Gerinnungsmanagement in der Herzchirurgie

Aktuelle Strategien
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Zusammenfassung

Fragestellung

Demografischer Wandel und medizinischer Fortschritt haben eine Fülle komplexer kardiovaskulärer Behandlungsstrategien generiert. Besonders herausfordernd sind dabei der Umgang mit dualer Plättchenaggregationshemmung („platelet aggregation inhibition“, PI) sowie dem perioperativen Gerinnungs- und Blutproduktmanagement.

Ziel der Arbeit

Die gegenwärtigen Strategien werden auf dem Boden tatsächlich vorhandener Evidenz bewertet und praktische Handlungsvorschläge abgeleitet.

Material und Methoden

Die Literatur der letzten 10 Jahre zu den Themen: duale PI, „Point-of-care“-Gerinnungsmanagement („point-of-care testing“, POCT), intra- und postoperatives Management, Blut- und Blutprodukte, Sekundärprophylaxe, Implantation eines „left ventricular assist device“ (LVAD) und Extrakorporale-Membranoxygenierung(ECMO)-Unterstützung wurde mihilfe einer PubMed-Recherche gesichtet und der Evidenzgrad der gegenwärtig empfohlenen Therapieempfehlungen bestimmt.

Ergebnisse

Der Nutzen der dualen PI ist unbestritten, führt aber zu perioperativen Herausforderungen. Quantität sowie Qualität der Aggregationshemmung können mit POCT erfasst und für individuell optimierte Therapien genutzt werden. Eine anerkannte Behandlungsstrategie bei Patienten mit heparininduzierter Thrombozytopenie Typ II (HIT II) ist nach wie vor nicht vorhanden. Nur wenige medizin-technische Innovationen der extrakorporalen Zirkulation haben sich klinisch nachhaltig etabliert. Phenprocoumon bleibt nach Herzklappenersatz unerlässlich; für eine notwendige Unterbrechung existieren etablierte Substitutionsprotokolle. Sekundärprophylaxe nach Bypassoperation ist unverzichtbar. Bei der LVAD-Langzeit-Antikoagulationstherapie bestehen gute Ansätze hinsichtlich eines Gleichgewichts zwischen Blutungs- und Thromboembolierisiko.

Schlussfolgerung

Herzchirurgen tragen nach wie vor die Hauptverantwortung für die Behandlung. Kenntnisse der komplexen und sich häufig ändernden Problematik des Gerinnungsmanagements sind unerlässlich. Die Aktualisierung stellt aber aufgrund der enormen Diversität eine Herausforderung dar.

Schlüsselwörter

Gerinnung „Point-of-care“-Systeme Sekundärprophylaxe Antikoagulation „Assist device“ 

Coagulation management in cardiac surgery

Current strategies

Abstract

Background

Demographic changes and medical progress have resulted in a panoply of complex cardiovascular treatment modalities. Dealing with dual platelet aggregation inhibition (PI) as well as blood and blood product management is particularly challenging.

Aim

The current strategies are evaluated based on currently existing evidence from which practical clinical treatment modalities are derived.

Material and methods

A search was made in PubMed for publications in the last 10 years regarding dual PI, point of care coagulation management (POCT), intraoperative and postoperative management, blood and blood products, secondary prophylaxis, implantation of left ventricular assist devices (LVAD) and extracorporeal membrane oxygenation (ECMO) support. The level of evidence concerning current therapeutic recommendations was verified.

Results

Dual PI has clear benefits but also results in perioperative challenges. The quantity and quality of PI can be verified by POCT tools in order to derive individualized therapeutic strategies. A generally acknowledged recommendation for the intraoperative treatment of heparin-induced thrombocytopenia type II (HIT II) does not yet exist. Some technical innovations in extracorporeal circulation have gained widespread clinical use. Phenprocoumon remains indispensable after heart valve replacement. In cases of a necessary interruption established substitution protocols exist. Secondary prophylaxis after coronary artery bypass graft (CABG) is mandatory. For long-term anticoagulation therapy of LVADs promising approaches concerning equipoise between hemorrhagic and thromboembolic risks are ongoing.

Conclusion

As cardiac surgeons are still mainly responsible for treatment, good knowledge regarding the complex and frequently changing issue of coagulation management remains mandatory; however, in view of the enormous diversity, keeping pace with new developments is a challenge.

Keywords

Coagulation Point-of-care systems Secondary prophylaxis Anticoagulation Assist device 

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Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  1. 1.Abteilung für Herzchirurgie, Herzzentrum BrandenburgImmanuel Klinikum BernauBernauDeutschland

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