Möglichkeiten und Grenzen der interventionellen Therapie von Vorhofflimmern

Zusammenfassung

Die Weiterentwicklungen der Diagnostik und Therapie des Vorhofflimmerns (AF) wurden in den letzten Jahren wesentlich durch den deutlich höheren Stellenwert der Katheterablation geprägt.

Die elektrophysiologisch geführte Diskonnektion der Pulmonalvenen (PV) ist heute der Eckpfeiler der interventionellen Therapie bei paroxysmalen Vorhofflimmerns (PAF). Bei Patienten mit symptomatischem PAF kann bei Versagen von mindestens einer antiaarrhythmischen Therapie, gemäß den Empfehlungen der internationalen Fachgesellschaften, die Indikation zur Pulmonalvenenisolation gestellt werden. Ziel der Behandlung ist, die Triggeraktivität durch elektrische Diskonnektion der Pulmonalvenen im Bereich der Übergangszone zum linken Vorhof dauerhaft zu isolieren. Dies führt in ca. 60 – 80 % der Fälle mit PAF nach der ersten Prozedur zur Beseitigung der Arrhythmie (≥ 80 % bei Wiederholung der Katheterablation) und wird auch bei seit kürzerer Zeit (Wochen bis Monate) bestehendem persistierendem Vorhofflimmern erfolgreich eingesetzt. Bei Patienten mit der lang anhaltenden, persistierenden Form (CAF) stellen die PV nur selten das alleinige Substrat zur Initiierung und Aufrechterhaltung des Vorhofflimmerns dar. Die Pulmonalvenenisolation allein ist bei der Mehrzahl dieser Patienten nicht ausreichend. Pathophysiologisch ist dies durch ein fortgeschrittenes atriales Remodelling auf struktureller und elektrischer Ebene zu erklären. Es konnte in den letzten Jahren gezeigt werden, dass Patienten mit CAF von einer zusätzlichen Substratmodifikation profitieren. Hierbei werden die herkömmlichen Ansätze (Pulmonalvenenisolation, Defragmentierung und ggf. lineare Läsionen) in einem „stepwise ablation approach” kombiniert angewendet, mit dem Ziel der Terminierung des Vorhofflimmerns durch die Ablation. Aufgrund des hohen zeitlichen Aufwandes, der mangelnden Übertragbarkeit dieser sehr komplexen Prozeduren mit noch fehlenden Langzeit-Ergebnissen und der möglichen Komplikationen ist die Katheterablation bei CAF derzeit noch nicht „klinisch etabliert” und sollte nur in Zentren mit großer Expertise durchgeführt werden. Es bedarf weiterer Studien, um Prädiktoren zu identifizieren, welche ein Fehlschlagen der Prozedur bei CAF vorhersagen und somit helfen, die Patientenauswahl zu verbessern.

Auch im Vergleich zur medikamentösen Therapie hat sich die Katheterablation insbesondere der paroxysmalen Form zunehmend bewährt. Dies zeigt sich auch in aktuellen Meta-Analysen randomisierter Studien, welche eine deutliche Überlegenheit der Katheterablation hinsichtlich der Supprimierung von Vorhofarrhythmien erbrachte. Allerdings muss die interventionelle Therapie heute noch als „symptomatische” Behandlung gelten, da sich vergleichende Studien mit harten Endpunkten wie Sterblichkeit oder Schlaganfallhäufigkeit erst auf dem Weg befinden.

Abstract

Recently, significant progress has been made treating atrial fibrillation (AF) with catheter ablation emerging as an increasingly important technique.

Electrical disconnection of the pulmonary veins (PV) is a widely accepted endpoint for interventional treatment of paroxysmal AF (PAF). According to the current guidelines, catheter ablation can be considered as a therapeutic option in patients who failed antiarrhythmic drug treatment for PAF. The procedural endpoint for PVI is achievement of permanent electrical isolation of the PVs, which in the vast majority of patients harbor triggered electrical activity inducing and maintaining PAF. The success rate of this approach in patients with PAF ranges between 60 and 80 % after a single procedure and augments to > 80 % in patients undergoing a repeat procedure to abolish recovered PV connection.

However, it is now evident that persistent or long-standing persistent AF may not be successfully treated by PVI alone since the majority of patients have AF maintaining substrate beyond the PV. From a pathophysiological perspective this is explained by structural and electrical remodeling of the atrial myocardium in patients with persistent AF. Therefore, it is today widely accepted that additional substrate modification is required to effectively address persistent AF using catheter ablation. It has been shown that a combined approach of PV isolation, ablation of fractionated atrial electrograms and application of lines to treat atrial macro-reentrant tachycardias („stepwise approach”) aiming for restoration of sinus rhythm is a favorable strategy to treat persistent AF. However, significant expertise is needed to accomplish all steps within these complex procedures. Therefore, catheter ablation for persistent AF cannot yet be considered „clinically established” and should only be performed in high volume centers. Additional data is needed to verify the beneficial effect of this strategy and determine „predictors” identifying patients profiting most from these ablation strategies.

In patients with PAF, catheter ablation has emerged as an established therapy also in comparison to antiarrythmic drug treatment. Recent studies have shown that catheter ablation for PAF is superior to antiarrhythmic drug treatment with regard to mid-term suppression of any atrial arrhythmia. Overall, catheter ablation for AF has still to be considered as a symptomatic treatment since evidence for beneficial effects with regard to more robust clinical endpoints such as death, rehospitalization and ischemic cerebral events are not yet available.

Schlüsselwörter

paroxysmales Vorhofflimmern - chronisches Vorhofflimmern - Katheterablation

Keywords

chronic atrial fibrillation - catheter ablation - paroximal atrial fibrillation

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