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Vorhofflimmern und Grenzen der oralen Antikoagulation – für wen eignen sich Vorhofohrokkluder?

Atrial fibrillation and the limits of oral anticoagulation: for whom are left atrial appendage occluders suitable?

Zusammenfassung

Hintergrund

Patienten mit Vorhofflimmern sind einem signifikant erhöhten Risiko für thromboembolische Ereignisse, insbesondere für ischämische Schlaganfälle, ausgesetzt. Eine orale Antikoagulation reduziert dieses Risiko zuverlässig, ist jedoch aus unterschiedlichen Gründen nicht bei jedem Patienten einsetzbar und geht mit einer relevanten Erhöhung des Blutungsrisikos einher. Alternativ bestehen zur Prophylaxe thromboembolischer Ereignisse bei Patienten mit Vorhofflimmern unterschiedliche Möglichkeiten eines Vorhofohrverschlusses.

Zielsetzung

Anhand einer Übersicht der aktuell verfügbaren Systeme zum Vorhofohrverschluss, eines Leitfadens zur Patientenauswahl und einer Zusammenfassung der aktuellen wissenschaftlichen Datenlage sollen die Möglichkeiten des interventionellen Vorhofohrverschlusses erläutert sowie die geeignete Patientenklientel charakterisiert werden.

Schlussfolgerung und Datenlage

Für Patienten mit Vorhofflimmern und relativer oder absoluter Kontraindikation einer oralen Antikoagulation stellt der interventionelle Verschluss des Vorhofohrs nach sorgfältiger Patientenselektion eine sichere Alternative zum Schutz vor thromboembolischen Ereignissen dar. Die aktuell verfügbare wissenschaftliche Evidenz aus randomisierten, kontrollierten Studien ist gering. Umfangreiche Registerstudiendaten lassen dennoch einen eindeutigen Nutzen vermuten, während die Ergebnisse mehrerer großer randomisierter, kontrollierter Studien in den kommenden Jahren erwartet werden.

Abstract

Background

Patients with atrial fibrillation are at a significantly increased risk of thromboembolic events, especially ischemic strokes. Oral anticoagulation reduces this risk, but cannot be used in some patients for various reasons and is associated with a relevantly increased risk of bleeding. As an alternative for prophylaxis of thromboembolic events in patients with atrial fibrillation, there are different options of left atrial appendage closure.

Aim

This article explains the possibilities of interventional atrial occlusion as well as the suitable patient clientele using an overview of the currently available systems for atrial occlusion, a guideline for patient selection and a summary of the current scientific data.

Conclusion and available scientific data

In carefully selected patients suffering from atrial fibrillation with relative or absolute contraindications for oral anticoagulation, interventional closure of the atrial appendage is a safe alternative for prophylaxis against thromboembolic events. The currently available scientific evidence from randomized controlled trials is sparse. Nevertheless, extensive amounts of registry study data suggest a benefit, while the results of several large randomized controlled trials are expected in the coming years.

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Correspondence to Sebastian Feickert.

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Interessenkonflikt

A. Öner und H. Ince erhielten Honorare für Referententätigkeiten von den Firmen Daiichi-Sankyo, Bristol Myers Squibb, Pfizer, Bayer, Boehringer Ingelheim, Boston Scientific und Abbott. S. Feickert, N.C. Ewertsen, G. D’Ancona und J. Ortak geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Feickert, S., Ewertsen, N.C., D’Ancona, G. et al. Vorhofflimmern und Grenzen der oralen Antikoagulation – für wen eignen sich Vorhofohrokkluder?. Internist (2021). https://doi.org/10.1007/s00108-021-01206-7

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Schlüsselwörter

  • Thromboembolie
  • Antikoagulanzien/Kontraindikationen
  • Schlaganfall
  • Vorhofohr
  • Patientenauswahl

Keywords

  • Thromboembolism
  • Anticoagulants/contraindications
  • Stroke
  • Atrial appendage
  • Patient selection