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„Sandwiched“ zwischen Ein- und Dreikammer-ICD: Brauchen wir den Zweikammer-ICD überhaupt noch?

  • Carsten W. Israel
Article
  • 58 Downloads

Zusammenfassung

Nachdem unter Zweikammer-ICDs bei Herzinsuffizienz eine höhere Rate unerwünschter Ereignisse als bei Einkammersystemen gefunden und gleichzeitig die Bedeutung der Vermeidung rechtsventrikulärer Stimulation bzw. der Erfolg einer biventrikulären Stimulation in zahlreichen Studien dokumentiert wurden, stellt sich die Frage, wozu Zweikammer-ICD-Systeme gebraucht werden. Die Einführung dieser Systeme war von Erwartungen an eine Verbesserung der Hämodynamik bei Patienten mit Bradykardie, eine Reduktion des Auftretens von Vorhofflimmern, eine Reduktion der Häufigkeit inadäquater Therapien und bradykardieabhängiger ventrikulärer Tachyarrhythmien begleitet.

Der Einsatz von Einkammer-ICDs erscheint bei Patienten mit (Sinus-)Bradykardie und Herzinsuffizienz problematisch, da bei einem nicht unerheblichen Teil eine Verschlechterung ihrer Herzinsuffizienz i. S. eines Schrittmachersyndroms zu befürchten ist. Auch wenn dieser Anteil so gering ist, dass er in großen Studien keine statistische Signifikanz erreichte, ist klinisch (und ökonomisch) auch ein geringer Anteil hämodynamisch verschlechterter Patienten nicht zu tolerieren. Da weiterhin die Entwicklung einer Bradykardie oder symptomatischen chronotropen Inkompetenz (z. B. unter Amiodaron) im Einzelfall schlecht vorhersehbar ist, sind Überlegungen, die Indikation zum Zweikammersystem großzügig zu stellen, berechtigt. Entscheidend ist hierbei die konsequente Vermeidung unnötiger rechtsventrikulärer Stimulation.

Von besonderer Bedeutung sind die überlegenen Möglichkeiten des Zweikammer-ICD, inadäquate Therapien zu vermeiden, die gute Diskriminationsalgorithmen und sorgfältige Programmierung voraussetzen. Auch die Interpretation gespeicherter Elektrogramme bei Tachykardieepisoden ist bei Zweikammer-ICDs zuverlässiger.

Zusammenfassend stellen Zweikammersysteme eine wertvolle Bereicherung der ICD-Therapie dar, erfordern jedoch eine sorgfältige Programmierung, um diesen Vorteil auszuspielen.

Schlüsselwörter

Implantierbare Kardioverter-Defibrillatoren Zweikammersysteme Hämodynamik inadäquate Therapien gespeicherte Elektrogramme 

Sandwiched between the single- and triple-chamber ICD: Do we still need the dual-chamber ICD?

Abstract

Since it has been shown that adverse events are more frequent with dual-compared to single-chamber ICDs in patients with heart failure, and since the importance of prevention of unnecessary right ventricular pacing and the success of biventricular pacing have been demonstrated in numerous studies, the need for dual-chamber ICD systems has to be reassessed. The development of these systems was accompanied by expectations of improved hemodynamics in patients with bradycardia, a reduced incidence of atrial fibrillation, inappropriate therapies, and bradycardia-associated ventricular tachyarrhythmias.

Single-chamber ICDs should be used restrictively and with great caution in patients with (sinus-) bradycardia and heart failure, since a relevant proportion of these patients is at risk of hemodynamic deterioration. Even if the proportion of patients with proven pacemaker syndrome is so small that it does not reach the level of statistical significance in large studies, a small percentage of patients with hemodynamic deterioration due to VVI pacing is still clinically (and economically) intolerable. Since the development of bradycardia or symptomatic chronotropic incompetence (e.g., due to amiodarone) is difficult to predict, it seems reasonable to use the indication for dualchamber systems liberally. However, the systematic prevention of unnecessary right ventricular pacing is crucial if dual-chamber ICDs are used.

If advanced tachycardia discrimination algorithms and careful, individual programming are used, dual-chamber ICDs are superior in the prevention of inappropriate therapies. Additionally, dualchannel electrograms allow a more reliable interpretation of stored tachycardia episodes. In summary, dual-chamber systems represent a valuable improvement of ICD therapy but require thorough programming to convey their advantage.

Key words

implantable cardioverter defibrillator dual-chamber systems hemodynamic inappropriate therapies stored electrograms 

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Copyright information

© Spinger 2008

Authors and Affiliations

  1. 1.Goethe-Universität Frankfurt a.M., Medizinische Klinik III – KardiologieFrankfurtGermany

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