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Perkutaner Vorhofohrverschluss

Effektive und sichere Schlaganfallprophylaxe bei nicht-valvulärem Vorhofflimmern

Percutaneous atrial appendage closure

Effective and safe stroke prophylaxis in non-valvular atrial fibrillation

  • Interventionelle Kardiologie
  • Published:
Der Kardiologe Aims and scope

Zusammenfassung

Hintergrund

Ein großer Teil der Patienten mit Vorhofflimmern erhält keine adäquate Schlaganfallprophylaxe oder ist mit den aktuellen Antikoagulanzien nicht optimal therapiert.

Ziel der Arbeit

Dargestellt wird die aktuelle Evidenz des perkutanen Vorhofohrverschlusses als Alternative zu oralen Antikoagulanzien bei nicht-valvulärem Vorhofflimmern.

Material und Methoden

Es erfolgen eine Auswertung und Interpretation der bisherigen Studien über verschiedene perkutane Vorhofohrverschlusssysteme.

Ergebnisse

Mit dem WATCHMANTM-Okkluder und dem Amplatzer Cardiac PlugTM (ACP) befinden sich aktuell 2 Systeme in breiter, klinischer Anwendung. Die größte Evidenz besteht derzeit für den WATCHMANTM-Okkluder. In der initialen PROTECT-AF-Studie zeigte sich bezüglich der Wirksamkeit (kombinierter Endpunkt aus Schlaganfall, Embolie und kardiovaskulärer Tod) eine Überlegenheit des WATCHMANTM-Systems gegenüber Warfarin. Neben der kardiovaskulären Mortalität konnte mit dem WATCHMANTM auch die Gesamtmortalität (relative Risikoreduktion 34 %) gesenkt werden. In Bezug auf die Sicherheit besteht zudem keine Unterlegenheit gegenüber der Warfarin-Therapie. Vergleichbare Resultate zeigte auch der ACP-Okkluder. Dieser wird darüber hinaus derzeit in einer prospektiven randomisierten Studie mit Warfarin und Dabigatran verglichen.

Diskussion

Der perkutane Vorhofohrverschluss stellt eine sichere und effektive Alternative zur oralen Antikoagulation bei nicht-valvulärem Vorhofflimmern dar. Aktuell wird das Verfahren in erster Linie bei Patienten angewandt, die eine Kontraindikation zur oralen Antikoagulation aufweisen. Aufgrund der in randomisierten Studien belegten Überlegenheit gegenüber Warfarin ist eine Ausweitung der Vorhofohrverschlusstechnik zu erwarten.

Abstract

Background

Many patients with atrial fibrillation do not receive an appropriate stroke prophylaxis or are not treated ideally with the currently available anticoagulant agents.

Objectives

To show current evidence of percutaneous left atrial appendage (LAA) closure as an alternative to oral anticoagulation.

Material and methods

Analysis of recent trials evaluating transcatheter closure devices of the LAA.

Results

The most widely used systems for LAA closure are the WATCHMANTM occluder and the Amplatzer Cardiac PlugTM (ACP). Most data are available for the WATCHMANTM device. The initial PROTECT-AF trial showed superiority (i.e. composite endpoint of stroke, embolism and cardiovascular death) of the WATCHMANTM compared to warfarin. Also, all-cause mortality was reduced with the WATCHMANTM treatment as compared to warfarin (relative risk reduction 34 %). In terms of safety there was no inferiority to warfarin. The ACP system showed comparable results in a number of smaller trials. A randomized controlled study comparing the ACP with warfarin and dabigatran is ongoing.

Conclusion

Percutaneous LAA closure is a safe and effective alternative to oral anticoagulation. Currently, the technique is used mainly in patients with contraindications for oral anticoagulation. Due to the superiority to warfarin, which was found in recent trials an extended use of transcatheter LAA closure is to be expected.

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Einhaltung ethischer Richtlinien

Interessenkonflikt. H. Mudra: Proctor-Tätigkeit für Boston Scientific. J. Ledwoch und R. Hein-Rothweiler geben an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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  1. Städtisches Klinikum München GmbH, Klinikum Neuperlach, Oskar-Maria-Graf-Ring 51, 81737, München, Deutschland

    J. Ledwoch, R. Hein-Rothweiler &  H. Mudra

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  1. J. Ledwoch
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  2. R. Hein-Rothweiler
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  3. H. Mudra
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Correspondence to H. Mudra.

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Ledwoch, J., Hein-Rothweiler, R. & Mudra, H. Perkutaner Vorhofohrverschluss. Kardiologe 9, 54–60 (2015). https://doi.org/10.1007/s12181-014-0617-5

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  • DOI: https://doi.org/10.1007/s12181-014-0617-5

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