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Patientenauswahl für die Implantation eines Vorhofohr-Okkluders in der Primär- und Sekundärprävention des kardioembolischen Schlaganfalls bei Vorhofflimmern


Patient selection for the Implantation of a left atrial appendage occluder in primary and secondary prevention of cardioembolic stroke in atrial fibrillation


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Zusammenfassung

In der Prävention des kardioembolischen Schlaganfalls bei Patienten mit Vorhofflimmern hat sich neben Antikoagulanzien der Vorhofohr-Okkluder als nicht pharmakologisches Therapieprinzip etabliert. In zwei randomisierten Studien als Alternative zur oralen Antikoagulation untersucht, wird er in den Leitlinien für Patienten mit einer Kontraindikation für eine dauerhafte Antikoagulation empfohlen. Dies entspricht der klinischen Praxis, in der ein Vorhofohr-Okkluder meist implantiert wird, wenn eine Antikoagulation wegen Kontraindikationen beendet oder gar nicht begonnen wurde. Für einen Vorhofohr-Okkluder erscheinen besonders Patienten geeignet, die gleichzeitig ein hohes Blutungs- und thromboembolisches Risiko aufweisen. Daneben stellt der Vorhofohr-Okkluder nach ausreichender Aufklärung eine Option für Patienten dar, die eine orale Antikoagulation ablehnen. Da einem großen Teil der Patienten mit einer Indikation zur Antikoagulation diese wegen Kontraindikationen oder aus Angst vor Blutungen vorenthalten wird und im Lauf von nur 2 Jahren mehr als die Hälfte der Patienten eine orale Antikoagulation beenden muss, kommt dem Vorhofohr-Okkluder in der Langzeitprophylaxe eines kardioembolischen Schlaganfalls bei Vorhofflimmern möglicherweise eine hohe Bedeutung zu.

Abstract

The implantation of a left atrial appendage (LAA) occluder has evolved into an established non-pharmacological alternative to oral anticoagulation (OAC) in the prevention of cardioembolic stroke in patients with atrial fibrillation. While 2 randomized trials investigated the LAA occluder as an alternative treatment in patients who can also undergo OAC, current guidelines recommend the LAA occluder rather as a second line therapy if permanent OAC is not possible due to contraindications. This is in line with current practice where an LAA occluder is usually only implanted if OAC is contraindicated or stopped due to bleeding. The LAA occluder seems most promising for patients with a high risk for both, stroke without OAC and severe bleeding with OAC. After patient informed consent, the LAA occluder may also represent an option for patients who are unwilling to undergo OAC. Since a large proportion of patients do not receive OAC despite an indication (because of contraindications or mere fear of bleeding) and since the majority of patients have to stop OAC during the course of 2 years, mostly due to bleeding, the LAA occluder may play an important role in the long-term prophylaxis of cardioembolic stroke due to atrial fibrillation.

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  1. Klinik für Innere Medizin – Kardiologie, Diabetologie und Nephrologie, Evangelisches Krankenhaus Bielefeld, Burgsteig 13, 33617, Bielefeld, Deutschland

    C. W. Israel, D. Ridjab, W. N. Tschishow & J. Buddecke

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Israel, . ., Ridjab, D., Tschishow, W. . et al. Patientenauswahl für die Implantation eines Vorhofohr-Okkluders in der Primär- und Sekundärprävention des kardioembolischen Schlaganfalls bei Vorhofflimmern
. Herzschr Elektrophys 24, 25–32 (2013). https://doi.org/10.1007/s00399-013-0266-6

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