TCNCYH PhiJ trwcyng 80 (3A) -2012 11. Wernovsky (2008). Transposition of and adolescents including the fetus and the great arteries. In- Allen HD et al. Moss young adults. 7* ed. Lippineott Williams &
and Adams' heart disease in infants, children, Wilkins. Section H, chapter 51; 1038 -1085.
Summary
SURGICAL NEED OF CONGENITAL HEART DISEASE DURING THE NEONATAL PERIOD IN NATIONAL HOSPITAL OF PEADIATRICS The aim was to determine the rate of congenital heart defects that should be interfering in Ihe neonatal period. Results showed that 1176 children in 3 months of hospitalization, in 1124 we screened 272 children with congenital heart defects, rate of 24 2%. Number of children with surgical intervention indicated in the neonatal period 145 children (53.3%), most children with transposition of the great arteries, double outlet right ventricle, truncus arteriosus, total abnoma- lous pulmonary venous connection, pulmonary atresia, hypoplastic left heart syndrome have indication for surgery in the neonatal period. In conclusion the rate of congenital heart defects was 24.2%. Percentage of children with surgical intervention in the neonatal period was 53 3%, especially with the ductus arteriosus in premature infants need inten/ention with the percentage of 64%. The transposition of the great arteries, double outlet right ventricle, truncus arteriosus, total abnomalous pulmonary venous connection, pulmonary atresia, hypoplastic left heart syn- drome that most children need to intervene in neonatal period
Keywords: congenital heart defects, neonatal period
KET QUA S d M DONG THONG LIEN T H A T P H A N M A N G B A N G
DUNG c y CHO TRE EM TAI BENH VIEN NHI TRUNG y O N G
Cao Viet Tiing, Pham HCru Hba Benh vien Nhi Trung uong Thong lien thit la benh tim bim sinh thuang gap nliit Bi tai nay dime tiin hanli ntiim dinh gia kit qua som dong thong lien thit phin mang bing dung cu cho tre em lai benh vien Nhi Trung uang TCr- thang 12/2010 din thang 12/2011 co 38 benh nhan thong lien thit phin mang duvc dong dii tai benh vien Nhi Trung uong. Chimg toi su dung dung cu dong thong lien thit ciia hang Lifetech va qua do nghien ciru vi tinh an toan va hieu qua ciia phuang phip diiu tn Kit qua cho thiy tuii trung binh tai thai aim diiu tn la 5 tuii (tu 2.5- 12 tuii) va can nang Irung binh la 16kg (tir 11 -34 kg). Kich thuoc ciia thong lien thit tren sieu am va kich thudc dt: dong thong lien thit tuang ung la 3,9 mm (tu 3 - 6,2mm) va si 6 (tir sis-8) Ap luc dong mach phii tam thu trung binh la 35 mmHg (Iu27- 49mmHg). Qp/Qs la 1.3 (tu 1.2 - 1,5). 97,4% si benh nhan duac dong du kin hoan toan ngay sau can thiep 1 benh nhan con shunt tin luu thong liin thit nho va duac ding kin hoan toan sau 4 thang thao doi Khing co truong hap nio tir vong. chay miu. tan miu hoac huyit khii sau can thiep. 15,8% co ha van dong mach chii rit nhe va 1 benh nhan ci ngoai tim thu thit thoing qua Khong co truang hap nio bi block nht thit hoan loan sau can thiep va Irong qua trinh theo dot Nhu vay. dong du thdng lien thit phin mang cho kit qua tit va hieu qua dong kin hoan toin cao. khong co tu vong vi khoi benh tit.
Tir khoa; Thong lien thit ph§n mang, phinh vach lien thit, dung cu dong thong lien that
TCNCYH Phu truung 80 (3A) - 2012
I. DAT VAN o e
Thdng lien thit la benh ly tim bim sinh thudng gap nhlt chilm ty le 20 - 25% cac benh tim b i m sinh d tre em. Thdng Hen thit ed t h i gap d nhilu vj tri khae nhau tren vaeh Hen thit tao nen su thdng thuang glCra tuin hoan he thing va t u i n hoan ddng mach phoi, vj tri thudng gap nhlt la thong lien thit phln mang chilm tdi 70% [1] Phuang phap dilu tn CO diln la phau thuat va thdng li§n thit sir dung may tuin hoan ngoal ca t h i . Tuy nhien, trong vdng mudi nam g i n day tren t h i gidi da ed nhilu phdt tnln trong dilu tn thdng Hen thit qua ean thiep tim maeh dat kit qua t i t [1.2],
Chiing tdi tiln hanh nghien ciru vdi muc tieu: Danh gia ket qua sdm dong thong lien that phin mang bdng dung cu cho tre em tai benh vien Nhi Trung wang.
II. D O I TU'ONG vA PHU'aNG PHAP 1. Doi tu'O'ng nghien ciru: Cac benh nhan thdng lien thit phln mang dilu tn tai khoa Tim mach benh vien Nhi Tmng uang tir thang 12/2010 din thang 12/2011 dwac ehf dinh dilu tri ddng thdng lien thit bang dung cu.
1.1. Tieu chuan chgn
- Sieu am tim ehln doan thdng lien thit phln mdng dan thuln
-Can nang > 8kg;
- T h i t t r a i dan,
- Khoang each giu'a gd tren ciia thdng Hen thit va van ddng maeh chu > 2mm,
- Khdng cd hd van ddng maeh ehii.
1.2. Tieu chuan loai trip
- Benh nhan dang cd tinh trang nhilm tnjng.
- Cd hien tugng huylt khli tai vj tri Id
thdng lien thit hoac vj tri dua catheter vdo - Cd cac b i t thudng chire nang ciia van dgng mach chu vd van 3 la.
- Cd tinh trang benh ty mach mau phli 2. Phu'Ong phap nghien ciru
2.1. Phuang phap: Nghien ciru md ta, ed phln can thiep dilu tri; chirng trudc sau, tiln ciru, ngan han, m l u thudn tien theo trinh tu thdl gian.
2.2. Cach tien hanh
- Theo quy trinh ddng thdng lien thit phln mang bing dung cu cua benh vien Nhi Trung uang
- Danh gia k i t qua;
-^ Thanh cdng (tot); du dat diing vj tri, khdng cd shunt TLT ton luu, hoac shunt ton luu nhd.
•^ Thit bai Khdng thuc hien dugc thu thuat, hoac da tiln hanh thii thuat song sau do lai phai chuyin sang phuang phap dilu tn khac do eac biln e l v l ky thuat (nhu trcl, di leeh du, shunt t i n luu qua Idn sau thu thuat phai chuyin m l ) .
- Biln chirng: Chay mau hcac tan huylt, tut dil, block nhT thit, t u vong
2.3. Xif ly s6 lieu: s l tieu thu duae duae xu ly theo phuang phap thing ke y hoc Sir dung chuang trinh phln m i m EPI-INFO 6 0 eiia Td chirc Y t l T h i gidi
III. KtT QUA
Trong thdl gian tir thang 12/2010 d i n thang 12/2011 ehiing tol ed 38 benh nhan thdng lien thit phln mdng dugc dieu tri ddng thong lien thit bang dung cu.
1. Dac d i l m chung cua nhom nghien CLFU
Bang 1. Dac dilm chung Tuoi (nam)
Ty le Nam/Nir Can nang (kg)
5(2,5-12) 20/18 16(11 -34) Phan loai theo NYHA
D p i B o l l Dp ill Bo IV
25 (68%) 13(34%)
0 0 2. Cac bilu hien can lam sang 2.1. Dien tam do
Bang 2. Cac bilu hien dien tam dd Bilu hien dien tam d5
Nhjp xoang Day that trai Day that phai Khong day that
n 38 16 0 22
%
100 42
0 58 2.2. Xquang tim phoi thing + Chf so tim ngirc trung binh 53%.
+ Hinh anh tang lu'u lu-gng mau phdi: 27 benh nhan (71%).
2.3. Sieu am tim
Bang 3. Dac didm sieu am tim Vj tri thong lien that (TLT)
TLT phln mang 33 (87) TLT phan mang lan 5(13) dtroi van chu
TLT CO phinh vach lien 25 (66) that
Dirong kinh thong lien 3,9 ( 3 - 6 , 2 ) thit (mm)
Bu'ong kinh that trai tam 118(103-
tru'ong (%) 133) Ty le Dpng mgch chu/
Nhi trai
1,2(1-1,4)
3. Thong so thong tim
Bang 4. Cac thong s6 thong tim Then gian ehieu tia (phut)
Ap ILTC dong maeh phdi tdi da (mmHg)
Qp/Qs
Gd van dong maeh chij - > 2 mm
- < 2 mm
2 0 ( 1 0 - 6 5 ) 35 (27 - 49) 1.3(1,2-1,5) 34 (90) 4(10) 4. K i t qua va biln chirng
Bang 5. Kit qua va biln chirng Thcng Hen thit ddng hoan toan 37 (97,4) ngay sau ddng dii
Cdn shunt tdn luu sau ddng dii 1 Hd van ddng mach ehu rit nhe 6 (15,8) Chay mau hoae tan huylt sau 0 ~ ddng dii
Tudt dil 0 Block nhT thit d p 3 0 Tir vong 0
Ngay dieu tri 4 (3 - 6)
IV. BAN LUAN
Trcng nghien cii'u nay tull trung binh phlu thuat la 5 tuli (2,5 - 12 tuli) va can nang trung binh la 16 kg (11 - 34 kg) Theo khuyen cao tren t h i gidl, benh nhan cd the duac lua chpn ddng thdng lien thit vdi can nang > 8kg. Tuy nhien vdi nhung benh nhan can nang cdng nhd thi nguy ca xult hien biln chirng cao vi vay benh nhan chiing toi lua chpn la tren 2 tuli va can nang tren 10 kg. Nghien ciru cua Zhang Zhtwei (2004) chpn benh nhan ed can nang tren 12 kg, Li Xin (2011) ehpn benh nhan > 2,5 tuli va can nang > 15 kg [2]
Nhom benh nhan ehln doan thong lien thit phan mang cua chung tdi cd phan loai
TCNCYH Phu truung 80 (3A) - 2012 NYHA dp 2 chiem 34%, Xquang cd tang tudi mdu phil 71%, tang ganh thit trai 42%, ap tuc dgng mach phli t i l da trung binh la 35 mmHg Bleu am tim danh gia trude m l ehln doan thdng lien thit phln mang chilm 87%
va cd 13% thdng lien thit phln mang lan dudi van dgng mach chii, cd 66% thdng lien that cd kem theo phinh vach lien thit Ddy chinh la nhung dac dilm quylt djnh lua ehon kieh thude vd dung cu ddng thong Hen thit.
Thong thudng kieh thudc thdng lien thit va gd van ddng mach chu duge danh gia qua ehup budng thit trai, dung cu dugc chpn ed kich thude ldn han kich thudc lo thdng lien thit 1 - 2 mm [3, 4] Nghien eiru nay thly dudng kinh thdng Hen thit trung binh la 3,9 mm (3 - 6,2 mm), co 90% trudng hap thdng lien thit ed gd van ddng mach chii
> 2 mm la ylu t l rit ein thilt cho dung cu ddng thdng Hen thit I n dinh va khdng anh hudng d i n van dgng mach ehii. Tuy nhien chung tol cung dac biet chu trgng danh gid tinh trang phinh vach lien thit trong viec ehpn dung cu, trudng hgp benh nhan cd thdng lien thit kem theo phinh vaeh lien thit ldn va cd nhilu Id thdng lien thit nhd, viec chon dung cu thdng lien thit typ 2 duac lua chpn se tranh dugc shunt t i n luu sau ddng thdng lien thit Trudng hap t l chirc phinh vach Hen thit nhd dung cu thdng Hen thit typ 1 se duge lua ehon ddng thdng Hen thit [2, 4] Nghien ciru eua chimg tdi cd 10% thdng lien thit ed gd chit han c h l k i t hap phinh vach lien thit ldn. Theo Lin Xin, trong cae trudng hgp nay d l tranh viec diing dung cu kich thudc qua cd ein thilt, ehiing ta nen dat dung cu dong thdng Hen thit trong tui phinh, khdng nen dat dung cu tai vi tri bd thit trai cua thdng lien thit vi se bit duac Id thdng gial phlu chlnh va tranh duge anh hudng d i n van ddng maeh ehu [2] Viec lua chpn chiln lugc ddng thdng Hen thit quylt
dinh thdl glan can thiep cho benh nhan, thdi gian chilu tia trung binh trong nghien ciru cua Chung tdi la 20 phiit ( 1 0 - 6 5 phiit) ngin han khi so sdnh vdi k i t qua nghien eiru cua Li Xin vdl thdi gian chilu tia trung binh la 32 phut (26 - 72 phiit), Butera G 29 phut (5 - 72 phiit), Malgozata S 26 phut [2, 5, 7]
Theo Arora R (2003) va Holzer R (2006) ty le thanh cdng ddng du thdng lien thit phln mang bang dung cu chilm 90 100%.
Nghien ciru ciia chiing tol cd ty le thanh cdng la 97.4%, chf ed 1 benh nhan con shunt tin luu nhd sau ddng du thdng Hen that va sau 4 thdng theo dol shunt ton luu da tu dong kin.
Chung tdi khdng gap benh nhan nao ed biln chirng chay mau, tan huylt hay tudt du sau m l . Chiing tdi gap 15,8 % benh nhan ed hd chil rit nhe sau ddng thdng lien thit, trong qua trinh kham dinh ky theo doi tinh trang hd van ddng mach chii khdng thly tang len.
Biln ehirng Block nhT thit elp 3 la biln chung dang sa nhlt trong can thiep ddng thdng lien that bing dung cu qua da vdi gia thuylt can nguyen cho ring dung eu se gay ehan thuang truc tilp dudng d i n truyln hoac do qua trinh viem xay ra sau khl dat dung cu. Biln ehirng Block nhT thit d p 3 theo nghien euu eiia Butera la 5,7%; Ll Xm la 6,4% trong glai doan sdm va ed 1,3% trong gial doan theo doi ve sau. Treng nghien eiru eiia ehiing tdi khdng cd benh nhan bi block nhT thit elp 3 sau dat dii cung nhu trong qua trinh theo ddl Dua tren gia thuylt v l can nguyen gay block nhT thit d p 3 ehimg tol e l gang chgn kich thudc dii nhc nhlt phii hgp vdi benh nhan va chu ddng dung eorticoid ding loat cho cac benh nhan sau ddng dii thdng lien thit. Cac tac gia Walsh MA va Holzer R (2006) cung d l xult phuang an dung eorticoid sau ddng dii thdng lien thit [6]
Nghien ciru eiia chiing tol khong ed
tru'crng hop nao tCr vong Thd'i gian n i m vien trung binh ia 4 ngay, tu'ang du'ong vol cae tae gia khae tren thS gioi [2, 5]
V. K e r LUAN
Dong thong lien that bang dung cu qua da la phu'Ong phap an toan, hieu qua cho thong lien that phan mang va co the ap dung tai cac trung tam tim maeh tre em nu'dc ta.
TAI LIEU THAM KHAO 1. Lee N, Benson, Shi Joo Yoo (2010).
Ventricular Septal Defect. Pediatric Cardiolo- gy, 3"" Edition 591-624.
2. Li Xin, Li Ling, Wang Xian (2011).
Clinical analysis of transcatheter closure of perimambranous ventricular septal defects with occluder made in China. Chinese medi- cal journal. 124 (14): 2117-2122.
3. Charles E.Mullins (2006). Transcatheter closure of ventneular septal defects. Cardiac catheterization in Congenital Heart disease;
Pediatric and Adult, l " Edition 803 - 841.
4. Yun Ching Fu, Ziyad M Hijazi (2007) Closure of perimembranous VSD using the Amplatzer membranous VSD occluder. Per- eutanous interventions for Congenital Heart Disease: ^49 - 355.
5. Butera G, Carminati M, Chessa M (2007). Transcatheter closure of perimambra- nous ventricular septal defects Early and long - tem results J Am Coll Cardial: 1189 -1195.
6. Holzer A, Balzer D, Qi Ling 0 (2004).
Amplatzer muscular ventricular septa! defect investigators. Device closur of muscular ventricular septal defect using the Amplatzer muscular ventricular septal defect occluder, J Am Coll Cardial, 43 1257-1263.
7. Malgorzata S, Jacek K, Jacek B (2008). Percutanous closure of perimambra- nous ventneular septal defects with Am- platzer occluders - a single center experi- ence Kardiol Pol, 66: 941 - 47
Summary
TRANSCATHETER CLOSURE OF PERIMEMBRANOUS VENTRICULAR SEPTAL DEFECT WITH OCCLUDER: EARLY RESULTS AT NATIONAL HOSPITAL OF PEDIATRICS Ventricular septal defect is a commonest congenital disease. This study was carried out to analyze early results of percutaneous closure ofpmVSD with Lifetech occluder at National Hos- pital of Pediatrics. Between December 2010 and December 2011, 38 patients underwent percu- taneous closure of pmVSD at NHP. The Lifetech VSD occluder was used for all subjects. The safety and the efficacy of the device were investigated. The results showed that: average age and weight at closure was 5 years (range 2.5 to 12 years) and 16 kg (range 11 to 34 kg). The size of VSD by echo and size of device used was 3.9 mm (range 3 to 6.2 mm) and 6 (range 5 to 8). respectively. The mean of systolic pulmonary pressure was 35 mmHg ( range 27 to 49 mmHg) , Qp.'Qs. 1.3 ( range 1.2 to 1.5). Total occlusion rate was 97.4 % at completion of the procedure, 1 patient had small residual shunt and closed after 4 months follow-up. During the perioperative period, no death, major bleeding, hemolysis or thromboembolism occurred in all patients. 15 8% trivial aortic regurgitation, 1 transient ventricular premature. None in our group had complete atrioventricular block (cAVB) in the early phase and during the follow-up In con- clusion, percutaneous pmVSD closure used VSD occluder is associated with excellent success and closure rates, no mortality, and low morbidity.
Keyvyords: Ven'-icular septal defect, aneurysm, device
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