechten medikamentösen Therapie. Bei weiterhin symptomatischen Patienten können Device-basierte elektrische Therapieverfahren in Betracht gezogen werden.

  • Für Patienten mit verbreitertem QRS-Komplex und idealerweise Linksschenkelblock hat die CRT eine Klasse-I-Indikation, allerdings erfüllen nur ca. 30 % der Patienten diese Kriterien. Die klinische Erfolgsrate liegt bei ca. 50 – 70 %.

  • Für Patienten mit schmalem bis mäßig verbreitertem QRS-Komplex ist die kardiale Kontraktilitätsmodulation (CCM) eine Therapieoption. Durch hochenergetische Signalabgabe während der absoluten Refraktärphase kann es über komplexe Interaktionen der am Kalziumhaushalt beteiligten Schlüsselproteine zu einer akuten und chronischen Kontraktilitätssteigerung kommen.

  • Bisher nur im Rahmen von Studien untersucht sind Methoden der autonomen Modulation. Zugrunde liegt das pathophysiologische Korrelat einer sympathisch-parasympathischen Dysregulation bei Herzinsuffizienz mit den Folgen einer erhöhten Mortalität. Mit unterschiedlichen Stimulationsmethoden kann an variablen Stellen des autonomen Nervensystems diese Dysbalance ausgeglichen werden. Mögliche Therapieoptionen sind die Vagusstimulation, Spinal Cord Stimulation oder Barorezeptor-Aktivierungs-Therapie. Der klinische Stellenwert der Modulationstherapie kann vor Abschuss laufender Studien noch nicht abschließend bewertet werden. Für die Vagusstimulation liegen Ergebnisse einer Pilotstudie vor mit nachgewiesener Verbesserung funktioneller und linksventrikulärer Parameter, der Lebensqualität sowie der Belastungskapazität.

 

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