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Diagnostik und Therapie der chronischen Myokardischämie

Rolle der kardialen Magnetresonanztomographie

Diagnosis and therapy of chronic myocardial ischemia

Role of cardiac magnetic resonance imaging

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Zusammenfassung

Bei der Behandlung von Patienten mit chronischer koronarer Herzerkrankung reichen die therapeutischen Optionen von einem konservativen Regime mit optimaler medikamentöser Therapie über Revaskularisationsmaßnahmen wie der primären perkutanen Koronarintervention bis hin zur koronaren Bypass-Operation. Je nach zugrunde liegendem Patientenkollektiv können die verschiedenen Therapieansätze die Prognose und auch die Symptomatik signifikant verbessern und sind den anderen Strategien überlegen. Zur Wahl der optimalen Therapie und somit zur Prognoseverbesserung ist der Nachweis von myokardialer Ischämie sowie persistierender Vitalität von immanenter Bedeutung. Hierbei kann die kardiale Magnetresonanztomographie (MRT) einen wichtigen Beitrag leisten. Zur Ischämiediagnostik ist mittels Perfusions-Stress-MRT der Nachweis von Perfusionsdefiziten und somit hämodynamisch relevanten Koronarstenosen möglich, wohingegen durch Dobutamin-Stress-MRT der Nachweis von Kinetikstörungen unter Belastung erfolgen kann. Beide Verfahren sind anderen bildgebenden Techniken wie der Single-Photonenemissions-Computertomographie oder der Stressechokardiographie teilweise überlegen. Zur Vitalitätsdiagnostik kann einerseits mittels MRT die enddiastolische Wanddicke wie auch das Ausmaß der Transmuralität einer Narbe durch Delayed-Enhancement-Imaging beurteilt werden. Des Weiteren kann mittels Low-dose-Dobutamin-Stress-MRT auch die kontraktile Reserve visualisiert werden. Da das Delayed-Enhancement-Imaging aufgrund der hohen zeitlichen und räumlichen Auflösung eine hohe Sensitivität und Spezifität erzielt und in Ruhe ohne medikamentösen Stress schnell durchführbar sowie leicht auswertbar ist, kann diese Technik nach derzeitiger Datenlage als bevorzugte Methode zur Vitalitätsdiagnostik empfohlen werden. In diesem Beitrag werden die verschieden MRT-Techniken zur Ischämie- und Vitalitätsdiagnostik vorgestellt und deren Rolle zur Diagnose und Therapie der chronischen Myokardischämie diskutiert.

Abstract

In patients with chronic coronary artery disease different therapeutic strategies, such as optimal medical therapy, revascularization by percutaneous coronary intervention or coronary artery bypass grafting have been shown to improve the prognosis and symptoms and yield proven superiority over other treatment strategies in different patient populations. Thus, individual assessment of cardiac function and structure is of paramount importance to choose the optimal therapeutic strategy and subsequently improve patient prognosis. In this setting cardiac magnetic resonance imaging (CMR) has been shown to provide important diagnostic information. Myocardial ischemia can be detected by either perfusion stress CMR demonstrating perfusion deficits indicative of hemodynamically relevant coronary artery stenosis or dobutamin stress CMR for objectifying wall motion abnormalities during stress. Both techniques are superior to single photon emission computerized tomography and stress echocardiography in specific patient populations. Myocardial viability can be assessed by means of end-diastolic wall thickness or delayed enhancement imaging which allows quantification of the transmural extent of scarring. Furthermore, low-dose dobutamin stress CMR can detect a contractile reserve. Delayed enhancement imaging leads to accurate results due to its high resolution, can be performed at rest requiring no stress within a short time period and is easy to analyze. Thus this technique can be recommended as the favored technique to assess myocardial viability. In the following article the CMR techniques for ischemia and viability testing will be presented and their role in diagnosis and therapy of chronic myocardial ischemia will be discussed.

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

    S. de Waha, I. Eitel, S. Desch, G. Fuernau, P. Lurz, G. Schuler & H. Thiele

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  1. S. de Waha
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  2. I. Eitel
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  3. S. Desch
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Correspondence to S. de Waha.

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de Waha, S., Eitel, I., Desch, S. et al. Diagnostik und Therapie der chronischen Myokardischämie. Herz 38, 350–358 (2013). https://doi.org/10.1007/s00059-013-3803-5

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