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
Literatur
- 1
Abraham W T, Fisher W G, Smith A L. et al .
Cardiac resynchronization in chronic heart failure.
N Engl J Med.
2002;
346
1845-1853
- 2
Adamson P B, Kleckner K J, VanHout W L, Srinivasan S, Abraham W T.
Cardiac resynchronization therapy improves heart rate variability in patients with
symptomatic heart failure.
Circulation.
2003;
108
266-269
- 3
Ahmed A, Thornton P, Perry G J, Allman R M, DeLong J F.
Impact of atrial fibrillation on mortality and readmission in older adults hospitalized
with heart failure.
Eur J Heart Fail.
2004;
6
421-426
- 4
Aronow W S, Ahn C, Kronzon I.
Prognosis of congestive heart failure after prior myocardial infarction in older persons
with atrial fibrillation versus sinus rhythm.
Am J Cardiol.
2001;
87
224-225, A8 - 9
- 5
Benjamin E J, Wolf P A, D’Agostino R B, Silbershatz H, Kannel W B, Levy D.
Impact of atrial fibrillation on the risk of death: the Framingham Heart Study.
Circulation.
1998;
98
946-952
- 6
Brignole M, Gammage M, Puggioni E. et al .
Comparative assessment of right, left, and biventricular pacing in patients with permanent
atrial fibrillation.
Eur Heart J.
2005;
26
712-722
- 7
Bristow M R, Saxon L A, Boehmer J. et al .
Cardiac-resynchronization therapy with or without an implantable defibrillator in
advanced chronic heart failure.
N Engl J Med.
2004;
350
2140-2150
- 8
Cleland J G, Daubert J C, Erdmann E. et al .
The CARE-HF study (CArdiac REsynchronisation in Heart Failure study): rationale, design
and end-points.
Eur J Heart Fail.
2001;
3
481-489
- 9
Cleland J G, Daubert J C, Erdmann E. et al .
The effect of cardiac resynchronization on morbidity and mortality in heart failure.
N Engl J Med.
2005;
352
1539-1549
- 10
Crijns H J, Tjeerdsma G, de Kam P J. et al .
Prognostic value of the presence and development of atrial fibrillation in patients
with advanced chronic heart failure.
Eur Heart J.
2000;
21
1238-1245
- 11
Doshi R N, Daoud E G, Fellows C. et al .
Left ventricular-based cardiac stimulation post AV nodal ablation evaluation (the
PAVE study).
J Cardiovasc Electrophysiol.
2005;
16
1160-1165
- 12
Etienne Y, Mansourati J, Gilard M. et al .
Evaluation of left ventricular based pacing in patients with congestive heart failure
and atrial fibrillation.
Am J Cardiol.
1999;
83
1138-1140, A9
- 13
Fung J W, Yu C M, Chan J Y. et al .
Effects of cardiac resynchronization therapy on incidence of atrial fibrillation in
patients with poor left ventricular systolic function.
Am J Cardiol.
2005;
96
728-731
- 14
Gasparini M, Auricchio A, Lamb B. et al .
Four year survival in 1285 patients undergoing cardiac resynchronization therapy (CRT):
The importance of atrioventricular junction ablation in patients with atrial fibrillation
(abstract).
ESC.
2006;
368
- 15
Gasparini M, Auricchio A, Regoli F. et al .
Four-year efficacy of cardiac resynchronization therapy on exercise tolerance and
disease progression: the importance of performing atrioventricular junction ablation
in patients with atrial fibrillation.
J Am Coll Cardiol.
2006;
48
734-743
- 16
Go A S, Hylek E M, Phillips K A. et al .
Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm
management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation
(ATRIA) Study.
JAMA.
2001;
285
2370-2375
- 17
Hanna N, Cardin S, Leung T, Nattel S.
Differences in atrial versus ventricular remodeling in dogs with ventricular tachypacing-induced
congestive heart failure.
Cardiovasc Res.
2004;
63
236-244
- 18
Hoppe U C, Casares J M, Eiskjaer H. et al .
Effect of cardiac resynchronization on the incidence of atrial fibrillation in patients
with severe heart failure.
Circulation.
2006;
114
18-25
- 19
Kay G N, Ellenbogen K A, Giudici M. et al .
The Ablate and Pace Trial: a prospective study of catheter ablation of the AV conduction
system and permanent pacemaker implantation for treatment of atrial fibrillation.
APT Investigators.
J Interv Card Electrophysiol.
1998;
2
121-135
- 20
Khand A U, Rankin A C, Kaye G C, Cleland J G.
Systematic review of the management of atrial fibrillation in patients with heart
failure.
Eur Heart J.
2000;
21
614-632
- 21
Leclercq C, Victor F, Alonso C. et al .
Comparative effects of permanent biventricular pacing for refractory heart failure
in patients with stable sinus rhythm or chronic atrial fibrillation.
Am J Cardiol.
2000;
85
1154-1156, A9
- 22
Leclercq C, Walker S, Linde C. et al .
Comparative effects of permanent biventricular and right-univentricular pacing in
heart failure patients with chronic atrial fibrillation.
Eur Heart J.
2002;
23
1780-1787
- 23
Leon A R, Greenberg J M, Kanuru N. et al .
Cardiac resynchronization in patients with congestive heart failure and chronic atrial
fibrillation: effect of upgrading to biventricular pacing after chronic right ventricular
pacing.
J Am Coll Cardiol.
2002;
39
1258-1263
- 24
Li D, Fareh S, Leung T K, Nattel S.
Promotion of atrial fibrillation by heart failure in dogs: atrial remodeling of a
different sort.
Circulation.
1999;
100
87-95
- 25
Linde C, Leclercq C, Rex S. et al .
Long-term benefits of biventricular pacing in congestive heart failure: results from
the MUltisite STimulation in cardiomyopathy (MUSTIC) study.
J Am Coll Cardiol.
2002;
40
111-118
- 26
Mahoney P, Kimmel S, DeNofrio D, Wahl P, Loh E.
Prognostic significance of atrial fibrillation in patients at a tertiary medical center
referred for heart transplantation because of severe heart failure.
Am J Cardiol.
1999;
83
1544-1547
- 27
Maisel W H, Stevenson L W.
Atrial fibrillation in heart failure: epidemiology, pathophysiology, and rationale
for therapy.
Am J Cardiol.
2003;
91
2D-8D
- 28
Molhoek S G, Bax J J, Bleeker G B. et al .
Comparison of response to cardiac resynchronization therapy in patients with sinus
rhythm versus chronic atrial fibrillation.
Am J Cardiol.
2004;
94
1506-1509
- 29
Pedersen O D, Bagger H, Kober L, Torp-Pedersen C.
Impact of congestive heart failure and left ventricular systolic function on the prognostic
significance of atrial fibrillation and atrial flutter following acute myocardial
infarction.
Int J Cardiol.
2005;
100
65-71
- 30
Sanders P, Morton J B, Davidson N C. et al .
Electrical remodeling of the atria in congestive heart failure: electrophysiological
and electroanatomic mapping in humans.
Circulation.
2003;
108
1461-1468
- 31
Shinebane J S, Wood M A, Jensen D N, Ellenbogen K A, Fitzpatrick A P, Scheinman M M.
Tachycardia-induced cardiomyopathy: A review of animal models and clinical studies.
J Am Coll Cardiol.
1997;
29
709-715
- 32
Sinha A M, Filzmaier K, Breithardt O A. et al .
Usefulness of brain natriuretic peptide release as a surrogate marker of the efficacy
of long-term cardiac resynchronization therapy in patients with heart failure.
Am J Cardiol.
2003;
91
755-758
- 33
Steinberg J S.
Desperately seeking a randomized clinical trial of resynchronization therapy for patients
with heart failure and atrial fibrillation.
J Am Coll Cardiol.
2006;
48
744-746
- 34
Swedberg K, Olsson L G, Charlesworth A. et al .
Prognostic relevance of atrial fibrillation in patients with chronic heart failure
on long-term treatment with beta-blockers: results from COMET.
Eur Heart J.
2005;
26
1303-1308
- 35
Sweeney M O, Hellkamp A S, Ellenbogen K A. et al .
Adverse effect of ventricular pacing on heart failure and atrial fibrillation among
patients with normal baseline QRS duration in a clinical trial of pacemaker therapy
for sinus node dysfunction.
Circulation.
2003;
107
2932-2937
- 36
Takemoto M, Sakamoto M, Kawagoe J. et al .
Effect of biventricular pacing therapy in patients with dilated cardiomyopathy with
severe congestive heart failure.
Jpn J Thorac Cardiovasc Surg.
2004;
52
175-1780
- 37
Toff W D, Camm A J, Skehan J D.
Single-chamber versus dual-chamber pacing for high-grade atrioventricular block.
N Engl J Med.
2005;
353
145-155
- 38
Wang T J, Larson M G, Levy D. et al .
Temporal relations of atrial fibrillation and congestive heart failure and their joint
influence on mortality: the Framingham Heart Study.
Circulation.
2003;
107
2920-2925
- 39
Wood M A, Brown-Mahoney C, Kay G N, Ellenbogen K A.
Clinical outcomes after ablation and pacing therapy for atrial fibrillation : a meta-analysis.
Circulation.
2000;
101
1138-1144
- 40
Young J B, Abraham W T, Smith A L. et al .
Combined cardiac resynchronization and implantable cardioversion defibrillation in
advanced chronic heart failure: the MIRACLE ICD Trial.
JAMA.
2003;
289
2685-2694
Prof. Dr. med. Uta C. Hoppe
Klinik III für Innere Medizin der Universität zu Köln
Kerpener Straße 62
50937 Köln
Phone: 0221/4785059
Fax: 0221/4787929
Email: Uta.Hoppe@uni-koeln.de
