İleri Mitral Yetersizliği Sistolik Disfonksiyon Halindeki Sol Ventrikülde Mural Trombüs Oluşumunu Önleyebilir mi?
Nihal ÖZDEMİR1, Enver DAĞLAR1, Cihangir KAYMAZ1, Osman KARAKAYA1, Murat AKÇAY1, Murat YÜCE1, Olcay ÖZVEREN1, Mehmet ÖZKAN1Koşuyolu Kalp ve Araştırma Hastanesi, Kardiyoloji Kliniğiİleri mitral yetersizliğinin (MY) sol atriyal trombüs (T) oluşumunu önleyici etkisi bilinmektedir. Ayrıca, ileri MY'nin sistolik disfonksiyonu (SD) bulunan sol ventrikül (SV) içinde mural T oluşumunu da önleyebildiği öne sürülmüştür. Çalışmamız, SV sistolik disfonksiyonu bulunan olgularda iskemik MY varlığının SVT sıklığına etkisini araştırmayı amaçlamaktadır. Çalışma grubu, koroner anjiyografi ve sol ventrikülografi ile iskemik sol ventrikül SD bulunan 1313 hastadan (E 1133, K 180, yaş 56±18 yıl) oluşturulmuştur. Olguların hiçbirinde kronik antikoagülan kullanım öyküsü mevcut değildi. Epikardiyal koroner arterler 91 olguda normal olup, tek damar, 2 damar ve 3 damar hastalığı, sırasıyla 328, 330 ve 564 olguda mevcuttu. Anjiyografik MY ciddiyeti hafif, orta ve ileri olarak derecelendirildi. Septal (S), apikal (AP) ve/veya anterolateral (AL) segmentlerde diskinezi ve anevrizma, sırasıyla 394 ve 470 olguda bulundu. Posterobazal (PB), posterolateral (PL) ve/veya inferiyor (I) segmentlerde diskinezi ve anevrizma, sırasıyla 110 ve 181 olguda bulundu. İskemik dilate kardiyomyopati 158 olguda mevcuttu. Mural SVT 191 (%14.5), ciddi iskemik MY 125 (%9.5) olguda gözlendi. Seri genelinde, ileri MY bulunan olgularda, MY bulunmayanlara kıyasla SVT sıklığı anlamlı olarak düşük bulundu (%4 ve %15.6, OR: 0.2, p<0.001). İleri MY varlığında, gerek iskemik dilate kardiyomyopati (%6.8 ve %34.2, OR:0.19, p<0.001), gerekse segmenter SVSD (%2.5 ve %13.7 %, OR: 0.2, p<0.01) gruplarında SVT sıklığında anlamlı azalma bulundu. İleri MY'nin bulunuşu halinde SVT sıklığı AL,S ve A segmentlerde anevrizma bulunanlarda anlamlı (%3 ve %18, OR: 0.14, p<0.0001), diskinezi grubunda ise anlamlı olmayan bir azalma (%4.7 ve %16, OR: 0.26, p= 0.1) göstermekteydi. Buna karşılık, ileri MY PB, I ve/veya PL segmentlerde anevrizma veya diskinezi bulunanlarda SVT sıklığı üzerinde etkili bulunmadı (%3.7 ve %3, OR: 1.2, p>0.05). Sonuç olarak; (1) İleri derecedeki MY'nin gerek iskemik dilate kardiyomyopati, gerekse anteriyor SV duvar anevrizması bulunan olgularda SVT oluşumunu önleyebildiği düşünülmüştür.
May Mitral Regurgitation Prevent Thrombus Formation in the Left Ventricle in Patients with Global and Segmentary Systolic Dysfunction?
Nihal ÖZDEMİR1, Enver DAĞLAR1, Cihangir KAYMAZ1, Osman KARAKAYA1, Murat AKÇAY1, Murat YÜCE1, Olcay ÖZVEREN1, Mehmet ÖZKAN1Protective effect of severe mitral regurgitation (MR) against left atrial thrombus (T) formation has been documented. It was also proposed that severe MR could prevent T formation in the left ventricle (LV) in the presence of systolic LV dysfunction (LVD). The purpose of this study is to investigate whether ischemic MR prevents T formation within the LV in patients with LVD. Study population comprised 1313 pts (M 1133, F 180, age 56±18 years) with is-chemic LVD documented by coronary angiography and left ventriculography. None of the patients had history of chronic anticoagulation. Epicardial coronary arteries were normal in 91 patients, and single-vessel, two-vessel, and triple-vessel disease were documented in 328, 330, and 564 patients, respectively. Global systolic LVD was defined as EF < 0.50. Severity of the angiographic MR was graded as mild, moderate and severe. Dyskinesia and aneurysm related to septal (S), apical (A) and/or anterolateral (AL) wall segments were found in 394 and 470 pts, respectively. Dyskinesia and aneurysm associated with posterobasal (PB), posterolateral (PL) and /or inferior (I) wall segments were detected in 110 and 181 pts, respectively. Ischemic dilated cardiomyopathy was documented in 158 patients. Mural LVT and severe ischaemic MR were detected in 191 (14.5 %) and 125 (9.5%) patients, respectively. Overall incidence of LVT was found to be lower in patients with MR as compared to those without MR (4% vs 15.6%, OR: 0.2, p<0.001). In comparison to the absence of MR, severe MR was associated with a lower incidence of LVT in patients with ischemic dilated cardiomyopathy (6.8% vs 34.2%, OR: 0.19, p<0.001) and in patients with segmentary LVD (2.5% vs 13.7%, OR: 0.2, p<0.01). There was a significant difference in reference to presence of severe MR in patients with aneurysm (3% vs 18%, OR: 0.14, p<0.0001), and a nonsignificant difference in patients with dyskinesia (4.7% vs 16%, OR: 0.26, p=0.1) related to A, AL, S wall segments. However, MR had no impact on incidence of LVT in the group with aneurysm or dyskinesia related to PB, I, or PL segments (3.7% vs 3%, OR: 1.2, p>0.05). Conclusions: (1) Severe MR seems to prevent mural LVT formation both in patients with ischemic dilated cardiomyopathy and in patients with aneurysm related to anterior LV wall segments, and (2) this protective effect of severe MR against LVT formation may be associated with diastolic volume overloading which may offset stagnation and procoagulant state within the LV with systolic dysfunction.
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