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Postoperativ persistierende Myokardischämie nach herzchirurgischen Eingriffen

Diagnose und Therapie

Postoperatively persisting myocardial ischemia after cardiac surgery

Diagnosis and therapy

  • Perioperative Medizin
  • Published:
Zeitschrift für Herz-,Thorax- und Gefäßchirurgie Aims and scope

Zusammenfassung

Hintergrund

Nach herzchirurgischen Eingriffen ist eine postoperativ persistierende Myokardischämie (ppMI) frühzeitig nur schwierig von der mit jeder Herzoperation einhergehenden Myokardschädigung zu unterscheiden. Die frühe Diagnose einer ppMI und die rechtzeitige Einleitung therapeutischer Maßnahmen stellen eine Herausforderung dar.

Ziel der Arbeit

Die zur Verfügung stehende Datenlage zu Diagnostik und Therapie der ppMI wird dargestellt und interpretiert. Hieraus werden klinische Entscheidungspfade abgeleitet.

Material und Methoden

Im Rahmen einer Recherche wurde in Medline nach der zum Thema verfügbaren Literatur gesucht. Folgende Suchbegriffe wurden eingegeben: „perioperative“, „myocardial infarction“, „CABG“, „graft failure“, „PCI“. Die hierbei gewonnenen Daten wurden analysiert und bezogen auf die Fragestellung interpretiert.

Ergebnisse

Die ppMI und der perioperative Myokardinfarkt (PMI) ohne weiterbestehende Ischämie werden in der Literatur selten unterschieden. Die Datenlage zu Inzidenz, Diagnosekriterien und Therapiemöglichkeiten der ppMI ist widersprüchlich. Die universelle Definition des Typ-5-Myokardinfarkts (PMI) ist zur frühzeitigen Diagnose einer ppMI nicht geeignet.

Schlussfolgerung

Die frühzeitige Erkennung einer ppMI ist schwierig, aber prognoseentscheidend. Einheitliche Diagnosekriterien existieren nicht. Eine sorgfältige postoperative Überwachung zur Erfassung der Zeichen einer ppMI scheint notwendig. Kriterien für die optimale Therapieentscheidung [perkutane Koronarintervention (PCI) vs. „coronary artery bypass graft“ (CABG) vs. konservativ] sind derzeit mit einem geringen Evidenzgrad belegt. Erkenntnisse über Referenzbereiche postoperativer Herzenzymkonzentrationsverläufe, klinische Entscheidungspfade und „Heart-team“-Entscheidungen könnten die Diagnose sowie die Therapie der ppMI künftig erleichtern und verbessern.

Abstract

Background

Early distinction between postoperatively persisting myocardial ischemia (ppMI) and the inherent cardiac damage incurred during every cardiac surgical procedure is difficult. Thus, early diagnosis and initiation of therapeutic measures for ppMI are challenging.

Aim

This article reviews the available data on ppMI after cardiac surgery. On this basis recommendations for the clinical diagnosis and therapy of ppMI are presented.

Material and methods

A literature search was carried out in Medline using the search terms perioperative, myocardial infarction, CABG, graft failure and PCI.

Results

According to the available literature ppMI and perioperative myocardial infarction (PMI) without postoperatively ongoing ischemia cannot be easily distinguished from each other. Data on the incidence, diagnostic criteria and therapeutic options of ppMI are conflicting. The universal definition of myocardial infarction type 5 (PMI) is not suitable for the early diagnosis of ppMI.

Conclusion

The early diagnosis of ppMI is difficult but relevant regarding patient prognosis. There are no standardized diagnostic criteria. Careful postoperative monitoring for sometimes subtle signs of ppMI seems to be necessary. There are few known criteria for optimal therapeutic decision-making (CABG vs. PCI vs. conservative treatment). Knowledge about upper reference limits of postoperative cardiac enzymes, clinical decision pathways and heart team-based decisions might facilitate and improve the diagnostics and therapy of ppMI in the future.

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Abbreviations

ACCF:

American College of Cardiology Foundation

AHF:

American Health Foundation

BARI:

Bypass Angioplasty Revascularization Investigation

CABG:

Coronary Artery Bypass Graft Surgery

CASS:

Coronary Artery Surgery Study

CK:

Kreatinkinase

CK-MB:

Kreatinkinase, Isoform MB

DES:

Drug-eluting stent

EACTS:

European Association For Cardio-Thoracic Surgery

ECLS:

Extracorporeal life support

ESC:

European Society of Cardiology

GOPCABE:

German Off-Pump Coronary Artery Bypass Grafting in Elderly Patients

HLM:

Herz-Lungen-Maschine

HR:

Hazard Ratio

IABP:

Intraaortale Ballonpumpe

LCOS:

Low-Cardiac-Output-Syndrom

PCI:

Perkutane Koronarintervenion

PMI:

Perioperativer Myokardinfarkt

ppMI:

Postoperativ persistierende Myokardischämie

RWBST:

Regionale Wandbewegungsstörungen

SYNTAX:

Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery

TAVI:

Transcatheter Aortic Valve Insertion

TEE:

Transoesophageale Echokardiographie

TNI:

Troponin I

TTE:

Transthorakale Echokardiographie

VARC:

Valve Academic Research Consortium

VT:

Ventrikuläre Tachykardie

WHO:

World Health Organization

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Authors and Affiliations

  1. Klinik für Herz-, Kinderherz- und Gefäßchirurgie, Universitätsklinikum Gießen und Marburg GmbH, Rudolf-Buchheim-Str. 7, 35392, Gießen, Deutschland

    P. Grieshaber, G. Görlach, B. Niemann & A. Böning

  2. Klinik für Herz- und Gefäßchirurgie, Universitäts-Herzzentrum Freiburg – Bad Krozingen, Freiburg, Deutschland

    G. Trummer

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  1. P. Grieshaber
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  2. G. Görlach
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Correspondence to P. Grieshaber.

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P. Grieshbaber, G. Görlach, A. Böning, B. Niemann und G. Trummer geben an, dass kein Interessenkonflikt besteht.

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Grieshaber, P., Görlach, G., Niemann, B. et al. Postoperativ persistierende Myokardischämie nach herzchirurgischen Eingriffen. Z Herz- Thorax- Gefäßchir 29, 185–193 (2015). https://doi.org/10.1007/s00398-015-0002-0

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