Y HOC VliT NAM THANG 8 - SO DAC BIET/2011
DONG THONG LIEN NHI BANG DU TAI BENH VIEN NHI DONG 2
Phan Thanh Tho*, Nguyin Minh Tri Viet*
TOM TAT
Muc tieu: Chiing tdi danh gia tinh hieu qua, dp an toan va dien tien sau khi ddng lo thdng lien nhi (TLN) bang du tai benh vien nhi dong 2.
PhWdng phap: Id thang 2 nam 2010 den thang 2 nam 2011 chiing tdi thUc hien ddng lo thong lien nhT du'dc 60 benh nhan. Chi djnh ddng thong lien nhT la: benh nhi cd lo thdng > 8mm va/ hoac kem theo viem hd hap tai phat, cham len can. Thii thuat dUdc thi/c hien dUdi gay me toan than va hu'dng dan ciia sieu am thiic quan va may thdng tim. Cd hai loai du dUdc chpn la Amplatzer Septal Occluder (ASO) va Oclutech Septal Occluder (OSO). Tham kham lam sang va sieu am dUdc thUc hien tru'dc va sau thu thuat (1, 3, 6, 12 thang va moi nam tiep theo).
Kit qua: Tuoi de ddng TLN tiT 6 thang tudi den 14 tuoi, tuoi trung blnh 35,5 thang. Cd 38 benh nhi du'dc ddng TLN bang dii ASO va 22 benh nhi ddng TLN bang du (OSO). Khdng cd ca nao t i i vong, khdng ca nao trdi dii can mo cap ciiu hay bien chu'ng cap tinh nang xay ra. 100%
het shunt ton Iu'u sau 6 thang. 1 benh nhan bj tan huyet man do kem hd van 2 la va 3 la sau dd chuyen sang phau thuat siia van tim. 1 benh nhan bj ngoai tam thu nhT phuc hoi hoan toan sau 3 thang dung cordarone. Sau khi ddng du tat ca benh nhan cai thien lam sang nhanh ehdng.
Kei luan: Vdi kinh nghiem hien tai, ddng TLN bang du cd the thUc hien an toan, hieu qua.
Tu'i<h6a:lhbng Lien NhT, ASO (Amplatzer Septal Occluder), OSO (Occlutech Septal Occluder)
SUMMARY
TRANSCATHETER CLOSURE OF ATRIAL SEPTAL DEFECT AT CHILDREN'S HOSPITAL 2
Objectives: This study sought to analyze the safety, efficacy, and follow-up results of
* B^nh vi$n Nhi d6ng 11
percutaneous closure of secundum atrial septal defect (ASD) at Children's Hospital 2.
Methods: Between february 2010 and february 2011, 60 patients percutaneously treated at our institution. Indications for closure were: elective closure in patients with ASD >
8mm and/or frequent respiratory infections;
failure to thrive. The procedure was carried out under general anesthesia with fluoroscopy and transesophageal control. Two different devices were used: 1) the Amplatzer Septal Occluder (ASO) and 2) the Oclutech Septal Occluder (OSO). Basal physical examinations and echocardiograms were performed prior to the procedure and at follow-ups ( 1 , 6, and 12 months, and yearly thereafter).
Results: The mean age at closure was 35,5 months from 6 months to 14 years. ASO was used in 38 subjects; OSO was used in 22 patients. No death or immediate major complications occurred. The total occlusion rate was 100% at 6 months of follow-up. No midterm major or minor complications occurred. 1 patient had chronic hemolytic anemia because mitral valve and tricuspid valve regurgitation. 1 patient with atrial premature beat had complete recovery after 3 months with cordarone PO. Symptomatic patients improved significantly.
Conclusions: In the current experienced hands, ASD closure can be performed safely and successfully, even in very young children.
Key words: ASD atrial septal defect; ASO (Amplatzer Septal Occluder); OSO (Occlutech Septal Occluder).
I. OAT V A N o f
Thdng lien nhT lo thii phat (TLN) chilm tir 6% din 10% tim bdm sinh ^'^ la mpt trong
TRUNG TAM TIM MACH BENH VIEN E - HQI NGHj KHOA HQC LAN THlf NHAT
nhiing loai benh thudng gap d tre em. Thdng thudng TLN cd shunt trai qua phai ldn hoac tim to deu cd chi dinh ddng lo thdng. Phau thuat ddng TLN la phuang phap dugc ap dung rpng rai va it nguy ca ^"\ tuy nhien cung cd nhiJng biln chiing nhat dinh ^''^\
benh nhan phai md tim hd. Thdng tim ddng (TLN) la phuang phap thay the phau thuat dugc mo ta ddu tien bdi King va cdng su ^'^^
Gdn day ky thuat thdng tim ddng (TLN) bdng ASO trd thanh phuang phap thay the phau thuat^'*-^^)
Cd nhieu nghien ciiu ve ddng ddng (TLN) bdng ASO dugc cdng bd ^'^'^'^ Chiing tdi tdng ket ve ket qua thuc hien ddng Id thdng lien nhT (TLN) bdng du tai benh vien Nhi Ddng 2.
Myc tieu nghien cihi:
Md ta dac diem lam sang, tinh hieu qua, dp an toan va diln tien sau khi ddng Id thdng lien nhT bang dii.
II. Odi TU^NG VA PHUONG PHAP NGHIEN COU L Doi tirong nghien cmi:
Benh nhi dugc ddng Id thdng lien nhT bang dii tai khoa tim mach benh vien Nhi Ddng 2 tir 02/2010 din 02/2011.
Tieu chudn chpn benh: Benh nhan cd TLN lo thii phat > 8mm vdi dau hieu ldn that phai; viem ho hdp thudng xuyen han 6 idn/nam^''^; cham ldn theo tieu chuan cua Hamil va cpng sir ^^\
Tieu chuan loai benh: (1) TLN lo thii phat kem theo tat tim phiic tap khac; (2) TLN kem bat thudng tinh mach phdi vl tim; (3) TLN lo nhd < 5mm khdng cd bang chiing ldn
thdt phai; (4) ria van 2 la, ria bd sau, ria tinh mach chii tren, ria tTnh mach chii dudi, ria xoang vanh <5mm.
2. Phuong phap nghien cihi Thiit ki nghien cuu:
Nghien ciiu cdt ngang md ta Co'/nfla:lay trpn
Cac budc tiin hanh
Benh nhan dugc gay me toan than, thu thuat dugc thuc hien dudi su hudng din cua sieu am qua dau dd thuc quan (GE. Vivit 7) va may thdng tim 2 binh dien (Siemen Artis).
Thdng tim phai do ap luc dpng mach phdi, do dudng kinh TLN bdng bdng (AGA Medical Corp) va sieu am qua dau dd thuc quan.
Hai loai dii dugc dvmg la Amplatzer , Septal Occluder (ASO) (AGA Medical
Corp.) va Occlutech Septal Occluder(0S0) (Occutech AB Sweden), ky thuat tha dii dugc thuc hien theo phuang phap dugc md ta trong hudng dan sii dung.
Shunt tdn luu: Shunt tdn luu dugc dinh nghTa khi cd flow tii nhT trai qua phai. Ludng thdng khdng dang kl khi chieu rpng flow
<lmm; nhd khi flow chilu rpng Iden 2mm;
trung binh khi flow chilu rpng 2 din 4mm;
ldn khi flow chieu rpng >4mm.
Quy trinh theo doi: Tdt ca benh nhan sau khi ddng dii diu dugc dung Aspirin 5mg/kg trong 6 thang, kham lam sang, sieu am qua thanh nguc trudc xudt vien va tai kham liic 1, 3,6,12 thang va moi nam sau do.
Phan tich kit qua bdng phdn mim SPSS 10.0
Y HOC VIET NAM THANG 8 - SO DAC BIET/2011
III. KET QUA
1. Dac diem chung
1 benh nhan sau khi vao phdng thdng tim phat hien hep tTnh mach chau 2 ben, nen dugc chuyin sang phiu thuat. Sd benh nhan dugc ddng TLN cdn 60 benh nhan.
Bang 1: Bang dac dilm benh nhan
, sd lu'dng benh nhan Tuoi
Gidi
< 'Can nang
OUdng kinh thong lien nhT qua sieu am thanh ngUc
60
35,5 thang (tii 6 thang - 14 tuoi) (nam/nii') 32/28
12,24 (tCr 6,3 - 43) (kg) 8 - 3 0 (mm)
Thdng tim ddng thdng lien nhT dugc thuc hien trong 60 benh nhan, tdt ca diu thanh cdng.
2. Ket qua liic thong tim
Thdng sd lien quan tdi thdng tim, dung cu va so ngay ndm vien dugc md ta trong bang 2.
Cd 3 benh nhi cd nhieu Id TLN nam gan nhau, chiing tdi ddng thanh cdng bdng 1 du duy nhat ASO. 1 benh nhi viia ddng thdng lien nhT vua ddng thdng lien thdt. 4 benh nhi vira ddng thdng lien nhT vira nong van ddng mach phdi. 3 benh nhi vira ddng thdng lien nhT vira ddng cdn dng dpng mach.
Ngay trudc va sau khi tha dii tat ca benh nhan deu sieu am thuc quan xac dinh dii nam diing vi tri va khdng gay chen ep hay hd van tim.
Bang 2: Bang thdng sd lien quan tdi thdng tim, dung cu DUdng kinh thdng lien nhT do bang bdng (mm)
Du'dng kinh thong lien nhT do qua sieu am thiic quan (mm) Kfch thu'dc dung cu du'dc diing (mm)
ASO (mm) OSO (mm)
Sd ngay nam vien (ngay)
3.8 (3-5) 17.4 (tir 9 - 27) 21.2 (tii 11 -34) 17.7 (tii 9 -34)
10-32 8-30 ASO = Amplatzer Septal Ocluder ; OSO = Occluder Septal Ocluder
3. Tai bien liic thong tim
Khdng cd ca nao tu vong hay trdi du xay ra liic thdng tim.
4. Shunt ton liru
Sieu am th\rc quan sau khi tha dii ti le cdn shunt tdn luu miic dp nhe 80%, trudc liic xudt vifn qua sieu am thanh nguc ti le shunt ton luu giam cdn 10%, sau 6 thang shunt ton luu hit hoan toan.
5. Ngay nam vien
Thdi gian ndm vien trung binh 3,8 ngay, ngoai trii 1 trudng hgp cd ngoai tam thu nhT phai theo ddi Holter ECG va xuat vien 5 ngay sau dd.
6. Theo doi
Thdi gian theo ddi trung binh la 6 thang (tir 1 thang din 12 thang). Khdng cd trudng hgp tii vong, khdng cd trudng hgp nao hi viem ndi tam mac, khdng tai bien do huyet
TRUNG TAM TIM MACH BENH VIEN E - HOI NGHI KHOA HOC LAN THOT NHAT
khdi, Trong qua trinh theo ddi cd 1 benh nhan (1,6%) bi tan huyet man do kem hd van 2 la va 3 la trudc dd, benh nhan nay dugc phdu thuat sua lai van. 1 benh nhan (1,6%) bi ngoai tam thu nhT hit sau 3 thang dung cordarone.
IV. BAN LUAN
TLN cd dudng kinh dudi 5mm din 8mm da sd tu ddng khi h:e din 3 tudi^'"''^^ vi vay chiing tdi chi dilu tri cho benh nhan TLN < 3 tudi khi cd trieu chung viem hd hdp tai phat nhieu ldn, cham len can hoac ldn thdt phai.
Chiing tdi ddng TLN thanh cdng cho 26 benh nhi (46%) < 3 tudi va dudng kinh Id thdng >
8mm cd trieu chiing viem hd hdp tai phat nhieu ldn, cham len can hoac ldn thdt phai.
Phiu thuat ddng Id TLN thudng thuc hien d tre tii 4 din 5 tudi ^^'^^\ do dd ddi vdi benh nhan TLN dudng kinh > 8mm khdng cd bilu hien lam sang, thdi dilm dl ddng TLN khi benh nhi > 3 tudi.
Thdng tim ddng TLN ngay nay dugc thirc hien thudng quy d ngudi ldn. Cd rdt nhieu loai dimg cu dung dk ddng TLN
(4,6,2,21,14) y ^ ^ ^ j.x^ ^ j i ^ ^^j j j . ^ ^x ^ ^ ^ g . p j ^ ^
d ngudi ldn ^''•^'^'^ Tuy nhien khdng cd nhilu nghien ciiu vl tinh an toan, kha thi va hieu qua cua thdng tim ddng TLN d tre em.
Rastegary va cdng su^^°^ bao cao thanh cdng loat 20 benh nhan thdng tim ddng TLN bdng ASO tudi tir 6 thang din 20 tudi, khdng cd bien chiing. Vogel va cpng sir ^^^^ thuc hien 12 benh nhan TLN < 2 tudi, trong dd 6 benh nhan cham len can, 5 benh nhan bi viem hd hdp tai phat nhieu lan, 1 benh nhan suy tim. Kit qua chi thanh cdng trong 10 benh nhan, 2 benh nhan can phai phau thuat \d dii ndm sai vi tri.
Trong nhdm nghien ciiu ciia chiing tdi thuc hien dugc 60 benh nhan, ti le ddng TLN thanh cdng la 100%. Khdng cd tai biln
nghiem trpng xay ra liic thdng tim. Chiing toi cd the thuc hien cung liic ddng TLN va ddng thdng lien that, ddng TLN va nong van dpng mach phdi, ddng TLN va ddng cdn dng dpng mach. Trong nhieu nghien ciiu cac tai biln du nam sai vi tri, trdi du deu cd thi xay ra.
Chessa va cpng sir^^^ bao cao khi thuc hien ddng TLN d 417 benh nhan ngudi ldn cd 10 trudng hgp (2,4%) du nam sai vi tri hay trdi dii. Cd nhieu ky thuat de thu du lai bdng thdng tim khi cd tai bien trdi du, tuy nhien ky thuat nay phai dung sheath ldn (>12F) do do han che d tre em.
Trong qua trinh theo ddi sau khi ddng du khdng cd bien chiing nghiem trpng xay ra, viem hd hap giam bdt, benh nhan len can tdt.
Loi ich ve mat lam sang: Thdng tim ddng TLN d tre em cd nhieu diem thuan Igi.
Thii nhat la it gay ra tac ddng ve mat tam ly cho benh nhan, cd bang chiing cho thay phau thuat md tim hd cd the gay ra rdi loan tam ly d tre em^^^l Thii hai la tranh dugc seo trudc nguc, gay me hoi siic phiic tap, phai ndm hdi siic, thdi gian nam vien keo dai. Thii ba la do khdng cd seo tren tam nhT nen giam nguy co rdi loan nhip nhT. Hien nay thdng tim ddn thay the phau thuat ddng TLN, tham chi d tre nhe can.
Gioi han thong tim: khdng phai tat ca TLN diu cd the ddng dugc bang thdng tim.
Chiing tdi chi thuc hien ddng TLN d benh nhan cd TLN Id thii phat cd ria day du va khdng cd bat thudng tTnh mach phdi ve hm.
Mac dii ky thuat ddng thong lien nhT chiing td an toan, tuy nhien vl dien tien lau dai thi cdn theo ddi them. Ngugc lai, tinh an toan va hieu qua trong phau thuat ddng TLN da dugc chirng minh^^'^'"''^''^'>
V. KET LUAN
Sau 12 thang thuc hien ddng thdng lien
Y HQC VIET NAM THANG 8 - S O PAC BIET/2011
nhT dugc 60 benh nhan, khdng cd trudng hgp nao trdi dii hay biln chiing nang xay ra, 1 trudng hgp tan huylt man do kem hd van 2 la tniac dd, 1 trudng hgp ngoai tam thu nhT hit sau 3 thang, tdt ca cdn lai diu cd diln tiln tdt. Do dd chiing tdi nhan thdy rdng thdng tim ddng TLN bdng du d tre em cd thi thuc hien thanh cdng, an toan va hieu qua.
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