Operative Myokardrevaskularisation bei schlechter linksventrikulärer Funktion – STICH forever?

Zusammenfassung

Allein in Europa leiden über 15 Mio. Menschen an den Folgen einer chronischen Herzinsuffizienz mit einer Prävalenz von 1–2 % pro Jahr. Langzeitergebnisse der SYNTAX-Studie zeigen klare Vorteile bei Patienten mit einer koronaren Herzerkrankung und besonders komplexen Stenosen für die aortokoronare Bypassoperation. Beim operativen Vorgehen war insbesondere die Re-Interventionsrate im Vergleich zur Intervention deutlich niedriger, und bei Patienten mit hohem SYNTAX-Score (≥ 33) ist dieser Vorteil noch nach 5 Jahren evident. Ohne eine langfristig suffiziente Revaskularisierung kann es zur Ausbildung einer ischämischen Kardiomyopathie (ICM) kommen. Bei diesen Patienten ist eine optimale medizinische Therapie (OMT) mit Diuretika, Angiotensin-Converting-Enzyme- und β-Blockern obligat, und es zeigten sich hier sowohl positive Effekte auf das Remodeling des Myokards als auch die Sterblichkeit der Patienten. Aufgrund der schlechten Prognose der ICM ist es nach wie vor nicht klar, ob die Patienten in diesem Stadium noch von einer Myokardrevaskularisation profitieren. In dieser Hinsicht konnte die multizentrisch-prospektiv randomisierte STICH-Studie in der Langzeitauswertung zeigen, dass eine zur OMT gleichzeitige operative Revaskularisierung die Letalität reduziert und eine positive Auswirkung auf die Angina-pectoris-Symptomatik hat. Nach Ausschöpfung sämtlicher konventioneller Therapiestrategien ist die Herztransplantation immer noch der Goldstandard in der Therapie der terminalen Herzinsuffizienz. Weltweit wurden mittlerweile 85 000 Eingriffe dieser Art erfolgreich durchgeführt. Bei ständig sinkenden Organspenderaten hat sich in den letzten Jahren die Implantation von miniaturisierten Linksherz-Unterstützungssystemen als akzeptable und jederzeit verfügbare Therapiealternative in der akuten Behandlung der terminalen Herzinsuffizienz etabliert. Bei stark zunehmenden Implantationszahlen bleibt abzuwarten, ob diese Therapiestrategie in der Behandlung der terminalen Herzinsuffizienz auch den gewünschten nachhaltigen und längerfristigen Erfolg zeigt.

Abstract

Advanced heart failure is an increasing worldwide problem with over 15 million people suffering from heart failure in Europe with a prevalence of approximately 1–2 %. The SYNTAX trial demonstrated favorable outcomes for coronary artery bypass surgery in patients with complex morphology of coronary artery stenosis in coronary artery disease. In the absence of adequate revascularization patients develop ischemic cardiomyopathy (ICM) with a poor long-term prognosis. Once the diagnosis of ICM is confirmed a clear benefit of myocardial revascularization at this stage is under debate. In addition, optimal medical treatment (OMT) with diuretics, angiotensin converting enzyme blockers and β-blockers has shown a beneficial effect on myocardial remodeling and reduced mortality of these patients. In this regard, the multicenter randomized STICH trial including patients with ICM demonstrated that myocardial revascularization in combination with OMT has long-term effects for the patients such as reduced mortality and symptoms of angina compared to OMT alone. After exhaustion of all medical and surgical therapeutic alternatives for these patients with end stage heart failure, heart transplantation is still the treatment of choice with over 85 000 procedures performed worldwide. Due to a constant shortage of donor organs implantation of mechanical circulatory support devices (MSC) has established itself as a realistic therapeutic alternative for patients with terminal heart failure. However, despite rising numbers of implants and short-term success, long-term results have to be awaited and the future will have to show the precise role of MCS in the treatment of heart failure.

Schlüsselwörter

myokardiale Vitalität - ischämische Kardiomyopathie - koronare Herzerkrankung - STICH-Trial - aortokoronarer Bypass - Herztransplantation

Key words

ischemic cardiomyopathy - coronary artery disease - STICH trial - myocardial viability - aortocoronary bypass - heart transplantation

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