Y HOC VIET NAM SO DAC BIET-THANG 11/2010 lam sang, 147-154,319-3 56.
Nguyen Lan Viet, Pham Manh Hiing , Pham Gia Khai (2003);" Chup dpng mach vanh ", Benh hoc Tim mgch, tap 1,NXB Y Hoc chi nhanh TPHCM, tr. 155-169.
Antoniucci D,Valentin R, Santoro GM, et al,(2001), " Restenosis After Coronary Stent in Current Clinical Practice", Am Heart J 135(3):510-518.
Bauters C, Hubert E, Prat A, et al (1998),"Predictors of Restenosis After Coronary Stent Inplantation.", JACC, 1291-
1298.
Bennett Martin R.(2003), "In-stent stenosis:
Pathology and Implications for the Development of Drug Eluting Stent", HEART 89:214-228.
8. Bhargava B, Karthikeyan G, et al (2003),"Restenosis",5M^327,274-279
9. Dangas George, Kuepper Frank (2002),"
Restenosis: Repeat Narrowing of a Coronary Artery Prevention and Treatment", Circulation, 105:2586
10. Degertekin M, Regar E, tanabe K,et al (2003)."Sirolimus-eluting stent for treatment of complex in -stent restenosis: the first clinical experience."J^7w Co//;41:184-189.
NHAN XET QUA 350 TRUdNG HOP TAO NHJP VINH VIEN
OB!
TAI BENH VIEN TRUNG aONG HUE
• • •
Hoang Van Quy*, Nguyen Curu Lgi*, Huynh Van Minh^
TOM TAT
Dat van de: Tao nhjp tim vTnh vien la ky thuat dieu trj cac rdi loan nhjp tim cham cd trieu chirng vdi sU ho trd ciia mpt may phat nhjp dugc cay vao trong c6 the. Gan day, ky thuat nay da du'dc phat trien d nhieu trung tam tim mach ciia ca nUdc. Do dd, can danh gia lai hieu qua cung nhu cac bien chu'ng da gap phai de cd hUdng phat trien ben vii'ng.
Ddi tu'dng va phu'dng phap: Gom tat ca cac benh nhan dUdc chi djnh dat may tao nhjp vTnh vien trong thdi gian tir 1995 den 2008. PhUdng phap nghien ciru: theo sd bp.
Kit qua: cd tat ca 350 benb nban, trong do nu' chiem 61,42%, tudi trung binh 60,21%
±25,5, cd 12 trUdng hdP tre em dUdi 5 tud'i va 1
* Tnmg tam Tim mcich - B^nh vi^n Trung Udng Hui
trUdng hgp cu gia 97 tudi. Chi dinh tao nhjp: Hau bet la bloc nhT that dp III (50,85%), hpi chiTng nut xoang benh ly (40%), bloc nhT that dp II (4%), rung nhT cham (2,28%), ngoai ra con cd cac benh khac nhU suy tim nang,benh cd tim phi dai. PhUdng thirc tao nhip: Hau het la 1 buong (WI,WIR) 88,4%,dac biet chiing toi bat dau tien hanh dat may tao nhjp tai ddng bp cd tim CRT cho 9 trUdng hdp va dat may pha rung tU dpng ICD cho 1 trUdng hdp bj rdi loan nhjp that nang.
OUdng vao chii yeu la tTnh mach dUdi don, mpt sd trUdng hdp la tTnh mach dau va hiem hdn la tTnh mach canh trong. Ddi vdi tre sd sinh va tre nho dudi 2 tudi chung toi tao nhjp thUdng tam mac qua thanh ngUc. Ket qua dai han: Co sU cai thien chat lUdng cupc sdng va ty le tir vong ro
CHUYEN DE: PHAU THUAT TIM MACH VA tONG NGUC VIET NAM ret sau dat may. Bien chu'ng tao nhip kha da I . D A T V A N OE
dang nhUng thudng xay ra vdi nhii'ng trUdng hdp dau tien
Kit luan: Ky thuat may tao nhjp vTnh viln co vai tro quan trpng khong the thieu trong dieu trj cac rdi loan nhjp cham cd trieu chiTng.
SUMMARY
REVIEW 350 CASES WHO WERE UNDERWENT PERMANENT CARDIAC PACING AT HUE CENTRAL HOSPITAL '
Background: permanent pace maker implantation is a decisive therapeutic procedure for symtomatic bradyarrythmias. Long period of development of this technic requires a review on efficacy and complications.
Method and materials: registry study of all patients in whom a pace maker was indicated for treatment of a symtomatic bradyarryhtmia from
1995 to 2008 at Hue Central Hospital.
Results: 350 patients were included in the study with 61,42% them were female, mean age 60,21±25,5, 12 cases under 5 years old and 1 case more than 97 years old. Indications: AV block (50,85%), sinus node dysfunction 40%, second degree AV block (4%), slow atrial fibrillation (2,28%), end-stage heart failure (9 patients) and malignant ventricular arrythmia in one patient.. Pacing mode: single chamber pacing was most often indicated (WI,VVIR) (88,4%), 9 CRT and 1 ICD. Vascular access:
most often subclavical vein, occasionaly brachiocephalic vein and rarely external jugular vein, transthoracic pericardium pacing for newborn and email children. There was significant improvement of quality of life, reduced mortality after pacemaker implantation.
Complications were raely reported and often occurred at the beginning of learning curve.
Conclusion: permanent cardiac pacing had an important and positive role for the treatment of symtomatic bradyarrythmias with low complications
Roi loan nhip tim cham la mpt trong nhimg nguyen nhan hang diu dan din ti le hi vong cao cua cac benh ly tim mach. Trong cac bien phap dieu tri, ngoai viec sir dung thuoc chong roi loan nhjp, tao nhip tim vTnh viln cd vai tro khong the thilu, dac biet la cac trudfng hpp nhip nhanh-nhip cham. Ngoai ra, tao nhip tai dong bp ca tim va khu rung tu dpng la nhimg phuang tien him hieu trong dieu tri suy tim giai doan cudi.
Ca cay may tao nhip tim dSu tien tren thi gidi vao nam 1958 tai Thuy Diln, sau d6 phat trien dan vdi tao nhip 1 buong, 2 bufing, pha rung tu dpng va tao nhip 3 bu6ng tim trong dieu tri suy tim.
Tai Viet Nam, ca tao nhip tim dau tien d Ha Npi nam 1973, sau do cac Benh vi?n Hihi Nghi, Benh vien Quan dpi 108, Benh vien Chg Ray va Benh vien Thdng Nhat nto 1990. Nam 1993, ca tao nhip 2 buong dau tien dugc thuc hien d Thanh pho Ho Chi Minh. Benh vien Trung uang Hue thuc hi?n cay may tao nhip lan dau vao nam 1996 va phat trien dan cho den nay vdi so lugng ngay cang tang.
I I . DOI TU'O'NG VA P H U O N G PHAP NGHIEN CU'U
2.1. Doi tirong nghien ciru:
Bao gom 350 benh nhan dugc cky may tao nhip tim, pha rung tu dgng va tao nhip tim 3 budng tai khoa Ngi Tim mach B?nh vien Trung uong Hue tir nam 1996 den 2008.
• Tieu chudn ehon b^nh: B?nh nhan dugc chi dinh cdy may tao nhip tim theo khuyen cao ve tao nhip cua Hpi Tim mach Hpc Hoa Ky ACC/AHA nam 1991 va khuyen cao mdi nam 1998, 2007.
Y HOC VIET NAM SO DAC BIET — THANG 11/2010
2.2. Phirong phap nghien cmi:
- Nghien curu theo s6 bp, theo doi dpc theo thdi gian.
• Ky thudt edy mdy tgo nhip tim:
- Cay may tao nhip tim dugc thuc hien tai phong thong tim Benh vien Trung uang Hul. Tir nam 1995 din nam 1997 thuc hien cay may duoi su hudng dSn cua sieu am dl dua dien cue vao budng tim. Nam 1998 bit dSu thuc hien dudi man huynh quang.
- Phau thuat cay may: Cay may dudi da viing dudi xuong don. Dien cue dugc dua vao qua 1 trong 3 tinh mach canh ngoai.
- Tao nhip tam thdi trong mgt vai tnrdng hgp cdn thilt trong luc chd tao nhip vinh vien. Khang sinh du phdng 1 ngay trude va 4 ngay sau cay may. Chgc tinh mach dudi don, tinh mach canh hoac bgc 16 tinh mach cdnh tay dau.
- Chup phim phoi kiem tra dien cue va may truac khi cho benh nhan xuat vien.
- Kiem tra may tao nhip 1 thang, 3 thang sau cay may va sau do la moi 6 thang mgt lan.
• Xu ly sd lieu: Cac so lieu dugc xir ly theo cac thuat toan thong ke y hgc.
I I I . KET QUA NGHIEN CU'U
3.1. So lirong benh nhan, gioi va tuoi:
Sd lugng benh nhan 350 ca, trong do cd 215 nir (61,42%) va 135 nam (38,57%). Tudi trung binh cua benh nhan la 60,21 ± 25,53 tudi. Trong do cd 12 trudng hgp tre em dudi 5 tudi va 5 trudng hgp cu gia tren 90 tudi, 1 trudng hgp 97 tuoi.
So lugng benh nhan cay may tao nhip tang dan theo timg nam, nam 1996 cd 7 trudng hgp cdy may, nam 2007 co 75 trudng hgp, rieng ihang 10 nam 2008 cd 51 cacdymay.
DPM
1996 1999 2002 2005 2008
Bieu do 1: So lugng benh nhan cay may tao nhjpqua cac nam Bang 1: Phan bd benh nhan theo gidi va tuoi
Tu6l
Nit
Nam
<20 6 (2.8%)
13 (9%)
20-40 26 (12.1%)
9 (6.7%)
41-60 50 (23.2%)
38 (30.4%)
>60 133 (61.9%)
75 (53.9%)
T6ng cdng 215 (61.42%)
135 (38.57%)
CHUYEN OE: PHAU THUAT TIM MACH VA LONG NGUC VIET NAM T6ng cong 19*
(5.4%)
34 (9.71%)
88 (25.14%)
208**
(59.2%)
350 (100%) 12 trudng hgp tre em <5 tuoi
** 1 trudng hgp ngudi gia 97 tuoi
3.2. Loai benh ly co chi dinh cay may tao nhip:
Nhi^u nhdt la Bloc nhT thdt hoan toan (50,85%) it nhat la rung nhT kem Bloc nhT thdt cao dp (2,38%).
Bang 2: Phan bo benh nhan theo loai roi loan nhip tim Rdi loan nhjp tim
• Bloc nhT that dp I I I
• Hpi chirng nut xoang benh ly
• Bloc nhT that dp I I
• Rung nhT kem theo block nhT that cao dp
• Benh cd tim gian
• - Loan nhjp that ac tinh Td'ng cong
Nam
68 51 5 5 7 1 214(61%)
NQ 110 89 10 3 2 0 136(39%)
Tdng cong
178 (50.85%) 140 (40%)
15 (4%) 8 (2,28%) 9 (2.87%) 1 (0,28%) 350(100%)
3.3 Cac thong so chinh ciia may tao nhip:
Bang 3: Nhimg thong so chinh cua may VVI Nhu'ng thong sd ciia may \A^I (n=309)
• Tan sd
• cudng dp
• Op rpng xung
• Thdi gian trd ;; '/ { j
• Op nhay cam
• Tan so dudi nam cham
Trung binh ± DS 68.45 ± 4.64 (l/p)
3.54 ±0.98 (V) 0.47 ±0.22 ms 277.13 ±60.69 ms
2.70 ± 0.26 mv 89.35 ±5.50 l/p Bang 4: Nhirng thong so chinh ciia may DDD
Nhij'ng thong sd may DDD ( n= 30 )
> Tan sd
> cudng dp
> Op rpng xung
• Thdi gian trd
• Op nhay cam
• Tan sd dUdi nam cham
> Khoang A-V
Buong nhl
64 ±5.48 l/p 3.54 ±0.96 V 0.45 ±0.07 ms
280 ms 280ms
941/p 165 ±25.2ms
Buong that
64 ±5.48l/p 3.24 ±1.11 V 0.45 ±0.07ms 290 ±20ms 0.82 ±0.16mv
941/p 166 ±25.2ms
Y HOC VIET NAM SO DAC BIET — THANG 11 /2010
• Ky thudt edy mdy: (0,85%) la tinh mach canh ngoai do that bai
> Dudng vdo: Giai doan ddu, chung toi vai cac dudng vao khac.
clipn dudng vao la TM tay ddu bdng each > Ngudng tgo nhip:
boc lp, ve sau chung toi thuc hien uu tien la - Nguong tao nhip that cao nhdt la IV, clipc tTnh mach duai don. K6t qua c6 83,42% thdp nhdt la 0,1V.
dudng vao la tTnh mach duai don, 3 ca - Nguong tao nhip nhT cao nhdt la 1,5V, , u , ,: : ,:. thdp nhdt la 0,3V.
Bang 5: Duong vao tTnh mach cua dien cue
TTnh mach canh tay dau
53(15.14%)
TTnh mach canh ngoai 3 (0.85%)
Tinh mach dUdi don
292 (83.42%)
Vj tri i<hac
7 (0.2%)
• Phuffng thiee tgo nhip vd logi mdy:
- Da so la may VVI (309 ca chilm 88,4%), 1 ca AAI, 1 ca ICD. Dac bet chiing toi da tien lianh dat 9 ca (2,5%o) may tao nhip 3 buong CRT (D, P) trong dieu tri suy tim thanh cong.
. i MMii Bang 6: Phuang thuc tao nhip
" -...^MI'.- W I , DDD (R)
CRT (D,P) ICD Biotronik
1 (0.3%) 309 (88,4%)
30(8,5%) 9( 2,5%) 1 (0,3%) 72(20,5%)
Bang 7: Ket qua theo doi dai han
Rat tdt
162 (45.34%
Tot
(khong co dau hieu ctf nang)
128 ( 36.6%)
Trung binh (co dau hieu cd
nang) 47 ( 13.4%)
Thai may tao nhjp
2 ( 0.1%)
Khong den theo doi may tao nhjp
4 (0.1%)
Tir vong
1*
(0.1%)
CHUYEN OE: PHAU THUAT TIM MACH VA LONG NGUC VIET NAM
• Ci ngudi lon tudi bi tai bien mach mau nao Bien chimg sdm
Rung that
6 mautu - •
Tran khi mang phoi ' t' Tran mau mang phoi
Injurie de plexus brachial Bien chung mudn
Nhiem triing
Hpi chimg may tao nhip Thai may tao nhip Gay dien cue Bung day dien cue Bien chuns hiem sap:
* Dien cue didtdi vao khoang mang phdi Bang 8: Bien chung cua thu thuat
Thai may
Bung day dien cUc Nhem triing 6 tu mau Tac mach nao Thiing nhi
2 7 3 5 1 1
IV. BAN LUAN
1. Chi djnh cay may tao nhip:
Cay may tao nhip dat ra d benh nhan cd rdi loan nhip cham cd trieu chiing va cd nguy ca cao: Bloc nhT that cap III, Bloc nhT thdt cap II, hpi chiing nut xoang benh ly cd trieu chung cay may pha rung tu dgng d benh nhan co con nhip nhanh that, ngoai tam thu that vai chiic nang that trai giam.
Cay may tao nhip tim 3 buong trong dieu tri tuy cd ket qua tdt a benh nhan cd chiic nang thdp trai giam (EF<35%)), Bloc nhanh trai hoan toan voi QRS >0,12S. Tuy nhien gia thanh con cao nen rat it benh nhan cd chi dinh dugc dat may.
2. Chon lira phwotig thirc tao nhip:
Chi dinh nhieu nhat van la may DDD, J nhung benh nhan khdng cd kha nang mua I may nen chiing toi phai tien hanh dat lojii s may VVI (gia thanh re nhdt). Tham chi ! chiing toi cdn sir dung lagi may cii dugc vien : trg de cay cho nhung benh nhan ngheo khong cd kha nang mua may.
3. Ky thuat cay may tao nhip: ] Dudng vao ciia chung toi nhiSu nhdt van
la tTnh mach duai don 292 ca (83,42%) so : sanh vdi tac gia Ta Tien Phudc 41,8%. TTnh i mach canh tay dau la 15%) so vdi tac gia Nguyen Manh Phan va cong su la 82,4%, ciia Tran Dd Trinh va cong su la 65,6%, cua Z Zhu va cs la 55%).
4. Bien chirng cua thii thuat cay mdy va theo ddi:
Tdi gap hau het cac bien chung nhu thdi may, tu mau, nhilm trimg,... nhung nhieu nhat van la bong dau dien cue, cd mpt trudng hgp thimg nhT d benh nhan dung dien cue vit.
Ve nhiem trimg may tao nhip:
Chung toi: 1%
- TaTilnPhuac: 2,3%
Qi. GaoYian 1,3%
Ket qua lam sang sau tao nhip: Co su cai thien chat lugng cuoc song va ty le tu vong ro ret sau dat may.
V. KET LUAN
Tu nhirng ket qua tren, chung toi dua ra mgt so ket luan sau :
-Chi dinh cay may tao nhjp:
Cay may tao nhip a cac benh nhan c6 chi dinh tuyet doi (loai I), mgt sd it loai Ila
Cay may tao nhip tim 3 buong (CRT) trong dieu tri suy tim nang vdi QRS> 0,12s va EF< 35% kem theo Bloc nhanh trai hoan toan.
Y HOC VIET NAM SO DAC BIET — THANG 11 /2010
- Chgn lira phuong thiic tao nhip:
cdy may tao nhip mpt budng thdt (VVI, VVIR) chiem da so va cd hieu qua tot, gia thanh chap nhan dugc.
Mpt sd benh nhan ngheo khdng co kha nang mua may thi cd th6 sir dung may cii duac vo khuan lai.
- Ky thuat cay may tao nhip:
Dudng vao cua dien cue qua tTnh mach duoi don cd ty le thanh cong cao. Vi tri gan dien cue that phai d mdm that phai, dien cue nhl phai d tieu nhi phai hoac thanh ben, dien c\rc that trai a tTnh mach xoang vanh cho ket qua tot va hieu qua.
Ngudng tao nhip dudi IV d ca nhT va thk, cay may vung dudi xuong ddn va vui may dudi da dugc thuc hien d toan bg benh nhan.
Khang sinh pho rgng duong tTnh mach nen dugc su dung ngay trude va sau cay may 5- 7 ngay.
- Theo doi sau cay may:
Cac may tao nhip tim hoat dgng tot, hieu qua lam sang sau cay may cao, ty le bien chiing nam trong giai han cho phep.
Ky thuat tao nhip cd vai tro quan trgng khong the thieu tai cac benh vien, dac biet la cac don vi cap ciiii tim mach can su quan tam va phat trien hon.
TAI LIEU THAM KHAO
1. Ta Tien Phiro'c (1996), "Kk qua va nhan dinh qua 94 ca tao nhjp vTnh vien". Tap chi Tim mach hoc Viet Nam,9,tr.20-35.
2.
3.
4.
Nguyen Ngoc Tirac, Ta Tien Phiro'c (2004)" Nghien cuu ung dung cac may tao nhjp tim the he mdi va cac chuong trinh tao nhjp mai dieu tri cho benh nhan roi loan nhip tim ", Tap chi Yhoc Viet Nam, l,tr.45-50.
Nguyen Manh Phan (2006), " Khuyen cao ciia Hoi Tim mach hoc Viet nam ve chan doan, dieu trj loan nhip tim ", Khuyen cao ve cac benh iy tim mach va chuyen hoa giai doan 2006-2010,tr. 183-254.
Denise I. Janosik, Arthur J.Labovitz, 1995 "Basic physiology of cardiac pacing", Clinical cardiac pacing, pp.371.
Linde-edelstam C, Hjemdahl P, 1992, Is DDD pacing superior to VVIR ? A study on cardiac sympathetic never activity and myocardial oxygen consumtion at rest and during exercise,Pace, 15 :425-434.
Peter H. Belott, 2001, "Implantation Techniques for Single-and Dual-Chamber Pacemakers ",Interventional
Electrophysiology,pp.713.
Kenneth A, 2001, "Clinical Trials in Cardiac Pacing", Interventional electrophysiology, pp.781.
8. Raul D.Mitrani, 2005, "Cardiac Pacemakers ", Manual of Cardiology, pp.131.
9. Philippe Ritter, 1997, "Pratique de la stimulation cardiaque".
10. Gilbert Pomalicki, 2004, "Cardiologie "
7.
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M = : i ; i *' •:::
