Kunstherz und Herztransplantation

Zusammenfassung

Die Behandlungsfortschritte bei vielen Herzerkrankungen haben einerseits zu einer deutlichen Verlängerung der Lebenserwartung, andererseits aber auch zu einer Zunahme von Patienten mit einer progredienten und schließlich terminalen Herzinsuffizienz geführt. Die Herztransplantation hat sich als Standardtherapie etabliert und bietet heute unter einer verbesserten immunsuppressiven Therapie eine signifikante Lebensverlängerung bei hoher Lebensqualität. Aufgrund eines zunehmenden Spendermangels verlängert sich die Wartezeit auf ein Organ stetig, und die demographische Entwicklung verschärft dieses Problem zusätzlich. So wurden in den letzten Jahren immer kleinere und funktionstüchtigere ventrikuläre Assistenzsysteme entwickelt, die zunächst als Überbrückung bis zu einer Transplantation eingesetzt wurden, heute aber auch als definitive Therapieoption für nicht transplantable Patienten Verwendung finden und mit denen die Patienten auch in ihre häuslich Umgebung entlassen werden können.

Abstract

The advances in the treatment of many different heart diseases have on the one side led to a significant prolongation of life expectancy but have also contributed to an increase of patients with heart failure. This tendency is supported even more so by the demographic development of our population. The replacement of insufficient organs has always been in the focus of medical research. In the 1960’s Shumway and Lower developed the technique of cardiac transplantation and also worked intensively on the treatment and diagnosis of rejection. However, it was Barnard who, in 1967 performed the first human cardiac transplantation. Other centers followed worldwide but the mortality was high and the new therapy was controversially discussed in many journals. By the introduction of cyclosporin as a new immunosuppressive agent in 1978, results improved rapidly and cardiac transplantation became an accepted therapeutic option for patients with end stage heart failure and also for children and newborns with congenital heart defects. Today, with newer immunosuppressive regimens and improved techniques, cardiac transplantation offers excellent results with a long-term survival of nearly 50% of patients after 15 years and among the pediatric population even after 20 years. However, the donor organ shortage as well as the increasing number of elderly patients with end stage heart failure has necessitated work on other alternatives. Neither stem cell transplantation nor xenotransplantation of animal organs are yet an option and there are still some obstacles to be overcome. In contrast, the development of so-called artificial hearts has made significant progress. While the first implants of totally artificial hearts were associated with many comorbidities and patients were seriously debilitated, new devices today offer a reasonable quality of life and long-term survival. Most of these systems are no longer replacing but mainly assisting the heart, which remains in place. These ventricular assist devices have been used as a bridge to transplantation for a long time and are now also offered as a destination therapy for patients who for a variety of reasons are no longer amenable to heart transplantation. Further miniaturization and a decrease of the costs will make these devices a realistic alternative to a sole medical therapy and studies have already proven the superiority in terms of survival as well as rehospitalization rates. However, at present they are still not an alternative to heart transplantation.