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Prozedurale Aspekte im Rahmen der primären PCI

Arterieller Zugang, Stentselektion, Thrombektomie, Behandlung der Non-culprit-Läsionen

Procedural aspects in primary PCI

Arterial access, stent selection, thrombectomy and treatment of non-culprit lesions

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Zusammenfassung

Der akute Myokardinfarkt war in Deutschland im Jahr 2011 eine der häufigsten Todesursachen. Nach den Leitlinien der Europäischen Gesellschaft für Kardiologie kommen für die Akutversorgung die systemische Fibrinolyse und die primäre perkutane Koronarintervention (PCI) in Frage. Der primären PCI ist aufgrund der Überlegenheit der Vorzug zu geben. Aufgrund der geringeren Blutungskomplikationsrate ist der transradiale Zugang zu bevorzugen. Bei der Stentauswahl ist der medikamentös beschichtete Stent (DES) der neueren Generation denen der ersten Generation und dem „Bare-metal“-Stent (BMS) überlegen. Es konnte mittlerweile gezeigt werden, dass die Ereignisraten der DES (Mortalität, „target vessel revascularization“, frühe und späte Stentthrombose, Myokardinfarkt) signifikant niedriger sind. Für bioresorbierbare Scaffolds (BRS) liegen noch keine Langzeitergebnisse für den Einsatz im Rahmen der STEMI-Versorgung vor. Erste Ergebnisse sind jedoch vielversprechend. Es Bedarf in Bezug auf die Stentauswahl jedoch einer individuellen Abwägung, um allen Aspekten gerecht zu werden. Hinsichtlich der Thrombektomie im Rahmen der Akutversorgung liegen heterogene Daten vor. Aktuell ergibt sich hieraus die Notwendigkeit einer hinreichenden Abwägung, da die Thrombusaspiration in Studien durchaus auch mit erhöhten Ereignisraten assoziiert sein kann. Derzeit – hämodynamische Stabilität vorausgesetzt – sollte nur die sog. „culprit lesion“ mittels Stent versorgt werden. Weitere Stenosen sollten nach individueller Abwägung und ggf. nach Evaluierung der hämodynamischen Relevanz elektiv interveniert werden.

Abstract

Acute myocardial infarction was one of the most common causes of death in Germany in 2011. According to the guidelines of the European Society for Cardiology, systemic fibrinolysis and primary percutaneous coronary intervention (PCI) are the methods of choice for acute treatment. Primary PCI should be given priority due to its superiority. The transradial access should be preferred due to the lower bleeding complication rate. In the selection of stents the new generation of drug-eluting stents (DES) are superior to the first generation of bare metal stents (BMS). It has now been demonstrated that the incident rates of DES (e.g. mortality, target vessel revascularization, early and late stent thrombosis and myocardial infarction) are significantly lower. For bioresorbable scaffolds (BRS) long-term results for the use in treatment of ST-elevation myocardial infarction (STEMI) are not yet available but initial results are very promising. However, the selection of a stent needs to be done on an individual basis in order to do justice to all aspects. Data with respect to thrombectomy in acute treatment are heterogeneous. Currently, a thorough consideration of all aspects is necessary because thrombus aspiration can also be associated with an increased rate of incidents. In a state of hemodynamic stability only so-called culprit lesions should currently be treated with a stent. Elective interventions on further stenoses should be carried out after consideration of individual factors and if necessary evaluation of the hemodynamic relevance.

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Einhaltung ethischer Richtlinien

Interessenkonflikt. N.F. Boeder, C.W. Hamm und H.M. Nef geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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  1. Medizinische Klinik I, Kardiologie und Angiologie, Universitätsklinikum Gießen und Marburg, Standort Gießen, Klinikstr. 33, 35392, Gießen, Deutschland

    N.F. Boeder, C.W. Hamm &  H.M. Nef

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Boeder, N., Hamm, C. & Nef, H. Prozedurale Aspekte im Rahmen der primären PCI. Herz 39, 685–691 (2014). https://doi.org/10.1007/s00059-014-4133-y

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