Intensivmedizin und Notfallmedizin

, Volume 48, Issue 4, pp 259–263 | Cite as

Therapie des nichtinfarktbedingten kardiogenen Schocks

Leitthema

Zusammenfassung

Eine Klappendysfunktion ist ebenso häufig Ursache für eine akut dekompensierte Herzinsuffizienz wie ein akutes koronares Syndrom. Therapierichtlinien und Studien zur Behandlung des nichtinfarktbedingten kardiogen Schocks sind aber rar. Neben der konventionellen Inotropika- und Vasopressorentherapie wurden therapeutische Alternativen [z. B. Ballonvalvuloplastie und ventrikuläre Assist-Systeme (VAD) bei Aortenklappenstenose und bei fulminanter Myokarditis] entwickelt, sodass insbesondere pharmakologische Therapiegrenzen (Vasopressoren-, Inotropikaobergrenzen) kritisch hinterfragt werden müssen. Diese Therapien sind bei Klappendysfunktion und Schock als „Bridging“ bis zur Operation zu sehen, ist doch der Klappenersatz bzw. die -rekonstruktion der anzustrebende Goldstandard bei diesen Erkrankungen. Bei akut fulminanter Myokarditis stellen VAD als „bridge to transplantation“ oder auch als „bridge to recovery“ therapeutische Alternativen dar. Neue Inotropika wie Istaroxime oder „cardiac myosin activators“ oder der transaortale Klappenersatz bedürfen noch eingehender klinischer Evaluierung bevor ihr Einsatz im nichtinfarktbedingten kardiogenen Schock diskutiert werden kann.

Schlüsselwörter

Klappendysfunktion Myokarditis Inotropika Klappenersatz Herzschrittmacher 

Treatment of noninfarct-related cardiogenic shock

Abstract

Valvular dysfunction is as frequent as acute coronary syndromes in the pathogenesis of acute decompensated heart failure. Guidelines and studies for the treatment of noninfarct-related cardiogenic shock are, however, scarce. A number of therapeutic alternatives to standard inotrope and vasopressor therapy were developed, e.g. balloon valvuloplasty and ventricular assist devices (VAD) in patients with severe aortic valve stenosis, and VAD in patients with fulminant myocarditis. Given these therapeutic alternatives, upper limits for vasopressor therapy in noninfarct-related cardiogenic shock are more questionable than ever. Nevertheless, they are to be considered as a “bridge to operation” in case of shock due to valvular dysfunction since valve repair/replacement are still the gold standard in this situation but are not always possible in the acute setting. In case of acute fulminant myocarditis, VAD have to be considered as a “bridge to transplantation” or as a “bridge to recovery.” New inotropes like istaroxime or cardiac myosin activators, and transaortic valve implantation require further clinical investigations until their use can be discussed in patients with cardiogenic shock.

Keywords

Valvular dysfunction Myocarditis Inotropic agents, positive cardiac Valvuloplasty Heart-assist devices 

Notes

Interessenkonflikt

Der korrespondierende Autor weist auf folgende Beziehungen hin: Der Autor hat in den letzten drei Jahren Vorträge für die Firmen Abbott und Orion-Pharma gehalten.

Literatur

  1. 1.
    Hochman JS, Sleeper LA, Webb JG et al (1999) Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should we emergently revascularize occluded coronaries for cardiogenic shock. N Engl J Med 341:625–634PubMedCrossRefGoogle Scholar
  2. 2.
    Hochman JS, Buller CE, Sleeper LA et al (2000) Cardiogenic shock complicating acute myocardial infarction – etiologies, management and outcome: a report from the SHOCK Trial Registry. Should we emergently revascularize occluded coronaries for cardiogenic shocK? J Am Coll Cardiol 36:1063–1070PubMedCrossRefGoogle Scholar
  3. 3.
    Nieminen MS, Harjola VP, Hochadel M et al (2008) Gender related differences in patients presenting with acute heart failure. Results from EuroHeart Failure Survey II. Eur J Heart Fail 10:140–148PubMedCrossRefGoogle Scholar
  4. 4.
    Cotter G, Moshkovitz Y, Milovanov O et al (2002) Acute heart failure: a novel approach to its pathogenesis and treatment. Eur J Heart Fail 4:227–234PubMedCrossRefGoogle Scholar
  5. 5.
    Dickstein K, Cohen-Solal A, Filippatos G et al (2008) ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur J Heart Fail 10:933–989PubMedCrossRefGoogle Scholar
  6. 6.
    Antman EM, Anbe DT, Armstrong PW et al (2004) ACC/AHA Guidelines for the Management of Patients with ST-elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction). Circulation 110:e82–e292PubMedCrossRefGoogle Scholar
  7. 7.
    De Backer D, Biston P, Devriendt J et al (2010) Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med 362:779–789CrossRefGoogle Scholar
  8. 8.
    Duranteau J, Sitbon P, Teboul JL et al (1999) Effects of epinephrine, norepinephrine, or the combination of norepinephrine and dobutamine on gastric mucosa in septic shock. Crit Care Med 27:893–900PubMedCrossRefGoogle Scholar
  9. 9.
    Annane D, Vignon P, Renault A et al (2007) Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: a randomised trial. Lancet 370:676–684PubMedCrossRefGoogle Scholar
  10. 10.
    Myburgh JA, Higgins A, Jovanovska A et al (2008) A comparison of epinephrine and norepinephrine in critically ill patients. Intensive Care Med 34:2226–2234PubMedCrossRefGoogle Scholar
  11. 11.
    Alexander JH, Reynolds HR, Stebbins AL et al (2007) Effect of tilarginine acetate in patients with acute myocardial infarction and cardiogenic shock: the TRIUMPH randomized controlled trial. JAMA 297:1657–1666PubMedCrossRefGoogle Scholar
  12. 12.
    Thompson CR, Buller CE, Sleeper LA et al (2000) Cardiogenic shock due to acute severe mitral regurgitation complicating acute myocardial infarction: a report from the SHOCK Trial Registry. Should we emergently revascularize occluded coronaries in cardiogenic shock? J Am Coll Cardiol 36:1104–1109PubMedCrossRefGoogle Scholar
  13. 13.
    Khot UN, Novaro GM, Popovic ZB et al (2003) Nitroprusside in critically ill patients with left ventricular dysfunction and aortic stenosis. N Engl J Med 348:1756–1763PubMedCrossRefGoogle Scholar
  14. 14.
    Folland ED, Kemper AJ, Khuri SF et al (1985) Intraaortic balloon counterpulsation as a temporary support measure in decompensated critical aortic stenosis. J Am Coll Cardiol 5:711–716PubMedCrossRefGoogle Scholar
  15. 15.
    Gu YL, Jessurun GA, Merkhof LF van den, Zijlstra F (2007) Intra-aortic balloon counterpulsation for complex aortic stenosis in hybrid strategy. Int J Cardiol 117:e46–e48PubMedCrossRefGoogle Scholar
  16. 16.
    Aksoy O, Yousefzai R, Singh D et al (2010) Cardiogenic shock in the setting of severe aortic stenosis: role for intra-aortic balloon pump support. Heart Oct 20 (epub ahead of print)Google Scholar
  17. 17.
    Loebe M, Zade Asfahani WH, Petrov GP et al (2009) Surgical considerations on the use of the percutaneous ventricular assist device TandemHeart in critical aortic valve stenosis. Thorac Cardiovasc Surg 57:50–52PubMedCrossRefGoogle Scholar
  18. 18.
    Frank CM, Palanichamy N, Kar B et al (2006) Use of a percutaneous ventricular assist device for treatment of cardiogenic shock due to critical aortic stenosis. Tex Heart Inst J 33:487–489PubMedGoogle Scholar
  19. 19.
    Hamid T, Eichhofer J, Clarke B, Mahadevan VS (2010) Aortic balloon valvuloplasty: is there still a role in high-risk patients in the era of percutaneous aortic valve replacement? J Interv Cardiol 23:358–361PubMedCrossRefGoogle Scholar
  20. 20.
    Doguet F, Godin M, Lebreton G et al (2010) Aortic valve replacement after percutaneous valvuloplasty – an approach in otherwise inoperable patients. Eur J Cardiothorac Surg 38:394–399PubMedCrossRefGoogle Scholar
  21. 21.
    Chatterjee K, Parmley WW, Swan HJ et al (1973) Beneficial effects of vasodilator agents in severe mitral regurgitation due to dysfunction of subvalvar apparatus. Circulation 48:684–690PubMedGoogle Scholar
  22. 22.
    Heuser RR, Maddoux GL, Goss JE et al (1987) Coronary angioplasty for acute mitral regurgitation due to myocardial infarction. A nonsurgical treatment preserving mitral valve integrity. Ann Intern Med 107:852–855PubMedGoogle Scholar
  23. 23.
    Shawl FA, Forman MB, Punja S, Goldbaum TS (1989) Emergent coronary angioplasty in the treatment of acute ischemic mitral regurgitation: long-term results in five cases. J Am Coll Cardiol 14:986–991PubMedCrossRefGoogle Scholar
  24. 24.
    Bonow RO, Carabello BA, Chatterjee K et al (2008) Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 52:e1–e142PubMedCrossRefGoogle Scholar
  25. 25.
    Hoefer D, Jonetzko P, Hoermann C et al (2006) Successful administration of levosimendan in a patient with low-gradient low-output aortic stenosis. Wien Klin Wochenschr 118:60–62PubMedCrossRefGoogle Scholar
  26. 26.
    Olimulder MA, Es J van, Galjee MA (2009) The importance of cardiac MRI as a diagnostic tool in viral myocarditis-induced cardiomyopathy. Neth Heart J 17:481–486PubMedCrossRefGoogle Scholar
  27. 27.
    Dennert R, Crijns HJ, Heymans S (2008) Acute viral myocarditis. Eur Heart J 29:2073–2082PubMedCrossRefGoogle Scholar
  28. 28.
    Poelzl G, Frick M, Antretter H et al (2006) Interventional and medical treatment of acute heart failure due to inflammation: four cases. Herz 31:761–766PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  1. 1.3. Medizinische Abteilung mit Kardiologie und interner NotaufnahmeWilhelminenspitalWienÖsterreich

Personalised recommendations