— t-mvwfKrm \ . . u u L A I M S A N G
TRIET DOT RUNG NHI BANG N A N G Ll/OTNG SONG CO TAN SO RADIO Dl/dl SlT H 6 TRO CUA HE THONG LAP BAN D 6 3 CHIEU BUONG TIM
Pham Tran Linh, Phan Dinh Phong, LeVo Kien, Vu Bien Thuy, Nguyen Thu PhUorng, Pham Quoc Khanh, Nguyen Lan Viet
Vien Tim mach Viet Nam
T 6 M T A T :
Dai cucmg: Chung toi dieu tri rung nhi kich phat (RN) bang phucmg phap su dung nang luong song radio (RF) triet d6t qua catheter CO lap tmh mach phoi va nhi trai ve dien hgc duai sir hudng dan cua he thong lap ban d6 3D buong tim.
Phirong phap va kef qua: Trong 32 benh nhan bi RN khong do cac benh van tim, chung toi sir dung catheter dimg hinh dien hoc 3 chieu buong nhi trai va triet dot RF co lap dien hgc nhl trai va tinh mach phoi va tran nhi trai.
Sau khi triet dot, danh gia ket qua thanh cong la khong con dien the dan truyen tir nhT trai vao tinh mach phoi hoac dan truyen bi cham che tren 60ms. Thai gian can thiep tnmg binh la 255 ± 96 phut, vai thai gian chieu tia X quang trung binh la 62 ± 28 phut (tvr 32 din 96 phut). Co 01 benh nhan bi bien chung tran dich mang tim cap. Trong 24 gia sau can thiep. 32 benh nhan (100 %) duy tri nhip xoang. Theo d6i sau can thiep tir 8,0 den 26 thang (trung binh: 17,3 ± 5.0 thang) co 27/ 32 benh nhan khong co trieu chung (84%) rung nhl \a 5 b?nh nhan tai phat rung nhi.
dot CO lap dien hgc nhT trai va ttnh mach phoi duai su ho tro dinh \ i cua he thong lap ban d6 dien hgc 3 chieu buong tun.
Tir khoa: rung nhT. kich phat, triet d6t, song radio, ban dfi 3 chieu.
DAI Cl/ONG:
Rung nhT (RN) la mgt trong nhung loai r6i loan nhip tim hay gap nhit, nhi^u nghien ciiu dich te hgc cho thay co tai 5% nhung nguoi tren 65 tuoi mic rung nhT [ 1 ]. Hien nay, chiln luac dieu tri rung nhl bao gom su dung thudc chfing loan nhip nhom IA, IC, HI, soc dien chuyen nhip va du phong huyet khoi [2]. G&i day, mgt so phuang phap dieu trj nliu triet d6t nut nhT th4t va cay may tao nhip dugc chi dinh cho mpt so trudng hgp dac biet. phlu thuat Maze dieu tri rung nhT cung da duac trien khai.
Phuang phap triet ddt rung nhT qua catheter dudi sir hd trg ciia he thdng lap ban do 3 chieu (3D) buong tim dang dugc iing dung rgng rati tren thi gidi dem lai hieu qua dang ghi nhan [5].
Ket luan: Rung nhT kich phat cd thi dugc 0 Viet Nam, tir nam 2009. Vien Tim mach dieu tri b ^ g su dung sdng cd tin sd radio triet Viet Nam da bat dau trien khai ky thuat dilu
58 I TAP CHl TLM MACH HQC V I £ T NAM - S(5 65.2014
NGHIEN CU'U LAM S A N C
tri ning nhl nay va buoc diu cH thu dugc nhung ket qua dang khich le. Chiing toi tiin h ^ nghien cuu nay vtji muc tieu:
- Nghien cuu dgc diim dien sinh ly hoc cua ccm rung nhl
- Buac ddu ddnh gid kit qud diiu tri ccm rung nhi bang song co tdn so Radio"
o6\ TUONG VA PHUdNG PHAP NGHIEN CHlS
Beob nhan
Bang I: Ddc diem chung benh nhm rung nht truac triet dot Dac di£in
Giai tinh (Xam/Nii) Tuoi Tang hu}'St ap (n) Benh dpng mach vanh (n) Thoi gian xudt hien rung nhT (nim) Thuoc chong loan nhjp Phan so tong mau (EF°o) Kich thirdc nhi trai (mm)
Thong so 25 7 55.3= 11.6 i : 1 2.6= i,2 2.1 = 1.0 62 = 8.5 42.6 = 4.7
Chiing toi tien hanh thu Ihuat cho 32 benh nhan rung nhT kich phat c6 trieu chiing, kem dap ling vol dieu tri npi khoa va thai gian rung nhl > 2 nam. Trong do co 25 benh nhan nam va 7 benh nhan nu, vol tuoi trung binh la 55,3
±11.6 tu6i (tu 31 - 71 tudi) (bang 1). Trong do CO 01 benh nhan co benh tim thieu mau cue bo da can thiep dat stent, 12 benh nhan bi Tang huyet ap cac miic do. 4 benh nhan ngoai rung nhi con co nhieu con nhip nhanh nhT k§t hgp va tat ca cac benh nhan dap ling kem vol cac thuoc chong loan nhip (Amiodarone, chen Beta giao cam. Fleicainide). Benh nhan dugc ghi Holler dien tam do 24 gio d^ phat hien nhung con rung nhT \a mgt so roi loan nhip khac kem theo nhu; nhip nhanh nhT. ngoai tam thu that.... Ngoai cac xet nghiem thucmg quy nhu cong thiic mau. sinh hoa mau, dong mau eg ban,... tat ca benh nhan nghien ciiu diu dugc chup MSCT nhT trai va tTnh mach ph6i danh gia giai phau tTnh mach ph6i va nhl trai.
32 benh nhan deu dugc sieu am tim qua thilc quan de loai trir hu} et khoi buong tim truoc khi lam thii thuat.
Tham do dien sinh ly tim:
Benh nhan dugc chi dinh tham do dien sinh ly tim va triet ddt rung nhT theo hucmg dl dieu tri rung nhT ciia Hgi Tim mach Viet Nai tham khao ACC guidelines cua Hoa Ky [4].
benh nhan dugc ngimg lhu6c diiu Irj roi lo nhip 7 nga\ truoc can thiep. Thu thuat c thiep dugc tien hanh tai phong chup mach tham do dien sinh ly tim cua Vien Tira ma Benh vien Bach Mai. Dien cue chan doan cue 5F qua itnh mach duoi don trai vao xoi tTnh mach ^ anh \ a dien cue chan doan 41 5F qua tTnh mach diii phai \ ao mom thit ph Hiiyet ap dgng mach dugc theo doi qua thong do ap lire dgng mach xam nhap lienti Dien cue dinh vi 3D lim (Ref - Star) dugc
T-^P CHI TIM .MACH HOC \ ' l £ T NAM - SO 65.2014
•^NGHlfeN CUTU LAM SANG
dinh d lung benh nhan ngang muc vdi tim va dien cue dilu khiln cac hudng lap ban dd 3D ket hofp triet ddt bang nang lugng sdng cd t£in sd Radio 7F cd lam lanh biing nude d dSu dot (Navi-Star). Chung tdi su dung ky thuat chgc xuyen vach lien nhT tvr buong nhT phai bang kim chgc xuyen vach Brockenbrough qua mgt dung cu md dudng vao mach mau loai dai 8F (long sheath) dl dua cac dien cue tilp xiic budng nhT trai lap ban dd ndi mac budng tim.
Sau khi xuyen vach lien nhT bSnh nhan dugc tiem 5.000 dan vi Heparin tTnh mach va theo ddi ACT 60 phut / \hn duy tri ACT tu 300 - 500 giay.
He thong l9p ban do 3D:
He thdng lap ban d6 dien hgc budng tun 3D CARTO bao gdm mdt cam bien tir trudng thu dpng thu nlid kit hgp vai dien cue 3D Navi-Star va dien cue dinh vi tim Ref - Star.
Di chuyin dien cue 3D Navi-Star tilp xue vdi cac vi tri trong budng nhT trai giup dung hinh 3 chieu budng tim chinh xac tir 0.5 - 1mm.
Viec lap ban dl 3D chinh xac buong nliT trai giiip cho viec triet ddt rung nhl an toan va hieu qua.
Quy trinh I^p ban do 3D:
Chiing tdi dua dien cue Navi - Star qua Long sheath vao budng nhT trai dudi man hinh X Quang k5' thuat sd cua may chup mach Phillip vdi miic chilu tia 3.75 Fr/giay. Chiing tdi di chuyen dien cue 3D vao 04 tmh mach phdi: ttnh mach phdi trai tren va dudi; tmh mach phdi tren va dudi de xac djnh vi tri Id dd ve cua tihh mach phdi vao nhi trai. Dien cue 3D ghi nhan lai toan bd hoat ddng dien ciia timg viing trong nhT trai nhu viing vach lien nhT, tieu nhT trai, vong van hai la,.... Mdi mdt vi tri trong budng tim dugc ghi nhan dien hgc tren 2mm va hoat ddng dien >2ms (LAT:
Local activation time). Vdi buong nhT trai chiing tdi tiep can trung binh khoang 138 ± 25 diem (tii 120 den 165 diem) de dimg hinh budng nhT trai 3D ve dien hoc. Chiing toi su dung hinh anh dimg hinh giai phau buong nhT trai tren phim chup MSCT de lam tieu chuan so sanh va dong bp hda dien hpe 3D budng nhT trai.
Triet dot bSng RT:
Nang lugng sdng Radio Frequency (RF) dugc cung cap tii may RF Osypka Smart 300, qua he thdng day dan den dau xa dien cue
Hinh I: Lap ban do 3 chieu buong nhT trdi vd Iriel ddi cd lap linh mach phdi (Binh nhdn Vo D, 54 tudi) 60 I TAP CHl TIM MACH HQC VI$T NAM - S 6 65.2014
N C H I E N COru LAM SAlj
NAVI-STAR. Miic nang lugng cung cap khi triet d6l mat sau nhT trai la 25W va mat truoc nhT trai la 30W, dien trd kiSm soat < 180 Ohm va nhiet dg t6i da 50°C, thai gian triet dot mot diem la 20 - 30 giay vdi nugc lam lanh 17ml /phiit. Chting tdi su dung dien cue chan doan vong 10 cue 6F (LASSO) dua vao Id dd vi cua tTnh mach phdi vao nhT trai trudc khi triet ddt de ghi nhan va do cac thdng so dien hgc.
Chiing tdi tiSn hanh triet ddt timg diem lien tiep nhau tao thanh nhirng dudng ddt cd lap rieng biet 04 tmh mach phdi va nhl trai vS dien hgc ket hgp vol cac dugng ddt cd lap dien hgc d tran nhT trai va vimg thanh ben vong van hai la. Sau khi triet ddt, chiing tdi danh gia kSt qua thanh cdng la khdng cdn dien thd dan truydn tir nhT trai den iTnh mach phdi hoac din truydn tir nhT trai den tTnh mach phdi bi keo dai tren 60ms so vai ban diu (bloc khdng hoan toan).
Sau thil thuat b$nh nhan dugc theo ddi lien tuc 24 gig va dugc theo ddi djnh ky 1 thang, 3 thang, 6 thang va 12 thang.
benh nhan con lai co bloc khdng hoan toi,1 dien the nhT trai \a tinh mach phdi.
Sau ^ i triet dot thanh cdng chiing toi thich tim theo chucmg trinh qua dien xoang vanh vdi cac xung kich thich 60 500ms, 400ms va 330ms ket hgp vgi cac thich sdm dan de danh gia chiic nang xoang va dan truyen qua mil nhl thjt cOng kich thfch gay rung nhi. TJt ca 32 benh i deu c d ^ i i c nang mil xoang trong gidi binhlwWne vdi thdi gian phuc hdi niit xc hieu chmh la 453 ± 86ms, Wenckebach nhTth&M 433 ± 57ms.
KETQUA
32 benh nhan dugc triet ddt cd lap nhT trai va tTnh mach phdi vd dien hgc vol thdi gian tien hanh thii thuat 255 ± 96 phiit, thdi gian chieu tia 62 ± 28 phiit (tir 32 phiit ddn 96 phiit).
Chiing tdi chu ydu chidu tia trong qua trmh dat cac dien cue, chgc xuyen vach lien nhiva xac dinh vi tri dien cue khi lap ban dd 3D budng nhT trai. Phin ldn thdi gian trong qua trinh thu thuat dua vao ban dd 3D, chiing tdi hiet dot khdng c4n phai sii dung tia X quang.
Sd diem tridt dot ciia moi benh nhan la 120
± 21 diem tao thanh nhieu dudng lien tuc cd lap dien hgc nhi trai va tTnh mach phdi. Trong dd cd 26 b|nh nhan sau triet ddt khdng edn difn the lit nhT trai ddn tinh mach phdi va 6
HIEU QUA CUA THU THUAT TRIET DOT RUNG NHI BANG RF
Ngay sau can thiep, 32 benh n h a n d d i ^ J tri nhjp xoang ddu (ghi dien tam ^^Hieffli trung binh 17,3 ± 5,0 thang (ttr 8 thang dSn 26 thang), trong 3 thang sau c a n ^ ^ cac benh nhan tidp tuc dugc duy tri Amiodarone 200mg / ngay, 24 / 32 benh nhan khdng A xuat hien trieu chiing rung nhT, 05 benh nhSn con cam giac hdi hop danh trdng nguc nSfeg khi Iheo ddi Hoher Dien tam dd chi cd bidu hien Ngoai tam thu nhT khdng cd bidu hien fiig nhi. Co 3/32 benh nhan trieu chiing c o H thien hon nhung theo ddi Holter Dien l a m p con xull hien ccm rung nhT ngSn (<30^fflt). Sau 03 thang 24 benh nhan khdng c d n ^ S nhT duoc ngimg Amiodarone va chi cdn m n g thu6c dieu tri benh ndn nhu Tang huydtlp. benh Iv mach vanh. 05 bdnh nhan c d n ^ a i lam ta nhT tiep tuc dugc cho diSu trj chin beta giao cam lau dai cdn 03 benh nhan r u ^ nhT ngin van tiep tuc duy tri Amiodarone. Theo doi sau 1 nam cd 5 benh nhan tai phat con rung nhi nhung trieu chiing giam nhidu va can rang nhi thuong ngSn, rat it khi xuit hien va dac biei
TAP CHI TIM MACH HOC Vl£T NAM B 65 2014 61
I
> NGHIEN CUTU LAM SANG
dap ling vdi thudc dieu tri nhu Amiodarone hoac chen Beta giao cam.
Trong qua trinh can thiep cd 01 benh nhan bi bidn chimg tran djch mang tim khi triet ddt tran nhl trai da dugc din lim mang ngoai tim ngay khi phat Men va din lim sau 48 gid dugc khoang 300ml djch mau khdng ddng. Benh nhan nay dugc sieu am danh gia lugng dich va riit din lim sau 48 gid.
Hai mugi tu gid sau can thiep, sieu am tim qua thanh nguc khdng thay ddi so vdi trudc can thiep d 29 benh nhan, cd 02 benh nhSn cd tran djch mang tim sd lugng rat it nhung khdng cd dau hieu viem mang ngoai tim va kiem tra sieu am sau 1 thang khdng cdn djch mang tim. Danli gia cac chiic nang nhT trai bing sieu am Doppler ddng chay hai la khdng thiy bat ky sir thay ddi sau khi triet ddt: E/A 1,37 ± 0,5ms so vdi 1,37 ± 0,4ms trudc va sau can thiep.
Bieu dd: Theo ddi sau triet ddt rung nhi sau I ndm
Theo ddi sau 1 nam, ty le thanh cdng khdng tai phat rung nhi la 27/32 (84,4%), ty le tai phat rung nhT la 15.6% va ty le bidn chirng cua can thiep la 1/32 (3%).
BAN L U A N
Triet ddt rung nhi bing sdng cd tin sd radio la mdt bien phap didu trj tien tidn, day hita hen trong tuong lai. Ty le thanh cdng cila chiing tdi la 84% cung tuang duong nhu ty le thanh cdng cua mdt sd tac gia khac tren the gidi [3]. Ty le bidn chirng thip 3%, tuy nhien vi khi mdi trien khai kj^ thuat nay nen kinh nghiem chiing tdi van chua cd nhieu nen bien chimg ciia chiing tdi cd the hon cao ban mdt sd nghien cim khac [6].
B A N CHAT KY THUAT TRIfT DOT TRONG RUNG NHl
Phuang phap triet dot rung nhT dua tren gia thuydt d khdi phat rung nhT thudng xuat phat tir cac tTnh mach phdi gay kich boat cac CO nhT vdi nhidu vdng vao lai nhd trong ca nhT. Do vay, cd lap dien hgc giua cac viing khac nhau trong tam nhT va gifla nhT trai va tinh mach phdi lam mit din truySn tir cac d khdi phat d tTnh raach phdi va cat eac dan truydn cua cac vdng vao lai nhd trong nhT [7].
KET LUAN
Triet ddt rung nhT bing nang lugng sdng cd tin so Radio la mgt lua chgn dieu tri nhiing truong hgp rung nhT kem dap iing vdi dieu trj ngi khoa. Cd lap dien hgc gifla nhT trai va tTnh mach phdi va giua cac vimg trong nhT trai bing RF dudi su hd trg djnh vj cua ban dd ndi mac 3 chidu nhT trai giup tang ty Id thanh cdng va giam thieu thdi gian chidu tia trong thil thuat. Trong tuong lai, vdi su phat trien ky thuat va cd nhieu kinh nghiem hon, chung ta hoan toan cd the lam chu ky thuat nay va timg budc hdi nhap vdi The gidi trong dieu trj rung nhT - mgt trong nhimg ganh nang benh tat cua the ky XXI.
62 I TAP CHl TIM MACH HOC VlfT NAM - SO 65.2014
N G H I £ N C C U L A M SANI I N S
ABHRACT:
BACKGROUND: We tr«led paroxysmal recurren. a n a l fibrillalion (AF) wift mdiofrequency (RFl calheleral by coaling long linear lesions in the alria. To achieve Ime coolinuily. a 3D ekcwanalomic nonfluoroseopic » # , : ]
^"
system was used.
METHODS AND RESfLTS: In 32 patients with recurrent AF, a catheter incorporating a passive mapelic M sensor was navigaled in left attia to constract a 3D activalion map. RF energy was delivered to create continuous ]i«, lesions long line encircling the pulmonary veins in the left atrium and TOO! line. After RF application, the atia « , remapped to validate completeness of Ihe block Imes, demonstrated by late activation of die areas cireumscribed bj ih, lines. The mean procedure duration was 255 ± 96 minutes, with mean fluoroscopy time of 62 ± 28 minutes (range, 32 lo » minutes) 01 acute complicanons occuired was tamponade. During the first day, 32 patients (100%) had free AF episode.
After a follow-up of 8,0 to 26 months (average, 17,3 ± 5,0 months), 27/32 patients are asymptomatic (84%), and 5 pajm are recurrent AF.
CONCLUSIONS: Paroxysmal recuirent dmg-reftactory AF can be treated by RF catiieter ablation. Creation of tag continuous linear lesions necessary to compartmentalize Ihe atria is facililaled by a nonfluoroscopic electroanatomie mapping system.
Keywords: affial fibrillation, paroxysmal, thoroughly burned, radio waves, 3D mappmg.
1
TAI Ulu THAM KHAO
1. Pham Nguyen Vinh (2009 ), "Rung nhl: ca che, chin doan va diiu tn ", (Nha xult ban Y hpe ).
2. Camm JA LY, Caterina R, et al. (2012 ), "2012 focused update of the ESC Guidelines for the management of atrial fibrillation An update of the 2010 ESC Guidelines for the management of atrial fibrillation Developed with the special contribution of the European Heart Rhythm Association.", European HearlJournal.
3. Cappato R CH, Chen SA, et al. (2010), "Updated worldwide survey on the methods, efficacy, and safety of cathetH ablation for human atrial fibrillation.", CircArrhyihm Eleclrophysiol. 3 pp. 32 - 8.
4. Fuster V RL, Cannom DS, e( al (2006), "ACC/AHA7ESC 2006 Guidelines for the Management of Patients wifli Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Com- mittee for Practice Guidelines {Writing Committee to Revise ihe 2001 Guidelines for die Management of Patients With Atrial Fibrillation)", Circulation, i 14, pp. 257-354
5. Khaykin ^', Wang X, Natale A, et aL (2009), "Cost companson of ablation versus antianhythraic drugs as first-line therapy for atrial fibrillation: an economic evaluation of the RAAFT pilot study", J Cardiovasc Electrophysiol, 20 pp. 7-12
6. Pappone C RS, Augello G, et al. (2003), "Mortality, morbidity, and quality of life after circumferential pulmonaij vein ablation for atrial fibrillation: outcomes from a controlled nonrandomized long-term study", J Am Coll Cardiol, 42, pp. 185-97
7. Pappone C RS. Oreto G, et al. (2000), "Circumferential radiofrequency ablation of pulmonary vein ostia: anew anatomic approach for curing atnal fibrillation". Circulation. 102, pp. 2619-28
TAP CHl TIM MACH HOC VIETNAM - 8(565.2014 I j
