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DOI: 10.1055/s-0035-1558071
Revaskularisation bei schlechter LV-Funktion
Revascularization in Patients with Reduced Left Ventricular FunctionPublikationsverlauf
Publikationsdatum:
26. Oktober 2015 (online)
![](https://www.thieme-connect.de/media/aktkardio/201505/lookinside/thumbnails/10-1055-s-0035-1558071_ka049-1.jpg)
Zusammenfassung
Die Prognose von Patienten mit eingeschränkter linksventrikulärer Funktion und interventionsbedürftiger koronarer Herzerkrankung ist deutlich eingeschränkt. Frühe Studien zum Vergleich medikamentöser mit operativer Therapie haben nachgewiesen, dass gerade diese Hochrisikopatienten von einer kompletten Revaskularisierung profitieren. Die Datenlage ist deutlich dünner für den Vergleich zwischen den beiden Revaskularisationsmethoden PCI und Bypassoperation. Dies liegt vor allen daran, dass in den meisten Studien eine eingeschränkte linksventrikuläre Funktion als Ausschlusskriterium definiert ist. Dementsprechend müssen hier Ergebnisse aus anderen Patientenkollektiven extrapoliert werden. Komplexe Koronaranatomien mit multiplen Stenosen und hoher Wahrscheinlichkeit großer Stentlängen sollten demnach genauso wie Diabetiker eher chirurgisch versorgt werden. Die PCI kann bei geringerer Stenosekomplexität eine wertvolle und weniger invasive Alternative sein. Um eine möglichst optimale Behandlung für diese häufig schwerkranken Patienten zu gewährleisten, sollte eine individuelle Therapiefestlegung durch das Heart Team erfolgen.
Abstract
Patients with reduced left ventricular (LV) function due to coronary artery disease are at risk of both sudden cardiac death and increased long-term mortality. Early landmark clinical trials proved benefits of coronary artery bypass grafting (CABG) compared to medical therapy with respect to symptoms and prognosis. Data comparing percutaneous coronary intervention (PCI) and CABG in coronary patients with depressed LV function are scarce because these patients were excluded in most revascularization trials. However, data derived from subgroups, registries and meta-analyses suggest preference of CABG in complex multi-vessel disease, whereas PCI is a valuable less invasive alternative in less complex coronary anatomy. The choice of the procedure should be made by the heart team.
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Literatur
- 1 Takaro T, Peduzzi P, Detre KM et al. Survival in subgroups of patients with left main coronary artery disease. Veterans Administration Cooperative Study of Surgery for Coronary Arterial Occlusive Disease. Circulation 1982; 66: 14-22
- 2 Coronary artery surgery study (CASS): a randomized trial of coronary artery bypass surgery. Survival data. Circulation 1983; 68: 939-950
- 3 Long-term results of prospective randomised study of coronary artery bypass surgery in stable angina pectoris. European Coronary Surgery Study Group. Lancet 1982; 2: 1173-1180
- 4 Heusch G. Hibernating myocardium. Physiol Rev 1998; 78: 1055-1085
- 5 Appoo J, Norris C, Merali S et al. Long-term outcome of isolated coronary artery bypass surgery in patients with severe left ventricular dysfunction. Circulation 2004; 110 (Suppl. 01) II13-II17
- 6 Nardi P, Pellegrino A, Scafuri A et al. Long-term outcome of coronary artery bypass grafting in patients with left ventricular dysfunction. Ann Thorac Surg 2009; 87: 1401-1407
- 7 Kunadian V, Zaman A, Qiu W. Revascularization among patients with severe left ventricular dysfunction: a meta-analysis of observational studies. Eur J Heart Fail 2011; 13: 773-784
- 8 Velazquez EJ, Lee KL, Deja MA et al. Coronary-artery bypass surgery in patients with left ventricular dysfunction. N Engl J Med 2011; 364: 1607-1616
- 9 Meier B. The worldʼs longest follow-up after percutaneous coronary intervention, 37 years and still going strong. Eur Heart J 2015; 36: 1154
- 10 Weintraub WS, Grau-Sepulveda MV, Weiss JM et al. Comparative effectiveness of revascularization strategies. N Engl J Med 2012; 366: 1467-1476
- 11 Marui A, Kimura T, Nishiwaki N et al. Three-year outcomes after percutaneous coronary intervention and coronary artery bypass grafting in patients with heart failure: from the CREDO-Kyoto percutaneous coronary intervention/coronary artery bypass graft registry cohort-2†. Eur J Cardiothorac Surg 2015; 47: 316-321 discussion 321
- 12 Marui A, Kimura T, Nishiwaki N et al. Comparison of five-year outcomes of coronary artery bypass grafting versus percutaneous coronary intervention in patients with left ventricular ejection fractions ≤ 50 % versus > 50 % (from the CREDO-Kyoto PCI/CABG Registry Cohort-2). Am J Cardiol 2014; 114: 988-996
- 13 Fortuna D, Nicolini F, Guastaroba P et al. Coronary artery bypass grafting vs. percutaneous coronary intervention in a ‚real-world‘ setting: a comparative effectiveness study based on propensity score-matched cohorts. Eur J Cardiothorac Surg 2013; 44: e16-e24
- 14 Serruys PW, Morice MC, Kappetein AP et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med 2009; 360: 961-972
- 15 Farkouh ME, Domanski M, Sleeper LA et al. Strategies for multivessel revascularization in patients with diabetes. N Engl J Med 2012; 367: 2375-2384
- 16 Windecker S, Kolh P, Alfonso F et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35: 2541-2619
- 17 Bonow RO, Maurer G, Lee KL et al. Myocardial viability and survival in ischemic left ventricular dysfunction. N Engl J Med 2011; 364: 1617-1625