Skurk Carsten, Hartung Johannes Jakob, Landmesser Ulf
Medizinische Klinik für Kardiologie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Deutschland.
Standort Berlin, Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Berlin, Deutschland.
Herzschrittmacherther Elektrophysiol. 2017 Dec;28(4):395-402. doi: 10.1007/s00399-017-0534-y. Epub 2017 Nov 3.
Atrial fibrillation (AF) is the most common arrhythmia affecting more than 1.6 million patients in Germany. Based on demographic developments, an the number is expected to increase. Embolic strokes in AF patients are particularly severe, and individualized new oral anticoagulant (NOAC) therapy reduces the incidence of stroke in these patients by approximately 70%. Besides vitamin K antagonists, the NOACs rivaroxaban, dabigatran, apixaban, and edoxaban have been introduced into clinical practice; however, major bleeding still occurs at a rate of 2-3% per year. Moreover, randomized studies and real-life registries suggest that >20% of patients with AF and an indication for anticoagulation cannot tolerate chronic oral anticoagulant therapy. Therefore, an alternative method for stroke prevention in AF patients has been developed, i. e., catheter-based exclusion of the left atrial appendage (LAA), a location that is prone for thrombus formation in these patients. The randomized trials of catheter-based LAA occlusion have compared this interventional therapy with vitamin K antagonists. In the future, however, LAA exclusion needs to be compared with NOAC therapy. Moreover, percutaneous LAA exclusion in clinical practice is mostly offered to patients ineligible for long-term oral anticoagulation or with high bleeding risk. However, no controlled, randomized trial data exist for this patient population. These data are needed for appropriate clinical judgment and optimal clinical management. Ongoing studies and scientific questions that are important to define the future for catheter-based LAA closure are discussed in this review.
心房颤动（AF）是最常见的心律失常，在德国影响着超过160万患者。基于人口统计学发展趋势，预计这一数字还会增加。AF患者发生的栓塞性中风尤为严重，个体化的新型口服抗凝药（NOAC）治疗可使这些患者的中风发生率降低约70%。除维生素K拮抗剂外，NOACs利伐沙班、达比加群、阿哌沙班和依度沙班已应用于临床实践；然而，每年仍有2% - 3%的患者发生大出血。此外，随机研究和真实世界登记数据表明，超过20%有抗凝指征的AF患者无法耐受长期口服抗凝治疗。因此，已开发出一种用于预防AF患者中风的替代方法，即基于导管的左心耳（LAA）封堵术，在这些患者中，LAA是血栓形成的易发部位。基于导管的LAA封堵术的随机试验已将这种介入治疗与维生素K拮抗剂进行了比较。然而，未来LAA封堵术需要与NOAC治疗进行比较。此外，在临床实践中，经皮LAA封堵术主要适用于不符合长期口服抗凝治疗条件或出血风险高的患者。然而，针对这一患者群体，尚无对照、随机试验数据。这些数据对于进行适当的临床判断和优化临床管理是必要的。本综述讨论了正在进行的研究以及对于界定基于导管的LAA封堵术未来发展至关重要的科学问题。
