Zusammenfassung
Mechanische Linksherzunterstützungssysteme haben sich zu einer bedeutenden Option
für die Therapie der terminalen Herzinsuffizienz entwickelt. Leider weist die Kunstherzimplantation
nach wie vor eine erhebliche perioperative Morbiditäts- und Sterblichkeitsrate auf.
Als wichtigste Komplikationen sind zu nennen: Rechtsherzversagen, Blutung, Infektionen
und technische Probleme. Die vorliegende Übersicht fasst aktuelle Strategien zur Einschätzung
des perioperativen Risikos und zur Prävention bzw. Therapie von typischen postoperativen
Komplikationen zusammen.
Abstract
Left ventricular assist devices (LVAD) have become an important option for the treatment
of patients with advanced heart failure. Unfortunately, patients undergoing LVAD-implantation
still experience considerable perioperative morbidity and mortality. Right ventricular
failure, bleeding, infections and device-associated problems represent the major postoperative
complications. The present overview summarizes current strategies for preoperative
risk estimation and for the prevention and treatment of frequently occurring perioperative
complications.
Schlüsselwörter:
Kunstherz - Rechtsherzversagen - Herzinsuffizienz - Blutung - Thrombose
Key words:
left ventricular assist device - right ventricular failure - heart failure - postoperative
bleeding - thrombosis
Kernaussagen
-
LVAD-Implantationen sollten in einem frühen Stadium der terminalen Herzinsuffizienz
und elektiv erfolgen. Zur Abschätzung des individuellen perioperativen Risikos für
den Patienten stehen die INTERMACS-Profile sowie der Risiko-Score nach Lietz und Miller
zur Verfügung.
-
Eine besondere Bedeutung kommt der Prophylaxe und Therapie des Rechtsherzversagens
zu, da dieses einen entscheidenden Einfluss auf das postoperative Outcome der Patienten
hat.
-
Postoperativ muss bei VAD-Patienten die Thrombozytenzahl zumindest während der Heparintherapie
engmaschig überwacht werden.
-
Bei klinisch anderweitig nicht erklärlichem Abfall und/oder fehlender Erholung der
Thrombozytenzahl und/oder dem Auftreten von Thrombosen muss eine HIT-Diagnostik initiiert
werden.
-
Bei begründetem Verdacht auf Vorliegen oder beim Nachweis einer HIT muss die Heparinzufuhr
umgehend gestoppt und auf alternative Substanzen zur systemischen Antikoagulation
gewechselt werden, wie z. B. Argatroban oder Lepirudin.
-
Um Infektionen zu vermeiden, ist auf strikte Asepsis beim Verbandswechsel sowie eine
Immobilisierung der Driveline zu achten.
Literatur
- 1
Wilson SR, Mudge Jr. GH, Stewart GC et al..
Evaluation for a ventricular assist device: selecting the appropriate candidate.
Circulation.
2009;
119
2225-2232
- 2
Kirklin JK, Naftel DC, Stevenson LW et al..
INTERMACS database for durable devices for circulatory support: first annual report.
J Heart Lung Transplant.
2008;
27
1065-1072
- 3
Kirklin JK, Naftel DC, Kormos RL et al..
Second INTERMACS annual report: more than 1000 primary left ventricular assist device
implants.
J Heart Lung Transplant.
2010;
29
1-10
- 4
Lietz K, Long JW, Kfoury AG et al..
Outcomes of left ventricular assist device implantation as destination therapy in
the post-REMATCH era: implications for patient selection.
Circulation.
2007;
116
497-505
- 5
Sidebotham D, McGeorge A, McGuinness S et al..
Extracorporeal membrane oxygenation for treating severe cardiac and respiratory failure
in adults: part 2 – technical considerations.
J Cardiothorac Vasc Anesth.
2010;
24
164-172
- 6
Sidebotham D, McGeorge A, McGuinness S et al..
Extracorporeal membrane oxygenation for treating severe cardiac and respiratory disease
in adults: part 1 – overview of extracorporeal membrane oxygenation.
J Cardiothorac Vasc Anesth.
2009;
23
886-892
- 7
Hernandez AF, Grab JD, Gammie JS et al..
A decade of short-term outcomes in post cardiac surgery ventricular assist device
implantation: data from the Society of Thoracic Surgeons' National Cardiac Database.
Circulation.
2007;
116
606-612
- 8
Slaughter MS, Pagani FD, Rogers JG et al..
Clinical management of continuous-flow left ventricular assist devices in advanced
heart failure.
J Heart Lung Transplant.
2010;
29
1-39
- 9
Frazier OH, Myers TJ, Gregoric ID et al..
Initial clinical experience with the Jarvik 2000 implantable axial-flow left ventricular
assist system.
Circulation.
2002;
105
2855-2860
- 10
Slaughter MS, Rogers JG, Milano CA et al..
Advanced heart failure treated with continuous-flow left ventricular assist device.
N Engl J Med.
2009;
361
2241-2251
- 11
Pitsis AA, Visouli AN.
Update on ventricular assist device management in the ICU.
Curr Opin Crit Care.
2008;
14
569-578
- 12
Slaughter MS, Naka Y, John R et al..
Post-operative heparin may not be required for transitioning patients with a HeartMate
II left ventricular assist system to long-term warfarin therapy.
J Heart Lung Transplant.
2010;
29
616-624
- 13
Schenk S, El-Banayosy A, Prohaska W et al..
Heparin-induced thrombocytopenia in patients receiving mechanical circulatory support.
J Thorac Cardiovasc Surg.
2006;
131
1373-1381
- 14
Schenk S, El-Banayosy A, Morshuis M et al..
IgG classification of anti-PF4/heparin antibodies to identify patients with heparin-induced
thrombocytopenia during mechanical circulatory support.
J Thromb Haemost.
2007;
5
235-241
- 15
Koster A, Huebler S, Potapov E et al..
Impact of heparin-induced thrombocytopenia on outcome in patients with ventricular
assist device support: single-institution experience in 358 consecutive patients.
Ann Thorac Surg.
2007;
83
72-76
- 16
Warkentin TE, Greinacher A, Koster A.
Heparin-induced thrombocytopenia in patients with ventricular assist devices: are
new prevention strategies required?.
Ann Thorac Surg.
2009;
87
1633-1640
- 17
Matthews JC, Koelling TM, Pagani FD et al..
The right ventricular failure risk score a pre-operative tool for assessing the risk
of right ventricular failure in left ventricular assist device candidates.
J Am Coll Cardiol.
2008;
51
2163-2172
- 18
Morgan JA, John R, Lee BJ et al..
Is severe right ventricular failure in left ventricular assist device recipients a
risk factor for unsuccessful bridging to transplant and post-transplant mortality.
Ann Thorac Surg.
2004;
77
859-863
- 19
Patel ND, Weiss ES, Schaffer J et al..
Right heart dysfunction after left ventricular assist device implantation: a comparison
of the pulsatile HeartMate I and axial-flow HeartMate II devices.
Ann Thorac Surg.
2008;
86
832-840
- 20
Drakos SG, Janicki L, Horne BD et al..
Risk factors predictive of right ventricular failure after left ventricular assist
device implantation.
Am J Cardiol.
2010;
105
1030-1035
- 21
Chumnanvej S, Wood MJ, MacGillivray TE et al..
Perioperative echocardiographic examination for ventricular assist device implantation.
Anesth Analg.
2007;
105
583-601
- 22
Germann P, Braschi A, Della RG et al..
Inhaled nitric oxide therapy in adults: European expert recommendations.
Intensive Care Med.
2005;
31
1029-1041
- 23
Winterhalter M, Fischer S, Tessmann R et al..
Using inhaled iloprost to wean from cardiopulmonary bypass after implanting a left
ventricular assist device.
Anesth Analg.
2006;
103
515-516
- 24
Rex S, Missant C, Claus P et al..
Effects of inhaled iloprost on right ventricular contractility, right ventriculo-vascular
coupling and ventricular interdependence: a randomized placebo-controlled trial in
an experimental model of acute pulmonary hypertension.
Crit Care.
2008;
12
- 25
Rex S, Schaelte G, Metzelder S et al..
Inhaled iloprost to control pulmonary artery hypertension in patients undergoing mitral
valve surgery: a prospective, randomized-controlled trial.
Acta Anaesthesiol Scand.
2008;
52
65-72
- 26
Vlahakes GJ, Turley K, Hoffman JI.
The pathophysiology of failure in acute right ventricular hypertension: hemodynamic
and biochemical correlations.
Circulation.
1981;
63
87-95
- 27
Mebazaa A, Pitsis AA, Rudiger A et al..
Clinical review: practical recommendations on the management of perioperative heart
failure in cardiac surgery.
Crit Care.
2010;
14
201
- 28
Missant C, Rex S, Segers P et al..
Levosimendan improves right ventriculovascular coupling in a porcine model of right
ventricular dysfunction.
Crit Care Med.
2007;
35
707-715
- 29
Santamore WP, Gray Jr. L.
Significant left ventricular contributions to right ventricular systolic function.
Mechanism and clinical implications.
Chest.
1995;
107
1134-1145
- 30
Jahanyar J, Noon GP, Koerner MM et al..
Recurrent device thrombi during mechanical circulatory support with an axial-flow
pump is a treatable condition and does not preclude successful long-term support.
J Heart Lung Transplant.
2007;
26
200-203
- 31
Chinn R, Dembitsky W, Eaton L et al..
Multicenter experience: prevention and management of left ventricular assist device
infections.
ASAIO J.
2005;
51
461-470
- 32
Rose EA, Gelijns AC, Moskowitz AJ et al..
Long-term use of a left ventricular assist device for end-stage heart failure.
N Engl J Med.
2001;
345
1435-1443
- 33
Kapur NK, Conte JV, Resar JR.
Percutaneous closure of patent foramen ovale for refractory hypoxemia after HeartMate
II left ventricular assist device placement.
J Invasive Cardiol.
2007;
19
PD Dr. med. Steffen Rex
Email: srex@ukaachen.de