Prediktor Kejadian Spontaneous Echocardiographic Contrast di Atrium Kiri pada Penderita Stenosis Mitral Rematik

Abstract

Spontaneous echocardiographic contrast (SEC) adalah suatu gambaran seperti asap dengan gerakan berputar-putar yang ditemukan pada saat pemeriksaan ekokardiografi. Penelitian sebelumnya menunjukkan adanya SEC di atrium kiri menjadi faktor risiko untuk pembentukan trombus. Pada pasien stenosis mitral rematik, risiko trombosis dan perkembangan SEC di atrium kiri tinggi. Beberapa penelitian sebelumnya melaporkan bahwa patofisiologi trombus dan SEC di atrium kiri selain fibrilasi atrium dan stasis aliran darah di atrium kiri juga adanya beberapa mekanisme lain seperti respon imun, inflamasi dan peningkatan aktifitas trombotik. Salah satu penanda inflamasi yang signifikan untuk penyakit kardiovaskuler yang akhir-akhir banyak diteliti adalah rasio netrofil/limfosit (RNL). Tujuan penelitian ini adalah untuk menentukan hubungan antara RNL, area katup mitral dan fibrilasi atrium dengan SEC di atrium kiri pada penderita stenosis mitral rematik. Ini adalah penelitian observasional yang bersifat cross sectional, dilakukan dari Juli 2015 sampai Juli 2017 terhadap pasien stenosis mitral rematik yang datang ke rumah sakit Adam Malik. Semua pasien dilakukan pemeriksaan darah, elektrokardiografi, dan ekokardiografi transtorakal. Pasien dibagi 2 kelompok berdasarkan kehadiran SEC di atrium kiri menurut hasil pemeriksaan ekokardiografi. Didapatkan 104 pasien, dimana 52 pasien (usia rata-rata 40 ± 11 tahun, 71% wanita) merupakan kelompok tanpa SEC, dan 52 pasien (usia rata-rata 40 ± 10 tahun, 73% wanita) merupakan kelompok dengan SEC. Tidak ada perbedaan bermakna pada lekosit, dimana kelompok tanpa SEC (8,06±1,54) dan kelompok dengan SEC (7,37±1,76). Dari analisis multivariat regresi logistik, didapatkan fibrilasi atrium (OR = 51,311, nilai IK 95% antara 3,723 – 707,100, p = 0,003) rasio netrofil/limfosit (OR = 21,641, nilai IK 95% antara 5,174 – 90,528, nilai p < 0,001), area katup mitral (OR = 14,423, nilai IK 95% antara 1,665 – 124,908, nilai p = 0,015), dan RDW (OR = 5,743, nilai IK 95% antara 1,349 – 24,445, nilai p = 0,018), merupakan prediktor independen untuk terjadinya SEC. Titik potong untuk nilai rasio N/L > 3,2 memiliki angka sensitivitas, sensitifitas, nilai prediktif positif dan nilai prediktif negatif yang sama yaitu masing-masing 81% untuk memprediksi kejadian SEC di atrium kiri pada pasien stenosis mitral rematik. Sebagai kesimpulan, fibrilasi atrium, rasio netrofil/limfosit, RDW dan area katup mitral dapat menjadi prediktor SEC di atrium kiri pada pasien stenosis mitral rematik.

Spontaneous echo contrast (SEC) is the presence of smoke like echoes with a characteristic swirling motion of blood found during echocardiography. Previously conducted researches showed that presence of SEC in the left atrium (LA) can constitute a risk factor for thrombus formation. In patients with rheumatic mitral stenosis (RMS) the risk of thrombosis and left atrial SEC development is eventually higher. Some previous studies have also reported that in addition to AF and blood stasis in the LA, the pathophysiology of left atrial thrombus and SEC occurring in patients with RMS exhibits some other mechanisms, such as autoimmunity, inflammation and increased thrombotic activity. The significance of the neutrophil/lymphocyte ratio (NLR) as a marker of inflammation in cardiovascular disease has been revealed by recent studies. The purpose of our study was to determinate the association between NLR, mitral valve area and atrial fibrillation with left atrial SEC in patients with RMS. Cross sectional study was conducted between July 2015 to July 2017 in patient who admitted to Haji Adam Malik Hospital due to mitral stenosis rheumatic. Blood examination, electrocardiography and transthoracic echocardiography were performed to all patients. They were divided into two groups according to presence of left atrial SEC. From 104 patients, 52 (mean age 40 ± 11 years; 71,2% women) were in the left atrial SEC-negative group and 52 patients (mean age 40 ± 10 years; 73,1% women) were in the left atrial SEC-positive group. There were no significant differences in the leucocyte, 8,06±1,54 were in the left atrial SEC-negative group and 7,37±1,76 were in the left atrial SEC-positive group. In multivariate analysis, atrial fibrillation (OR = 51,311, 95% CI 3,723 – 707,100, p = 0,003) neutrophil/lymphocyte ratio (OR = 21,641, 95% CI 5,174 – 90,528, p < 0,001), mitral valve area (OR = 14,423, 95% CI 1,665 – 124,908, p = 0,015), and RDW (OR = 5,743, 95% CI 1,349 – 24,445, p = 0,018), These study show that neutrophil/lymphocyte ratio with cut off point of >3,2 had sensitivity, spesificity, positive predictive value, and negative predictive value to predict left atrial SEC is the same 81%, respectively. As Conclusion, atrial fibrillation, neutrophil/lymphocyte ratio, RDW and mitral valve area can predict left atrial spontaneous echocardiographic contrast in rheumatic mitral stenosis patients.