Erstellt am 02 Jan 2019 21:39
Zuletzt geändert: 14 May 2019 09:23
Generell
Zur Katheterablation, der Verödungstherapie mit Katheterzugang über die Leiste, bei Patienten mit Rhythmusstörungen der Herzkammern ("ventrikulären Tachykardien") nach Herzinfarkt, gibt es nun mehrere Studien, die zeigen, dass die Katheterablation effektiver ist als jede medikamentöse Behandlung in Bezug auf Unterdrückung neuerliche Episoden ventrikulärer Tachykardien. Prof. Deneke: "Doch war kein Effekt hinsichtlich eines besseren Überlebens erkennbar. Der Grund dafür könnte sein, dass es sich in diesen Studien um sehr kranke Patienten handelte, die am Fortschreiten ihrer kardialen Erkrankung verstarben und nicht an einem arrythmogenen Ereignis."
Bei Patienten ohne Veränderungen an den Herzkranzgefäßen, also ohne vorangegangenem Herzinfarkt, scheint es so zu sein, dass die Erfolge der Ablation, wenn sie in erfahrenen Expertenzentren durchgeführt wird, ebenfalls sehr gut sind, so Prof. Deneke.
Die Anzahl jener Patienten, die bei ventrikulärer Tachykardie abladiert wurden, hat sich in den vergangenen zehn Jahren verdreifacht. Pro Jahr werden in Deutschland zwischen 5.000 und 6.000 Ablationen bei ventrikulären Tachykardien durchgeführt. Einige deutschlandweite Zentren haben sich auf die Therapie dieser Patienten spezialisiert, wodurch die Versorgungsstruktur sich deutlich verbessert hat..
"Eine Katheterablation könnte einen ICD bei Kammertachykardien ersetzen, vor allem dann, wenn die Pumpfunktion des linken Ventrikels nicht hochgradig eingeschränkt ist", so Prof. Deneke. "Prinzipiell ist die Methode aber als Therapie zusätzlich zum ICD gedacht, weil es bisher keine Studie gibt, die zeigt, dass es in diesem Setting zu einer Verbesserung der Prognose kommt."
- Holmqvist F, Kesek M, Englund A, et al. A decade of catheter ablation of cardiac arrhythmias in Sweden: ablation practices and outcomes. Eur Heart J. 2018 Nov 17. doi: 10.1093/eurheartj/ehy709. [Epub ahead of print]
Aims:
Catheter ablation is considered the treatment of choice for many tachyarrhythmias, but convincing 'real-world' data on efficacy and safety are lacking. Using Swedish national registry data, the ablation spectrum, procedural characteristics, as well as ablation efficacy and reported adverse events are reported.
Methods and Results:
Consecutive patients (≥18 years of age) undergoing catheter ablation in Sweden between 01 January 2006 and 31 December 2015 were included in the study. Follow-up (repeat ablation and vital status) was collected through 31 December 2016. A total of 26 642 patients (57 ± 15 years, 62% men), undergoing a total of 34 428 ablation procedures were included in the study. In total, 4034 accessory pathway/Wolff-Parkinson-White syndrome (12%), 7358 AV-nodal re-entrant tachycardia (21%), 1813 atrial tachycardia (5.2%), 5481 typical atrial flutter (16%), 11 916 atrial fibrillation (AF, 35%), 2415 AV-nodal (7.0%), 581 premature ventricular contraction (PVC, 1.7%), and 964 ventricular tachycardia (VT) ablations (2.8%) were performed. Median follow-up time was 4.7 years (interquartile range 2.7-7.0). The spectrum of treated arrhythmias changed over time, with a gradual increase in AF, VT, and PVC ablation (P < 0.001). Decreasing procedural times and utilization of fluoroscopy with time, were seen for all arrhythmia types. The rates of repeat ablation differed between ablation types, with the highest repeat ablation seen in AF (41% within 3 years). The rate of reported adverse events was low (n = 595, 1.7%). Death in the immediate period following ablation was rare (n = 116, 0.34%).
Conclusion:
Catheter ablations have shifted towards more complex procedures over the past decade. Fluoroscopy time has markedly decreased and the efficacy of catheter ablation seems to improve for AF.
- Aliot EM, Stevenson WG, Almendral-Garrote JM, et al. EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias: developed in a partnership with the European Heart Rhythm Association (EHRA), a Registered Branch of the European Society of Cardiology (ESC), and the Heart Rhythm Society (HRS); in collaboration with the American College of Cardiology (ACC) and the American Heart Association (AHA). Europace. 2009 Jun;11(6):771-817. doi: 10.1093/europace/eup098.
Medikamente (Antiarrhythmika) nach Ablation
- Kaitani K et al. Efficacy of Antiarrhythmic Drugs Short-Term Use After Catheter Ablation for Atrial Fibrillation (EAST-AF) trial. Eur Heart J. 2016 Feb 14;37(7):610-8. (Volltext)
Die EAST-AF-Studie zeigte, dass eine Kurzzeittherapie mit Antiarrhythmika (am häufigsten Flecainid, Pilsicainid und Cibenzolin) über 90 Tage nach erfolgreicher Katheterablation von Vorhofflimmern das Risiko von erneutem Vorhofflimmern/- flattern während dieser Behandlungsphase zwar signifikant senkt, aber weder die langfristige Rezidivfreiheit noch den funktionellen Outcome nach 1 Jahr beeinflusst.
Die Details: Nach 90 Tagen lag die Rezidivrate in der Antiarrhythmikagruppe bei 41,0 Prozent und in der Kontrollgruppe bei 47,9 Prozent (p = 0,013). Nach dem Absetzen der Antiarrhythmika nach 3 Monaten glichen sich die Rezidivraten an. Die 1-Jahres-Raten für Rezidivfreiheit betrugen 69,5 Prozent in der Antiarrhythmikagruppe und 67,8 Prozent in der Kontrollgruppe (adjustierte Hazard Ratio [HR]: 0,93; 95%-Konfidenzintervall: 0,79-1,09; p = 0,38). (Zusammenfassung nach Rosenfluh: CongressSelection: Kardiologie. Dezember 2015;29.)
Ventrikuläre Tachykardien
- Maagh P, Christoph A, Müller MS, et al. Point-by-point versus multisite electrode mapping in VT Ablation. Journal of Interventional Cardiac Electrophysiology (2018) 51:169–181. https://doi.org/10.1007/s10840-018-0311-9
"… The endpoint of VT non-inducibility after ablation was achieved in 34 patients (45.9%) with no differences determined between either of the two groups. There were two cases in the Thermocool® SF group which were considered as failures. Furthermore, there were two cases complicated by hemopericardium as well as one case complicated by persistent cardiogenic shock. There were no strokes, phrenic palsies, coronary injuries, or procedure-related deaths. …
After adjusting the follow-up time to 12 months in both groups, hereby ensuring that all patients had the same amount of follow-up time, we observed a drop in VT recurrence in the PentaRay® group after 3 months, which did not undergo any change in development until the end of the 12-month follow-up period (see Fig. 4). After 12 months, 57 patients had freedom from VT recurrences (79.2%). The result was insignificant between the groups (38 patients (80.9%) in group 1 and 19 patients (76.0%) in group 2). We could not observe differences between ICM and NICM patients. …"
Vorhofflimmern
- König S, Ueberham L, Schuler E, et al. In-hospital mortality of patients with atrial arrhythmias: insights from the German-wide Helios hospital network of 161 502 patients and 34 025 arrhythmia-related procedures. Eur Heart J. 2018 Nov 21;39(44):3947-3957. doi: 10.1093/eurheartj/ehy528.
Aims:
Atrial fibrillation (AFib) and atrial flutter (AFlut) are common arrhythmias with increased use of invasive procedures. A steady re-evaluation of relevant safety endpoints is recommended and both quality management and pay-for-performance programs are evolving. Therefore, the aims of this study were (i) to investigate and report overall in-hospital mortality and mortality of invasive arrhythmia-related procedures and (ii) to identify mortality predictors in a German-wide hospital network.
Methods and results:
Administrative data provided by 78 Helios hospitals between 2010 and 2017 were examined using International Statistical Classification of Diseases and Related Health Problems- and Operations and Procedures-codes to identify patients with AFib or AFlut as main discharge diagnosis or secondary diagnosis combined with invasive arrhythmia-related interventions. In 161 502 patients, in-hospital mortality was 0.6% with a significant decrease from 0.75% to 0.5% (P < 0.01) during the observational period. In multivariable analysis, age [odds ratio (OR) 2.69, 95% confidence interval (CI) 2.36-3.05; P < 0.01], high centre volume (OR 0.57, 95% CI 0.50-0.65; P < 0.01), emergency hospital admission (OR 1.57, 95% CI 1.38-1.79; P < 0.01), and Charlson Comorbidity Index (CCI, OR 4.95, 95% CI 4.50-5.44; P < 0.01) were found as independent predictors of in-hospital mortality. Mortality rates were 0.05% for left atrial catheter ablation (CA, n = 21 744), 0.3% for right atrial CA (n = 9972), and 0.56% for implantation of a left atrial appendage occluder (n = 2309), respectively.
- Aagaard P, Di Biase L, Natale A. Ablation of atrial arrhythmias in heart failure. Heart Fail Clin. 2015 Apr;11(2):305-17. doi: 10.1016/j.hfc.2014.12.008. PMID: 25834977.
HF and AF are on the rise and often coexist. Pharmacologic rhythm control has not been shown to improve outcomes compared with pharmacologic rate control. It is possible that the benefits of maintaining SR are offset by the adverse effects of AADs. Catheter ablation of AF offers an opportunity to achieve SR without the downside of AADs. Several studies have shown that AF ablation improves prognostic markers, including ventricular function, exercise tolerance, and perceived quality of life in HF patients. Studies addressing the impact of this treatment strategy on cardiovascular outcomes and cost-effectiveness are ongoing.
- Al Halabi S, Qintar M, Hussein A, et al. Catheter Ablation for Atrial Fibrillation in Heart Failure Patients: A Meta-Analysis of Randomized Controlled Trials. JACC Clin Electrophysiol. 2015 Jun 1;1(3):200-209.
CONCLUSIONS:
In patients with HF and AF, AF catheter ablation is superior to rate control in improving LVEF, quality of life and functional capacity. Prior to accepting a rate control strategy in HF patients with persistent or drug refractory AF, consideration should be given to AF ablation.
- Electrophysiology Department of San Donato Hospital, Milano: Atrial Fibrillation Ablation (CPVA)
- Vladimir Guluta, MD, at San Donato Hospital, Milano: When arrhythmias complicate the postoperative period
- Vladimir Guluta, MD, at San Donato Hospital, Milano: When arrhythmias complicate heart failures
Siehe auch in diesem Wiki:
- Abgrenzungsfragen zum EBM
- Herzkatheteruntersuchung
- Herzinsuffizienz
- Hypertonie
- Kardioversion
- Implantierbarer Kardioverter-Defibrillator (ICD)
- Kardiomyopathie
- Kardiomyopathie vs. KHK
- LifeVest
- Myokarditis
- Ventrikuläre Arrhythmie
- Vorhofflimmern.
Sonstiges, Weblinks
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