TCNCYH Phu truung 80 (3A) - 2012
11. Sinzobahamvya N, Wetter J, Mai Coeur Vaiss. 93 (12); 1503-1510.
Blaschczok HC (2000). Heart surgery under 12. Stark de Leval, Tsang (2006). Sur- eardiopulmonary bypass during the neonatal gery for Congennital Heart Defects; Third period remains a high - risk procedure. Areh Edition wiley.
Summary
RESULTS OF OPEN HEART SURGERY IN NEWBORN AT NATIONAL HOSPITAL OF PEDIATRICS
The study was to analyze results of treatment, the progress of open-head surgery in 38 newborns with congenital heart disease at the National Hospital of Pediatrics for the period 2006 - 2011 Results showed that of 38 infants whose average age was 16 days (3-33), average weight was 3.2 kg (2.1 to 4). the congennital heart defects intervene neonatal period mainly transposition great artery (TGA): 22/38 (57.89%>), pulmonary atresia (PA): 6/38 (15.79%,). total anormalous pulmonary veins connection (TAPVC): 3/38 (7 89%>), and some other defects 7/38 (18.42%). Results of treatment the survival rate was 81.58%, of which 77.27%o success TGA patients, PA 100%c. TAPVC 100%o in period 2010 - 2011 25/38 newborn underwent open heart surgery, 88% survival, higher than the period 2006 - 2009 (69.23%). Complications after surgery were the most common pneumonia (68.42%). renal failure 21.05%. sepsis 10 52%>, Infection of the sternum 7.89%>. A number of factors affecting mortality are age < 15 days (p < 0 05). lactate level >4.4 mg/l (p < 0.001). duration of CPB > 160 minutes (p < 0.05), duration of aortic clamp >
110 minutes (p < 0.05). In conclusion, open heart surgery in newborn at National Hospital of Pediatrics had high survival rate. There have a lot progress in this field in recent years (2010 - 2011). it Is need to aware of the complications after surgery such as pneumonia, kidney failure, sepsis, also a number of factors affecting mortality such as age, lactate level, duration of CPB time and duration of aortic clamp.
Keywords: congenital heart disease, surgery repair in neonatal period, cardio-pulmonary bypass
MOT SO CHI SO SIEU AM TIM TRITQC VA SAU PHAU THUAT a TRE MAC BENH TTNH MACH PHOI V ^ LAC CHO HOAN TOAN
Pham HQ'U Hoa, Pham Quoc Khwong Benh vien Nhi Trung wang oi tdi dwac tiin hanh nham nghidn ciru cdc dac diim sidu dm chinh vd ddnh gid sw thay ddi cdc thdng si sidu dm trwdc vd sau phdu thudt bdnh tinh mach phdi vd lac cho hoan toan d trd em Phdn tich 34 benh nhan da dwac xac dinh chin dodn bing sieu dm Doppler tim vd dw<yc phdu thudt tai benh vien Nhi Trung wang. kit qua cho thdy thi trdn tim chiim 52,9%, thi trong tim 44.1%. thi hdn hop 3,0%. Cac diu hidu sieu am goi y chin doan la: tim phai dan. khdng thiy ddng chay tJnh mach phdi dd trwc tiip vi nhi trai shunt phai - trai qua ting nhi hoac cdc tTnh mach he thing hoac xoang vanh dan Nhirng thay ddi cdc thong si sidu dm trwdc va theo ddi 1 tuin diu sau md cho thdy dwdng kinh thit phai, dp Iwc tdm thu dong mach phdi vd chdnh dp qua van ddng mach phdi giam cd y nghla thing ke. Nghidn ciru da chi ro mgt sd dap diim sidu dm chinh cd vai trd quan trong trong chin dodn, theo doi didu tn vd nhdng thay ddi cua mdt sd thong sd sieu am tim trong tuin diu sau md benh tinh mach phdi vi lac chd hodn todn Tir khda: benh tinh mach phoi v l lac chd hoan toan, cac thong s l sieu am tim
I. DAT VAN DE
Benh tTnh maeh phli v l lac ehd hoan todn la loai tim bim sinh It gap trong dd cac tTnh mach phil thay vi do vao nhT trai lai 66 true tilp hoac gidn tilp ve nhT phai Neu khong dugc ehln doan va dilu tn phlu thuat kip thdi, benh nhan sdm tif vong nhat la eac the ed t i c nghen [1, 4, 7] Sieu am doppler tim ddng vai trd quan trgng trong chin doan, ehi dmh phlu thuat va danh gia kit qua phau thuat D l tai nay duge tiln hanh nham muc tieu:
- Nghien ciru cac dac diem sieu am chinh trong cac thi benh tfnh mach phoi vi lac cho hoan toan
- Danh gia sw thay doi mot s6 thdng so sieu am tim trwdc va sau phiu thuat II. D 6 | T U ' Q N G V A PHU'aNG PHAP
TCNCYH Phu trwang 80 (3A) - 2012 benh tTnh maeh phli v l lac chd hoan toan cd kem cac benh tim bim smh khae
2. Phu'ong phap nghien ciru: nghien ciru md ta, tiln eiru Cd mau chon mlu thuan tien theo trinh tu thdi gian
Cac benh nhdn duac theo ddi theo mlu benh an nghien eiru rieng Danh gia mirc dd suy tim theo NYHA, tinh ap lue ddng mach phli dua vao chenh ap qua hd van 3 la [4], Su dung may sieu am tim Philip SONO 500, dau dd 3,5-12 MH. Sieu am dugc lam trudc phlu thuat, cd so sanh vdi kit qua m l , so sanh tru'dc va sau phlu thuat 7 ngay.
3. Xir ly sd lieu: theo phuang phap thong ke y hgc bang phln mim SPSS 10 0 ciia Td chii'c Y t l T h i gidl
III. KET QUA 1. Ooi tu'O'ng nghien ciru: Gdm tat ea
benh nhan duac chin doan benh tTnh maeh phli v l lae ehd hoan toan dilu tn tai benh vien Nhi Trung uang tir 2/2006 d i n 4/2009
-Tieu ehuin ehon benh nhan Cac benh nhan benh tTnh mach phoi ve lae ehd hodn toan da duac phlu thuat
Loai khdi nghien ciru nhu-ng trudng hap
2. Mpt s6 dac d i l m lam sang chinh tru'dc phau thuat
Bang 1. Mot s l dac d i l m lam sang chinh tru'dc phau thuat
Trong thdi gian nghien eiru ed 34 benh nhdn duac chin doan benh tTnh mach phli v l lac c h l hoan toan bing sieu am tim va da duae phau thuat
1. Oac diem chung cua nhdm ddi tu'ong nghien ciiru: Tuoi trung binh 5.45 thang (tir 20 ngay - 60 thang tuli) Can nang trung binh 5,35 kg (tir 4 - 13.1 kg). Ty le Nam/ NCP - 18/16
Oac diem lam sang chinh Tim
Suy hd hap Suy tim
27 28 34
%
79,4 82,4 100,0 SPOjtrung binh 75, 50±15,7%.
3. Mot s6 dac d i l m chinh v l tim qua sieu am trudc phau thuat: Tim phai dan 100%, Khong thly 4 tTnh mach phli hoac ddng chay cua 4 tTnh mach phli d l truc tiep vao nhi trai.
100%, Shunt phai-> trdi qua PFO hoae thdng lien nhT 100%
4. Phan Ioai tmh mach phoi do ve lac chd hoan toan dua theo ket qua sieu am tim va p h l u thuat
65
TCNCYH PhiJ truung 80 (3A) - 2012
Bang 2. Cac t h i tinh mach p h l i d l v l lac c h l hoan toan Cac the va vi tri do ve cua tmh mach phdi
T h i tren tim TM thing - > TM vd danh - > TMC tren
Truc tilp vao TMC tren 52,9
T h i trong tim T h i hdn hgp
Vao xoang vdnh Vao nhT phai
3 TMP d l va hgp luu -> TMT - > TM vd danh - ^ TMCT 1 TMP d l true tilp vao nhT phai
14 1 1
44,1 3,0
5. Du'dng kinh nhT trai, t h i t trai, t h i t phai, dpng mach phdi tru'dc va sau phau thuat Bang 3. Du'dng kinh nhT trai, t h i t trai, t h i t phai, dpng mach phdi
Cac chi s l NhT trai
NhT trai/DMC
DK that trai tam tru'ong (Dd) DK that trai tam thu (Ds) Phan suit ting mau (EF %) DK that phai tam tru'crng DK dong maeh phli
Triroc m l 20,7±5,5 1,45 ±0,33
24,3 ±8,8 15,4 ±5,3 69,8 ±5,7
18,5±6,8 17,1 ±6,5
Sau m l 21,1 ±5,4 1,40 ±0,27
29,5 ±5,5 17,2 ±4,9 72,5 ±6,1 1 2 , 7 ± 4 4 16,5 ±5,2
P
>0,06
>0,05
<0,05
>0,05
>0,05
<0,05
>0,05 6. Ap tire dong mach p h l i va chenh ap qua cac van tru'dc va sau p h l u thuat
Bang 4. Ap lire dpng mach phdi va chenh ap qua cac van Cac chi so
Ap lu'C dong maeh phoi Chenh ap,qua van DMP Chenh ap qua van DMC Chenh ap qua van hai la
Tru'O'C mo 72,2 + 28,6
10,8 ±7,8 3,4 ± 1,7 4,2 ±2,2
Sau m l 38,8 ± 13,6
4,0 ±3,6 5,2 ±3,1 4,3 ±2,3
P
<0,05
<0,05
>0,05
>0,05 IV. BAN LUAN
Dae dilm nhdm d l i tuang nghien ciru' Tull phat hien benh trung binh la 5,45 thang (sdm nhlt la 2 ngay, mudn nhlt la 5 tull), ty ie nam/ nir tuang duang Cae d i u hieu ldm sang nli bat la cac trieu ehirng v l hd h i p S l benh nhan duac ghi nhan ed tim tren ldm sang la 79,4% va SPO2 trung binh khoang 75,5 ± 15,7%. Bilu hien suy tim thly d t i t ea benh nhan vdi cac mire do khae nhau Nhin chung, eae d i u hieu lam sang khong dac
hieu, it cd gia tn ehln doan benh ma chf gdp phln danh gia mire do nang cua benh. Kit qua nay phii hap vdi nhan dmh cua mdt s l nghien ciru trudc day [1, 2, 6]
Mdt s l d i u hieu sieu am tim trudc phlu thuat- Chung tdi nhan thay- 100% benh nhi d i u ed nhT phai, thit phai dan tg vdi lo PRO hoac thdng lien nhT cd shunt phai - > trai Day la d i u hieu sieu am ggi y quan trong trong chin doan tTnh maeh phli d l v l lac ehd hoan toan Mdt dau hieu quan trong khac la khong
66
TCNCYH Phil truung 80 (3A) -2012 thay hlnh anh tTnh mach phoi hoac dong mau
ciia tTnh mach phli d l true tilp vao nhT trai Vdl cdc may sieu am t h i he mdi va ky nang lam sieu am t i t thi khdng qua khd khan khi xac dinh d i u hieu ndy. Tuy nhien, trong mdt s l trudng hgp do tre khdc, tre cd suy hd hap, viee xae djnh vi tri d l v l cua eae tTnh mach phli cd t h i gap khd khan Mdt s l dau hieu gian tilp khae eung h i tra eho chin doan nhu vdi t h i tren tim tTnh mach thing va tTnh mach khdng ten ddn to, vdl t h i trong tim xoang vanh dan to, va vdi the dudi tim- tTnh mach chu dudi dan to) Bleu am doppler mdu giiip danh gia van tie ddng chay gdp phan danh gia mirc do tac nghen, mdt dau hieu quan trgng trong chf dmh dilu tri va tien Iugng benh nhan tTnh mach phoi do v l lac ehd hoan toan.
Nghien ciru cung cho thly cd 18 benh nhan t h i tren tim chilm 52,9%, trong dd 16 trudng hap hdi luu tTnh mach phli qua tTnh mach thing, qua tTnh mach khdng ten do vao tTnh mach ehii tren vd d l vao nhT phai Chf ed 2 trudng hap hpi luu tTnh mach phli 66 truc tilp vao tTnh maeh ehii tren. The trong tim co 15 benh nhan, chilm 44,1%, trong dd 14 trudng hap hdi luu tTnh mach phoi d l vdo xoang vanh r i l vao nhT phai, 1 trudng hap hdi luu d l truc tilp vao nhT phai Chiing tdi chf gap 1 trudng hgp t h i hdn hap trong dd 3 tTnh mach phli d l vdo hpi luu vao tTnh mach vd danh sau d l vao nhT phai, con 1 tTnh mach phli dd true tilp vao nhT phai. Chiing tol khdng gdp trudng hap nao t h i dudi tim Theo eae nghien eiru eiia Constantlne M., Kirklin va Robert H.A dua tren kit qua phlu thuat va m l tir thi thi t h i tren tim gap 45 - 50%, t h i trong tim gap 20 - 25%, t h i dudi tim gap d 20% vd t h i hdn hap gap 5 - 10%
.[1, 4, 7]. Cae tdc gia tren nhan thly t h i dudi tim thudng kem theo t i c nghen Day cd le la ly do nhCrng t h i dudi tim thudng nang vd
benh nhan tie vong sdm trudc khi den vien hoac tu vong sdm sau khi vao vien ma ehua kip sieu am tim
3. Mpt so thay ddi sieu am tru'dc va sau
Trudc m l , thit phai, nhT phai va ddng mach phoi dan do toan bd mau tTnh mach phdi diu trd v l nhT phai Nguae lal, thit trai, nhT trai thudng nho do luang mau v l -It han binh thudng Kieh thude thit trai, nhT trdi phu thudc vao luang mau qua thdng hen nhT hoae lo PFO Vi the. Id PFO nho la mot ylu t l lien quan din mirc dd nang va tien luang benh Sau mo, mau tir phli trd v l nhTtrai nen tinh trang huylt ddng ben tim trai 6u'ac cai thien dan, va that phai, nhT phai, ddng mach phli nho di
Trong nghien ciru ndy, dudng kinh thit phai giam tU' 18,5 ± 6,8 mm xuing cdn 12,7
± 4,4 mm (p < 0,05) Dudng kinh dong maeh phli giam han so vdi trudc m l , dudng kinh that trai euoi tam truang tang han sau m l nhung su khac biet nay tai thdi dilm theo doi khdng ed y nghTa thing ke Mot so tac gia trong nghien ciru ciia minh cung eho k i t qua tuang tu [1, 2, 4, 6] Su khdc biet cua dudng kinh that trai tam thu la khong nhieu, do vay phan s l ting mau cd tang len nhung cung khong co y nghTa, Khdng ed su khae biet v l dudng kinh nhT trai va ty le nhT trai / dong maeh chii gii>a trude va sau m l ,
Trude md ap lue dong mach phil tang kha cao la 72,2 ± 28,6 mmHg Sau m l , ap lue dong mach phdi tam thu giam di ro ret, edn 38,8 + 13,6 mmHg (p < 0,05). Kit qua nay duae danh gia sau mo trung binh 1 tuin, Chenh ap"
qua van ddng maeh phoi eung giam di rd ret do luang mdu qua van ddng mach phdi giam di Ket qua cung phii hgp vdi ket qua nghien cuu cua mdt s6 tac gia nudc ngodi [3, 4, 5] Trong khl dd chenh dp qua van hai la va van dpng mach chil ed tang nhung khdng ed y nghTa. Cd 67
TCNCYH Phu truung 80 (3A) - 2012 le dieu nay phu thudc chlnh vdo su dan nd ciia thit trai sau phlu thuat.
V. K t T LUAN
Qua nghien ciru 34 benh nhan bi tTnh maeh phli d l v l lac ehd hoan toan dugc phlu thuat tai benh vien Nhi Trung uang:
+ Mot s l d i u hieu sieu am tim gidn tilp cd t h i ggi y chin doan PVLCHT la ; Khdng thly ddng chay cae TMP d l truc tilp vao nhT trai, lo PFO (hoac TLN) shunt phai - trai, hinh anh tim phai dan vd tim trai nho, gian cae tTnh mach he thing hoae gian xoang vanh
+ TTnh mach phli d l v l lae eho hoan toan the tren tim ehilm 52,9%. tTnh mach phli d l v l iac chd hoan toan t h i trong tim la 41,5%
va tTnh mach phli d l v l lac chd hoan toan the hdn hap la 0,3%), Chimg tdi khdng gap bit thudng t h i dudi tim trong nghien eiru nay.
+ Sau m l , dudng kinh thit phai giam tir 18,5 ± 6,8 mm xuing 12,7 ± 4,4 mm, ap luc ddng mach phli giam tu 72,2 ± 28,6 mmHg xuing con 38,8 ± 13,6 mmHg va ehenh ap qua dpng maeh phli giam tir 10,8 mmHg xuing edn 4,0 mmHg trong khi eac chi s l sieu am khac khong thay d l i nhilu
TAI LIEU THAIVI K H A O 1. Constantlne Mavroudis (2003). Total anomalous pulmonary venous connection.
Pediatnc cardiac surgery, Mosby; 612 - 623.
2. Emmel Mathias, Screeram Na- yanswami (2004). Current treatment options in cardiovascular medicine Total anomalous pulmonary vein connection - Diagnosis, man- agement and outeome. Current science Inc:
423 - 429.
3. Karamlou Tara, Gurofsky Rebecca et al. (2007). Factors associated mortality and reoperation in 337 patients with total anoma- lous pulmonary venous connection. Circula- tion 115 1591 -1598.
4. Kirklin, Barrat Boyes (2003). Total anomalous pulmonary venous connection. Car- diac surgery, Churehil Livingston' 753 - 776.
5. Morantz Carrie A (2005). ACCP guide- lines for pulmonary arterial hypertention Copyright 2005 by the American academy of family physicians.
6. Myung K. Park (2010). Total anoma- lous pulmonary venous return. The pediatric cardiology handbook. Fourth edition, Mosby Elsevier: 140-144
7. Robert H. Anderson, Fergus J. Mac- artney (2002). Totally anomalous pulmonary venous connection. Peadlatric cardiology, Second edition, vol.1, Churehil Livingston, Harcourt publishers limited : 867 - 874.
Summary
ECHOCARDIOGRAPHIC FINDING AND
EVALUATION ON PERI - OPERATIVE ECHO CHANGES OF THE PATIENTS WITH TOTAL ANOMALOUS PULMONARY VENOUS RETURN
The study was carried out to assess some main echocardiographic finding and to evaluated changes of several peri-operative echo-parameters In patients with total anomalous pulmonary venous return (TAPVR). Analysed 34 operated TAPVR cases at NHP, Echocardiography classi- fication showed that supra-cardiac type account for 52.9%,, cardiac type 44 7% and infra-cardiac type 3, . Some suggested ultrasound sign were right heart dilatation, no pulmonary venous flow directed to left atrium, right to left shunting at atnal level or dilated systemic pulmonary venous and/or enlarged coronary sinus. Definite diagnosis was made by combination TM, 2D and Dop-
TCNCYH Phit tmung 80 (3A) - 2012 pier technique Perioperative comparison showed that 1 to 7 days after operation, right ventricu- lar diameter decreased, pulmonary artery pressure and right ventricular - pulmonary valve PG max decreased significantly.
Keywords: Total Anomalous Pulmonary Venous Return (TAPVR), echo parameters
NHU CAU PHAU THUAT CAC BENH TIM BAM SINH TRONG GIAI DOAN SO SINH TAI BENH VIEN NHI TRUNG U'QNG
Nguyin Trung Kien, Pham Hiru Hoa Benh vien Nhi Trung Wang Nghien ciru nhdm xac dinh ty Id di tat tim bim sinh cin dwgc can thiep trong giai doan so sir)h. Kit qua trong 3 thang cd 1176 tre nhap vien, chung toi sdng loc 1124 tre cd 272 di tdt tim bim smh ty le 24.2% Sd trd cd chi dinh can thiep ngoai khoa ngay trong giai doan sa sinh 145 tre (53.3%o), phin Idn nhirng trd cd di tdt ddo gdc ddng mach, thit phai hai dwdng ra, thdn chung dong mach. bit thudng dd vi tmh mach phdi hodn todn, teo van ddng mach phdi, hdi chwng thidu sdn tim trdi cd chi dinh phdu thudt ngay trong thdi ky sa smh. Ty Id di tat tim bim smh tal khoa So sinh Id 24,2%, Ty Id trd cd chi dmh can thiep ngoai khoa trong giai doan so smh cao vdi 53,3%,: ddc bidt vdi dng ddng mach d tre de non ty le tre cin can thidp 64%. Cac di tat dao gdc ddng mach, thit phdi hai dwdng ra, than chung ddng mach, tmh mach phdi dd vi bit thwang hodn toan, hdi chieng thiiu sdn tim trdi, teo van dong mach phoi cd phdn Idn tre cin can thiep trong giai doan sa smh.
TCr khoa: ty le dj tat tim bim sinh, gial doan so sinh
I. D A T V A N D £ ciru nao nhim xdc dmh nhu elu dilu tn phlu Tim bim smh la dj tat r i t hay gap, theo ^huat dli vdl benh nhan tim bim sinh trong giai nhilu nghien cuu tren t h i gidi, ty le benh doan sa sinh. Vi vay chiing tdi thuc hien nghien khoang tir 5 - 8/1000 tre sinh ra sing [2, 9] cu'u nay vdi muc tieu: Xac djnh ty le tre co chl Tai eac ca sd dilu tri sa sinh, t u vong do ^ " ^ P^^^ ^^^^' ' ' ^ ^ ^ ^ s/nrt a tre diiu tri tai tim b i m sinh gdp phln dang k l trong t u khoa So sinh benh vien Nhi Trung wang.
vong Chung d lira tudi sa smh Tren t h i gidi, u ^^^ TU'CXNG VA PHU'aNG P H A P viec sang loc t i t ea cae tre sau khi sinh da
du'oc thU'C hien & nhilu nu'dc phat triln do ^- °^'' '"'9'"3 "S'"'^" '=''" '^' '^^ ^'^ ''^°
do di tat tim b i m sinh dtrac phat hien va ean '^'^" '^ t^i khoa So sinh benh vien Nhi Trung ,^.. . , • w- • „ , „ „ h „ U'ang tir thang 10 d i n hit thang 12/2010.
thiep som mang lai hieu qua cao cho y a a ngu'Oi benh. Tieu chuan chon benh nhan nghien eiru;
Tat ca tre mac cac di tat tim b i m sinh dieu tn tai khoa So sinh
Benh vien Nhi Trung LKong da tien hanh cong tac sang Ipc tim bim smh a tre so smh
nam 2010. Kit qua bu'dc a l u eho thly tyle tre Tieu chuan loai tni: nhu-ng tre khong bi bi cac di tat tim bam sinh kha cao, trong do co eac di tat tim b i m sinh hoae nhu'ng tre chet nhilu tre ein can thiep ngoai khoa ngay trong trong vdng 12 gid sau khi vao khoa ma chu'a giai doan so sinh Tuy nhien chu'a eo nghien du'gc xac dmh chin doan.
