Zusammenfassung
Die Therapie von Herzrhythmusstörungen bei erwachsenen Patienten mit angeborenen Herzfehlern (EMAH) hat in den letzten Jahrzehnten einen deutlichen Wandel von einem konservativen, medikamentös geprägten Vorgehen hin zu interventionellen Verfahren wie der Katheterablation oder der Device-Implantation (Schrittmacher, Kardioverter-Defibrillator) erfahren. Der Langzeiterfolg der therapeutischen Maßnahmen ist sowohl vom hämodynamischen Status des Patienten und der Art der Herzrhythmusstörung abhängig als auch vom zugrunde liegenden Vitium und den durchgeführten operativen Eingriffen. In der Therapie tachykarder Rhythmusstörungen stehen akut medikamentöse Maßnahmen und die elektrische Kardioversion im Vordergrund. Zu beachten sind sowohl akut als auch im Langzeitmanagement Maßnahmen zur individualisierten Thrombembolieprophylaxe. Bei supraventrikulären Tachykardien erscheint im Langzeitverlauf die Katheterablation als kurativer Ansatz einer medikamentösen Therapie überlegen. Auch operative Maßnahmen mit Rhythmuschirurgie (z. B. die Fontan-Konversionsoperation) können eine Verbesserung der rhythmologischen Situation erreichen. Bei symptomatischen bradykarden Herzrhythmusstörungen (z. B. Sinusknotendysfunktion) ist i. d. R. eine Schrittmacherimplantation indiziert. Im Management ventrikulärer Tachykardien wird die Katheterablation ebenfalls zunehmend eingesetzt. Hier ist v. a. die individuelle Risikostratifizierung zur Prophylaxe des plötzlichen Herztods von Bedeutung, wobei noch immer die Implantation eines Kardioverter-Defibrillators in der überwiegenden Zahl der Fälle die Therapie der Wahl darstellt. Die Behandlung von Herzrhythmusstörungen bei EMAH-Patienten sollte in einem spezialisierten Zentrum erfolgen, das alle Aspekte der Diagnostik und Therapie abdecken kann.
Abstract
During the last few decades, the management of cardiac arrhythmias in adult patients with congenital heart disease (CHD) has undergone a significant change from a conservative, mainly pharmacological approach, to interventional techniques such as catheter ablation or device implantation (pacemakers, implantable cardioverter defibrillators [ICD]). The long-term efficacy of these strategies is as dependent on the hemodynamic status of the patient and the type of arrhythmia as it is on the underlying heart defect and any preceding surgery. Pharmacological agents and electrical cardioversion are at the forefront of treatment for tachyarrhythmias. Individualized thromboprophylaxis plays an important role in acute and in long-term management. Catheter ablation seems to show a more favorable outcome compared with a pharmacological approach in the long-term management of supraventricular tachyarrhythmias. Surgical procedures, including arrhythmia surgery (such as the Fontan conversion operation), may improve the arrhythmia. In symptomatic patients with bradyarrhythmias, such as sinus node dysfunction, pacemaker implantation is usually indicated. In the management of ventricular arrhythmias catheter ablation is also increasingly used. This is dominated by the individual risk stratification for the prevention of sudden cardiac death (SCD). However, the ICD is still the therapeutic cornerstone in most cases. The management of cardiac arrhythmias in adult CHD patients should be performed at specialized centers where all aspects of diagnosis and treatment are covered.
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Hessling, G. Herzrhythmusstörungen bei Erwachsenen mit angeborenem Herzfehler. Herzschr Elektrophys 27, 81–87 (2016). https://doi.org/10.1007/s00399-016-0430-x
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DOI: https://doi.org/10.1007/s00399-016-0430-x