Summary
The indication for cardiac resynchronization therapy (CRT) using biventricular pacing or ICD systems has to be highly differentiated to optimize the proportion of patients who derive significant symptomatic benefit from this therapy, on the one hand, and to avoid this invasive treatment in patients with a low probability of clinical success of CRT, on the other hand. As a consensus in 2005, it can be put forward that there is sufficient evidence for an indication for CRT from clinical studies for the following characteristics: 1) Heart failure in NYHA functional class III or IV (if cardiac recompensation to class III is at least temporarily successful), 2) left ventricular ejection fraction ≤35%, 3) QRS duration >130 ms, particularly if left bundle branch block is present, 4) sinus rhythm. In addition, available data also suggest an indication for CRT in patients with atrial fibrillation if the other criteria listed above are met. The indication for CRT is unclear in patients with other intraventricular conduction delay (particularly right bundle branch block) while patients with left bundle branch block and a QRS duration of 120–130 ms seem to benefit if echocardiographic criteria demonstrate ventricular dyssynchrony. Since a multiplicity of echocardiographic criteria of ventricular dyssynchrony exists which is neither standardized nor evaluated in large-scale randomized trials, ventricular dyssynchrony on echocardiography alone cannot be regarded as an established indication for CRT without a QRS complex ≥120 ms. Similarly, whether heart failure in functional state NYHA II should be regarded as a CRT indication is currently being investigated in the randomized RAFT and MADIT-CRT trials.
Zusammenfassung
Die kardiale Resynchronisationstherapie (cardiac resynchronization therapy, CRT) mittels Implantation biventrikulärer Schrittmacher- bzw. ICD-Systeme erfordert eine differenzierte Indikationsstellung, um einerseits den Anteil von Patienten, bei denen diese Therapie eine signifikante symptomatische Verbesserung erreicht, zu optimieren und andererseits dieses invasive Therapieverfahren nicht bei Patienten einzusetzen, bei denen nur eine sehr geringe Aussicht auf einen klinischen Nutzen besteht. Als Konsensus 2005 kann formuliert werden, dass eine durch Studien abgesicherte Indikation zur CRT bei folgenden Patienten besteht: 1. NYHA-Stadium III sowie IV (falls eine Rekompensation in Stadium III zumindest kurzfristig möglich ist), 2. linksventrikuläre Ejektionsfraktion ≤35%, 3. QRS-Dauer >130 ms, vor allem bei Linksschenkelblock, 4. Sinusrhythmus. Darüber hinaus existieren relativ einheitliche Daten, dass Patienten mit Vorhofflimmern von der CRT profitieren können, sofern die anderen genannten Kriterien erfüllt sind. Unklar ist die Indikation derzeit für Patienten mit anderen Schenkelblockierungen (v. a. Rechtsschenkelblock). Für Patienten mit einer QRS-Dauer zwischen 120 und 130 ms scheint bei Linksschenkelblock ein Vorteil für die CRT zu bestehen, sofern echokardiographische Zeichen für eine ventrikuläre Dyssynchronie bestehen. Da die multiplen echokardiographischen Kriterien der ventrikulären Dyssynchronie noch wenig standardisiert und in Studien abgeklärt worden sind, kann eine alleinige Dyssynchronie bei schmalem QRS-Komplex (< 120 ms) derzeit noch nicht als etablierte CRT-Indikation betrachtet werden. Ähnliches gilt für das funktionelle Stadium NYHA II, für das die CRT-Indikation derzeit im Rahmen der RAFT- und MADIT-CRT-Studien abgeklärt wird.
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Israel, C.W., Butter, C. Indikation zur kardialen Resynchronisation: Konsensus 2005. Herzschr. Elektrophys. 17 (Suppl 1), i80–i86 (2006). https://doi.org/10.1007/s00399-006-1112-x
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DOI: https://doi.org/10.1007/s00399-006-1112-x
Key words
- Cardiac resynchronization therapy
- biventricular pacing
- heart failure
- indications
- left bundle branch block