Die aktuelle Therapie des Vorhofflimmerns erfordert eine grundlegende strategische Entscheidung: Entweder persistierendes Vorhofflimmern zu akzeptieren („Frequenzkontrolle”) oder aber soweit möglich Sinusrhythmus herzustellen und zu erhalten („Rhythmuskontrolle”). Zur Stabilisierung des Sinusrhythmus nach Kardioversion oder bei paroxysmalem Vorhofflimmern empfiehlt sich in erster Linie ein nach Maßgabe der kardialen Grunderkrankung dimensionierter Versuch der antiarrhythmischen Arzneimitteltherapie. Bei medikamentöser Therapieresistenz kommt die Anwendung alternativer invasiver Behandlungstrategien in Frage. Neben der präventiven Schrittmachertherapie sowie der pharmakologischen und ablativen Hybridtherapie stehen kathetergestützte Ablationstechniken mit linearen atrialen Läsionen oder Isolation von Pulmonalvenenarealen bei fokal induziertem Vorhofflimmern zur Verfügung. Diese interventionellen Verfahren sollten aufgrund ihrer begrenzten Effektivität und möglicher Komplikationen dem symptomatischen Patienten mit hohem Leidensdruck vorbehalten bleiben. Beim älteren Patienten wird aufgrund seines höheren Substratanteils an der Vorhofflimmerarrhythmie erst dann eine linksatriale Vorhofflimmerablation in Frage kommen, wenn neben der Triggerelimination die Mitbehandlung des Substrates einen etablierten Stellenwert erlangt hat. Die Durchführung einer pharmakologischen und ablativen Hybridtherapie mit Ablation des kavotrikuspidalen Isthmus ist dagegen auch in höherem Patientenalter eine gut praktikable Therapieform.
Summary
Actual therapy of atrial fibrillation follows either the rate or rhythm control strategy. To stabilize sinus rhythm after cardioversion or in case of paroxysmal atrial fibrillation, medical treatment is currently first line therapy. In patients who develop drug-refractory atrial fibrillation, further invasive treatment modalities like preventive pacing, hybrid therapy or catheter-based ablation techniques including pulmonary vein ablation or linear atrial lesion are available. However, interventional atrial fibrillation therapy should be reserved for the highly symptomatic patient due to its limited efficacy and risk of complication. Due to the higher relevance of the AF substrate in elderly patients, ablation therapy will be of limited use until substrate modification in addition to trigger elimination will reach an established stage as a clinical procedure. Hybrid therapy however, with ablation of the cavotricuspid isthmus is as suitable in elderly patients as in the young or middle-aged.
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