Kardiale Resynchronisationstherapie und Vorhofflimmern: Möglichkeiten und Grenzen

Zusammenfassung

Vorhofflimmern und Herzinsuffizienz treten häufig gemeinsam auf. Die kardiale Resynchronisationstherapie (CRT) verbessert bei schwerer systolischer Herzinsuffizienz und dyssynchronen Kontraktionen im Sinusrhythmus die Symptomatik und Prognose. Die CRT schützt dagegen nicht vor der Induktion von Vorhofflimmern. Wenn Vorhofflimmern auftritt, bleiben die günstigen Effekte der CRT erhalten, falls eine adäquate Kontrolle der Ventrikelfrequenz durch Betablocker und Herzglykoside erzielt werden kann. Während eine pharmakologische Herzfrequenzeinstellung bei Patienten mit paroxysmalem Vorhofflimmern und Vorhofflimmern von kurzer Dauer ausreichend sein kann, muss bei permanentem Vorhofflimmern nicht selten zusätzlich eine Katheterablation durchgeführt werden. Beobachtungssstudien und eine randomisierte Untersuchung deuten auf einen potenziellen günstigen Effekt der CRT auch bei herzinsuffizienten Patienten mit chronischem Vorhofflimmern hin. Insbesondere bei den Patienten erscheint die biventrikuläre Stimulation einer konventionellen rechtsventrikulären Stimulation überlegen, bei denen ohnehin eine Schrittmacherindikation vorliegt. Aktuelle Daten weisen jedoch daraufhin, dass selbst ein relativ hoher prozentualer Anteil einer biventrikulären Stimulation nicht ausreichend ist, sondern dass nur Patienten mit chronischem Vorhofflimmern und vorausgegangener AV-Knotenablation und damit fast 100 %iger Stimulation von der CRT profitieren. Bevor jedoch die CRT routinemäßig bei chronischem Vorhofflimmern eingesetzt werden sollte und somit eine große Anzahl herzinsuffizienter Patienten schrittmacherabhängig gemacht werden, sind zunächst weitere randomisierte Studien erforderlich.

Summary

Atrial fibrillation (AF) and heart failure often coexist and are believed to directly predispose to each other. Cardiac resynchronization does not prevent or increase the incidence of AF. However, new onset of AF does not seem to diminish the beneficial effects of CRT on symptoms, cardiac function and, more importantly, mortality from all causes, if appropriate control of ventricular rate by beta-blockers or digoxin is being achieved. While a pharmacological approach to controlling ventricular rate may be sufficient in most patients with paroxysmal AF or AF of short duration, in those with permanent AF ablation strategies may have have to be employed. Observational studies and one randomized trial indicate a potential benefit of CRT also in patients with heart failure and chronic AF. In particular, biventricular pacing was superior to conventional right univentricular stimulation in patients with an indiaction for a pacemaker. However, recent results suggest that even a relatively high percentage of biventricular capture may be inadequate, and that the benefits of CRT may only be extended to those patients with chronic AF who had previous AV junctional ablation. However, before CRT is routinely performed in chronic AF and thus before pacemaker dependency is created in a large number of patients in heart failure, definitive results from well designed and adequately powered randomized clinical trials are required.

Schlüsselwörter

Herzinsuffizienz - kardiale Resynchronisation - Vorhofflimmern - biventrikuläre Stimulation

Key words

heart failure - cardiac resynchronization - atrial fibrillation - biventricular pacing

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