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Hauptstamminterventionen

Möglichkeiten und Grenzen der interventionellen Kardiologie

Left main intervention

Options and limitations in interventional cardiology

Herz volume 36, Article number: 214 (2011) Cite this article

Zusammenfassung

Patienten mit signifikanter Hauptstammstenose sollten aus prognostischer Indikation einer Revaskularisationstherapie zugeführt werden. Das dafür vorgesehene Therapieverfahren war bisher die koronare Bypass-Operation. Die Indikation für ein katheterbasiertes Vorgehen beschränkte sich auf Patienten mit inadäquat hohem Operationsrisiko und „geschützter“ Hauptstammstenose. Aktuelle Studien haben zu einer Neubewertung der PCI geführt. Mittlerweile ist die PCI bei Hauptstammstenosen mit einer Klasse-II-Indikation bewertet. Nach den vorliegenden Daten der SYNTAX-Studie kann eine PCI bei Patienten mit isolierter Hauptstammstenose, mit Hauptstammstenose und gleichzeitiger koronarer Eingefäßerkrankung, mit einem SYNTAX-Score unter 33 sowie mit erhöhtem Operationsrisiko mit guten Ergebnissen durchgeführt werden. Patienten mit koronarer Mehrgefäßerkrankung bzw. einem hohen SYNTAX-Score (>33) sind weiterhin Kandidaten für eine Bypass-Operation. Eine Hauptstammintervention sollte spezialisierten Zentren vorbehalten bleiben. Die Therapieentscheidung sollte, wenn möglich, gemeinsam mit dem Kardiochirurgen im sog. Heart-Team erfolgen. Weitere Studien, die beide Therapieverfahren mit ausschließlich „harten“ Endpunkten (Tod, Myokardinfarkt, Schlaganfall) vergleichen, laufen derzeit.

Abstract

Revascularisation is indicated in patients with left main stenosis (LMS) because of its known positive effect on long-term survival. Coronary artery bypass graft (CABG) surgery has been the traditional procedure of choice for LMS patients, with percutaneous coronary intervention (PCI) being reserved for high-risk surgical patients or for those who have one or more functioning distal bypass grafts (i.e. “protected” left main PCI). Recent studies have re-examined the role of PCI in LMS, however, leading to a recent Class II recommendation for its use in selected patients. The SYNTAX Trial demonstrated that PCI can be performed with good results in the following patient subgroups: patients with isolated LMS, particularly if confined to the ostium; patients with concomitant LMS and isolated single vessel disease; patients with a SYNTAX score of <33; and patients who are at high risk for conventional CABG surgery. Patients with complex coronary anatomy (SYNTAX score >33) or those with concomitant double- or triple-vessel disease are more suited to CABG surgery. Patients who undergo PCI for LMS should be treated in specialized centers with surgical back-up, preferably with patient management decisions being made by a “heart team” consisting of at least one cardiologist and one cardiac surgeon. Ongoing studies are being performed using the hard clinical endpoints of death, myocardial infarction, and stroke in order to further compare the results of PCI vs CABG in LMS patients.

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Affiliations

  1. Klinik für innere Medizin/Kardiologie, Universität Leipzig – Herzzentrum, Strümpellstr. 39, 04289, Leipzig, Deutschland

    E. Boudriot, H. Thiele & G. Schuler

Authors
  1. E. Boudriot
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  2. H. Thiele
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  3. G. Schuler
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Correspondence to E. Boudriot.

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Boudriot, E., Thiele, H. & Schuler, G. Hauptstamminterventionen. Herz 36, 214 (2011). https://doi.org/10.1007/s00059-011-3460-5

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  • DOI: https://doi.org/10.1007/s00059-011-3460-5

Schlüsselwörter

  • Hauptstammstenose
  • Perkutane Koronarintervention
  • CABG
  • Bypass-Operation
  • SYNTAX-Studie

Keywords

  • Left main stem stenosis
  • Percutaneous coronary intervention
  • Coronary artery bypass grafting
  • Bypass surgery
  • SYNTAX trial