Romatizmal Mitral Kapak Hastalığı Ülkemizde Güncelliğini Koruyor mu? Romatizmal Kökenli Mitral Kapak Replasmanı Erken ve Uzun Dönem Sonuçlarımız

Giriş: Bu çalışmanın amacı kliniğimizde etyolojik olarak sık görülen romatizmal mitral kapak hastalığı tedavisinde uyguladığımız mitral kapak replasmanı sonrası erken ve uzun dönem sonuçları sunmaktır. Hastalar ve Yöntem: Temmuz 2008 ila Aralık 2017 tarihleri arasında kliniğimizde mitral kapak replasmanı yapılan tüm olgular geriye dönük olarak incelendi. Çalışmaya, romatizmal etyoloji zemininde mitral kapak replasmanı olan olgular dahil edildi. Primer olarak önem verilen sonuçlar, postoperatif mortalite oranları, geç dönem sağkalım oranları ve geç dönem mortaliteye etki eden faktörler idi. Bulgular: Çalışmaya 88 hasta dahil edildi. Dört (%4.5) hastada ilk 30 gün içinde mortalite görüldü. Preoperatif dönemde AF ritmi bulunan ve eş zamanlı aritmi cerrahisi uygulanan 19 (%21.6) hastanın 11 (%12.5)’i sinüs ritmine döndü. Tüm hastaların 5 yıllık sağkalım oranı %77.9 idi. Mitral darlık, yetmezlik ve kombine mitral darlık ve yetmezlik patolojisine göre 5 yıllık sağkalım oranları sırası ile %72.6, %81.8 ve %86.7 idi ve gruplar arasında istatistiksel olarak fark yoktu (Log Rank, p= 0.63). Uzun dönem mortaliteye etki eden bağımsız prediktörler preoperatif kronik böbrek yetmezliği varlığı (HR: 33.4, %95 CI: 4.1-272.3, p= 0.001) ve kardiyopulmoner baypas süresi (HR: 1.05, %95 CI: 1.02-1.08, p< 0.001) idi (Cox regresyon). Sonuç: Romatizmal mitral kapak hastalığı, kırsal ve sınır ötesinden gelen göç nedeniyle ülkemizde halen güncelliğini korumaktadır. Rekürrensin önlenmesi, efektif kapak orifis alanının sağlanması ve sol ventrikül çıkım yolu darlık riskini azaltması açısından kapak replasmanı sonuçları oldukça iyi olup, daha iyi bir seçenek olmaktadır. Ayrıca uzun dönem sağkalıma etkisi açısından preoperatif kronik böbrek yetmezliği varlığında önlemlerin alınması ve operasyon esnasında uzamış kardiyopulmoner baypas sürelerinden kaçınılması gereklidir.

Anahtar Kelimeler:

Akut eklem romatizması, atriyal fibrilasyon, mitral kapak replasmanı, romatizmal mitral kapak hastalığı

Is Rheumatic Mitral Valve Disease Still Maintaining its Prevalence in Our Country? Early and Long-term Outcomes After Mitral Valve Replacement with Rheumatic Origin

Introduction: The purpose of this study was to present early and long-term results of mitral valve replacement in the treatment of rheumatic mitral valve disease, encountered frequently as an etiology in our clinic. Patients and Methods: All patients undergoing mitral valve replacement in our clinic between July 2008 and December 2017 were retrospectively reviewed. Patients with rheumatic mitral stenosis and/or regurgitation were included in the study. Primary outcome of interest was early mortality rates, long-term survival rates, and independent predictors of long-term survival. Results: In total, 88 patients were included in the study. Early mortality was observed in 4 (4.5%) patients. Concomitant arrhythmia surgery was performed in 19 (21.6%) patients with preoperative atrial fibrillation, and 11 of the 19 (12.5%) patients showed sinus rhythm after the operation. Overall 5-year survival rate was 77.9%. When compared to the valve pathologies, 5-year survival rates was 72.6% in patient group with isolated mitral stenosis, 81.8% in patient group with isolated mitral regurgitation, and 86.7%, in patient group with combined mitral stenosis and regurgitation. There was no statistically significant difference among the groups (p= 0.63). The existence of preoperative chronic renal failure (HR, 33.4; 95% CI, 4.1-272.3; p= 0.001) and cardiopulmonary bypass time (HR, 1.05; 95% CI, 1.02-1.08; p< 0.001) were independent predictors of long-term survival. Conclusion: Rheumatic mitral valve disease remains a problem in our country due to rural and border migration. Valve replacement is an optimal choice and produces satisfactory results in terms of prevention of recurrence and provision of effective valve orifice area. In addition, it is necessary to take precautions in the presence of preoperative chronic renal failure and to avoid prolonged cardiopulmonary bypass periods during the operation to ensure long term survival.

Keywords:

Acute rheumatic fever, atrial fibrillation, mitral valve replacement, rheumatic mitral valve disease,

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1. Remenyi B. Rheumatic heart disease of the mitral valve: Is there such thing as an ideal operation? Heart Lung Circ 2018;27:779-81.
2. Watkins D, Johnson C, Colquhoun S, Karthikeyan G, Beaton A, Bukhman G, et al. Global, regional and national burden of rheumatic heart disease, 1990-2015. N Engl J Med 2017;377:713-22.
3. Remenyi B, Carapetis J, Wyber R, Taubert K, Mayosi B. Position statement of the world heart federation on the prevention and control of rheumatic heart disease. Nat Rev Cardiol 2013;10:284-92.
4. Wyber R, Taubert K, Marko S, Kaplan E. Benzathine penicillin G for the management of RHD: Concerns about quality and access and opportunities for intervention and improvement. Glob Heart 2013;8:227-34.
5. Kassem A, El-Walili T, Zaher S, Ayman M. Reversibility of mitral regurgitation following rheumatic fever: Clinical profile and echocardiographic evaluation. Indian J Pediatr 1995;62:717-23.
6. Yanagawa B, Butany J, Verma S. Update on rheumatic heart disease. Curr Opin Cardiol 2016;31:162-8.
7. Gewitz M, Baltimore R, Tani L, Sable C, Shulman S, Carapetis J, et al. Revision of the jones criteria for the diagnosis of acute rheumatic fever in the era of doppler echocardiography: A scientific statement from the american heart association. Circulation 2015;131:1806-18.
8. Carapetis J, Steer A, Mulholland E, Weber M. The global burden of group A streptococcal diseases. Lancet Infect Dis 2005;5:685-94.
9. Günther G, Asmera J, Parry E. Death from rheumatic heart disease in rural Ethiopia. Lancet 2006;367:391.
10. Gupta M, Lent R, Kaplan E, Zabriskie J. Serum cardiac troponin I in acute rheumatic fever. Am J Cardiol 2002;89:779-82.
11. Chen M, Wu C, Yip H, Chang H, Chen C, Yu T, et al. Increased circulating endothelin-1 in rheumatic mitral stenosis: Irrelevance to left atrial and pulmonary artery pressures. Chest 2004;125:390-6.
12. Guilherme L, Kalil J. Rheumatic fever and rheumatic heart disease: Cellular mechanisms leading autoimmune reactivity and disease. J Clinic Immunol 2010;30:17-23.
13. Ellis N, Li Y, Hildebrand W, Fischetti V, Cunningham M. T cell mimicry and epitope specificity of cross-reactive t cell clones from rheumatic heart disease. J Immunol 2005;175:5448-56.
14. Fae K, da Silva D, Oshiro S, Tanaka A, Pomerantzeff P, Douay C, et al. Mimicry in recognition of cardiac myosin peptides by heart-intralesional t cell clones from rheumatic heart disease. J Immunol 2006;176:5662-70.
15. Delunardo F, Scalzi V, Capozzi A, Camerini S, Misasi R, Pierdominici M, et al. Streptococcal-vimentin cross-reactive antibodies induce microvascular cardiac endothelial proinflammatory phenotype in rheumatic heart disease. Clin Exp Immunol 2013;173:419-29.
16. Fischetti V. Streptococcal m protein. Sci Am 1991;264:58-65.
17. Russell E, Walsh W, Reid C, Tran L, Brown A, Bennetts J, et al. Outcomes after mitral valve surgery for rheumatic heart disease. Heart Asia 2017;9:1-7.
18. Russell EA, Tran L, Baker RA, Bennetts JS, Brown A, Reid CM, et al. A review of valve surgery for rheumatic heart disease in Australia. BMC Cardiovasc Disord 2014;14:134.
19. Russell EA, Tran L, Baker RA, Bennetts JS, Brown A, Reid CM, et al. A review of outcome following valve surgery for rheumatic heart disease in Australia. BMC Cardiovasc Disord 2015;15:103.
20. Rusingiza E, El-Khatib Z, Hedt-Gauthier B, Ngoga G, Dusabeyezu S, Tapela N, et al. Outcomes for patients with rheumatic heart disease after cardiac surgery followed at rural district hospitals in Rwanda. Heart 2018;0:1-7.
21. Coutinho G, Bihun V, Correia P, Antunes P, Antunes M. Preservation of the subvalvular apparatus during mitral valve replacement of rheumatic valves does not affect long-term survival. Eur J Cardiothorac Surg 2015;48:861-7.
22. Little S. The challenges of managing rheumatic disease of the mitral valve in Jamaica. Cardiol Young 2014;24:1108-10.
23. Thomson Mangnall L, Sibbritt D, Fry M, Gallagher R. Short- and long-term outcomes after valve replacement surgery for rheumatic heart disease in the South Pacific, conducted by a fly-in/fly-out humanitarian surgical team: A 20-year retrospective study for the years 1991 to 2011. J Thorac Cardiovasc Surg 2014;148:1996-2003.
24. Celermajer D, Chow C, Marijon E, Anstey N, Woo K. Cardiovascular disease in the developing world: Prevalences, patterns and the potential of early disease detection. J Am Coll Cardiol 2012;60:1207-16.

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