Christian Meyer

Ein demokratischer Rechtsstaat wie die Schweiz muss rational handeln und sich dabei auch wissenschaftlichen Wissens bedienen. Der vorliegende Beitrag stellt Konzepte und Instrumente vor, um diesen Anforderungen gerecht zu werden, und beleuchtet deren normative Verankerung. Anhand des Verhältnismässigkeitsprinzips wird die Bedeutung wissenschaftlicher Rationalität als Garantin rationalen Staatshandelns näher untersucht und gezeigt, dass die entsprechenden rechtlichen Strukturen teilweise nicht mehr adäquat sind. -- Un État de droit démocratique comme la Suisse est tenu d'agir rationnellement et doit, à cette fin, tenir compte des connaissances scientifiques existantes. Cet article présente les concepts et les instruments permettant de répondre à ces exigences et met en évidence leur ancrage normatif. L'importance de la rationalité scientifique en tant que garante d'une l'action rationnelle de l'État est examinée à la lumière du principe de proportionnalité. Il est en outre démontré que les structures juridiques concernées sont en partie obsolètes.

Ventrikuläre Tachykardien (VT) sind eine der häufigsten Todesursachen von Patienten mit struktureller Herzerkrankung. Betroffene Patienten weisen häufig vielschichtige Komorbiditäten und eine erhöhte Mortalität auf. Die vielseitigen Ursachen sowie die zunehmenden Behandlungsmöglichkeiten erfordern insbesondere bei wiederholten oder nicht beherrschbaren VT eine umgehende und strukturierte Betreuung betroffener Patienten in einem speziell ausgebildeten Team aus Ärzten verschiedener Sub-Disziplinen, sowie Pflege- und technischem Personal. Vor diesem Hintergrund wurden an einigen Schwerpunktzentren in der jüngeren Vergangenheit gezielte Versorgungsstrukturen geschaffen, durch welche eine rasche und effiziente Behandlung von VT erreicht werden kann. Ziel der vorliegenden Arbeit ist es, mögliche Versorgungswege darzustellen. Aufgrund der zunehmenden Bedeutung der Katheterablation zur Modifizierung des zugrunde liegenden arrhythmogenen Substrats und neuer neuromodulatorischer Interventionen wird insbesondere auch auf periprozedurale Aspekte eingegangen, die in der Indikationsstellung sowie der Nachbetreuung der Patienten von besonderer Bedeutung sind. Ventricular tachycardia (VT) are one of the most common causes of death in patients with structural heart disease. The increasing understanding of different etiologies and the rising number of therapeutical interventions of recurrent VT warrant an immedeate and structurized treatment in an interdisciplinary team of different health care professionals. Grounded in this knowledge dedicated VT units have been established in some centers. The aim of the present brief review is to discuss possible options which might increase health management in a relevant number of patients with VT who are at risk of sudden cardiac death. In the light of recent developments, we will address periprocedural aspects which are important for patients undergoing radiofrequency cather ablation for myocardial substrate modification and/or newer neuromodulating approaches.

Cardiorespiratory autonomic control is in tight interaction with an intracardiac neural network modulating sinus node function. To gain novel mechanistical insights and to investigate possible novel targets concerning the treatment of inadequate sinus tachycardia, we aimed to characterize functionally and topographically the right atrial neural network modulating sinus node function. In 16 sheep 3-dimensional electro-anatomical mapping of the right atrium was performed. In five animals additionally magnetically steered remote navigation was used. Selective stimulation of nerve fibers was conducted by applying high frequency (200 Hz) electrical impulses within the atrial refractory period. Histological analysis of whole heart preparations by acetylcholinesterase staining was performed and compared to the acquired neuroanatomical mapping. We found that neural stimulation in the cranial part of the right atrium, within a perimeter around the sinus node area, elicited predominantly shortening of the sinus cycle length of −20.3 ± 10.1 % (n = 80, P < 0.05). Along the course of the crista terminalis atrial premature beats (n = 117) and atrial fibrillation (n = 123) could be induced. Catheter stability was excellent during remote catheter navigation. Histological work-up (n = 4) was in accord with the distribution of neurostimulation sites. Ganglions were mainly innervated by the dorsal right-atrial subplexus, with substantial additional input from the ventral right atrial subplexus. In conclusion, our findings suggest a functional and topographic concordance of right atrial neural structures inducing sinus tachycardia. This might open up new avenues in the treatment of heart rate related disorders.

The beneficial effects of cardiac resynchronization therapy (CRT) are thought to result from favorable left ventricular (LV) reverse remodeling, however CRT is only successful in about 70% of patients. Whether response to CRT is associated with a decrease in ventricular arrhythmias (VA) is still discussed controversially. Therefore, we investigated the incidence of VA in CRT responders in comparison with non-responders. In this nonrandomized, two-center, observational study patients with moderate-to-severe heart failure, LV ejection fraction (LVEF) ≤35%, and QRS duration >120 ms undergoing CRT were included. After 6 months patients were classified as CRT responders or non-responders. Incidence of VA was compared between both groups by Kaplan-Meier analysis and Cox regression analysis. ROC analysis was performed to determine the aptitude of LVEF cut-off values to predict VA. In total 126 consecutive patients (64±11years; 67%male) were included, 74 were classified as responders and 52 as non-responders. While the mean LVEF at baseline was comparable in both groups (25±7% vs. 24±8%; P = 0.4583) only the responder group showed an improvement of LVEF (36±6% vs. 24±7; p<0.0001) under CRT. In total in 56 patients VA were observed during a mean follow-up of 28±14 months, with CRT responders experiencing fewer VA than non-responders (35% vs. 58%, p7% was found to be a predictor of a significantly lower incidence of VA (AUC = 0.606). Improvement of left ventricular function under cardiac resynchronization therapy goes along with a reduced incidence of ventricular arrhythmia.