Der Kardiologe

, Volume 4, Issue 3, pp 214–225 | Cite as

Katheterablation bei Vorhofflimmern

Update der aktuellen therapeutischen Möglichkeiten
  • I. Drewitz
  • T. Rostock
  • B.A. Hoffmann
  • D. Steven
  • T. Meinertz
  • S. Willems
Interventionelle Elektrophysiologie
First Online:

Zusammenfassung

In den letzten Jahren haben sich wesentliche Entwicklungen in der Diagnostik und Therapie des Vorhofflimmerns (AF) ergeben, die insbesondere den Stellenwert der interventionellen Therapie erhöhen. Basierend auf der Erkenntnis, dass fokale Trigger aus den Pulmonalvenen (PV) die prädominanten Ursprungsorte des paroxysmalen Vorhofflimmerns (PAF) darstellen, hat sich die Katheterablation in Form einer elektrophysiologisch geführten Diskonnektion der PV zunehmend etabliert. Das Prinzip dieser Therapie stellt die Elimination der Trigger dar, die für die Initiierung insbesondere des PAF verantwortlich sind. Bei Patienten mit lang anhaltendem, persistierendem Vorhofflimmern (CAF) stellen die PV sehr selten das alleinige Substrat zur Initiierung und Aufrechterhaltung des Vorhofflimmerns dar, sodass die Pulmonalvenenisolation bei einem großen Teil dieser Patienten nicht ausreichend ist. Es konnte in den letzten Jahren gezeigt werden, dass Patienten mit CAF von einer zusätzlichen Substratmodifikation profitieren. Hierbei werden die herkömmlichen Ansätze in einem „stepwise ablation approach“ kombiniert angewendet mit dem Ziel der Terminierung des Vorhofflimmerns durch die Ablation. Die Katheterablation bei CAF ist derzeit noch nicht „klinisch etabliert“ und sollte nur in erfahrenen Zentren durchgeführt werden. Im Gegensatz dazu konnte auch im Vergleich zur medikamentösen Therapie eine Überlegenheit der Katheterablation zur symptomatischen Behandlung von PAF gezeigt werden.

Schlüsselwörter

Paroxysmales Vorhofflimmern Chronisches Vorhofflimmern Katheterablation Diagnostik Therapie 

Catheter ablation of atrial fibrillation

An update of current therapeutic options

Abstract

In recent years there have been substantial developments in the diagnostics and treatment of atrial fibrillation (AF) which in particular increase the value of interventional treatment. Based on the knowledge that focal triggers from the pulmonary veins (PV) represent the predominant site for paroxysmal atrial fibrillation (PAF), catheter ablation in the form of an electrophysiological disconnection of the PV has become increasingly established. The principle of this treatment is elimination of the trigger (e.g. atrial extrasystole) responsible for initiation of AF, and in particular, PAF. According to the recommendations of international societies the indication for isolation of pulmonary veins is fulfilled if patients with symptomatic PAF fail at least one anti-arrhythmic therapy. The aim of ablation is to permanently isolate the trigger activity by electrical disconnection of the PV in the area of the transition to the left atrium. Pulmonary vein isolation is now the generally accepted primary aim and will, in 60–80% of cases with PAF, lead to successful treatment after the first attempt. The success rate of repeated catheter ablation is ≥80%. In patients with long-lasting, chronic atrial fibrillation (CAF) it is very rare that PVs are the only substrate for initiating and maintaining AF, so in the majority of these patients isolation of pulmonary veins alone is not sufficient. This can be pathophysiologically explained in long-lasting AF by advanced atrial remodeling at electrical and structural levels. In recent years it could be shown that patients with CAF benefit from additional substrate modification. Subsequently, pulmonary vein isolation, followed by defragmentation and possibly linear lesions were combined in a step-wise ablation approach with the aim of terminating AF through ablation. Under these circumstances approximately half of the patients need several procedures which require treatment of the subsequently occurring atrial tachycardia. Because treatment is time-consuming, the lack of transferability of these very complex procedures with lacking long-term results and the possible complications, catheter ablation is not yet clinically established for CAF patients and should only be carried out in experienced centers with great expertise. In summary the invasive treatment of symptomatic medical therapy refractive AF has become increasingly more established in recent years. Current meta-analyses in randomized studies comparing the success rates of radio frequency ablation with medical anti-arrhythmic therapy indicate that catheter ablation is advantageous with respect to freedom from recurrence. Studies with prognostically relevant endpoints, such as mortality or frequency of stroke are ongoing.

Keywords

Paroxysmal atrial fibrillation Chronic atial fibrillation Catheter ablation Diagnostics Therapy 
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Notes

Interessenkonflikt

Der korrespondierende Autor gibt an, dass kein Interessenkonflikt besteht.

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Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  • I. Drewitz
    • 1
  • T. Rostock
    • 1
  • B.A. Hoffmann
    • 1
  • D. Steven
    • 1
  • T. Meinertz
    • 1
  • S. Willems
    • 1
  1. 1.Klinik für Kardiologie mit Schwerpunkt ElektrophysiologieUniversitäres Herzzentrum HamburgHamburgDeutschland

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