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Kardioprotektion beim herzchirurgischen Patienten

Alles Gute kommt von Herzen

Cardioprotection in cardiac surgical patients

Everything good comes from the heart

  • Leitthema
  • Published:
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Zusammenfassung

Hintergrund

Trotz signifikanter Fortschritte in operativen Techniken, der Anästhesie und in der Intensivmedizin zeigen Patienten nach herzchirurgischen Eingriffen regelmäßig Organdysfunktionen mit bedeutenden klinischen Auswirkungen.

Fragestellung

Welche Strategien zur Kardioprotektion sind bei diesen gefährdeten Patienten mit einem klinischen Nutzen assoziiert?

Material und Methoden

Vorstellung der etablierten und neueren Strategien zum Schutz dieser Patienten, die gemeinsam zum Ziel haben, die körpereigenen protektiven Mechanismen zu nutzen.

Ergebnisse

Sowohl die Hypothermie als auch die Kardioplegie gehören zu den lang etablierten protektiven Strategien während myokardialer Ischämie. Die Applikation von volatilen Anästhetika zeigte bei Patienten mit herzchirurgischen Eingriffen eine signifikant verbesserte linksventrikuläre Funktion sowie eine reduzierte Myokardschädigung im Vergleich zur Kontrollgruppe mit intravenöser Anästhesie. Ebenso konnte eine verkürzte Aufenthaltsdauer auf der Intensivstation und im Krankenhaus nachgewiesen werden. Allerdings fehlen bis heute große randomisiert-kontrollierte Multicenter-Studien, die einen positiven klinischen Nutzen belegen. Die Translation von weiteren kardioprotektiven Strategien ist in der klinischen Anwendung bisher mehrheitlich gescheitert. Im Gegensatz zur initial demonstrierten Reduktion der Troponinfreisetzung nach Remote Ischemic Preconditioning konnte in den zuletzt publizierten großen Multicenter-Studien durch Fernkonditionierung kein Nutzen im Hinblick auf die klinischen Ergebnisse belegt werden.

Schlussfolgerung

Neben der Kardioplegie und Hypothermie hat sich der Gebrauch von volatilen Anästhetika aufgrund der konditionierenden und kardioprotektiven Eigenschaften fest etabliert. Bei weiteren vielversprechenden pharmakologischen Strategien ist die Translation der experimentellen Ergebnisse in die klinische Praxis bisher gescheitert. Weitere systematische Grundlagenforschung ist notwendig, um potenzielle Störfaktoren zu identifizieren.

Abstract

Background

Despite substantial success in the anesthetic and surgical management of cardiac surgery, patients frequently show postoperative complications and organ dysfunctions. This is highly relevant for mid- to long-term outcomes.

Objectives

To evaluate cardioprotective strategies that may offer effective protection in vulnerable cardiac surgery patients.

Methods

To demonstrate recent cardioprotective approaches for cardiac surgery patients, aiming to modulate the body’s own protective mechanisms in cardiac surgery patients.

Results

Both cardioplegia and hypothermia belong to the well-established protective strategies during myocardial ischemia. Volatile anesthetics have been repeatedly shown to improve the left ventricular function and reduce the extent of myocardial injury compared to a control group with intravenous anesthesia. Furthermore, patients receiving volatile anesthetics showed a significantly shortened stay in the ICU and in hospital after cardiac surgery. In contrast, numerous other protective strategies failed translation into the clinical practice. Despite the published reduction of troponin release after remote ischemic preconditioning, two recent large-scale randomized multicenter trials were unable to demonstrate a clinical benefit.

Conclusions

Beside the use of cardioplegia and hypothermia, the use of volatile anesthetics is well-established during cardiac surgery because of its conditioning and protective properties. Regardless of the promising results derived from experimental studies and small clinical trials, the majority of other approaches failed to translate their findings into the clinic. Therefore, systematic experimental studies are needed to identify potential confounding factors that may affect the protective effects.

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Danksagung

Wir danken Dr. Lutz Kuntzsch (Gesellschaft für deutsche Sprache e. V.) für die freundliche Unterstützung bei der Erstellung dieses Manuskriptes.

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  1. Klinik für Anästhesiologie, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland

    C. Stoppe & M. Coburn

  2. Institut für Biochemie und Molekulare Zellbiologie, RWTH Aachen, Aachen, Deutschland

    C. Stoppe

  3. Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Frankfurt, Frankfurt/Main, Deutschland

    P. Meybohm

  4. Klinik für Thorax-, Herz- und Gefäßchirurgie, Uniklinik RWTH Aachen, Aachen, Deutschland

    A. Goetzenich

Authors
  1. C. Stoppe
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  2. P. Meybohm
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  3. M. Coburn
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  4. A. Goetzenich
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Correspondence to C. Stoppe.

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Interessenkonflikt

C. Stoppe gibt an, dass er durch die Deutsche Forschungsgemeinschaft unterstützt wird (STO 1099/ 2‑1). Darüber hinaus ist C. Stoppe in der Vergangenheit als Referent für die Firma biosyn Arzneimittel GmbH (Fellbach) sowie für die Firma Air Liquide (Paris) tätig gewesen. A. Goetzenich gibt an, dass er als Referent für die Firma biosyn Arzneimittel GmbH (Fellbach) tätig war. M. Coburn gibt an, dass er in der Vergangenheit Beraterhonorar von der Firma Air Liquide erhalten hat. P. Meybohm gibt an, dass kein Interessenskonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Stoppe, C., Meybohm, P., Coburn, M. et al. Kardioprotektion beim herzchirurgischen Patienten. Anaesthesist 65, 169–182 (2016). https://doi.org/10.1007/s00101-016-0141-z

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  • DOI: https://doi.org/10.1007/s00101-016-0141-z

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