JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol.11 - NM/IOie
Cac bien chung trong qua trinh ciy may tao nhip tai dong bo tim
Complications during procedure of cardiac resynchronization therapy
Pham Nhir Hiing*, Dmrag Dire Hung** *Benk vien Tim Hd Noi
** Vien Tim mgch - Benh vien Bgch Mai
Tom t^t
Muc tieu: Chiing tdi nghidn ciJu bien chUng trong qua trinh c l y may tao nhip tai ddng bd t i m . Doi tugng vd phuang phdp: 143 bdnh nhan {104 nam/39 nu') vdi t u d i trung binh 58,14 ± 11,34 t u d i dupc cay.
K i t (jud: may tao nhjp tai ddng bd tim tU 1/2008 ddn 3/2016. Cac bien chiitig ghi nhan bao gdm: PhCi phdi cap (0,6%), tran djeh mang t i m (2,1%), tach thanh tlnh mach vanh (2,8%), bide nhT that (13%), t u t huyet ap (0,6%), rung that (0,6%), rdi loan nhip nhT (2,1%), di Idch dau didn cue thit t r l i {2,1 %). Chiing tdi khdng ghi n h l n dupc trudng hpp nao tU vong trong nghidn cUu. Kit ludn: Cae bldn e h i ^ g t r o n g tao nhjp tai dong bp tim la rat thap nhung kha nguy hiem va cd thd dan den X& vong.
TUkhda: C l y may tao nhjp, tai ddng bd t i m . S u m m a r y
Objective: We investigated the complications in cardiac resynchronization therapy (CRT) procedures.
Subject and method: 143 patients (104 male/39 female) aged 58.14+ 11.34 years underwent CRT from January 2008 to March 2016. Result The complications were recorded including: Acute pulmonary edema (0.6%), pericardial effijsion (2.1%), coronary venous dissection (2.8%), AV block (1.3%), hypotension (0.6%), ventricular fibrillation (0.6%), atrial arrhythmias (2.1%), dislodgement of left ventricular lead (2.1%). No death were recorded in CRT procedures. Conclusion: Complications during procedure of cardiac resynchronization therapy is low but dangerous and may be dead.
Keywords: Cardiac, resynchronization therapy.
1 . D a t van d e nien cCia may tao n h j p tai d o n g b o didu tri suy t i m . Suy t i m la nguyen nhan tCf vong hang dau t r o n g " ^ ^ • ' ° " ^ i P « ' * ° " 9 '^ ' ' " " « * S6p phSn cSi thien nhOng nguyen nhan t i m mach. Tai IVly, hien co * ^ " 9 ''^ " * " ' " ' " 9 =^°"9 '=*^° ' ' ^ " ' ^ " * ' ^ " '"^ " " ^ 5.000.000 benh nhan suy t i m . So t l v o n g do suy t i m " ^ " 9 ' ^ ' ^1- ^ h l n g viec t i e n hanh m 6 t l<y thuat can hang nam tai IMy la 250.000 benh nhan [1]. Trong ' " ' * P " " " ""^"^ " * " ^^"*^ "*>=" ^"y ' ' " " " ? " 9 ""'^
m o t vii nam t r d lai day, thay t i m duoc tien hanh 6 " " ^ " 9 lai nhieu rCii ro. Vi viy c h i i n g t o i \im nghiSn m o t so t r u n g t a m t i m mach ct nude ta. Tuy nhien, """ " ' > ' "^^'"'- ' " ' ' " ' ' 9 ' ° " ' ^ ' " * ' * ' ^ " 9 ''° "'^ 9^P Chung ta gap nhieu van de vi thay t i m n h u nguM ' ' ' " " ^ "^"^ '^° "'"'P ' * ^°"3 bo tim.
cho t i m , d i i n g thuoc sau thay t i m chua ke l<inh p h i 2 . B o i t u o n g va phuong p h a p rat I6n ma gia d m h benh nhan nhieu i<hi I<h6ng t h e
tiep can duoc. Thap nien vira qua, duoc cho la thSp ^ " ' ' "''""• ^^^ ^"'^ " ' ' ^ n d u o c cay may tao nhjp tai d o n g bo t h a n h cong t i r 1/2008 d ^ n thang 3/2016. Benh nhan d u a c t h u t h a p t i r cac t r u n g tam Phan b i j n khoa hoc: POS.TS. P H A M N G U Y f i N SON la Vien Tim mach - Benh vien Bach Mai, Benh vien
TAP CHf Y DUpc LAM SANG 108
Tfp n-So 4/2016
Tim Ha Ndi, Bdnh vidn Tim Bdng fid, Bdnh vien Buu fiien HI Ndi.
Bdnh nhln dat may dupc chl dinh dUa tren nhffng tieu chu^n theo HUdng d i n eCia Hdi Tim m?ch hoc Hoa Ky nim 2008 [4]: (1) Bdnh nhln suy tim ed dd NYHA III v l IV; (2) Sidu I m tim cd EF 35%;
(3) Nhip xoang; (4) Cd rdi loan mat ddng bd tim (chan doan qua dien tam dd vdi QRS 120ms v l sieu am doppler md tim); (5) Bdnh nhln dupe didu trj toi uu bang cac thude ehdng suy tim.
Cay mdy tgo nhip tai dSng bd tim
Chiing tdi thudng cly didn cue that phai trUdc.
fiien cUc that phli thudng dupe ehiing tdi cay vao vj tri vIch hole vCing mdm. Sau dd ehung tdi tien hanh cly didn cue vao that trai. fiien cue that trai thudng dupe ehiing tdi cay vao cic nhanh 6 thinh sau ben.
bdn va trUdc bdn. fildn cue nhT se dupe ely cuoi cung thudng d tieu nhT hoac thanh tU do.
Cdc thdng s666nh gid
Tat c l eac bien chUng dupc ghi nhln trong va ngay sau cay may tao nhjp tai ddng bd tim (den khi ra vidn) dUdc ghi nhan.
XCtlysolieu
Cic sd lieu ciia nghidn COXJ deu dupc nhap v l
xd ly theo cle thult toln thdng ke trdn miy tinh vdisUtrpgiiip cua phin mem SPSS for Windows version 17.0. (SPSS. Inc South Waeker Drive, Chicago, IL).
3. Ket qud
fiac diem lam sang cCia nhdm benh nhln nghidn cUu dupc trinh bay d BIng 1.
Bdng 1. Dac diem lam sang cua nhdm benh nhdn nghidn cviu
Cac thong so Tudi (nam)
Gidi (nam/nOf) fid NYHA (dp lll/dd IV) Huyet ap tam thu (mmHg) Huyet ap tam chUdng (mmHg) Tan sd t i m (chu kjf/phiit)
Trung binh ±€>d lech chuan va so benh nhdn (%) 58,14± 11,34
104/39 68 bdnh n h l n / 7 5 bdnh nhan.
97,3 ± 7,2 64,3 ± 5,3 90,1 + 18,3
Mdt so cic thdng so vd huyet hpc va sinh hda dupe trinh biy d BIng 2.
Bing 2. Mdt so thdng s6 vd xet nghidm huyet hoc va sinh hoa mau cua bdnh nhan trade khi cay may
Cacthong so Hdng cau (T/l) Hemoglobin (g/l) Ure (mmol/l) Creatinin (mmol/l) fiudng mau (mmol/l) Pro-BNP (pmol/l)
Trung binh ± D o lech chu^n 4,34 + 0,62 137,12+12,16
8,57 + 3,16 99,32+24,38 6,12 ±3,21 965,34 + 872,12
Cac thdng sd sieu am tim benh nhan dupe trinh bay 6 Bang 3.
JOURNAL OF 108 - CLINICAL jMEDICINE AND PHARMACY VoLll-N'4/20r6
Bing 3. Cac thong so sieu am tim benh nhan trudc cify may Thong so
Dudng kinh nhT trai (mm) Dd (mm)
Ds (mm) Vd (ml) Vs(ml)
%D EF(%)
€)u6ng idnh that phSi (mm) CO (I/phut)
Dien tfch hd hai la (cm^) Ap luc dpng mach phdi (mmHg) The tfch nh« bop (SV) (ml)
Trung binh + Do lech chuan 43,15±6,58 70,03 + 12,32 63,51 ±11,23 279,13 + 105,37 204,11+84,33
14,19 + 3,76 25,43 + 6,32 24,36 + 6,12 2,32 + 0,80 6,52 + 5,35 41,02± 12,26 52,25 ±12,81
T;^ Id cay may t h i n h cdng dupc t r i n h b I y d hlnh 1. Trong d d t ^ Id thanh cdng I I 97,9% va t y Id that bai I I 2,1 %. Trong 3 ca that bai, chiing t d i gap 1 ca bi hep tTnh mach vanh sau d d da dugc nong ra n h u n g da gay ra tach thanh tTnh mach vanh c l n t r d dUdng vao. Ca t h U 2, chiing t d i gap d o nhanh d l vao thanh sau ben q u i nhd khdng phu hpp vdi vide cay. Ca t h U
3 c h i i n g t d i g a p I I benh nhan cd tTnh mach ehO trdn trai lam gian Idn. Chiing t d i c h u p v l g h i nhan lai thay chl cd 1 n h l n h tTnh mach v i n h chay tUdng Ung vdi nhanh tTnh maeh Idn va m d t n h l n h tUdng Ung vdi nhanh tTnh mach giiJfa. C l 2 nhanh nay khdng p h i i h p p vdi c l y dien cUc t h a t trai.
Thanh c6ng
Th^t b£ii Hinh 1 . Ty Id thanh cdng va that bai eiia ky thuat c l y may tao nhjp tai ddng bd t i m . Cle t h d n g sd lidn quan d^n q u i trinh cay may dupe t r i n h b I y d Bang 4.
BSng 4 . T h d i g i a n t i e n h a n h thO t h u a t vk thofi g i a n c h i d u t i a Thong s6
Thdi gian tien hanh thu thuat (phiit) Thdi gian chidu tia (phut)
T r u n g b i n h ± D o Idch c h u ^ n 99,14 + 32,46 22,28 ±21,74.
Cle bien chUng xiy ra trong qua trinh thii thult dupc trinh bay d BIng 5.
TAP CHf Y Di;OC LAM SANG 108 Tapl1-S64/2016
Bdng 5. Cac bien chdiig xay ra t r o n g qua trinh t h u thudt Cdc bien chuTng gap p h l i
Phii phdi cap T r l n djeh m i n g tim Tach thanh tTnh maeh vanh Bloc nhT that t h o i n g qua Rdi loan nhjp t h i t Rung that
Di ehuyen ^ e n cue t h i t trai Tut huydt ap
Tim nhanh xoang va rdi loan nhjp nhT
T ^ l d % 0,6 2,1 2,8 1,3 1,3 0,6 2,1 0,6 2,1
4. Ban luin
Khi so sinh vdi mot sd nghidn ciixj Idn tren the gidi nhU AfllRACLE-ICD [5], Leon [6] va RESERVE [7], eae
i bien chUng eOa ehiing tdi gan nhU la tUdng tU (Bang 6).
I Bdng 6. Cdc bien chihig trong qud trinh c£y may tao nhip tdi dong bo tim [(hi so sdnh vdi mot s6 nghidn cihj Idn tren the gidi
Cac bien chUngTif vong Phil phoi cap Tran djeh mang t i m Tach thanh tTnh mach vanh Bloc nhr that
Tut huyet ap R6i.loan nhjp that Tran khf mang ph6i Di chuyen di&n cUc th^t tr^i Rung nhT
Rung that Huyet I<h6l Suy tim mat btl
Chung toi (n = 143)
0,6%
2,1%
2,8%
1,3%
0,6%
0,5%
-
2,1%
2,1%
0,6%
-
MIRACLE ICD (n = 369)
- -
1 % 4%
1 % 1 % 1,4%
0,8%
6,8%
-
0,8%
-
1,6%
Leon (n = 2078)
0,3%
-
3,1%
2,8%
1,2%
0,9%
0,6%
0,5%
6,6%
0,8%
0,3%
0,2%
0,4%
RESERVE ( n 3 419) 0,3¥o 0,5%
4 % 3,4%
0,5%
0,3%
0,7%
1 %
-
1 % 0,5%
0,7%
-
Dii trong nghien cufu ciia chung t6i cung nhu thir nghiem MIRACLE ICD [5] khfing ghi nhan b6nh
• nhan tijvong nao nhung nghien cdu ciia Leon [6] va RESERVE [7] CO ghi nhan tOfvong. DO ty le niy la nh6 (0,3%) nhung co the x5y ra. Trong thUc t l nhCfng bien chiing trong nghien cO'u ciia chung toi cho th^y nlu khong duoc xCf ly kheo leo va kjp thdi d l u
CO the gly tCf vong nhu phii phdi cap, tran djeh
mang tim, bloc nhT thSt, roi loan nhjp that tham chf
rung that, tut huyet ap, tran khf mang phoi, suy tim
mat bii. Bieu nay doi hoi bac si dat miy tao nhip tai
dong bo tim dong thSi cung phSi la bic sT lam sang
CO kinh nghiem cSp ciiu tim mach.
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol.11-N''4/2016
M d t bldn chUng nijfa cung g l y sU ehii y cho ehiing ta khi e l y may tao nhjp tai d d n g b p la bloc nhi that, Bldn chUng nay glJD tU 0,5 ddn 2,3%. Bien chUng nay t h u d n g la d o c l e d n g t h d n g v l dien cUc khi lam cham vao vCing vach lien that, vDng nay gan nhanh b d phai ciia bd His nen cd the gay bloc nhanh p h l i t h o a n g qua. Tren c d sd eiia benh n h l n bj bide nhanh trai ndn rat de g l y ra t l n h trang bloc nhT t h a t hoan toan. Mdt sd tac g i l dat day t h d n g didn cUc tao nhjp binh t h u d n g n h u dien cUc t h I m d d dien sinh ly qua d u d n g tTnh mach d i i i de ed t h e tao nhjp khi cd bide nhT that xay ra [8]. Tuy nhien, m o t sd t i c g i l k h i e [9] cung nhU chiing t d i cay trudc dien cue that phai va cd d j n h dien cue that phai trudc de neu cd bloc nhT that x i y ra se d u n g dien cue n l y de tao nhjp tam thdi.
M o t bien ehUng khdng g l y nguy hiem nhUng ed t h e I n h hudng den kdt q u i l l u d l i cay may tao nhip tai d d n g b d l l m chung ta nhidu khi p h l i tidn h l n h phau t h u a t lai eho bdnh nhan I I di lech dau dien cue that trai. SU di leeh ciia dau didn eUc that t r l i cd t h d dan ddn t m h trang mat dan, tang n g u d n g tao nhjp, g i l t c d h o l n h [10].
5. Ket luan
C l e bien chUng t r o n g tao nhjp tai d d n g bp t i m la rat t h a p nhUng k h i nguy hiem va cd t h d dan d ^ n tCfvong.
Tai lieu tham ichdo
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3. Linde C, Abraham WY, Gold MR et al (2008) Randomized trial of cardiac resynchronization in
mildly symptomatic heart failure patients and in asymptomatic patients with left ventricular dysfunction and previous heart failure symptoms. J Am Coll Cardiol 52:1834-1843.
4. Epstein EA, DiMareo JP et al (2008) ACOAHA/HRS 2008 guidelines for Device-Based therapy of cardiac Rhythm Abnormalities. JACC 21:1 -62.
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MIRACLE-iCD TriaL JAMA 289:2685-2694 6. Leon AR, Albraham WT, Curtis AB et al (2005)
Safety of tranvenous cardiac resynchronization system implantation in Pts with chronic heart Failure. JACC 46; 2348-2356.
7. Daubert C, Gold MR, Abraham WT (2009) Prevention of disease progression by cardiac resynchronization therapy in patients with asymptomatic or mildly symptomatic left ventricular dysfunction: Insights from the European cohort of the REVERSE (Resynchronization Reverses Remodeling in Systolic Left Ventricular Dysfunction) trial. J Am Coll Cardiol 54(20): 1837-1846.
8. Hanky B, Schulte ES, Vogt J et al (2004) Lead selection and implantation technique for biventricular pacing. Eur Heart J 6:112-116.
9. Daoud E, Kalbfleisch FJ, Hummel et al (2002) Implantation technique and chronic lead parameters of biventricular pacing dual chamber defibrillators. J Cardiovasc Eleetrophysiol 13:
964-970.
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Chin Med J (Engl) 119:449-453.