İbrahim GÖKŞİN, Ahmet BALTALARLI, Engin TULUKOĞLU, Ufuk Ali TÜRK, Mansur ŞAĞBAN, Arif YILMAZ, Gökhan ÖNEM, Mustafa SAÇAR

Hafif fonksiyonel triküspid regürjitasyonu: Mitral kapak replasmanı sonrası seyri ve postoperatif rezidüel triküspid regürjitasyonunu gösteren preoperatif ekokardiyografik prediktif kriterler

Amaç: Hafif fonksiyonel triküspid kapak regürjitasyonu (TR) mitral kapak replasmanı sonrası sıklıkla regrese olur veya tümüyle ortadan kalkar, fakat hastaların %13'ünde progresyon şansı vardır. Rezidüel TR postoperatif hasta morbidite ve mortalitesini arttırır. Bu çalışmanın amacı, hafif fonksiyonel TR'nin mitral kapak replasmanı sonrası postoperatif seyrini, postoperatif rezidüel TR kalan veya tümüyle kaybolan hastalar arasında preoperatif ekokardiyografik paremetreler yönünden fark olup olmadığını belirlemekti. Materyal ve Metod: Hafif fonksiyonel TR'ye sahip 25 hasta çalışmaya dahil edildi. Preoperatif ve postoperatif fonksiyonel TR'nin derecelendirilmesi, renkli doppler ekokardiyografi ile apikal 4 boşluk görüntüsünde sistol sırasında sağ atriyum içerisinde oluşan mozaiklenme alanı ölçülerek yapıldı. Her hasta için, sağ atriyum inferior-superior (RA inf/sup), mediolateral (RA med/lat), sağ ventrikül çıkım yolu (RVOT) ve giriş yolu (RVIT), sol ventrikül ejeksiyon fraksiyonu (LVEF) ve pulmoner arter sistolik basınç (PAPs) ölçümleri ekokardiyografik olarak yapıldı. Verilerin analizleri için Wilcoxon macthed pairs signed rank testi kullanıldı. Bulgular: Kapak replasmanı sonrası hafif fonksiyonel TR, 12 hastada (%48) tümüyle ortadan kalktı, 14 hastada (%56) regresyon gösterdi, 8 hastada (%32) aynen kaldı, 3 hastada (%12) ise progresyon gösterdi. Postoperatif rezidüel TR kalan ve TR'nin tümüyle kaybolduğu hastaların preoperatif ekokardiyografik ölçümleri sırasıyla RA inf/sup 56.53 ± 8.78 / 50.25 ± 3.33 mm, RA med/lat 44.46 ± 4.71 / 38.16 ± 4.04 mm, RVOT 24.84 ± 2.6 / 24.25 ± 2.49 mm, RVIT 40.69 ± 2.28 / 39 ± 3.71 mm, LVEF %57.69 ± 8.15 / %61.75 ± 5.81, PAPs 58.92 ± 8.97 / 55.33 ± 6.89 mmHg idi. Postoperatif rezidüel TR kalan ve TR'nin tümüyle kaybolduğu hastalar arasında, preoperatif ekokardiyografik paremetreler yönünden sağ atriyum boyutlarında anlamlı farklılık vardı (p < 0.05). Sonuç: Sonuç olarak, preoperatif sağ atriyum boyutları postoperatif rezidüel TR için prediktif bir kriterdir.

Mild functional tricuspid regurgitation: An its course after mitral valve replacement and preoperative echocardiographic predictive criterion showing postoperative residual tricuspid regurgitation

Background: Mild functional tricuspid regurgitation (TR) generally regresses or completely disappears after mitral valve replacement, but there is a chance of progression in 13% of patients. Residual TR increases patient's morbidity and mortality postoperatively. The aim of the study was to determine the postoperative course of mild functional TR after mitral valve replacement and whether or not there was any significant differences in preoperative echocardiographic parameters between the patients with or without residual TR. Methods: Twentyfive patients with mild functional TR was included to this study. Preoperative and postoperative functional TR was evaluated with color flow doppler echocardiography in apical 4-chamber view with the measurment of mosaic formation area in the right atrium during systole. For every patient, right atrial inferior-superior (RA inf/sup), mediolateral (RA med/lat) diameters, right ventricular outflow tract (RVOT) and inflow tract (RVIT) diameters, left ventricular ejection fraction (LVEF) and pulmonary arterial sistolic pressure (PAPs) were measured. Wilcoxon macthed pairs signed rank test was used for analysis of data. Results: After mitral valve replacement, mild functional TR completely dissapeared in 48% (12), regressed in 56% (14), remained the same in 32% (8) and progressed in 12% (3) of the patients. Preoperative echocardiographic parameters in patients with or without postoperative residual TR were as following: RA inf/sup 56.53 ± 8.78 / 50.25 ± 3.33 mm, RA med/lat 44.46 ± 4.71 / 38.16 ± 4.04 mm, RVOT 24.84 ± 2.6 / 24.25 ± 2.49 mm, RVIT 40.69 ± 2.28 / 39 ± 3.71 mm, LVEF %57.69 ± 8.15 / %61.75 ± 5.81, PAPs 58.92 ± 8.97 / 55,.33 ± 6.89 respectively. There was a significant difference in preoperative right atrial dimension between the patients with or without residual TR (p < 0.05). Conclusion: In conclusion, preoperative right atrial diameters are predictive criterion for postoperative residual TR.

PDF

___

1. Tager R, Skudicky D, Mueller U, Essop R, Hammond G, Sareli P. Long-term follow-up of rheumatic patients undergoing left-sided valve replacement with tricuspid annuloplasty. Validity of preoperative echocardiographic criteria in the decision to perform tricuspid annuloplasty. Am J Cardiol 1998;81:1013-6.
2. Breyer RH, McClenathen JH, Michaelis LL, Melntosh CL, Morrow AG. Tricuspid regurgitation. A comparison of nonoperative management, tricuspid annuloplasty, and tricuspid valve replacement. J Thorac Cardiovasc Surg 1976;72:867-74.
3. Pluth JR, Ellis FH. Tricuspid insufficiency in patients undergoing mitral valve replacement. Conservative management, annuloplasty or replacement. J Thorac Cardiovasc Surg 1969;58:484-91.
4. King RM, Schaff HV, Danielson GK, et al. Surgery for tricuspid regurgitation late after mitral valve replacement. Circulation 1984;70:193-7.
5. Baughman KL, Kallman CH, Yurchak PM, Daggett WM, Buckley MJ. Predictors of survival after tricuspid valve surgery. Am J Cardiol 1984;54:137-41.
6. Rivera JM, Vandervoort PM, Vazquez JA, et al. Which physical factors determine tricuspid regurgitation jet area in the clinical setting? Am J Cardiol 1993;72:1305-9.
7. Yousof AM, Shafei MZ, Endrys G, Khan N, Simo M, Cherian G. Tricuspid stenosis and regurgitation in rheumatic heart disease: A prospective cardiac catheterization study in 525 patients. Am Heart J 1985;110:60-4.
8. Duran CMG, Pomar JL, Colman T, Figueroa A, Revuelta JM, Ubago JL. Is tricuspid valve repair necessary? J Thorac Cardiovasc Surg 1980;80:849-54.
9. Cohen SR, Sell JE, McIntosh CL, Clark RE. Tricuspid regurgitation in patients with acquired, chronic, pure, mitral regurgitation. I. Prevalence, diagnosis, and comparison of preoperative clinical and hemodynamic features in patients with and without tricuspid regurgitation. J Thorac Cardiovasc Surg 1987;94:481-7.
10. Sagie A, Schwammenthal E, Palacious IF. Significant tricuspid regurgitation does not resolve after percutaneous ballon mitral valvotomy. J Thorac Cardiovasc Surg 1994;108:727-35.
11. Curtis JM, Thyssen M, Breuer HWM, Loogen F. Doppler versus contrast echocardiography for diagnosis of tricuspid regurgitation. Am J Cardiol 1985;56:333-6.
12. DePace NL, Ross J, Iskandrian AS, et al. Tricuspid regurgitation: Noninvasive techniques for determining causes and severity. J Am Coll Cardiol 1984;3:1540-3.
13. Miller MJ, McKay RG, Ferguson JJ, et al. Right atrial pressure-volume relationships in tricuspid regurgitation. Circulation 1986;73:799-808.
14. Waggoner AD, Quinones MA, Young JB, et al. Pulsed doppler echocardiographic detection of right-sided valve regurgitation. Am J Cardiol 1981;47:279-86.
15. Sugimoto T, Okada M, Ozaki N, Kawahira T, Fukuoka M. Influence of tricuspid regurgitation on right ventricular function. Ann Thorac Surg 1998;66:2044-50.
16. Wong M, Matsumura M, Kutsuzawa S, Omoto R. The value of doppler echocardiography in the treatment of tricuspid regurgitation in patients with mitral valve replacement. Perioperative and two-year postoperative findings. J Thorac Cardiovasc Surg 1990;99:1003-7.
17. Hayashi J, Okazaki H, Nokazawa S, Watanabe H, Miyamura H, Eguchi S. Right ventricular systolic performance before and after surgery for tricuspid regurgitation associated with mitral stenosis. Jpn Circ J 1996;60:96-101.