Dejeneratif Mitral Kapak Hastalıkları

Ahmet Rüçhan  Akar; Mehmet Cahit  Sarıcaoğlu; Ali Fuat  Karaçuha; İsmet Onur  Tanıyan; Emre  Şen; Volkan  Kozluca; İrem  Dinçer; Mustafa Bahadır İnan

doi:10.37609/akya.3889

Dejeneratif Mitral Kapak Hastalıkları

Yazarlar

Ahmet Rüçhan Akar ; Mehmet Cahit Sarıcaoğlu ; Ali Fuat Karaçuha ; İsmet Onur Tanıyan ; Emre Şen; Volkan Kozluca; İrem Dinçer; Mustafa Bahadır İnan

DOI: https://doi.org/10.37609/akya.3889.c5339

Özet

Dejeneratif mitral kapak hastalığı (DMKH), aort darlığından sonra en sık görülen edinsel kapak hastalığı olup, yaşla birlikte prevalansı artan ve primer mitral yetersizliğin en sık nedeni olan bir kapak patolojisidir. Toplum temelli çalışmalarda mitral kapak prolapsusu (MVP) prevalansı genç erişkinlerde %2–3 düzeyinde iken, 65 yaş üzerindeki bireylerde %6–10’a kadar yükselmektedir. MVP, yaprakçıkların sistolde sol atriyuma ≥2 mm yer değiştirmesi ile tanımlanır ve hastalığın en belirgin fenotipini oluşturur. Fibroelastik yetersizlik (FED), ileri yaşlarda daha sık görülen; yaprakçıklarda incelme, kısalık ve kordalarda frajilite ile karakterize, çoğunlukla tek segment tutulumu (özellikle P2) ve ani kordal rüptür sonucu akut ciddi yetmezlik ile seyreden bir formdur. Barlow hastalığı ise genç yaşlarda başlayabilen, yaprakçıklarda diffüz kalınlaşma, miksomatöz dejenerasyon, fazlalık doku ve anüler dilatasyon ile karakterize; genellikle çok segmentli tutulumu olan ve aritmi riski yüksek bir fenotiptir. Ayrıca kordal rüptür, mitral anüler kalsifikasyon (MAK), mitral anülus ayrışması (disjunction) ve GAP-BAV gibi fenotipler de klinik spektrumun çeşitliliğini artırmaktadır.

Tanıda ekokardiyografi temel yöntemdir. Carpentier sınıflaması (Tip I: normal hareket, Tip II: aşırı hareket/prolapsus, Tip III: kısıtlı hareket) cerrahi planlamada halen altın standarttır. Segmental anatomi analizi (A1–A2–A3, P1–P2–P3, kommissural segmentler C1-C2) onarım stratejisinin belirlenmesinde kritik rol oynar. Fonksiyonel değerlendirmede anüler dilatasyon, yaprakçık hareketleri, koaptasyon yüksekliği, jet özellikleri ve ventrikül fonksiyonları analiz edilerek kapak onarımının başarısı öngörülür. Yüksek hacimli merkezlerde uygulanan modern kapak onarım teknikleri, düşük mortalite oranları, düşük tromboemboli/enfektif endokardit riski ve replasmana göre üstün uzun dönem sağkalım sonuçlarıyla öne çıkmaktadır. Mitral cerrahiye ek olarak, atriyal fibrilasyonu (AF) olan hastalarda eş zamanlı cerrahi ablasyon önerilmekte; sol atriyal apendiks oklüzyonu (LAAO) oral antikoagülasyona ek strateji olarak inme ve tromboemboli riskini azaltmaktadır. İleri evre olgularda sıklıkla gelişen triküspit yetersizliğinde ring veya sütür ile yapılan triküspit anüloplastisi sağ ventrikül fonksiyonunun korunması açısından önemlidir. Ulusal ölçekte, mitral kapak onarım tekniklerinin yaygın ve etkin uygulanabilmesi için eğitim programları Türk Kalp Damar Cerrahisi Derneği (TKDCD) öncülüğünde sürdürülmektedir. Minimal invaziv mitral cerrahi, medyan sternotomiye alternatif olarak sağ torakotomi veya hemitorakotomi yaklaşımlarıyla daha az travma, daha hızlı iyileşme ve kozmetik avantaj sağlar. Robotik mitral cerrahi, üç boyutlu görüntüleme ve robotik enstrümantasyon sayesinde kompleks onarımlarda üstün hassasiyet sunar.

Tedavi stratejilerinin belirlenmesinde multidisipliner kalp ekibi yaklaşımı günümüzde standart hale gelmiştir. Bu ekip, her hastanın klinik özelliklerini, anatomisini, cerrahi riskini ve yaşam beklentisini değerlendirerek bireyselleştirilmiş kararlar vermekte; böylece onarımın başarısı ve uzun dönem prognoz iyileştirilmektedir. Transkateter yaklaşımlar, yüksek riskli hasta grubunda cerrahiye alternatif oluşturmaktadır. Gelecek perspektifinde yapay zekâ tabanlı görüntüleme analizleri, biyomekanik modelleme, yeni nesil transkateter sistemler, 4D akım manyetik rezonans görüntüleme ve mitral yaprakçık biyolojisi üzerine translasyonel araştırmalar, bireyselleştirilmiş tedavi stratejilerinin gelişimine katkı sağlayacaktır.

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Kalp ve Damar Cerrahisi (Cilt 1-2)

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23 Mart 2026

Dejeneratif Mitral Kapak Hastalıkları

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