Ahmet GÜLER, Mustafa BULUT, Cihan DÜNDAR, Kürşat TİGEN, Tansu KARAAHMET, Yeliz GÜLER, Uğur ASLANTAŞ, Süleyman EFE, Emrah ACAR, Süleyman BARUTCU, İsmail BALABAN, Selçuk PALA

Mitral Darlığı Olan Hastalarda Atriyal Elektiriksel ve Elektromekanik Özellikler

Giriş: Mitral darlığı olan hastalarda atriyal fibrilasyon (AF) önemli bir mortalite ve morbidite nedenidir ve bu hastalarda perkütan mitral balon valvüloplasti (PMBV) semptomlarda ve ekokardiyografik parametrelerde önemli düzelme sağlayan başarılı bir girişimdir. Bu çalışmada mitral darlıklı hastalarda PMBV’nin AF gelişimini predikte edebilen yeni ekokardiyografik ve elektrokardiyografik parametreler üzerindeki bir yıllık dönemdeki etkisinin gösterilmesi amaçlanmıştır. Hastalar ve Yöntem: Orta ve ileri mitral darlığı olan 28 hasta (ortalama yaş 37.6 ± 7.4, %50’si erkek) çalışmaya dahil edilmiştir. PMBV girişimine aday olan hastaların işlem öncesi ve sonrasındaki birinci yılda atriyal ileti zamanı (ACT) açısından ayrıntılı ekokardiyografik incelemeleri doku Doppler yöntemiyle yapılmıştır. Ayrıca her hastanın işlemden bir gün önce ve birinci yılda maksimum ve minimum P dalga süreleri (Pmax ve Pmin) ve P dalga dispersiyonu (PWD) elektrokardiyografi ile değerlendirilmiştir. Bulgular: PMBV işleminden sonra ACT (148.1 ± 20.5 vs. 121.3 ± 20.5, p< 0.001), Pmax (151.7 ± 15.8 vs. 137.3 ± 15.6, p< 0.001), PWD (84.7 ± 18.8 vs. 71.1 ± 18.5, p< 0.001) değerleri istatistiksel anlamlı olarak düşmüştür. İşlem öncesi ve sonrası ACT, Pmax, PWD, LAVi ve PAPs parametreleri arasında güçlü pozitif korelasyon tespit edilmiştir. Ayrıca işlem sonrası ve öncesi değerlerin çıkarılmasıyla hesaplanan Δ değerleri arasında güçlü korelasyon tespit edilmiştir. Buna göre; ΔACT’nin ΔPmax ve ΔPWD (r= 0.5, p= 0.007 ve r= 0.55, p= 0.002, sırasıyla) değerleriyle korele olduğu tespit edildi ve ΔACT, ΔPmax ve ΔPWD, ekokardiyografik parametrelerden sadece ΔLAVi ve ΔPAP ile anlamlı olarak korele idi. Sonuç: Bu çalışma mitral darlıklı hastalarda EKG ve TDI yöntemleriyle değerlendirilen atriyal ileti özelliklerinin diğer ekokardiyografik parametrelerle önemli derecede korele olduğunu göstermiştir. Ayrıca işlem sonrası birinci yılda bu parametrelerde önemli düzeyde düzelme meydana gelmiştir. Yapılacak prospektif özellikte daha fazla çalışma atriyal elektromekanistik özellikler ve AF gelişimi arasındaki ilişki açısından daha fazla bilgi sağlayabilir.

Anahtar Kelimeler:

Romatizmal mitral darlık, atriyal fibrilasyon, atriyal ileti zamanı, P dalga dispersiyonu, perkütan mitral balon valvüloplasti

Atrial Electrical and Electromechanical Characteristics in Patients with Rheumatic Mitral Stenosis

Introduction: AF in patients with mitral stenosis (MS) causes significant morbidity and mortality. PMBV, which is a treatment of choice for patients with MS, is a highly successful procedure that provides significant improvement in symptoms and echocardiographic parameters. In this study we aimed to demonstrate the probable effects of PMBV on novel echocardiographic and electrocardiographic parameters that can predict the development of AF in 1-year period in patients with MS. Patients and Methods: Twenty-eight patients with moderate or severe rheumatic MS (mean age 37.6 ± 7.4 years; 14 (50%) males) were enrolled this study. All patients who were eligible for this procedure underwent comprehensive echocardiographic examinations with evaluation of ACT measured using tissue Doppler imaging (TDI) before PMBW and repeated at the end of the 1 year after successful PMBV. In addition, 12-lead ECGs were recorded for each patient 1 day before PMBV for the evaluation of baseline maximum and minimum P-wave duration and P-wave dispersion (PWD); this was repeated at the end of the 1 year after successful PMBV. Results: ACT (148.1 ± 20.5 vs 121.3 ± 20.5 p< 0.001), P-max (151.7 ± 15.8 vs 137.3 ± 15.6 p< 0.001) and PWD (84.7 ± 18.8 vs 71.1 ± 18.5 p< 0.001) were found to be significantly decreased after PMBV. A strong positive correlation was detected between ACT, P-max, PWD, LAVi ve PAPs before and after PMBV. In addition, there was a strong correlation between Δ values that were measured by subtracting the baseline measurements from the post-PMBV measurements. Accordingly, ΔACT was correlated with ΔP-max ve ΔPWD (r= 0.5 p= 0.007 and r= 0.55 p= 0.002, respectively). ΔACT, ΔP-max and ΔPWD correlated significantly with only ΔLAVi and ΔPAP in echocardiographic parameters. Conclusion: This study demonstrated that atrial conduction properties that have also been evaluated with ECG and TDI studies significantly correlate with other echocardiographic parameters in patients with MS. In addition, significant improvement occurred in these parameters at the end of the 1 year after PMBV. Further prospective investigations may provide useful data for the detection of the relation between atrial electromechanical characteristics and development of AF in patients with MS.

Keywords:

Rheumatic mitral stenosis, atrial fibrillation, atrial conduction tine P-wave dispersion, percutaneous mitral balloon valvuloplasty,

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1. Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, et al. American Society of Echocardiography’s Nomenclature and Standards Committee; Task Force on Chamber Quantification; American College of Cardiology Echocardiography Committee; American Heart Association; European Association of Echocardiography, European Society of Cardiology. Recommendations for chamber quantification. Eur J Echocardiogr 2006;7:79-108.
2. Kircher B, Abbott JA, Pau S, Gould RG, Himelman RB, Higgins CB, et al. Left atrial volume determination by biplane two-dimensional echocardiography: validation by cine computed tomography. Am Heart J 1991;121(3 Pt 1):864-71.
3. Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr 2010;23:685-713.
4. Cui W, Roberson DA, Chen Z, Madronero LF, Cuneo BF. Systolic and diastolic time intervals measured from Doppler tissue imaging: normal values and Z-score tables, and effects of age, heart rate, and body surface area. J Am Soc Echocardiogr 2008;21:361-70.
5. Inoue K, Owaki T, Nakamura T, Kitamura F, Miyamoto N. Clinical application of transvenous mitral commissurotomy by a new balloon catheter. J Thorac Cardiovasc Surg 1984;87:394-402.
6. Braunwald E. Valvular heart disease. In: Braunwald E, Zipes DP, Libby P. Heart Disease: A Textbook of Cardiovascular Medicine. 6th ed. Philadelphia: WB Saunders, 2001:1643-53.
7. Kannel WB, Abbott RD, Savage DD, McNamara PM (1982) Epidemiologic features of chronic atrial fibrillation: the Framingham study. N Engl J Med 306:1018-22.
8. Vaziri SM, Larson MG, Benjamin EJ, Levy D. Echocardiographic predictors of nonrheumatic atrial fibrillation. The Framingham Heart Study. Circulation 1994;89:724-30.
9. Psaty BM, Manolio TA, Kuller LH, Kronmal RA, Cushman M, et al. Incidence of and risk factors for atrial fibrillation in older adults. Circulation 1997;96:2455-61.
10. Tsang TS, Barnes ME, Gersh BJ, Bailey KR, Seward JB. Left atrial volume important risk marker of incident atrial fibrillation in 1,655 older men and women. Mayo Clin Proc 2001;76:467-75.
11. Tani T, Tanabe K, Ono M, Yamaguchi K, Okada M, Sumida T, et al. Left atrial volume and the risk of paroxysmal atrial fibrillation in patientswith hypertrophic cardiomyopathy. J Am Soc Echocardiogr 2004; 17:644-8.
12. Tsang TS, Abhayaratna WP, Barnes ME, Miyasaka Y, Gersh BJ, et al. Prediction of cardiovascular outcomes with left atrial size: Is volume superior to area or diameter? J Am Coll Cardiol 2006;47:1018-23.
13. Dilaveris PE, Gialafos EJ, Sideris S, Theopistou AM, Andrikopoulos GK, Kyriakidis M, et al. Simple electrocardiographic markers for the prediction of paroxysmal idiopathic atrial fibrillation. Am Heart J 1998;135:733-8.
14. Wang K, Xiao HB, Fujimoto S, Gibson DG. Atrial electromechanical sequence in normal subjects and patients with DDD pacemakers. Heart 1995;74:403-7.
15. Mizuno R, Fujimoto S, Nakano H, Nakajima T, Kimura A, Nakagawa Y, et al. Atrial conduction abnormalities in patients with systemic progressive sclerosis. Eur Heart J 1997;18:1995-2001.
16. Ramsaran EK, Spodic DH. Electromechanical delay in the left atrium as a consequence of interatrial block. Am J Cardiol 1996;77:1132-4.
17. Barletta G, Del Bene R, Fantini F. The normal sequence of right and left atrial conduction. Ann Noninvasive Electrocardiol 2001;6:222-8.
18. Tsang TS, Barnes ME, Gersh BJ, Bailey KR, Seward JB. Left atrial volume important risk marker of incident atrial fibrillation in 1.655 older men and women. Mayo Clin Proc 2001;76:467-75.
19. Tani T, Tanabe K, Ono M, Yamaguchi K, Okada M, Sumida T, et al. Left atrial volume and the risk of paroxysmal atrial fibrillation in patients with hypertrophic cardiomyopathy. J Am Soc Echocardiogr 2004;17:644-8.
20. Pala S, Tigen K, Karaahmet T, Dundar C, Kilicgedik A, Güler A, et al. Assessment of atrial electromechanical delay by tissue Doppler echocardiography in patients with nonischemic dilated cardiomyopathy. J Electrocardiol 2010;43:344-50.
21. Alizade E, Sahin M, Simşek Z, Açar G, Bulut M, Güler A, et al. Cilostazol decreases total atrial conduction time in patients with peripheral artery disease. Perfusion 2014;29:265-71.
22. Aytemir K, Ozer N, Atalar E, Sade E, Aksoyek S, Ovunc K, et al. P wave dispersion on 12-lead electrocardiography in patients with paroxysmal atrial fibrillation. Pacing Clin Electrophysiol 2000;23:1109-12.
23. Turhan H, Yetkin E, Senen K, Yilmaz MB, Ileri M, Atak R, et al. Effects of percutaneous mitral balloon valvuloplasty on P-wave dispersion in patients with mitral stenosis. Am J Cardiol 2002;89:607-9.
24. Erbay AR, Turhan H, Yasar AS, Bicer A, Senen K, Sasmaz H, et al. Effects of long-term beta-blocker therapy on P-wave duration and dispersion in patients with rheumatic mitral stenosis. Int J Cardiol 2005;22:102:33-7.
25. Guntekin U, Gunes Y, Tuncer M, Gunes A, Sahin M, Simsek H. Long-term follow-up of P-wave duration and dispersion in patients with mitral stenosis. Pacing Clin Electrophysiol 2008;31:1620-4.
26. Ozer N, Yavuz B, Can I, Atalar E, Aksöyek S, Ovünç K, et al. Doppler tissue evaluation of intra-atrial and interatrial electromechanical delay and comparison with P-wave dispersion in patients with mitral stenosis. J Am Soc Echocardiogr 2005;18:945-8.
27. Rezaian GR, Rezaian S, Liaghat L, Zare N. P-wave dispersion in patients with rheumatic mitral stenosis. Int J Angiol 2007;16:20-3.
28. Eid Fawzy M, Shoukri M, Al Sergani H, Fadel B, Eldali A, Al Amri M, et al. Favorable effect of balloon mitral valvuloplasty on the incidence of atrial fibrillation in patients with severe mitral stenosis. Catheter Cardiovasc Interv 2006;68:536-41.
29. Turhan H, Yetkin E, Senen K, Yilmaz MB, Ileri M, Atak R, et al. Effects of percutaneous mitral balloon valvuloplasty on P-wave dispersion in patients with mitral stenosis. Am J Cardiol 2002;89:607-9.
30. Demirkan B, Guray Y, Guray U, Ege MR, Kisacik HL, Sasmaz H, et al. The acute effect of percutaneous mitral balloon valvuloplasty on atrial electromechanical delay and P-wave dispersion in patients with mitral stenosis. Herz 2013;38:210-5.

ISSN: 2149-2972
Yayın Aralığı: Yılda 3 Sayı
Başlangıç: 1990
Yayıncı: Sağlık Bilimleri Üniversitesi, Kartal Koşuyolu Yüksek İhtisas Eğitim ve Araştırma Hastanesi