Die elektrische Kardioversion bei Vorhofflimmern

Zusammenfassung

Die elektrische Kardioversion ist in den meisten Fällen das Mittel der ersten Wahl zur schnellen Wiederherstellung des Sinusrhythmus bei Patienten mit Vorhofflimmern. Dieser Übersichts-Beitrag soll das Vorgehen bei der elektrischen Kardioversion beschreiben. Patienten mit kurz anhaltenden Vorhofflimmern (< 48 h) können aufgrund des geringen Risikos einer intraatrialen Thrombusformierung einer sofortigen Kardioversion zugeführt werden (Ausnahme: Hochrisikopatienten für thrombembolische Ereignisse). Vor elektrischer Kardioversion einer länger anhaltenden (> 48 h) Vorhofflimmerepisode müssen entweder intraatriale Thromben mittels transösophagealer Echokardiographie ausgeschlossen oder zuvor eine mindestens 3-wöchige therapeutische Antikoagulation durchgeführt werden. Beide Vorgehensweisen sind hinsichtlich des kurz- oder längerfristigen Kardioversionsserfolges als gleichwertig anzusehen. Zeigen sich echokardiographisch spontane Echokontraste als Zeichen einer potentiell thrombogenen Verlangsamung des atrialen Blutflusses, so ist die Durchführung der Kardioversion wahrscheinlich trotzdem als sicher anzusehen, es sollte jedoch eine patientenindividuelle Risikostratifizierung bzw. Indikationsstellung erfolgen. Die Chance einer erfolgreichen Kardioversion ist neben Patientencharakteristika auch von diversen technischen Variablen abhängig. Größte klinische Bedeutung im Sinne einer höheren Erfolgsrate hat hierbei die Verwendung von biphasischen anstelle monophasischer Schockformen. Kommt es nach primär erfolgreicher Kardioversion zu einem Frührezidiv, so kann der Erfolg einer neuerlichen Kardioversion durch eine vorherige Therapie mit einem Antiarrhythmikum, z. B. Amiodaron, erhöht werden. Durch eine antiarrhythmische Therapie nach erfolgreicher Kardioversion kann die Rezidivrate gesenkt werden. Das Risiko von thrombembolischen Komplikationen ist in den ersten Tagen nach Kardioversion am höchsten, die Indikation zur Antikoagulation nach Kardioversion ist neben Patientencharakteristika (CHADS₂-Score) vor allem von der Dauer der Vorhofflimmerepisode abhängig.

Abstract

Electrical cardioversion ist often the treatment of first choice for restoring sinus rhythm in patients with atrial fibrillation. This article reviews the management of patients undergoing electrical cardioversion. As risk of formation of an intra-atrial thrombus formation is low after a short duration of AF (less than 48 h), immediate cardioversion can be performed in these patients (except those with a high risk for thrombembolic events). However, if the AF has lasted for more than 48 hours, patients have to be treated either with anticoagulants for at least three weeks or an atrial thrombus has to be excluded by transesophageal echocardiography. Both options achieve the same short- or long-term success rate for cardioversion. Cardioversion is probably safe even if there are spontaneous echocardiographic contrasts as signs of potential thrombogenic slowing of atrial blood flow, but individual factors of risk/indication have to taken into account. Success rate of cardioversion depends on various patient characteristics as well as on some technical variables, biphasic instead of monophasic shocks being more effective. If there is an early recurrence of AF after initially successful cardioversion, administration of amiodarone (for 4 weeks) increases the success rate of subsequent cardioversion. After successful cardioversion subsequent antiarrhythmic therapy can reduce recurrence of AF. Thrombembolic complications are more frequent within the first few days after cardioversion. Indication for and duration of post-cardioversion anticoagulation depends on individual characteristics (CHADS₂ score) as well as on the duration of the preceding episode of AF.

Schlüsselwörter

Vorhofflimmern - elektrische Kardioversion

Keywords

atrial fibrillation - electrical cardioversion

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