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Koronarphysiologie im Herzkatheterlabor

Coronary physiology in the catheter laboratory

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Zusammenfassung

Die Regulation des koronaren Flusses erfolgt im Wesentlichen in den Widerstandsgefäßen der Mikrozirkulation, sodass sich die funktionelle Relevanz einer Koronarstenose aus dem Wechselspiel zwischen Stenose und nachgeschalteter Mikrozirkulation ergibt. Diese Zusammenhänge werden durch koronarphysiologische Messungen, wie die Bestimmung der iwFR („instantaneous wave-free ratio“) oder der fraktionellen Flussreserve (FFR), sehr präzise erfasst. Im Gegensatz dazu führen rein visuelle Beurteilungen der koronaren Anatomie oft zu Fehlinterpretationen und möglicherweise zu falschen Revaskularisationsentscheidungen. Entsprechend findet sich in den aktuellen Revaskularisierungsleitlinien der European Society of Cardiology (ESC) für die FFR und die iwFR eine Klasse-IA-Indikation bei intermediären Koronarstenosen mit unklarer hämodynamischer Relevanz. Dennoch wird die Methodik im klinischen Alltag oftmals nicht eingesetzt. Neben der rein hämodynamischen Beurteilung können neuartige Methoden wie Koregistrierung und koronares Mapping auch zur Planung einer perkutanen transluminalen Koronarangioplastie (PTCA), insbesondere bei Gefäßen mit diffusen Veränderungen oder seriellen Stenosen, angewandt werden. Darüber hinaus stratifiziert die invasive Flussmessung auch zwischen konservativ und interventionell zu behandelnden Patienten im akuten Koronarsyndrom, bei denen im Vergleich zur stabilen koronaren Herzkrankheit weitere Faktoren der Flusslimitation wie Spasmus, Thrombus und akute Mikrozirkulationsstörungen hinzukommen.

Abstract

The regulation of coronary flow is mainly located in the resistance vessels of the microcirculation, so that the functional relevance of a coronary stenosis arises from the interaction between the epicardial stenosis and the downstream microcirculation. These complex interactions are precisely detectable by physiological measurements, such as the instantaneous wave-free ratio (iwFR) or the fractional flow reserve (FFR). In contrast, the purely visual assessment of the coronary anatomy could lead to misinterpretation and possibly to incorrect revascularization decisions. Consequently, in the current guidelines on myocardial revascularization of the European Society of Cardiology (ESC) the measurement of iwFR and FFR has a class IA indication in intermediate stenoses with unclear hemodynamic relevance. Despite this clear recommendation, physiological measurements are not yet regularly used in the clinical routine. Besides the purely hemodynamic assessment, novel methods such as co-registration and coronary mapping can be used for virtual planning of percutaneous coronary interventions, especially in vessels with diffuse lesions and serial stenoses. Furthermore, invasive flow measurements are also helpful for risk stratification between conservative and interventional treatment of patients with acute coronary syndrome, where additional factors of flow limitation, such as coronary spasm, thrombus and acute disturbance of the microcirculation play an important role.

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Danksagung

Wir danken der Firma Volcano Corporation, Koninklijke Philips N.V. (Amsterdam, Niederlande) und dem Springer Verlag (Heidelberg, Deutschland) für das Überlassen der Bildrechte.

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Authors and Affiliations

  1. I. Medizinische Klinik, Abteilung für Kardiologie, Pneumologie, Angiologie und internistische Intensivmedizin, Universitätsklinikum Mannheim, Universität Heidelberg und Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Standort Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland

    Stefan Baumann

  2. Kemperhof II, Abteilung für Kardiologie, Gemeinschaftsklinikum Mittelrhein, Koblenz, Deutschland

    Waldemar Bojara

  3. Klinik für Kardiologie, Contilia Herz- und Gefäßzentrum, St. Marien-Hospital Mülheim, Mülheim an der Ruhr, Deutschland

    Heiner Post

  4. Abteilung für Kardiologie, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Deutschland

    Tanja Rudolph

  5. Universitätsklinik für Kardiologie, Inselspital Bern, Bern, Schweiz

    Tim Schäufele

  6. Abteilung für Kardiologie, Robert-Bosch-Krankenhaus, Stuttgart, Deutschland

    Peter Ong

  7. Medizinische Klinik I, Kardiologie, Angiologie, Internistische Intensivmedizin, Asklepios Kliniken Langen-Seligenstadt GmbH, Langen-Seligenstadt, Deutschland

    Ralf Lehmann

  8. Universitäts-Herzzentrum Freiburg-Bad Krozingen und Medizinische Fakultät Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland

    Constantin von zur Mühlen

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  1. Stefan Baumann
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  2. Waldemar Bojara
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  3. Heiner Post
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  8. Constantin von zur Mühlen
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Correspondence to Stefan Baumann.

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Interessenkonflikt

S. Baumann erhält Studienunterstützung von den Firmen Abbott Vascular (Abbott Park, IL, USA) und Siemens Healthineers (Forcheim, Germany); W. Bojara, H. Post, T. Rudolph, T. Schäufele, P. Ong, R. Lehmann und C. von zur Mühlen erhalten Vortragshonorare der Firma Volcano Corporation, Koninklijke Philips N.V. (Amsterdam, Niederlande).

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Baumann, S., Bojara, W., Post, H. et al. Koronarphysiologie im Herzkatheterlabor. Herz 46 (Suppl 1), 15–23 (2021). https://doi.org/10.1007/s00059-019-04878-y

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