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Kardiologie up2date 2015; 11(02): 109-125
DOI: 10.1055/s-0034-1392452
Herzklappenerkrankungen
© Georg Thieme Verlag KG Stuttgart · New York

Neuentwicklungen der Herzunterstützungssysteme – Möglichkeiten und Grenzen

Thomas Pühler
,
Stephan Ensminger
,
Michiel Morshuis
,
Jan Gummert
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Publication History

Publication Date:
24 July 2015 (online)

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Abstract

Advanced Heart failure is worldwide an increasing problem. Implantation of mechanical circulatory support devices (MSCD) in the latter patients and especially the implantation of left ventricular assist devices (LVAD) is nowadays an established therapeutic option for advanced heart failure and becoming a more and more realistic alternative to heart transplantation (HTX. There are a number of different treatment options for these patients, such as bridge to transplantation (BTT), bridge to candidacy (BTC), bridge to recovery (BTR) and the destination therapy (DT) option. The latter option has become more frequent during the last years as a consequence of a rising number of older patients with terminal heart failure requiring therapy whilst not being eligible for HTX. These factors have led to a rapid increasing number of LVAD implantations and centers performing these strategies. Survival rates and quality of live have improved since the introduction of smaller, intra-pericardial and more durable continuous flow left ventricular devices. Though improvements in LVAD pump-design and durability have been made, most common complications for these patients are still device related problems, such as coagulation disorders, gastrointestinal bleeding, device related infection, pump thrombosis or cerebrovascular accidents. However, some questions still remain unanswered or are still under debate such as the exact timepoint for LVAD implantation. In addition aspects such as better biocompatibility to reduce device related problems are still a major challenge for the upcoming LVAD era. This paper will concentrate on the different treatment options and LVAD systems and their outcome, current trends in the LVAD development and the limitations of the devices for the patients.

Kernaussagen

  • Als Konsequenz aus dem Ungleichgewicht von Organangebot, durchgeführten Herztransplantationen und Patienten mit einer terminalen Herzinsuffizienz, die für eine Herztransplantation gelistet sind, und bei einer immer älter werdenden Bevölkerung kann die Herztransplantation nicht mehr die alleinige Option in der Therapie der terminalen Herzinsuffizienz sein. Daher hat sich in den meisten Fällen die LVAD-Therapie als „destination therapy“ als einzig sinnvolle Alternative für diese Patienten herauskristallisiert, insbesondere bei einer klaren Kontraindikation zur Herztransplantation.

  • Neben dem DT-Konzept können LVAD auch implantiert werden, um die Zeit bis zur Herztransplantation zu überbrücken (BTC = „bridge to candidacy“), um den Patienten zu stabilisieren und die Möglichkeit einer Herztransplantation zu beurteilen (BTT = „bridge to transplantation“) oder um ihn ggf. vom LVAD zu entwöhnen (BTR = „bridge to recovery“).

  • Das extraperikardiale HeartMate-II- und das intraperikardiale HeartWare-LVAD sind dabei im Moment die beiden weltweit am häufigsten implantierten LVAD mit kontinuierlichem Fluss – im Gegensatz zum früher verwendeten pulsatilen Fluss.

  • LVAD können heute unter Verzicht auf eine Herz-Lungen-Maschine implantiert werden, wobei die Inflow-Kanüle in der linken Herzspitze über eine linkslaterale Thorakotomie verankert und die Outflow-Kanüle über eine partielle obere Sternotomie minimal-invasiv in die Aorta eingenäht wird.

  • Indikationen der LVAD-Implantation wurden von der ESC bereits 2012 publiziert Tab. [ 1 ]). Der klinische Zustand der Patienten lässt sich u. a. durch die objektivierbaren INTERMACS-Stadien beurteilen. Die meisten LVAD-Implantationen gehen auf eine DT-Indikation zurück, d. h., dass eine spätere Herztransplantation kontraindiziert ist.

  • Obwohl die Adverse-Event-Raten, d. h. die Häufigkeiten von Pumpenthrombosen, Driveline-Infektionen und thromboembolischen Ereignissen in den letzten Jahren durch Verbesserung des Patientenmanagements rückläufig waren, sind diese Ereignisse immer noch die Lebensqualität beeinträchtigende und zum großen Teil lebensbedrohliche Komplikationen für den Patienten und limitieren darüber hinaus die LVAD-Therapie im Langzeitverlauf.

Keywords

mechanical circulatory support (MCS), left ventricular assist device (LVAD)
 

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