Zusammenfassung
In Deutschland sind mehr als 1,6 Mio. Patienten von Vorhofflimmern (VHF) betroffen. Aufgrund der demografischen Entwicklung wird diese Zahl in den nächsten Jahren noch erheblich zunehmen. Patienten mit Vorhofflimmern erleiden unbehandelt 5‑mal häufiger einen Schlaganfall als eine gesunde Population. Eine potente Schlaganfallprävention kann heute insbesondere mit neuen oralen Antikoagulanzien (NOAK) durchgeführt werden, die das Schlaganfallrisiko um etwa 70–80 % senken können. Die Risikobewertungen für Schlaganfall (CHA2DS2-VASc) und Blutungen (HAS-BLED) zeigen überlappende Variablen, sodass Patienten mit dem höchsten Schlaganfallrisiko häufig auch ein hohes Blutungsrisiko aufweisen. Ein relevanter Anteil der Patienten (etwa 20–30 %) kann unter anderem aufgrund eines sehr hohen Blutungsrisikos nicht dauerhaft antikoaguliert werden. Für diese Patientenpopulation besteht ein dringender Bedarf an alternativen Schlaganfallpräventionsstrategien wie dem katheterbasierten Vorhofohrverschluss. Aktuelle Daten zur Effektivität und Sicherheit dieses Therapieverfahrens sowie die Diskussion laufender klinischer Studien sind Gegenstand dieser Arbeit.
Abstract
In Germany more than 1.6 million patients suffer from atrial fibrillation (AF). Within the next decades this number will substantially increase due to current demographic trends with the increasing average age of the population. When untreated, patients with atrial fibrillation have a five times higher risk for stroke as compared with a control cohort. A potent stroke prevention therapy reducing the risk of stroke by approximately 70–80% is primarily treatment with new oral anticoagulants (NOACs). The risk scores for stroke (CHA2DS2-VASc) and major bleeding (HAS-BLED) in patients with atrial fibrillation share common variables, so that patients with the highest stroke risk often carry a very high bleeding risk. A significant number of patients (ca. 20–30%) are, however, not eligible for long-term anticoagulation, e.g. because of a high bleeding risk. For this population there is an urgent need for alternative stroke prevention strategies, such as catheter-based percutaneous left atrial appendage closure. Current data about the efficiency and safety of this treatment as well as a discussion of ongoing recruitment for randomized studies are discussed in this review.
Literatur
Kirchhof P, Benussi S, Kotecha D et al (2016) 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 37:2893–2962
Ruff CT, Giugliano RP, Braunwald E et al (2014) Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet 383:955–962
Lip GY, Frison L, Halperin JL, Lane DA (2011) Comparative validation of a novel risk score for predicting bleeding risk in anticoagulated patients with atrial fibrillation. J Am Coll Cardiol 57:173–180 (the HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly) score)
Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY (2010) A novel user-friendly score (HAS-BLED) to assess 1‑year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest 138:1093–1100
Paquette M, Riou Franca L, Teutsch C et al (2017) Persistence with Dabigatran therapy at 2 years in patients with atrial fibrillation. J Am Coll Cardiol 70:1573–1583
Johnson ME, Lefevre C, Collings SL et al (2016) Early real-world evidence of persistence on oral anticoagulants for stroke prevention in non-valvular atrial fibrillation: a cohort study in UK primary care. BMJ Open 6:e11471
Blackshear JL, Odell JA (1996) Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg 61:755–759
Holmes DR, Reddy VY, Turi ZG et al (2009) Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet 374:534–542
Holmes DR Jr., Kar S, Price MJ et al (2014) Prospective randomized evaluation of the Watchman Left Atrial Appendage Closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial. J Am Coll Cardiol 64:1–12
Reddy VY, Doshi SK, Kar S et al (2017) 5‑year outcomes after left atrial appendage closure: from the PREVAIL and PROTECT AF trials. J Am Coll Cardiol 70:2964–2975
Reddy VY, Sievert H, Halperin J et al (2014) Percutaneous left atrial appendage closure vs warfarin for atrial fibrillation. A randomized clinical trial. JAMA 312(19):1988–1998. https://doi.org/10.1001/jama.2014.15192
Boersma LV, Ince H, Kische S et al (2017) Efficacy and safety of left atrial appendage closure with WATCHMAN in patients with or without contraindication to oral anticoagulation: 1‑Year follow-up outcome data of the EWOLUTION trial. Heart Rhythm 14:1302–1308
Landmesser U, Schmidt B, Nielsen-Kudsk JE et al (2017) Left atrial appendage occlusion with the AMPLATZER Amulet device: periprocedural and early clinical/echocardiographic data from a global prospective observational study. EuroIntervention 13:867–876
Reddy VY, Mobius-Winkler S, Miller MA et al (2013) Left atrial appendage closure with the Watchman device in patients with a contraindication for oral anticoagulation: the ASAP study (ASA Plavix Feasibility Study With Watchman Left Atrial Appendage Closure Technology). J Am Coll Cardiol 61:2551–2556
Bergmann MW, Ince H, Kische S et al (2018) Real-world safety and efficacy of WATCHMAN LAA closure at one year in patients on dual antiplatelet therapy: results of the DAPT subgroup from the EWOLUTION all-comers study. EuroIntervention 13:2003–2011
Landmesser U, Tondo C, Camm J et al (2018) Left atrial appendage occlusion with the AMPLATZER Amulet device: one-year follow-up from the prospective global Amulet observational registry. EuroIntervention 14(5):e590–e597. https://doi.org/10.4244/EIJ-D-18-00344
Sedaghat A, Schrickel JW, Andrie R, Schueler R, Nickenig G, Hammerstingl C (2017) Thrombus formation after left atrial appendage occlusion with the Amplatzer amulet device. Jacc Clin Electrophysiol 3:71–75
Weise FK, Bordignon S, Perrotta L et al (2018) Short-term dual antiplatelet therapy after interventional left atrial appendage closure with different devices. EuroIntervention 13:e2138–e2146
Osmancik P, Tousek P, Herman D, Neuzil P, Hala P, Stasek J, Haman L, Kala P, Poloczek M, Branny M, Chovancik J, Cervinka P, Holy J, Vancura V, Rokyta R, Taborsky M, Kovarnik T, Zemanek D, Peichl P, Haskova S, Jarkovsky J, Widimsky P, PRAGUE-17 Investigators (2017) Interventional left atrial appendage closure vs novel anticoagulation agents in patients with atrial fibrillation indicated for long-term anticoagulation (PRAGUE-17 study). Am Heart J 183:108–114. https://doi.org/10.1016/j.ahj.2016.10.003
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Interessenkonflikt
U. Landmesser hat Vortrags- und Beraterhonorare von Abbott und Boston Scientific erhalten. C. Skurk, J.J. Hartung und D.M. Leistner geben an, dass kein Interessenkonflikt besteht.
Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.
Additional information
Redaktion
G. Hasenfuß, Göttingen
Caption Electronic Supplementary Material
Video 1: Transseptale Punktion (TEE)
Video 2: Darstellung des LAA mittels Fluoroskopie
Video 3: Implantation eines WatchmanTM-Okkluders
Video 4: Tug-Test
Video 5: Doppler-TEE-Kontrolle der Dichtigkeit nach Device-Implantation
Video 6: 3‑D-TEE zur Kontrolle der richtigen Lage des Devices
Rights and permissions
About this article
Cite this article
Skurk, C., Hartung, J.J., Leistner, D.M. et al. Der katheterbasierte Vorhofohrverschluss – aktuelle Daten und künftige Entwicklungen. Internist 59, 1028–1040 (2018). https://doi.org/10.1007/s00108-018-0483-5
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00108-018-0483-5