Echokardiografie – Echokardiografie als Monitoring auf der Intensivstation?

Zusammenfassung

Eine zielgerichtete Therapie mittels Volumensubstitution und/oder Herzkreislauf-wirksamen Medikamenten zur Erhöhung des Schlagvolumens und damit der Gewebeoxygenierung kann perioperative Komplikationen verringern. Bisherige hämodynamischeMonitoringverfahrenkönnen allerdings häufig nur die Einschränkung verschiedener kardiovaskulärer Funktionsparameter messen,ein Rückschlussauf die pathophysiologische Ursache der Einschränkung ist nicht immer unmittelbar möglich. Diese ist jedoch für eine zielgerichtete hämodynamische Optimierung unabdingbar. In diesem Rahmen gewinnt die diskontinuierliche transthorakale (TTE) und –ösophageale multiplane (TEE) Echokardiografie zunehmend an Bedeutung. Zudem besteht neuerdings die Möglichkeit, eine kontinuierliche,hämodynamisch fokussierte,transösophageale Echokardiographie („hämodynamische TEE“, hTEE) mittels einer miniaturisierten, monoplanen Sonde durchzuführen. Mit dieser Sonde ist es möglich, die 3 wichtigsten Schnittbilder zur Differenzierung verschiedener kardialer Pathologien einzustellen. Sie wird oral in die Speiseröhre eingeführt und kann bis zu 72 Stunden im Patienten verbleiben. Erste klinische Erfahrungsberichte/Studien konnten zeigen, dass zur Durchführung einer solchen fokussierten Untersuchung ein kurzes intensiviertes Trainingsprogramm selbst bei Echokardiographie unerfahrenen Ärzten ausreicht, um eine adäquate zielgerichtete Therapie zu initiieren. Weitere Studien müssen jedoch die klinische Anwendbarkeit überprüfen und einen positiven Effekt auf das Outcome der Patienten zeigen.

Abstract

A goal-directed hemodynamic therapy (GDT) using volume substitution and/or cardiovascular agents in order to increase stroke volume and consecutively tissue oxygenation has been shown to reduce perioperative complications. Previous hemodynamic monitoring devices mostly are only able to detect a restriction in several parameters of cardiovascular function not always diagnostically conclusive to their pathophysiological cause. However, this is mandatory for GDT. In this context, discontinuous transthoracic (TTE) and transesophageal (TEE) echocardiography is gaining clinical relevance. In addition, recently there exists the opportunity to perform a continuous hemodynamic focused transesophageal echocardiography (“hemodynamic TEE”, hTEE) via a miniaturized monoplane probe. With its flexible probe tip the three most important two-dimensional views of the heart can be obtained to differentiate between aforementioned pathophysiological causes of a low cardiac output syndrome. It is introduced orally in the patient's esophagus and can remain up to 72 hours in situ. First clinical reports/studies were able to demonstrate that a short intensive training programme for physicians unexperienced in echocardiographywas sufficient to adequately initiate GDT. However, further studies have to prove the clinical feasibility and the positive effect on patient's outcome.

Kernaussagen

• Die Grundlage einer zielgerichteten hämodynamischen Therapie ist die Sicherstellung des globalen O₂-Angebots an die Gewebe durch Optimierung der kardiovaskulären Funktion.

• Determinanten des Schlagvolumens: Vor- und Nachlast, intrinsische Kontraktilität, Herzfrequenz und -rhythmus sowie eine intakte Klappenfunktion.

• Eine kontinuierliche hTEE könnte einen zeitlichen und inhaltlichen Vorteil gegenüber invasiven Methoden wie z. B. dem PAK bedeuten, sodass rascher eine zielgerichtete hämodynamische Therapie begonnen werden kann.

• Zur Aufrechterhaltung eines ausreichenden Herzzeitvolumens ist ein adäquater Volumenstatus unabdingbar. Häufig sind die visuelle Abschätzung sowie die relativen Veränderungen echokardiografischer Parameter auf eine Volumengabe die entscheidenden Hinweise einer Volumenreagibilität. Als absolutes Hypovolämie-Zeichen gilt das Bild der „kissing papillary“.

• Ein valider Funktionsparameter zur Einschätzung der rechtsventrikulären Vorlast / Funktion fehlt bis heute. Daher sind aktuell die Diagnose und Therapie eines Rechtsherzversagens nur mittels echokardiografischer Parameter (z. B. RV-Dilatation, eingeschränkte systolische Funktion, paradoxe Septumbewegung) – v. a. im Vergleich mit dem präoperativen Ausgangsbefund – zu bewerkstelligen.

• Der transthorakale parasternale Kurzachsenblick bzw. der transgastrale mittpapilläre Querschnitt (TGSAX) erlauben eine schnelle orientierende Aussage zur globalen linksventrikulären systolischen Funktion („eye balling“).

• Wenn immer in der 2D-Echokardiografie der Verdacht auf ein hämodynamisch relevantes Vitium gestellt wird, sollte umgehend eine ausführliche Evaluation von einem zertifizierten Untersucher durchgeführt werden.

Schlüsselwörter

Echokardiografie - Monitoring - hTEE - zielgereichte hämodynamische Optimierung

Key words

Echocardiography - monitoring - hTEE - goal directed therapy

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