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Therapie des akuten und chronischen Rechtsherzversagens

Treatment of acute and chronic right ventricular failure

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Zusammenfassung

Ein akutes oder chronisches Rechtsherzversagen wird als Ursache einer kardiopulmonalen Insuffizienz häufig nicht oder zu spät diagnostiziert. Neben klinischen Symptomen und laborchemischen Parametern sind v. a. Echokardiographie und invasive Messungen der Hämodynamik im Rechtsherzkatheter für Diagnose und Therapiekontrolle entscheidend. In der Akutsituation ist zunächst eine symptomatische Therapie des vital bedrohlichen Zustands notwendig. Hauptziele sind die Optimierung der Koronarperfusion und damit der myokardialen Sauerstoffversorgung sowie die Nachlastsenkung des rechten Ventrikels. Bei anhaltendem Rechtsherzversagen kommen zunehmend passagere, extrakorporale oder implantierbare intrakorporale Organersatzverfahren zum Einsatz. Prognostisch entscheidend ist die zielgerichtete Therapie der auslösenden Grunderkrankung.

Abstract

Acute or chronic right ventricular failure is an often misdiagnosed cause of cardiopulmonary insufficiency. In addition to clinical symptoms or laboratory testing, echocardiography and invasive hemodynamic measurement by means of right-heart catheterization are essential for diagnosis and treatment control. In case of acute right ventricular failure, adequate symptomatic treatment of the life-threatening situation is important. Main issues are maintenance of coronary artery perfusion pressure and myocardial oxygen delivery as well as reduction of right ventricular afterload. In persistent right ventricular failure extracorporeal or intracorporeal assist devices are increasingly used as bridging or destination therapy. On a long-term basis, the targeted therapy of the underlying disease is crucial.

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Authors and Affiliations

  1. Abteilung für Thoraxchirurgie, Kerckhoff Klinik gGmbH, Benekestr. 2‑8, 61231, Bad Nauheim, Deutschland

    T. Kramm, S. Guth, C. B. Wiedenroth & E. Mayer

  2. Abteilung für allgemeine Pneumologie, Kerckhoff-Klinik gGmbH, Bad Nauheim, Deutschland

    H. A. Ghofrani

  3. Medizinische Klinik II, Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Universitätsklinikum Gießen und Marburg GmbH, Gießen, Deutschland

    H. A. Ghofrani

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  1. T. Kramm
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  2. S. Guth
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  3. C. B. Wiedenroth
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  4. H. A. Ghofrani
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Correspondence to T. Kramm.

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Interessenkonflikt

T. Kramm, S. Guth, C. B. Wiedenroth, H. A. Ghofrani und E. Mayer geben folgende Interessenskonflikte an: T. Kramm erhielt Vortragshonorare der Firmen Actelion und Bayer. S. Guth erhielt Vortragshonorare der Firmen Actelion, Bayer und GSK. C. B. Wiedenroth hat keine Interessenskonflikte. H. A. Ghofrani erhielt Vortragshonorare und finanzielle Unterstützung im Rahmen klinischer Studien der Firmen Actelion, Bayer, Ergonex, GSK, Merck, Novartis, Pfizer. E. Mayer erhielt Vortrags- und Beraterhonorare der Firmen Actelion, Bayer, GSK und Pfizer.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Redaktion

U. Janssens, Eschweiler

M. Joannidis, Innsbruck

K. Mayer, Gießen

CME-Fragebogen

CME-Fragebogen

Was ist im Fall einer akuten kardiopulmonalen Dekompensation auf der Intensivstation für die Differenzialtherapie entscheidend?

Röntgenübersichtsaufnahme und Echokardiographie

Bestimmung laborchemischer Parameter von Infektion und Herzbelastung

CT zum Ausschluss einer akuten Lungenarterienembolie

Einsetzen eines PiCCO-Katheters

Einschwemmen eines Swan-Ganz-Katheters

Zum Ausschluss einer akuten Lungenarterienembolie ist welche Diagnostik am sinnvollsten?

Alterskorrigierte D‑Dimer-Konzentration

Echokardiographie

Kardiale Magnetresonanztomographie

EKG-getriggerte Computertomographie

Pulmonalarterienangiographie

Die häufigste Ursache eines akuten Rechtsherzversagens ist?

Idiopathische pulmonalarterielle Hypertonie

Akut dekompensierte chronische Linksherzinsuffizienz

Chronisch-obstruktive Lungenerkrankung

ARDS

Lungenfibrose

Nach Diagnose des Rechtsherzversagens zielt die Initilatherapie auf …

Steigerung der myokardialen Inotropie.

Nachlastsenkung des linken Ventrikels.

Intubation und lungenprotektive Ventilation.

Vorlastreduktion des rechten Ventrikels.

Aufrechterhalt eines adäquaten koronaren Perfusionsdrucks.

In der Differenzialtherapie des Rechtsherzversagens sind folgende Parameter anzustreben:

Mittlerer arterieller Druck > 100 mmHg

Gemischtvenöse Sättigung > 65 %

Herzindex < 2,0 l/min und Quadratmeter

Mittlerer pulmonalarterieller Druck < 25 mmHg

Zentralvenöser Druck < 8 mmHg

Zur hämodynamischen Therapiekontrolle eines Patienten im akuten Rechtsherzversagen eignet sich am besten ein/e:

Rechtsherzkatheter (Swan-Ganz-Katheter).

PiCCO-Katheter.

Zentraler Venenkatheter.

Invasive Blutdruckmessung.

Engmaschige Röntgenkontrollen.

Aspekte der Beatmungstherapie eines Patienten im akuten Rechtsherzversagen sind:

Lungenprotektive Ventilation mit niedrigen Tidalvolumen.

Niedrigfrequente Beatmung mit hohen Tidalvolumen.

Absolute Vermeidung eines PEEP.

Patienten im Rechtsherzversagen sollten nicht beatmet werden.

Patienten im Rechtsherzversagen sollten nicht invasiv beatmet werden.

Welche Aussage zur ECMO-Therapie im akuten Rechtsherzversagen ist richtig?

Sie ist Therapie der ersten Wahl.

Sie ist lediglich eine Bridging-Therapie bis zum Greifen der Kausaltherapie.

Sie ist eine Option als Destination-Therapie.

Sie ist nur bei intubierten Patienten einsetzbar.

Sie verhindert die Mobilisation des Patienten.

Welche Aussage zu Patienten mit chronischem Rechtsherzversagen ist richtig?

Sie dürfen sich nicht körperlich belasten.

Sie erhalten unabhängig von der Grunderkrankung die gleiche Medikation.

Sie benötigen erst ab einem PaO2 < 50 mmHg eine Sauerstofftherapie.

Ihnen sollte ein spezialisiertes Trainingsprogramm angeboten werden.

Sie müssen zwingend an Schwerpunktambulanzen angebunden sein.

Welche Aussage zur First-line-Therapie der chronisch-thromboembolischen pulmonalen Hypertonie (CTEPH) ist richtig?

Sie ist seit Zulassung von Riociguat eine medikamentöse.

Sie erfolgt durch eine Katheterinterventionen (Ballonangioplastie).

Sie erfolgt durch die Operation, eine pulmonale Endarteriektomie.

Sie kann nur mit einer Lungentransplantation behandelt werden.

Sie erfolgt nur mit einer Antikoagulation.

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Kramm, T., Guth, S., Wiedenroth, C.B. et al. Therapie des akuten und chronischen Rechtsherzversagens. Med Klin Intensivmed Notfmed 111, 463–480 (2016). https://doi.org/10.1007/s00063-016-0181-9

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  • DOI: https://doi.org/10.1007/s00063-016-0181-9

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