Kardiale Resynchronisation – wie viel mechanische Dyssynchronie und wie viel Bildgebung ist im Vorfeld notwendig?

Zusammenfassung

Die kardiale Resynchronisationstherapie (CRT) soll die mechanische Dyssynchronie bei Patienten mit Herzinsuffizienz und breitem QRS-Komplex korrigieren. Bisher fußt die Indikation zur CRT vorwiegend auf klinischen und elektrokardiographischen Kriterien. Da die QRS-Breite nur schwach zur mechanischen Dyssynchronie korreliert ist, bieten sich daher bildgebende Verfahren wie die Echokardiographie und die kardiale Magnetresonanztomographie (MRT) zur Analyse der kardialen Dyssynchronie an. Die Echokardiographie ist in zahlreichen Studien zur Identifikation von geeigneten CRT-Kandidaten untersucht worden. Neben konventionellen Verfahren wie M-Mode-, 2D-und Doppler-Echokardiographie wurden dazu auch die Gewebe-Doppler-Echokardiographie und andere Techniken, die in dieser Übersicht diskutiert werden, verwandt. Trotz zahlreicher, positiver Ergebnisse in einzelnen Studien konnte kein einzelner echokardiographischer Parameter in einer prospektiven, multizentrischen Studie mit ausreichender Genauigkeit die CRT-Responder identifizieren. Daher muß zum jetzigen Zeitpunkt die QRS-Breite weiterhin als „Goldstandard” zur Patientenidentifikation für die CRT angesehen werden. In Grenzfällen kann möglicherweise eine Kombination verschiedener, echokardiographischer Verfahren hilfreich sein. Die Ergebnisse mit neuen Techniken (2D-„Strain”-Analyse, 3D-Echokardiographie) müssen abgewartet werden. In der Zukunft könnte die Magnetresonanztomographie eine größere Rolle spielen.

Abstract

Cardiac resynchroinsation therapy (CRT) aims to correct the mechanical dyssynchrony in patients with heart failure and broad QRS complex. Until now, indication for CRT is based mainly on clinical and electrocardiographic criteria. Because QRS width is only weakly correlated to mechanical dyssynchrony, imaging techniques such as echocardiography and magnetic resonance tomography (MRT) seem suitable for analysis of dyssynchrony. Echocardiography has been studied in several studies for identification of suitable CRT candidates. Apart from conventional methods such as M mode-, 2 D-, and Doppler echocardiography other techniques which will be discussed in this article, including tissue Doppler echocardiography, have been used. Despite many positive results in individual studies no single echocardiographic parameter was able to predict positive CRT response in a prospective multicenter trial. Thus, QRS width remains the ”gold standard” for CRT patient identification at present. In borderline cases, a combination of several echocardiographic measures of dyssynchrony may prove helpful. The results of studies with new techniques such as 2-dimensional strain analysis or 3D-echocardiography remain to be awaited. In the future, MRT may play a bigger role in this setting.

Schlüsselwörter

Herzinsuffizienz - kardiale Resynchronisationstherapie - Echokardiographie - Kernspintomographie - biventrikuläre Stimulation

Keywords

heart failure - cardiac resynchronisation therapy - echocardiography - magnetic resonance imaging - biventricular stimulation

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