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Thrombembolien und pulmonale Hypertonie

Thromboembolism and pulmonary hypertension

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Zusammenfassung

Die chronisch thrombembolische pulmonale Hypertonie stellt eine häufige Form der pulmonalen Hypertonie dar, die als Spätfolge nach symptomatischen und symptomlosen Lungenarterienembolien auftritt und mit einer hohen Morbidität und Mortalität assoziiert ist. Die Prognose der Erkrankung wird maßgeblich durch das Ausmaß der rechtsventrikulären Dysfunktion bestimmt. Eine unvollständige Revaskularisation des Gefäßbetts sowie möglicherweise auch eine In-situ-Thrombosierung führen zu einer Verminderung des Gefäßbettdurchmessers, aus der eine veränderte Druck- und Volumenbelastung der noch perfundierten Gefäße resultiert. Dies kann in den noch perfundierten Arealen ähnliche Prozesse auslösen, wie sie bei der pulmonalarteriellen Hypertonie beschrieben sind. Allerdings sind die zum Umbau der Pulmonalarterien beitragenden Pathomechanismen noch unzureichend verstanden. Therapeutisch sollte prinzipiell die Endarteriektomie des organisierten thrombotischen Materials bei gegebener Indikation angestrebt werden. Bei inoperablen Patienten oder postoperativ persistierender pulmonaler Hypertonie sind die für die pulmonalarterielle Hypertonie zugelassenen medikamentösen Therapien in Erwägung zu ziehen. Diese könnten Symptomatik und Langzeitüberleben verbessern, allerdings bleibt dies in kontrollierten Studien zu prüfen.

Abstract

Chronic thrombembolic pulmonary hypertension (CTEPH) represents a common type of pulmonary hypertension and is associated with significant morbidity and mortality. The prognosis of this condition reflects the degree of associated right ventricular dysfunction. Unresolved thrombemboli and possible in situ thrombosis lead to obstruction of pulmonary arteries resulting in elevated pressures in those areas of the vasculature that were spared from thromboembolic occlusion. This can resemble pathomechanisms in patients with pulmonary arterial hypertension. However the understanding of pulmonary vascular remodeling in patients with CTEPH is incomplete. Pulmonary endarterectomy of the obstructing thromboembolic material should be performed in patients who are accessible to surgery. In patients who are judged inoperable or with persistent pulmonary hypertension treatment with pulmonary arterial hypertension medications can be considered. This could contribute to improved clinical outcome and survival, whereas further controlled studies are required addressing this question.

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Interessenkonflikt

Der korrespondierende Autor weist auf folgende Beziehungen hin:

Honorare Referententätigkeit Encysive, Reisekostenübernahmen Actelion, Bayer Vital.

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  1. Medizinische Klinik III, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland

    D. Drömann

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  1. D. Drömann
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Drömann, D. Thrombembolien und pulmonale Hypertonie. Internist 50, 1080–1085 (2009). https://doi.org/10.1007/s00108-009-2338-6

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