Vorhofflimmern nach Herzoperation: Wie und wie lange behandeln?

Zusammenfassung

Vorhofflimmern ist eine der häufigsten Komplikationen nach herzchirurgischen Eingriffen. Als Risikofaktoren gelten die gleichen, die auch sonst zu Vorhofflimmern prädisponieren, vor allem höheres Lebensalter, bekanntes Vorhofflimmern und eine arterielle Hypertonie. Daneben steigt mit der Komplexität des Eingriffs auch das postoperative Vorhofflimmerrisiko. Neben dem unabhängig von der Operation vorhandenen Substrat werden Sympathikusaktivierung, Entzündungsreaktionen und oxidativer Stress als Trigger diskutiert. Hier setzen auch die prophylaktischen Maßnahmen an, insbesondere die Fortsetzung oder präoperative Initiierung einer Betablockertherapie. Tritt Vorhofflimmern auf, stehen die Embolieprophylaxe mit Heparin oder nicht Vitamin-K-abhängigen Antikoagulanzien (NOAC) bzw. Phenprocoumon in Abwägung des Blutungsrisikos und Medikamente zur Frequenzkontrolle im Vordergrund, hier v. a. Betablocker. Da bei vielen Patienten mit postoperativem Vorhofflimmern kein Rezidiv zu erwarten ist, sollte die Indikation zur Fortführung der eingeleiteten Therapie einschließlich der Antikoagulation 6–12 Wochen nach Operation auf ihre weitere Notwendigkeit überprüft werden. Da Vorhofflimmerrezidive oftmals asymptomatisch sind, sollte andererseits das Beenden einer dauerhaften Antikoagulation besonders kritisch hinterfragt werden. Zumindest mehrere Langzeit-EKG-Kontrollen erscheinen vor Absetzen einer Antikoagulation sinnvoll.

Abstract

Atrial fibrillation (AF) after cardiac surgery is a common complication. Risk factors equal those predisposing to AF, namely advanced age, history of AF and hypertension. Risk for postoperative AF also increases with the type of cardiac surgery. In addition to a pre-existing substrate, increased sympathetic tone, inflammation and oxidative stress have been identified as triggers for postoperative AF. Prophylactic measures aim at attenuating these triggers and include continuation or initiation of preoperative beta-blocker therapy. If AF occurs, initiation of anticoagulation after assessment of the individual stroke and bleeding risk and medication for heart rate control – based on symptoms and left ventricular function – are the main therapeutic goals. As postoperative AF is self-limiting in most patients, they often do not require long-term treatment. That is why therapy prescribed for these purposes should be re-evaluated 6 to 12 weeks after surgery. Because AF is often asymptomatic, discontinuation of oral anticoagulation in particular requires careful evaluation. Serial Holter-ECG to detect AF appear reasonable prior to discontinuation.

Schlüsselwörter

Vorhofflimmern - Herzoperation - Therapie

Key words

atrial fibrillation - cardiac surgery - treatment

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