Zusammenfassung
Eine häufige und klinisch schwerwiegende Komplikation des Vorhofflimmerns stellt der kardioembolische zerebrale Gefäßverschluss dar. Ort dieser Emboliequelle ist in der Mehrzahl der Fälle das linke Vorhofohr. Durch einen chirurgischen Verschluss des linken Auriculums im Rahmen einer Ablationstherapie gelingt vermutlich eine Reduktion dieser Schlaganfälle. Als mögliche Therapie stehen unterschiedliche chirurgische Techniken zur Verfügung: die Exklusion durch Übernähung oder Knotenverschluss oder die Exzision mittels Schere oder Klammernaht. Alle genannten Techniken weisen ein gewisses Restrisiko in Bezug auf Rekanalisation, Wiedereröffnung, weiterhin bestehende Kommunikation mit dem linken Vorhof oder erneute Thrombenbildung auf. In Anbetracht der postoperativen Ergebnisse stellt die chirurgische Exzision die Therapie der Wahl zum Ausschluss des linken Vorhofohres dar. Ob dieser Eingriff tatsächlich zu einer Reduktion der Schlaganfallsrate, insbesondere bei Patienten mit Vorhofflimmerrezidiv nach Ablationstherapie, führt, muss anhand von großen, prospektiv randomisiert kontrollierten Studien untersucht werden.
Abstract
Cardiac embolisation in patients with atrial fibrillation accounts for the most serious complication of cerebral infarction. The left atrial appendage resembles the origin of these cardiac emboli in the majority of cases, although other anatomical areas of the left atrium might also be prerequisites for thrombus formation. Surgical closure of the left atrial appendage during an ablation therapy incorporates the theoretical possibility of reducing the rate of cardiac cerebral infarction. In order to achieve closure, different surgical strategies exist: either exclusion by over-sewing or snaring or excision by using scissors or a stapling device. All therapies incorporate pros and cons. One of the major complications and most feared side-effect is the recanalisation of a formerly closed left atrial appendage, especially in a thrombus filled left atrial appendage cavity. But also reopening of the formerly closed orificium and still existing remnants with communication to the left atrium might stand for an increased risk. Due to the good results of left atrial appendage excision, this surgical therapy at the moment presents the surgical gold standard, as this therapy is recommended in the updated ESC guidelines for the management of atrial fibrillation. If excision of the left atrial appendage will reduce the risk of cardiac embolisation needs to be examined in large prospective-randomized trials with a controlled systemic follow-up. So far, excision of the left atrial appendage as an alternative to oral anticoagulation, especially in patients with atrial fibrillation, is not recommended.
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Der korrespondierende Autor weist für sich und seine Koautoren auf folgende Beziehung/en hin: Dr. T. Weimar und Prof. Dr. N. Doll sind Consultants für AtriCure.
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Hanke, T., Sievers, HH., Doll, N. et al. Operative Verfahren zum Verschluss des linken Vorhofohrs bei Patienten mit Vorhofflimmern. Herzschr Elektrophys 24, 53–57 (2013). https://doi.org/10.1007/s00399-013-0249-7
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DOI: https://doi.org/10.1007/s00399-013-0249-7