Indikation zur kardialen Resynchronisation: Konsensus 2005

Article

Zusammenfassung

Die kardiale Resynchronisationstherapie (cardiac resynchronization therapy, CRT) mittels Implantation biventrikulärer Schrittmacher- bzw. ICD-Systeme erfordert eine differenzierte Indikationsstellung, um einerseits den Anteil von Patienten, bei denen diese Therapie eine signifikante symptomatische Verbesserung erreicht, zu optimieren und andererseits dieses invasive Therapieverfahren nicht bei Patienten einzusetzen, bei denen nur eine sehr geringe Aussicht auf einen klinischen Nutzen besteht. Als Konsensus 2005 kann formuliert werden, dass eine durch Studien abgesicherte Indikation zur CRT bei folgenden Patienten besteht: 1. NYHA-Stadium III sowie IV (falls eine Rekompensation in Stadium III zumindest kurzfristig möglich ist), 2. linksventrikuläre Ejektionsfraktion ≤35%, 3. QRS-Dauer >130 ms, vor allem bei Linksschenkelblock, 4. Sinusrhythmus. Darüber hinaus existieren relativ einheitliche Daten, dass Patienten mit Vorhofflimmern von der CRT profitieren können, sofern die anderen genannten Kriterien erfüllt sind. Unklar ist die Indikation derzeit für Patienten mit anderen Schenkelblockierungen (v. a. Rechtsschenkelblock). Für Patienten mit einer QRS-Dauer zwischen 120 und 130 ms scheint bei Linksschenkelblock ein Vorteil für die CRT zu bestehen, sofern echokardiographische Zeichen für eine ventrikuläre Dyssynchronie bestehen. Da die multiplen echokardiographischen Kriterien der ventrikulären Dyssynchronie noch wenig standardisiert und in Studien abgeklärt worden sind, kann eine alleinige Dyssynchronie bei schmalem QRS-Komplex (< 120 ms) derzeit noch nicht als etablierte CRT-Indikation betrachtet werden. Ähnliches gilt für das funktionelle Stadium NYHA II, für das die CRT-Indikation derzeit im Rahmen der RAFT- und MADIT-CRT-Studien abgeklärt wird.

Schlüsselwörter

Kardiale Resynchronisationstherapie biventrikuläre Stimulation Herzinsuffizienz Indikationen Linksschenkelblock 

Indication for cardiac resynchronization therapy: Consensus 2005

Summary

The indication for cardiac resynchronization therapy (CRT) using biventricular pacing or ICD systems has to be highly differentiated to optimize the proportion of patients who derive significant symptomatic benefit from this therapy, on the one hand, and to avoid this invasive treatment in patients with a low probability of clinical success of CRT, on the other hand. As a consensus in 2005, it can be put forward that there is sufficient evidence for an indication for CRT from clinical studies for the following characteristics: 1) Heart failure in NYHA functional class III or IV (if cardiac recompensation to class III is at least temporarily successful), 2) left ventricular ejection fraction ≤35%, 3) QRS duration >130 ms, particularly if left bundle branch block is present, 4) sinus rhythm. In addition, available data also suggest an indication for CRT in patients with atrial fibrillation if the other criteria listed above are met. The indication for CRT is unclear in patients with other intraventricular conduction delay (particularly right bundle branch block) while patients with left bundle branch block and a QRS duration of 120–130 ms seem to benefit if echocardiographic criteria demonstrate ventricular dyssynchrony. Since a multiplicity of echocardiographic criteria of ventricular dyssynchrony exists which is neither standardized nor evaluated in large-scale randomized trials, ventricular dyssynchrony on echocardiography alone cannot be regarded as an established indication for CRT without a QRS complex ≥120 ms. Similarly, whether heart failure in functional state NYHA II should be regarded as a CRT indication is currently being investigated in the randomized RAFT and MADIT-CRT trials.

Key words

Cardiac resynchronization therapy biventricular pacing heart failure indications left bundle branch block 

Literatur

  1. 1.
    Abraham WT (2000) Rationale and design of a randomized clinical trial to assess the safety and efficacy of cardiac resynchronization therapy in patients with advanced heart failure: the Multicenter InSync Randomized Clinical Evaluation (MIRACLE). J Card Fail 6:369–380PubMedGoogle Scholar
  2. 2.
    Abraham WT, Fisher WG, Smith AL, Delurgio DB, Leon AR, Loh E, Kocovic DZ, Packer M, Clavell AL, Hayes DL, Ellestad M, Trupp RJ, Underwood J, Pickering F, Truex C, McAtee P, Messenger J (2002) Cardiac resynchronization in chronic heart failure. N Engl J Med 346:1845–1853PubMedGoogle Scholar
  3. 3.
    Aranda JM Jr, Conti JB, Johnson JW, Petersen-Stejskal S, Curtis AB (2004) Cardiac resynchronization therapy in patients with heart failure and conduction abnormalities other than left bundle-branch block: analysis of the Multicenter InSync Randomized Clinical Evaluation (MIRACLE). Clin Cardiol 27:678–682PubMedGoogle Scholar
  4. 4.
    Auricchio A, Stellbrink C, Block M, Sack S, Vogt J, Bakker P, Klein H, Kramer A, Ding J, Salo R, Tockman B, Pochet T, Spinelli J (2002) Long-term clinical effect of hemodynamically optimized cardiac resynchronization therapy in patients with heart failure and ventricular conduction delay. J Am Coll Cardiol 39:2026–2033PubMedGoogle Scholar
  5. 5.
    Auricchio A, Stellbrink C, Block M, Sack S, Vogt J, Bakker P, Klein H, Kramer A, Ding J, Salo R, Tockman B, Pochet T, Spinelli J (1999) Effect of pacing chamber and atrioventricular delay on acute systolic function of paced patients with congestive heart failure. Circulation 99:2993–3001PubMedGoogle Scholar
  6. 6.
    Brecker SJ, Xiao HB, Sparrow J, Gibson DG (1992) Effects of dual-chamber pacing with short atrioventricular delay in dilated cardiomyopathy. Lancet 340:1308–1312CrossRefPubMedGoogle Scholar
  7. 7.
    Breithardt OA, Stellbrink C, Kramer AP, Sinha AM, Franke A, Salo R, Schiffgens B, Huvelle E, Auricchio A (2002) Echocardiographic quantification of left ventricular asynchrony predicts an acute hemodynamic benefit of cardiac resynchronization therapy. J Am Coll Cardiol 40:536–545CrossRefPubMedGoogle Scholar
  8. 8.
    Brignole M, Gammage M, Puggioni E, Alboni P, Raviele A, Sutton R, Vardas P, Bongiorni MG, Bergfeldt L, Menozzi C, Musso G (2005) Comparative assessment of right, left, and biventricular pacing in patients with permanent atrial fibrillation. Eur Heart J 26:712–722CrossRefPubMedGoogle Scholar
  9. 9.
    Bristow MR, Saxon LA, Boehmer J, Krueger S, Kass DA, De Marco T, Carson P, DiCarlo L, DeMets D, White BG, DeVries DW, Feldman AM (2004) Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med 350:2140–2150CrossRefPubMedGoogle Scholar
  10. 10.
    Cazeau S, Leclercq C, Lavergne T, Walker S, Varma C, Linde C, Garrigue S, Kappenberger L, Haywood GA, Santini M, Bailleul C, Daubert JC (2001) Effects of multisite biventricular pacing in patients with heart failure and intraventricular conduction delay. N Engl J Med 344:873–880CrossRefPubMedGoogle Scholar
  11. 11.
    Cazeau S, Ritter P, Bakdach S, Lazarus A, Limousin M, Henao L, Mundler O, Daubert JC, Mugica J (1994) Four chamber pacing in dilated cardiomyopathy. Pacing Clin Electrophysiol 17:1974-1979PubMedGoogle Scholar
  12. 12.
    Cleland JG, Daubert JC, Erdmann E, Freemantle N, Gras D, Kappenberger L, Tavazzi L (2005) The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med 352:1539–1549CrossRefPubMedGoogle Scholar
  13. 13.
    Egoavil CA, Ho RT, Greenspon AJ, Pavri BB (2005) Cardiac resynchronization therapy in patients with right bundle branch block: analysis of pooled data from the MIRACLE and Contak CD trials. Heart Rhythm 2:611–615CrossRefPubMedGoogle Scholar
  14. 14.
    Etienne Y, Mansourati J, Gilard M, Valls-Bertault V, Boschat J, Benditt DG, Lurie KG, Blanc JJ (1999) Evaluation of left ventricular based pacing in patients with congestive heart failure and atrial fibrillation. Am J Cardiol 83:1138–1140CrossRefPubMedGoogle Scholar
  15. 15.
    Gasparini M, Lunati M, Bocchiardo M, Mantica M, Gronda E, Frigerio M, Caponi D, Carboni A, Boriani G, Zanotto G, Ravazzi PA, Curnis A, Puglisi A, Klersy C, Vicini I, Cavaglia S (2003) Cardiac resynchronization and implantable cardioverter defibrillator therapy: preliminary results from the InSync Implantable Cardioverter Defibrillator Italian Registry. Pacing Clin Electrophysiol 26:148–151PubMedGoogle Scholar
  16. 16.
    Gasparini M, Mantica M, Galimberti P, Marconi M, Genovese L, Faletra F, Simonini S, Klersy C, Coates R, Gronda E (2003) Beneficial effects of biventricular pacing in patients with a “narrow” QRS. Pacing Clin Electrophysiol 26:169–174PubMedGoogle Scholar
  17. 17.
    Gasparini M, Mantica M, Galimberti P, Genovese L, Pini D, Faletra F, Marchesina UL, Mangiavacchi M, Klersy C, Gronda E (2003) Is the outcome of cardiac resynchronization therapy related to the underlying etiology? Pacing Clin Electrophysiol 26:175–180PubMedGoogle Scholar
  18. 18.
    Gras D, Leclercq C, Tang AS, Bucknall C, Luttikhuis HO, Kirstein-Pedersen A (2002) Cardiac resynchronization therapy in advanced heart failure the multicenter InSync clinical study. Eur J Heart Fail 4:311–320PubMedGoogle Scholar
  19. 19.
    Gregoratos G, Abrams J, Epstein AE, Freedman RA, Hayes DL, Hlatky MA, Kerber RE, Naccarelli GV, Schoenfeld MH, Silka MJ, Winters SL, Gibbons RJ, Antman EM, Alpert JS, Gregoratos G, Hiratzka LF, Faxon DP, Jacobs AK, Fuster V, Smith SC Jr (2002) ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices: summary article. Circulation 106:2145–2161CrossRefPubMedGoogle Scholar
  20. 20.
    Hay I, Melenovsky V, Fetics BJ, Judge DP, Kramer A, Spinelli J, Reister C, Kass DA, Berger RD (2004) Short-term effects of right-left heart sequential cardiac resynchronization in patients with heart failure, chronic atrial fibrillation, and atrioventricular nodal block. Circulation 110:3404–3410CrossRefPubMedGoogle Scholar
  21. 21.
    Higgins SL, Hummel JD, Niazi IK, Giudici MC, Worley SJ, Saxon LA, Boehmer JP, Higginbotham MB, De Marco T, Foster E, Yong PG (2003) Cardiac resynchronization therapy for the treatment of heart failure in patients with intraventricular conduction delay and malignant ventricular tachyarrhythmias. J Am Coll Cardiol 42:1454–1459CrossRefPubMedGoogle Scholar
  22. 22.
    Hochleitner M, Hortnagl H, Ng CK, Gschitzner F, Zechmann W (1990) Usefulness of physiologic dual-chamber pacing in drug-resistant idiopathic dilated cardiomyopathy. Am J Cardiol 66:198–202CrossRefPubMedGoogle Scholar
  23. 23.
    Hoppe UC, Böhm M, Dietz R, Hanrath P, Kroemer HK, Osterspey A, Schmaltz AA, Erdmann E (2005) Leitlinien zur Therapie der chronischen Herzinsuffizienz. Z Kardiol 94:488–509CrossRefPubMedGoogle Scholar
  24. 24.
    Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B (2005) ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult–Summary Article. Circulation 112:1825–1852CrossRefGoogle Scholar
  25. 25.
    Leclercq C, Victor F, Alonso C, Pavin D, Revault d’Allones G, Bansard JY, Mabo P, Daubert C (2000) Comparative effects of permanent biventricular pacing for refractory heart failure in patients with stable sinus rhythm or chronic atrial fibrillation. Am J Cardiol 85:1154–1156CrossRefPubMedGoogle Scholar
  26. 26.
    Lemke B, Nowak B, Pfeiffer D (2005) Leitlinien zur Herzschrittmachertherapie. Z Kardiol 94:704–720CrossRefPubMedGoogle Scholar
  27. 27.
    Leon AR, Greenberg JM, Kanuru N, Baker CM, Mera FV, Smith AL, Langberg JJ, DeLurgio DB (2002) Cardiac resynchronization in patients with congestive heart failure and chronic atrial fibrillation: effect of upgrading to biventricular pacing after chronic right ventricular pacing. J Am Coll Cardiol 39:1258–1263PubMedGoogle Scholar
  28. 28.
    Linde C, Leclercq C, Rex S, Garrigue S, Lavergne T, Cazeau S, McKenna W, Fitzgerald M, Deharo JC, Alonso C, Walker S, Braunschweig F, Bailleul C, Daubert JC (2002) Long-term benefits of biventricular pacing in congestive heart failure: results from the MUlti-site STimulation in cardiomyopathy (MUSTIC) study. J Am Coll Cardiol 40:111–118CrossRefPubMedGoogle Scholar
  29. 29.
    Molhoek SG, Bax JJ, Bleeker GB, Boersma E, van Erven L, Steendijk P, van der Wall EE, Schalij MJ (2004) Comparison of response to cardiac resynchronization therapy in patients with sinus rhythm versus chronic atrial fibrillation. Am J Cardiol 94:1506–1509CrossRefPubMedGoogle Scholar
  30. 30.
    Moss AJ, Brown MW, Cannom DS, Daubert JP, Estes M, Foster E, Greenberg HM, Hall WJ, Higgins SL, Klein H, Pfeffer M, Wilber D, Zareba W (2005) Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy (MADITCRT): Design and Clinical Protocol. Ann Noninvasive Electrocardiol 10 (Suppl 4):34–43PubMedGoogle Scholar
  31. 31.
    Pitzalis MV (2002) Cardiac resynchronization therapy tailored by echocardiographic evaluation of ventricular asynchrony. J Am Coll Cardiol 40:1615–1622CrossRefPubMedGoogle Scholar
  32. 32.
    Reuter S, Garrigue S, Barold SS, Jais P, Hocini M, Haissaguerre M, Clementy J (2002) Comparison of characteristics in responders versus nonresponders with biventricular pacing for drug-resistant congestive heart failure. Am J Cardiol 89:346–350CrossRefPubMedGoogle Scholar
  33. 33.
    Young JB, Abraham WT, Smith AL, Leon AR, Lieberman R, Wilkoff B, Canby RC, Schroeder JS, Liem LB, Hall S, Wheelan K (2003) Combined cardiac resynchronization and implantable cardioversion defibrillation in advanced chronic heart failure: the MIRACLE ICD Trial. JAMA 289:2685–2694CrossRefPubMedGoogle Scholar
  34. 34.
    Yu CM, Lin H, Zhang Q, Sanderson JE (2003) High prevalence of systolic and diastolic asynchrony in patients with congestive heart failure and normal QRS duration. Heart 89:54–60PubMedGoogle Scholar

Copyright information

© Steinkopff-Verlag 2006

Authors and Affiliations

  1. 1.J.-W.-Goethe-Universitätsklinik, Medizinische Klinik III—KardiologieFrankfurt

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