Dynamische kardiomyoplastik: Bewertung eines alternativen verfahrens zur behandlung der terminalen herzinsuffizienz

Dynamic cardiomyoplasty (DCMP) was developed as an alternative treatment for patients with end-stage heart failure. The first clinical application of this technique was in 1985 by Carpentier und Chachques. Since then, DCMP has been performed in more than 1000 patients world-wide. During the initial experience with DCMP, survival for NYHA class IV patients was clearly shown to be much worse than that for class III patients. By careful patient selection, operative mortality has decrease from 31 % in the past to less then 5 % today. The vast majority of patients have demonstrated significant improvement in NYHA class and overall quality of life with only minor effects on systolic cardiac function. Clinical work, as well as recent animal work supports the hypothesis that by a combination of long-term elastic constraint and active dynamic assist, DCMP decreases myocardial wall stress. This process results in a "reverse remodeling" of the insufficient heart with an improvement of the "contractility reserve". To prove the effectiveness of DCMP versus medical therapy alone, the C-SMART study started in 1994, as the first and only randomized trial. Unfortunately the study was stopped in 1998 due to slow patient recruitment after enrolling 103 patients. The study showed that, from a symptoms standpoint, patients with DCMP were improved over those who were medically treated. However, there was no significant difference for survival between the two groups after 12 months. The lack of a clear survival advantage and the relatively poor and inconsistent hemodynamic benefit of DCMP have hindered its acceptance to date as a treatment alternative for patients with end-stage heart failure. The ultimate role of DCMP in the treatment of heart failure will depend on the outcome of future developments to improve the contractility and the long-term durability.