İlkay ERDOĞAN, Hazım Alper GÜRSU, Murat ÖZKAN, Birgül VARAN

Ameliyat edilmiş Fallot tetralojili hastalarda pulmoner kapak replasmanı öncesi ve sonrası sağ ventrikül fonksiyonlarının doku Doppler görüntüleme ile değerlendirilmesi

Amaç: Bu çalışmada sağ ventrikül disfonksiyonunun tanısında ve pulmoner kapak replasmanına yanıtın değerlendirilmesinde doku Doppler ekokardiyografisinin etkinliği araştırıldı. Çalışma planı: Aralık 2008 - Aralık 2010 tarihleri arasında Fallot tetralojisi nedeni ile tam düzeltme yapılmış, izleminde pulmoner kapak yetmezliği gelişmiş ve pulmoner kapak replasmanı yapılmış toplam 15 hasta (8 erkek, 7 kadın; ort. yaş 14.5±4.5 yıl; dağılım, 7-22 yıl) çalışmaya alındı. Replasman öncesi ve replasmandan bir, üç ve altı ay sonra ekokardiyografik görüntüleme yapıldı. Nabız dalga Doppleri ile triküspit kapak akım velosite eğrisindeki erken diyastolik E dalgası ve geç diyastolik A dalgası ölçüldü. Doku Doppler ölçümleri, sağ ventrikülün serbest duvar bazal segmentinden ve interventriküler septumdan yapıldı. S, e ve a velositeleri ile izovolümetrik kontraksiyon zamanı, izovolümetrik relaksasyon zamanı ve ejeksiyon zamanı ölçüldü. Her hasta için miyokard performans indeksi hesaplandı. Bulgular: Replasman öncesi sağ ventrikülün serbest duvarının bazal segmentine kıyasla interventriküler septumdan alınan s, e, a velositeleri ve ejeksiyon zamanı daha düşük iken, izovolümetrik kontraksiyon zamanı ve izovolümetrik relaksasyon zamanı ile miyokard performans indeksi daha yüksek idi. Replasman öncesi döneme kıyasla, replasman sonrası birinci ayda interventriküler septum değeri, replasman öncesine göre sağ ventrikülün serbest duvarında anlamlı olarak azalır iken, triküspid kapakta replasman sonrası birinci ayda izovolümetrik kontraksiyon zamanı düştü ve miyokard performans indeksi azaldı, üçüncü ayda izovolümetrik relaksasyon zamanı azaldı, altıncı ayda ise s velositesi, izovolümetrik kontraksiyon zamanı ve miyokard performans indeksi arttı. Septumda replasman öncesi doku Doppler değerleri, sağ ventrikülün serbest duvarına göre daha erken dönemde miyokardiyal sistolik ve diyastolik disfonksiyon geliştiğini gösterdi. Bu sonuç, replasman sonrası altıncı ayda sağ ventrikülde yeterli düzelmenin olmadığını gösterdi. Sonuç: Doku Doppler ile replasman öncesi sağ ventrikül fonksiyonlarındaki bozulma gösterilebilir; ancak, tedavi sonrası altıncı aya kadar sağ ventrikülde yeterli düzelmeyi göstermede yetersiz kalabilir.

Evaluation of right ventricular function in operated tetralogy of Fallot patients with tissue Doppler imaging before and after pulmonary valve replacement

Background: This study aims to investigate the efficacy of tissue Doppler echocardiography for the diagnosis of right ventricular dysfunction andfor the evaluation of the response to pulmonary valve replacement. Methods: Between December 2008 and December 2010, a total of 15 patients(8 males, 7 females; mean age: 14.5±4.5 years; range, 7 to 22 years) with pulmonary valve insufficiency in the follow-up of total correction of tetralogy of Fallot who underwent pulmonary valve replacement were included in the study. Echocardiographic imaging was performed before and one, three, and six months after replacement. Using pulse wave Doppler, early diastolic E and late diastolic A waves were measured in the flow velocity curve of tricuspid valve. Tissue Doppler measurements were made from the basal segment of right ventricular free wall and interventricular septum. S, e, and a myocardial velocities, isometric contraction time, isovolumetric relaxation time and ejection time were measured. Myocardial performance index was calculated for each patient.Results: In pre-pulmonary valve replacement phase, s, e, a velocities and ejection time were lower in the interventricular septum compared to the basal segment of right ventricular free wall, while isometric contraction time, isovolumetric relaxation time and myocardial performance index values were higher. In the first post-replacement month, there was a significant decrease in the s value of interventricular septum, compared to pre-pulmonary valve replacement period; isometric contraction time decreased and myocardial performance index increased in the first post-pulmonary valve replacement month in the free wall of right ventricle, while isovolumetric relaxation time decreased in the postoperative third month, and s velocity, isometric contraction time and myocardial performance index increased in the postoperative sixth month. Pre-pulmonary valve replacement tissue Doppler values at the septum showed that myocardial systolic and diastolic dysfunction developed earlier than the basal segment of right ventricular free wall. This result showed that right ventricular recovery wasnot complete in the sixth post-pulmonary valve replacement month. Conclusion: Tissue Doppler can show right ventricular dysfunctionbefore replacement, but it may be insufficient to visualize right ventricular recovery until six months after treatment.

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