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Stellenwert der koronaren Bypass operation in der Therapie der akuten Koronarsyndrome

Coronary Artery Bypass Surgery for the Treatment of Acute Coronary Syndromes

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Zusammenfassung

Die Koronarrevaskularisation des akuten Koronarsyndroms basiert aufgrund ihrer unmittelbaren Verfügbarkeit primär auf katheterinterventionellen Verfahren (PCI). Daneben ergeben sich jedoch bei komplexen Koronarbefunden, erfolgloser PCI, PCI mit Komplikationen oder im kardiogenen Schock auch Indikationen zur dringlichen oder notfallmäßigen koronarchirurgischen Bypassversorgung. Der Zeitpunkt der Operation richtet sich dabei ganz wesentlich nach dem Beschwerdebild des Patienten, der Koronarpathologie und der Form des akuten Koronarsyndroms. Herzchirurgische Optionen beinhalten im akuten Koronarsyndrom u.a. den Einsatz minimalinvasiver Operationsverfahren mit Durchführung des Eingriffs am schlagenden Herzen. Ein differenziertes perioperatives Management ermöglicht zudem die erfolgreiche Behandlung immer älter werdender, komorbider Patienten und schließt beim kardiogenen Schock auch die Verwendung kreislaufunterstützender Assistenzsysteme ein.

Die in der Literatur berichteten Frühergebnisse der koronaren Bypassoperation beim akuten Koronarsyndrom schwanken sehr in Abhängigkeit von den eingeschlossenen Patientenkollektiven, der Dringlichkeit und der hämodynamischen Stabilität. Sie sind somit nur begrenzt vergleichbar, wobei aber Hospitalüberlebensraten von > 95% erreicht werden. Eine frühzeitige und enge Kommunikation zwischen Interventionalist und Herzchirurg stellt dabei eine wesentliche Voraussetzung dar, um ein individuelles Revaskularisations- und Behandlungskonzept für den jeweiligen Patienten optimal umzusetzen.

Abstract

According to the current guidelines coronary revascularization in acute coronary syndromes (ACS) is primarily performed by percutaneous coronary interventions (PCI). However, in several scenarios like complex coronary pathologies, unsuccessful PCI, complicated PCI or cardiogenic shock, surgical coronary revascularization might be indicated. Then, timing of the operation is based on clinical symptoms, coronary artery pathology, and the type of underlying ACS (Figure 1). Surgical strategies among others include the use of beating-heart strategies. Furthermore, a modern perioperative management allows improved results in a more aged and comorbid patient population as well as in patients presenting with hemodynamic instability. In cardiogenic shock, a variety of different cardiopulmonary assist devices are available today including intra-aortic balloon pump, several ventricular assist devices, and extracorporeal membrane oxygenation (Figure 2).

In the literature, results of coronary artery bypass grafting (CABG) in ACS patients vary significantly because of different patient populations, different timing of the operation, and different hemodynamic status. Thus, comparison of surgical concepts is almost impossible. Until today, randomized surgical trials for ACS patients are pending. However, hospital survival of > 95% is reported even in emergency CABG patients during the last 5 years (Table 1). For all surgical candidates a close and direct communication between interventionalist and cardiac surgeon is mandatory to early identify the best treatment strategy and to achieve best possible revascularization results.

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Authors and Affiliations

  1. Klinik für Herzchirurgie, Universität Leipzig, Herzzentrum Leipzig, Leipzig, Germany

    Ardawan Julian Rastan & Friedrich Wilhelm Mohr

  2. Klinik für Kardiologie, Universität Leipzig, Herzzentrum Leipzig, Leipzig, Germany

    Holger Thiele & Gerhard Schuler

  3. Klinik für Herzchirurgie, Universität Leipzig, Herzzentrum Leipzig, Strümpellstraße 39, 04289, Leipzig, Germany

    Ardawan Julian Rastan

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  1. Ardawan Julian Rastan
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Correspondence to Ardawan Julian Rastan.

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Rastan, A.J., Thiele, H., Schuler, G. et al. Stellenwert der koronaren Bypass operation in der Therapie der akuten Koronarsyndrome. Herz 35, 70–78 (2010). https://doi.org/10.1007/s00059-010-3327-1

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