Klotz Stefan, Loeher Andreas, Drees Gabriele, Scheld Hans Heinrich
Klinik und Poliklinik für Thorax-, Herz- und Gefässchirurgie, Universitätsklinikum Münster, Münster.
Herz. 2006 Aug;31(5):445-54. doi: 10.1007/s00059-006-2840-8.
Cardiac transplantation still remains the gold standard despite recent success in organ-preserving therapy. However, organ shortage forces to process alternative therapies. Cardiac resynchronization therapy and cardiac contractility modulation are new and promising therapies, which are able either to delay or even prevent the need for cardiac transplantation. High-risk cardiac revascularization and valve replacement is another important therapy in especially evaluated patients. With newer organ-protective procedures and novel treatment options like the off-pump bypass surgery, end-stage heart failure could be treated successfully. The volume reduction surgery, the so-called Batista procedure, has its indication only in special selected patients with dilated cardiomyopathy. A modified procedure, the surgical ventricular restoration (SVR) therapy, however, has a definitive potential and is evaluated in a multicenter trial (RESTORE). Mechanical cardiac assist devices have still a high impact in the therapy of acute or chronic end-stage heart failure. By means of smaller devices with axial rotary blades, the high rates of thromboembolic events, infections and mechanical device complications were significantly reduced. Survival to transplant with mechanical assist device support is nowadays around 80%. New centrifugal pumps are tested in clinical trials right now. Passive cardiac support devices and the total artificial heart are limited to special indications. The organ shortage could be overcome with the xenotransplantation. However, the problem of hyperacute rejection and the risk of transfection of animal diseases limit the clinical use considerably. The cell therapy has probably the highest potential for the future. Still unsolved are problems with the potential trigger of arrhythmias and ethical preconceptions regarding embryonic stem cells. In summary, cardiac transplantation still remains the gold standard in the therapy of end-stage heart failure with 10-year survival rates of 50%. With increasing donor shortage a potential combination therapy of organ-preserving cardiac surgery and cell transplantation might be the future for the 21st century.
尽管近年来在心脏保存治疗方面取得了成功，但心脏移植仍然是金标准。然而，器官短缺迫使人们寻求替代疗法。心脏再同步治疗和心脏收缩力调制是新的且有前景的疗法，它们能够延缓甚至避免心脏移植的需求。高风险心脏血管重建和瓣膜置换是另一种重要的疗法，尤其适用于经过评估的患者。随着更新的器官保护程序和诸如非体外循环搭桥手术等新的治疗选择，终末期心力衰竭能够得到成功治疗。容积减少手术，即所谓的巴蒂斯塔手术，仅适用于特定选择的扩张型心肌病患者。然而，一种改良手术，即外科心室修复（SVR）疗法，具有确定的潜力，正在一项多中心试验（RESTORE）中进行评估。机械心脏辅助装置在急性或慢性终末期心力衰竭的治疗中仍然具有重要影响。通过使用带有轴向旋转叶片的小型装置，血栓栓塞事件、感染和机械装置并发症的发生率显著降低。如今，在机械辅助装置支持下存活至移植的概率约为80%。新型离心泵目前正在临床试验中进行测试。被动心脏支持装置和全人工心脏仅限于特殊适应症。异种移植可以克服器官短缺问题。然而，超急性排斥问题和动物疾病传播风险极大地限制了其临床应用。细胞治疗可能具有最高的未来潜力。心律失常潜在触发因素以及关于胚胎干细胞的伦理观念等问题仍然悬而未决。总之，心脏移植仍然是终末期心力衰竭治疗的金标准，10年生存率为50%。随着供体短缺加剧，心脏保存手术和细胞移植的潜在联合治疗可能是21世纪的未来方向。
