Akut Romatizmal Ateş ve Romatizmal Mitral Kapak Hastalıkları
Özet
Romatizmal mitral kapak hastalığı (RMKH), özellikle düşük ve orta gelirli ülkelerde önemli bir kardiyovasküler morbidite ve mortalite nedenidir. Dünya Sağlık Örgütü (WHO) verilerine göre, dünya genelinde 40 milyondan fazla kişi bu hastalıktan etkilenmekte ve her yıl 300.000’den fazla ölüm romatizmal kalp kapak hastalıklarına atfedilmektedir. Çoğunlukla çocukluk çağında geçirilen akut romatizmal ateş (ARA) sonrası gelişen bu hastalık, en sık mitral kapakta olmak üzere kalp kapaklarında ilerleyici yapısal bozukluklara yol açar. Komissüral füzyon, yaprakçık kalınlaşması ve kalsifikasyonu, subvalvüler aparat tutulumu ve anüler deformasyon sürecin temel özellikleridir. Epidemiyolojik veriler RMKH’nin halen dünya çapında genç erişkinleri etkilediğini ve gebelik gibi fizyolojik süreçlerde ciddi komplikasyonlara yol açabildiğini göstermektedir. Klinik seyirde atriyal fibrilasyon, pulmoner hipertansiyon, tromboembolik olaylar ve sağ kalp yetmezliği sık karşılaşılan sorunlardır. Tanıda transtorasik ve transözofageal ekokardiyografi temel yöntemler olup, kapak morfolojisi, hemodinamik etkiler ve cerrahi endikasyonlar açısından kritik bilgiler sağlar. Kardiyak manyetik rezonans, bilgisayarlı tomografi ve multimodalite görüntüleme yöntemleri özellikle ileri cerrahi planlamada tamamlayıcı rol oynar. Hastalığın dinamik ve progresif yapısı nedeniyle yakın takip, erken müdahale ve bireyselleştirilmiş tedavi stratejileri hasta prognozunu iyileştirmede temel unsurlardır. Tedavi yaklaşımları arasında medikal tedavi, perkütan mitral balon valvüloplasti (PMBV), cerrahi mitral kapak onarımı veya replasmanı yer alır. PMBV, uygun morfolojideki semptomatik mitral darlığında ilk basamak tedavidir. Cerrahi ise ağır semptomlu, ileri fibrotik veya kalsifik kapaklarda ön plana çıkar. Atriyal fibrilasyonun varlığında ablasyon ve sol atriyal apendiks kapatılması (LAAO) önerilmektedir. Gebelikte yönetim, anne ve fetusun güvenliği açısından multidisipliner yaklaşım gerektirir; hemodinamik stabiliteyi korumak, tromboemboli riskini azaltmak ve doğum planlamasını optimize etmek bu sürecin temel hedefleridir. Gelecek perspektiflerinde yapay zekâ destekli ekokardiyografi taramaları, yeni biyobelirteçler, genetik predispozisyonun aydınlatılması, minimal invaziv ve chordal-sparing cerrahi teknikler ile transkateter kapak girişimlerinin romatizmal hastalarda uygulanabilirliği önemli araştırma alanlarıdır.
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