Zusammenfassung
Der kardiogene Schock ist mit einer Mortalität von bis zu 50 % weiterhin der schwerwiegendste prognoserelevante Faktor beim akuten Myokardinfarkt. In der Frühphase dieser Erkrankung vor und nach früher Revaskularisation spielt vor allem die hämodynamische Unterstützung der Patienten eine Rolle. Die Katecholamintherapie mit Inotropika und Vasopressoren, aber auch die Erwägung mechanischer Unterstützungssysteme wie intraaortaler Ballonpumpen (IABP), perkutaner linksventrikulärer Unterstützungssysteme und extrakorporaler Membranoxygenation (ECMO) sind hier wichtige Eckpunkte der Therapie. Die Anlage einer IABP ist aufgrund der aktuellen Datenlage nicht mehr generell zu empfehlen, aber die Datenlage zur Implantation perkutaner linksventrikulärer Assist-Devices (LVAD) bei Patienten im kardiogenen Schock ist sehr limitiert und bedarf weiterer Untersuchung. Ein Vergleich von perkutanen LVAD-Systemen mit einer medikamentösen Standardtherapie in großen randomisierten Studien ist bislang nicht erfolgt. Ein direkter Vergleich der verschiedenen mechanischen Unterstützungssysteme untereinander existiert ebenfalls nicht. Aus diesen Gründen gibt es in den deutschen und internationalen Leitlinien derzeit nur eine Empfehlung für Patienten im kardiogenen Schock, die refraktär gegenüber der medikamentösen Standardtherapie sind. Diese Übersicht soll die Möglichkeiten der mechanischen Kreislaufunterstützung im kardiogenen Schock beleuchten und die aktuelle (Leitlinien-)Empfehlungslage zur Anwendung der verschiedenen Systeme reflektieren.
Abstract
Treatment of patients in cardiogenic shock (CS) presenting with acute myocardial infarction (AMI) is still a challenge and mortality rates remain high, approaching 50 %. Hemodynamic stabilization before and/or after early revascularization remains the primary goal in these patients. In addition to hemodynamic support by inotropes and vasopressors, support with mechanical devices such as intra-aortic balloon pumping (IABP), percutaneous left ventricular assist devices (LVAD) and complete extracorporeal life support (ECLS) with extracorporeal membrane oxygenation (ECMO) may be considered. The use of IABP cannot be recommended anymore on a routine basis. Unfortunately, there are no large randomized data from studies evaluating treatment with mechanical support systems compared to standard treatment with respect to the clinical outcome of patients and no head-to-head comparison of different devices is available. Another important open question to be answered is which subgroups of patients may have a benefit from LVAD therapy. Guidelines discourage the routine use of mechanical support as a first-line treatment in CS patients and emphasize that the application should be restricted to those patients with refractory shock. This article gives an overview of the different devices for percutaneous mechanical support in CS and describes the available evidence and guideline recommendations.
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T. Graf: Vortragshonorare von Medtronic, Daiichi Sankyo, Bristol-Myers Sqibb und Heart Ware. H. Thiele: Vortragshonorare und Wissenschaftsunterstützung von Maquet Cardiovascular, Hirrlingen, Deutschland; Wissenschaftsunterstützung von Teleflex Medical, USA.
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Dieser Beitrag erschien ursprünglich in der Zeitschrift Herz 2015, 40:224–230. DOI 10.1007/s00059-015-4208-4
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Graf, T., Thiele, H. Mechanische Unterstützung im kardiogenen Schock. Kardiologe 9, 434–441 (2015). https://doi.org/10.1007/s12181-015-0033-5
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DOI: https://doi.org/10.1007/s12181-015-0033-5
Schlüsselwörter
- Kardiogener Schock
- Intraaortale Ballonpumpe
- Extrakorporale Membranoxygenation
- Mikroaxiale Pumpen
- Perkutane linksventrikuläre Unterstützungsverfahren