İskemik Mitral Yetersizliği
Özet
İskemik mitral yetersizliği (İMY), sekonder mitral yetersizliğin (SMY) en önemli alt grubunu oluşturan, koroner arter hastalığının sık ve prognostik açıdan olumsuz seyirli komplikasyonlarından biridir. Akut miyokard enfarktüsü (AMİ) sonrasında veya kronik iskemik süreçlerde gelişebilen İMY; sol ventrikül yeniden şekillenmesi (remodelling), papiller kas yer değiştirmesi, yaprakçık gerilmesi/çekilmesi (tethering), anülüs dilatasyonu ve mitral anülüsün dinamik eyer biçimli yapısının kaybı gibi birbirini besleyen mekanizmaların sonucunda ortaya çıkar. Yapısal olarak normal mitral yaprakçıkların, ventriküler yeniden şekillenme ile yetersiz koaptasyonu, İMY’nin temel özelliğidir (Carpentier IIIb). Epidemiyolojik veriler, AMİ sonrası hastaların %15–64’ünde İMY görüldüğünü, bu olguların %3–16’sında ise orta-ciddi düzeylere ulaştığını göstermektedir. İMY varlığı, mortalite ve kalp yetersizliği riskini bağımsız olarak artırmakta, kardiyojenik şokta sol ventrikül yetmezliğinden sonra ikinci en sık neden olarak öne çıkmaktadır. Hafif düzeydeki İMY dahi uzun dönem prognozu olumsuz etkilerken, ≥3+ düzeydeki mitral yetersizlik erken ve geç mortalite açısından güçlü bağımsız bir risk faktörüdür. Patofizyolojik süreçte ventrikülo-mitral-atrial aksın bütünsel disfonksiyonu ön plandadır. Papiller kas dislokasyonu, yaprakçıkgerilme/çekilmesi, anüler dilatasyon ve atriyal yeniden yapılanma birlikte ilerleyerek kendini besleyen olumsuz bir döngü oluşturur. Bu süreç yalnızca mekanik değil, aynı zamanda moleküler ve hücresel düzeyde fibrozis, inflamasyon ve matriks yeniden yapılanması ile desteklenmektedir. Tanıda ekokardiyografi (TTE, TEE, stres eko) temel yöntemlerdir. EROA ≥40 mm² ve regürjitan volüm ≥60 mL/atım ciddi İMY’nin göstergeleridir. Kardiyak manyetik rezonans (KMR), sol ventrikül volümleri ve fibrozis yükünü değerlendirmede altın standarttır. Bilgisayarlı tomografi (BT) ve nükleer yöntemler, koroner anatomi ve miyokard viabilitesi hakkında tamamlayıcı bilgiler sağlar. Erken ekokardiyografik tarama, yakın klinik takip ve uygun olgularda hedeflenmiş cerrahi veya girişimsel tedavi stratejileri prognozun iyileştirilmesi açısından kritik öneme sahiptir. Multimodalite görüntüleme, bireyselleştirilmiş tedavi planlamasında vazgeçilmezdir. Tedavide temel yaklaşım, kılavuzlar eşliğinde optimal medikal tedavi (GDMT) ve uygun olgularda revaskülarizasyonun yanı sıra mitral kapak onarımı veya korda-koruyucu mitral kapak replasmanıdır. Transkateter edge-to-edge repair (TEER), ileri yaş veya yüksek cerrahi riskli hastalarda giderek daha fazla kullanılmaktadır. Kardiyak resenkronizasyon tedavisi (CRT), ventriküler senkronizasyonu düzelterek regürjitasyonu azaltabilir. Atriyal fibrilasyon varlığında eş zamanlı cerrahi ablasyon ve sol atriyal apendiks kapatılması (LAAO) önerilmektedir. Gelecek perspektifleri arasında yapay zekâ destekli görüntü analizi, biyobelirteçler (NT-proBNP, yüksek duyarlılıklı troponin), 4D flow MRI, yeni nesil TMVR platformları; mitral yaprakçık biyolojisi, fibrozis ve genetik predispozisyonu inceleyen translasyonel araştırmalar ile kordal-sparing ve papiller kas reposition gibi yenilikçi cerrahi teknikler öne çıkmaktadır.
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