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Kardiale Unterstützungs- und Ersatzsysteme

Cardiac support and replacement systems

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Zusammenfassung

In der Intensivmedizin des Erwachsenen haben in den letzten Jahren mechanische Herz-Kreislauf-Unterstützungs- (perkutane Assist Devices) und Ersatzverfahren der Herzfunktion vor allem zur Behandlung des therapierefraktären infarktbedingten kardiogenen Schocks Einzug gehalten. Dabei unterscheidet man partielle Unterstützungssysteme und die Möglichkeit eines kurzzeitigen kompletten Herz- und (Lungen)-Ersatzes mittels Extracorporeal Life Support (ECLS). Trotz Einsatz dieser Systeme bleibt der kardiogene Schock mit einer hohen Mortalität verbunden. Die Erwägung mechanischer Systeme, wie perkutaner linksventrikulärer Unterstützungssysteme und ECLS, sollte erst nach Ausschöpfung medikamentöser Therapien zur Stabilisation der hämodynamischen Zielparameter erfolgen. Die Datenlage zur Implantation perkutaner Left Ventricular Assist Devices (LVAD) oder des ECLS bei Patienten im kardiogenen Schock ist bisher noch deutlich begrenzt. Eine Empfehlung zur Implantation des ECLS gibt es in den deutschen und internationalen Leitlinien erst nach Ausschöpfung der medikamentösen Therapie im kardiogenen Schock. In anderen Fällen eines nichtinfarktbedingten kardiogenen Schocks (z. B. Intoxikation, Myokarditis) kann ein ECLS als Überbrückung genutzt werden.

ECLS kann auch in Fällen der Reanimation als sogenannte E‑CPR eingesetzt werden und zeigte nach Register-Daten einen möglichen Mortalitätsbenefit bei ausgewählten Patienten.

Eine weitere Sondersituation für den Einsatz von ECLS stellt die akzidentielle schwere Hypothermie mit Herzkreislaufstillstand dar, auch hier gibt es limitierte Daten für die Anwendung der Systeme. Bei fehlender Therapie-Alternative sollte aber in diesen Fällen frühzeitig über den Einsatz der Organersatzsysteme nachgedacht werden.

Abstract

In recent years, the widespread use of partial mechanical cardiac support and even temporary complete replacement of cardiac function has been established in many intensive care units in the treatment of refractory cardiogenic shock. There is a difference between partial left-ventricular assist devices (LVAD) and the possibility of complete heart (and lung) replacement by extra corporeal life support (ECLS). Despite the use of mechanical support devices, the mortality of cardiogenic shock remains high. The consideration of using percutaneous LVAD and ECLS in cardiogenic shock should be considered in refractory cardiogenic shock patients in addition to support by catecholamines and after early revascularization in acute coronary syndromes. However, there are no large randomized studies evaluating mechanical support systems with respect to outcome in cardiogenic shock patients. German and international guidelines do not recommend the routine use of mechanical support as a first-line treatment in cardiogenic shock patients and emphasize that their application should be restricted to patients with therapy refractory shock. In other cases of noninfarct-related cardiogenic shock (e. g., poisoning, myocarditis), ECLS use should be considered as bridging therapy. ECLS may also be considered in cardiopulmonary resuscitation which is termed E‑CPR. According to registry data, E‑CPR may reduce mortality in selected patients. A possible application of ECLS is severe accidental hypothermia with cardiac arrest despite limited data. In these rare cases, early ECLS should be considered for rewarming and stabilization.

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Authors and Affiliations

  1. Universitäres Herzzentrum Lübeck Medizinische Klinik II (Kardiologie, Angiologie, Intensivmedizin), Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland

    T. Graf &  H. Thiele

  2. Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK) Standort Hamburg/Kiel/Lübeck, Lübeck, Deutschland

    T. Graf &  H. Thiele

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Correspondence to H. Thiele.

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T. Graf und H. Thiele geben an, dass kein Interessenkonflikt besteht.

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Graf, T., Thiele, H. Kardiale Unterstützungs- und Ersatzsysteme . Med Klin Intensivmed Notfmed 112, 417–425 (2017). https://doi.org/10.1007/s00063-017-0295-8

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