Y HOC VIET NAM THANG 5 - SO 1/2D15
NGHIEN CU'U DAC DIEM LAM SANG VA DIEN SINH LY TIM TREN BENH NHAN RUNG NHI KICH P H A T
Pham Tran Linh*, Pham Quoc Khanh*, Nguyen Lan Viet*
TOM TAT
Chiing toi tien hanh tham do dien sinh ly tim, ghi nhan cac hoat dpng dien trong buong tim khi nhjp xoang va khi rung nhT de danh gia hoat dgng cua nhi va that. Phu'dng phap va ket qua: Trong 42 benh nhan nghien cu'u, chung toi ghi Holter dien tam do 24 gid de ghi nhan tan suat cung nhu" thdi diem xuat hien aJn rung nhi cung nhu" miTc dp trieu chiTng ciia benh nhan khi xuat hi^n edn rung nhT. Chiing toi su* dung Si^n CLTC lap ban do ngi mac buong tim ket hop vdi he thong djnh vj 3 chieu lap ban do dien hpc buong tim ghi nh?n tdi tren 70% 6 ngoai tam thu nhi khdi phat ojn rung nhi xuat phat d lo do ve nhT trai ciia 4 tinh m?ch phoi, danh gia hoat dpng dien cua nhT va ttiat cac khoang din truyen trong nhl, nhT that, thdi gian phgc hoi nut xoang, thdi gian trd hieu qua nhi va that.
Ket lu|n: 100% BN rung nhT can deu cam thay hoi h$p danh trong ngiTc. Cac trieu chutig khac gom met moi chiem 72,1%, dau ngiTc chiem 59,3%, kho thd khi gSng siTc chiem 41,9%. Mii'c dp tneu chiTng ciia benh nhan theo thang diem EHflA la 3,19 ± 0,45. Thdi gian trd cd nhi, thdi gian chu ky cd ban, thdi gian phan ly nhi that d nhiJTig benh nhan tren 60 tuoi deu keo dai hdn nhom b?nh nhan du'di 60 tuoi. Ngoai tam thu nhi ki'ch hoat edn rung nhT co tdi tren 70% cac tru'dng hdp xuat phat tiT lo tJnh mach phoi do ve nhT trai. Dac biet CO ti3i 83,3% ngoai tam thu nhT khdi phat tir tTnh mach phoi trai tren trong khi chi co 4,8% ngoai tam thu nhT khdi phat tir nhi phai.
Ti^khSa: rung nhi - dien sinh ly - kich phat - ban do dien hpc
SUMMARY
CLINICAL M A N I F E S T A H O N S AND ELECTROPHYSIOLOGIC FEATURES
I N PATIENTS W I T H PAROXYSMAL ATRIAL F I B R I L L A T I O N Cardiac electrical activity during sinus rhythm and episodes of atrial fibrillation w/ere recorded when 42 patients underwent electrophysiologic study procedures. Frequency and time of occurrence, severity of functional symptoms of episodes of atrial fibrillation were evaluated by 24-hour
* Vien Tim mach Viet Nam - Benh vien Bach Mai Chju trach nhiem chfnh: Pham Quoc Khanh Email: [email protected] Ot: 0913232552 Ngay nh|n bai: 6/1/2015
Ngay phan bien khoa hpc: 26/3/2015 Ngay duyet b4i: 2/4/2015
electrocardiogram recordings. Catheter-based endocardial mapping with the assistance of three- dimensional electroanatomic mapping systems were conducted to localize the original triggers of atrial fibrillation, to explore electrical activity of atria and ventricles and to measure conduction time within atnal and ventncular tissues. Programmed atnal and ventncular stimulation protocols were performed to study sinus node recovery time and effective refractory periods of atria and ventricles. Results:
100% of patients suffered from episodes of atrial fibrillation reported the symptom of palpitations. Other symptoms were fatigue (72.1%), chest pain (69.3%) and dyspnea at effort (41.9%). Severity of symptoms evaluated by EHRA score were 3.19 ± 0.45. Basic cycle length of sinus rhythm, atria's effective refractory period were significant longer in the subgroup of over 60 year-old patients when compared to under 60 year-old group. 70% of patients were determined the location of prematured atrial complexes triggering episodes of atrial fibrillation onginating from the pulmonary vein ostia of those 83.3% of prematured atrial complexes firing from left superior pulmonary vein whereas 4.8% of ones emerging from right atrium.
Keywords: atrial fibrillation, paroxysmal, electrophysiologic study, endocardial electroanatomic mapping.
I. OAT VAN OE
Rung nhl la mpt trong nhO'ng roi loan nhjp tim thu'dng gap nhat trong cpng dong va thu'dng gay ra nhu'ng bien chiTng nang ne. Rung nhT co the la nguyen nhan gay ra khoang 5 % cac tru'dng hdp dot quy moi nam. Benh nhan suy tim CO kem theo rung nhi thi ty le tiT vong tang den 34%. Nghien ciTu dac diem lam sang cung nhu' dien sinh ly tim tren benh nhan rung nhT kjch phat giiip cho viec dieu trj rung nhi bang can thiep triet dot hay phau thuat Maze dat du'dc ty le thanh cong cao va han che du'dc toi thieu cac blen chutig khi can thiep dieu trj rung nh?.
II. OOI TU'pWG VA PHU'aNG PHAP NGHIEN CO'U 2 . 1 . 0 6 1 tu'dng nghien cu'u
Bao gom 42 benh nhan du'dc chan doan xac djnh la edn rung nhT kich phat tren lam sang, OTO 12 chuyen dao, va tham do dien sinh ly tim.
Tat ca benh nhan nay deu du'dc nam dieu t n npi tru tai Vien Tim mach Benh vien Bach mai t i f
Y HOC VIET NAM THANG 5 - SO 1/2015
thang 10 nam 2009 den thang 3 nam 2014, cac benh nhan nay deu sir dung 2,5 ± 1,0 loai thudc cliong roi loan nhjp tim (nhom IA, IC va nhdm 3).
2.2. Tien hanh thu thuat
2.2.1. Dat dien cifc- Gay te tai vi tri' choc tTnh mach bang Novocain.
- Du'di SlT hu'dng dan ciia man huynh quang tang sang ky thuat so, cac day dien ci/c du'dc du'a tdi cac vi tri' can thiet giup cho qua trinh tham do dien sinh ly tim va dot bang song cd tan sd Radio. Thong thu'dng cac day dien ciTc can thiet bao gom day dien cy'c xoang vanh, nhl phai, that phai. His,
- Day dien CLTC xoang vanh mu'di ci/c, 6F, thu'dng du'dc du'a qua du'dng TM du'di don trai.
- Day dien cifc that phai, nhT phai, His 4 cifc, 5F du'dc du'a qua du'dng TM diii phai.
- Day dien cy'c lap ban dp npi mac va triet dot qua du'dng TM diii phai sau khi da tham do dien sinh ly tim.
2.2.2. Lap bin dd ngi mac
• Choc vacli lien nhT: Vj tri choc vach lien nhT duUc xac dinh bang dau moc nam tren du'dng giij^ ciia dau thong pigtail va bd ngoai bong nhT trai. Qua lo choc vach lien nhT, chiing toi du:a
catheter Lasso 10 CLTC 6F, du'dng kfnh 15mm vao nhl trai ghi dien the ciia tTnh mach phoi, va du^
catheter NAVI STAR, 7F, irrigated sang nhT trai de lap ban do ba chieu nhT trai va co lap tinh macli phoi.
- Ghi dien the goc 4 tfnh mach phoi: bang dien cu'c Lasso gom co: tTnh mach phpi tren trai, tinh mach phoi du'di trai, tTnh mach phoi tren phai va tTnh mach phoi du'di phai.
- Du'ng hinh 3D buong nhi trai:
Du'di Sl/ ho trd ciia he thong lap ban do dien hpc 3 chieu co tac dung chuyen nhiJng tin hi4u dien the thanh cac cau triic 3D, chung toi duS dien cu'c ghi nhan tfn hieu^dien trong buong nhi, qua cac tinh mach phoi, lo do vao ciia tieu nhi trai, vong van tiai ta va diTng hinh 3 chieu dl?n hpc nhT trai.
- Tham do diSn sinh ly tim vd do cdc khoang dan truyen cd ban: ghi nhan dien the hoat dpng dien sdm trong edn rung nhT va vj tri ngoai tam thu nhT khdi phat rung nhT, cac khoang dan truyen PA, AH, HH, HV, thdi gian QRS, QT, thdi gian chu ky nhjp cd sd, kfeh thfch nhl va that danh gia chu'c nang dien sinh ly tim.
Hinh l:Cac dien CLTC cd ban dat trong buong tim.
Hinh Xquang nghieng trai Bff: NP: diin cut vung cao nhi phai, XV: dien cu'c xoang vanh, TP: di$n cdc that phai, His: dien cdc His
Hinh2:D\Inq hinh hoat dpng dien hpc 3 chieu buong nhi trai
(Mau xanh lam ia cac hoat dong dien sdm nhat ghi dude trong edn rung nhi xuat phat tCf 4 tinh mach phoi)
Y HOC VlfeT NAM THANGS-SO 1/2015
III. KET QUA VA BAN LUAN
3.1. Dac diem lam sang ciia benh nhan nghien cu'u
42 BN nghien cutj ciia chung toi bao gom: 36 nam (85,7%) nhieu hdn dang ke so vdi nu" chf co 6 ngu'di (14,3%). Dac diem chung ciia benh nhan the hien d bang 1.
Bang 1. Mpt sd thong sd lam sang ciia benh nhan nghien ciru Dac diem
Gidi ti'nli fnam/nu') Tuoi Can nang (kg) Chieu cao fm) Chi so BMI (l<g/m^) Tan so tim (cl</phut) HATT (mmHq) HATTr (mmHg) Hoi hop danh trong ngu'c
t^et moi Bau ngu'c Kho thd Chonq m3t Choang vang So nam phat hien
So edn/than^
Ttianq diem EHRA
Thong so 36/6 55,9 ± 9,6 64,2 ± 8,8 1,63 ± 0,06 24,0 ± 2,2 76,0 ± 13,5 124,6 ± 15,3 78,0 ± 10,2
42 31 30 18 13 5 5,0 ± 3,5 6,9 ± 9,4 3,19 ± 0,45
Gia tri 85,7/14,3 {%)
2 7 - 7 0 4 6 - 8 0 1,50 - 1,74 18.4 - 28,7 54 - 120 100 - 180
60 - 100 100 (%) 72,1 (%) 69,8 (%) 41,9 (%) 30,2 (%) 11,5 (%) 1 - 1 0 (nSm) 2 - 1 5 (can)
3 - 4 Bleu dS 1. Phin bd Rung nhl theo gicli tinh (%)
Bliii dS 2. Bieu do phan bo benh nhan rung nhl theo tuoi (%)
50 40 30 20 10
0 I ?5A
=50 51-60 =61
B^ tuoi trung binh li 55,9 ±9,6 tuSi, Tuoi cao nhat la 70 tuoi va thap nhat ia 27 tuoi. ^ Khi tim hieu kyhdnviiOi tuSi, chung toi co tdi 67,5% benh nhan t$p trung d Ida tuSi trung nien tren 50 tuoi Ltfa tuoi tri dddi 50 tuoi chi chiem 32,6%,
161
Y HOC VIET NAM THANG 5 - SO 1/2015
Bang2, Thdi diem thu'dng xuat hien edn runq nhT (n=42) Th6i diem
Sanq (6 - 12 qid) Chieu (12 - 18 qid)
Toi (18-22 qid) Bem (22 - 6 qid)
So lu'dng 37 42 42 25
Tv le (%) 86,0
100 100 58,1 Dieu i<ien xuat hien:
Khi nqhi nqdi Khi qanq su'e
Khonq ro
36 4 2
86,0 9,3 4,7 Chung toi ghi Holter Dien tam do 24 gid de
tim hieu ve thdi gian xuat hien edn rung nhT va nhan thay edn rung nhT khdi phat vao tat ca cac thdi diem trong ngay, trong do co 37 benh nhan CO xuat hien edn RN vao buo'l sang (86,0%),
bupi chieu va toi 42 benh nhan co xuat hien edn rung nhT (100%). Dac biet buoi dem ciing co tdi 58,1% benh nhan bj xuat hien edn RN. Chung toi cung nhan thay co 86% benh nhan xuat hien rung nh! khong lien quan den gang siTc.
Bang3.Tr'ieu chu'ng lam sang thu'dng gap Trieu cliu'ng
Hoi hop danh trong ngu'c Met moi Bau nguC
Kho thd Chong mat Choang vang
So lu'dng (n=42) 42 31 30 18 13 5
Ty le (%) 100 72,1 69,8 41,9 30,2 11,5 Trieu chiTng ciia benh nhan RN rat da dang
tiiy thupe vao eac yeu to nhU: tan so that, chiTc nang tim, cae benh ly di kem va sy nhay cam cua tiTng benh nhan.
Trong nghien ciTu cua chitng toi trieu chu'ng thu'dng gap nhat la hoi hop danh trong ngi/c chiem den 100 % eac tru'dng hdp, cac trieu
chiTng khac gom met moi chiem 72,1%, dau ngiTc chiem 69,3%, kho thd khi gang siTc chlem 41,9% va chong mat chlem 30,2% (bang 3.2).
Theo Gregory Y.H. Lip va Hung-FatTse cac trieu chiTng thu'dng gap trong rung nhT la hoi h6p danh trong ngiTc, dau ngi/c, kho thd, met moi va chdng mat [6].
Bang 4, Cac yeu to nguy cd lam sang B@nh phoi hdp
THA Benh mach vanh Benh van tim chu^ can phau thuat
Dai thao du'dng Khong ro YTNC
Sd'lu'dng (n=42) 22
2 1 5 13
Ty le {%) 51,2
4,7 2,3 11,6 30,2 Tien siJ:
Hut thuoc Hut thuoc da bo Lam dung ru'du
16 5 1
37,2 11,6 2,3
77*1 chiem ty 1$ cao nhat trong cac YTNC iam sang cua binh nhin RN chiem 51,2%. Chung tdi ding gap 13 b$nh nhan bi rung nh! nhuhg khong tim thay bat ky nguyin nhan nao (vo can) chiem ty I?
30,2%. Chung toi cung thay co tdi 37,2% binh nhan hut thuoc ia thddng xuyin trong do chi co
11,6% benh nhan da bo hut thuoc la.
Y HOC VIET NAM THANG 5 - SO 1 /2015
3.2. Dac diem dien sinh ly tim of benh nhan rung nhl edn 3.2.1. £>ac diem cac Ichoang din truyen trong tim:
Bang 5. Cae l<hoanq dien sinh iv tim ed ban d cac BN runq nhT edn Cac khoang OSL
tim cd ban TGCK nhip cd ban (ms)
Khoang PA (ms) Khoanq AH (ms) Do rong His (ms) Khoanq HV (ms) Do rong QRS (ms)
Khoang QT (ms)
< 60 tuoi (n=25) 760,2 ± 188,8
21,0 ± 5,1 91,7 ± 18,3 19,0 ± 6,9 47,4 ± 5,7 91,3 ± 11,9 389,3 ± 342,2
> 60 tuoi (n=17) 886,7 ± 113,5
23,9 ± 5,2 88,1 ± 12,3
18,1 ±2,9 48,1 ±3,9 91,2 ± 13,4 391,4 ± 29,3
So sanh (P) 0,021 0,124 0,092 0,488 0,618 0,975 0,834
Chung ( x + SD) 810,8 ± 172,9
26,7 ± 8,6 90,5 ± 15,9
18,7 ± 5,6 47,7 ± 5,0 91,3 ± 12,4 390,2 ± 30,7 Da so cac khoang dien do ed ban nhu thdi
gian gian truyen nhl that (AH), dan truyen His that (HV, dan truyen trong that (QRS),... deu nSm trong gidi han binh thu'dng ciia ngu'di Viet Nam[l].
So sanh cac l<hoang dien do d 2 nhom < 60 tuoi va nhom > 60 tuoi thi chung toi thay rang thdi gian chu Ity (TGCK) nhip xoang cd ban d nhom > 60 tuoi dai hdn so vdi nhdm < 60 tuoi (p<0,05). Chiing toi cho r§ng cd the d nhutig BN
£ 60 tuoi CO tinh trang tSng tru'dng luc than l(inh giao cam nen nhjp tim thu'dng nhanh hdn, TGCK
nhip cd ban ngan hdn. Trong l<hi do eac thong so ithac thi ichong co sir khae biet. Tinh trang tang tru'dng life eiia he giao cam eo the lam tang dan truyen trong tim, iam rut ngan eac khoang dien do ed ban, nhu'ng mu'c do anh hu'dng khong nhieu nhu' ia anh hu'dng ien tan so tim.
3,2,2, Ket qua tham do chifc nang nilt xoang:
Chile nang nut xoang dude danh gia qua cae thong so thdi gian phuc hoi nut xoang (tPHNX) va thdi gian phuc hoi nut xoang eo dieu ehinh (tPHNXd) du'dc trinh bay d bang sau:
Bang 6, tPHNX va tPHNXd chunq cho benh nhan theo tuoi va qidi Thong so
GIdl Tuoi
Nam (n=36) Nu'(n=6)
<60 (n=25)
>60 (n=17) Chung(n=42)
tPHIVX (ms) f X ± SD) 1181,8 ± 201,0 1120,7 ± 170,6 1140,6 ± 190,5 1222,0 ± 200,9 1173,9 ± 196,4
P 0,523 0,207
tPHNXd (ms) ( X ± SD) 310,8 ± 143,2
403,7 ± 89,2 319,8 ± 114,1 326,8 ± 174,9 322,7 ± 140,1
P 0,169 0,881
Khi so sanh tPHNX giO'a 2 nhom < 60 tuoi va nh6m > 60 tuoi, chiing toi thay rang tPHNX 6 nhom < 60 tuoi ngSn hdn nhom > 60 tuoi nhutig khong co y nghTa thong ke (p = 0,881).
Dieu nay co the du'dc giai thfch la do tuoi eang nhieu thi hoat dpng than kinh giao cam thu'dng giam hdn nen tPHNX ciia nhom BN > 60 tuoi dai hdn cf nhom < 60 tuoi mac dii khong co y nghTa thong ke. Mpt nghien ciTu cua Kistler da nhan thay tuoi cao cd thdi gian phuc hoi nut xoang
keo dai dang ke trong d tat ca cac dp dai chu ky ki'ch thfch. Nguyen nhan co the do sy* gia tang cac sdi dan hoi ciing vdi sy" xam nhap m3 va bat thu'dng trong tai cau true va ki'ch thu'dc ciia cae sdi cd ciing vdi thdi gian lao h6a[5].
3.2.3. Thdi gian trd co hieu qui cd nhi, cd that vi phan ly nhi that:
Nghien cirtJ ve thdi gian trd (TGTr) co hieu qua cd nhl, cd that va phan ly nhT that d 42 BN RN edn, chiing toi co ket qua sau:
Bang 7, Thdi qian trd hieu qua cd nhl va cd that d tat ca BN va theo nhom tuoi ThSng so
< 60 tuoi (n=25)'
>60tuoi(n=17)' Chunq (n=42)
pi!
TGTr cd nhl (ms) { X ± SD) 198,7 ± 19,4 215,6 ± 15,9 205,6 ± 19,7
0,007
TGTr cd that (ms) L x ± S D ) 218,7 ± 58,7 222,5 ± 15,3 220,3 ± 17,2
0,505
Phan ly nhT that (ms)( x±SD) 395,3 ± 21,0 426,3 ± 73,5 407,9 ± 66,1
0,001
Y HOC VIET HAM THANG 5 - SO 1/2015
Ket qua nay cua chiing toi cung tu'dng tu' nhu" nhUng cac tac gia khac khi nghien cuXi tren BN RN. Khi so sanh vdi cac ket qua dien sinh ly tim d ngu'di binh thu'dng, chiing toi thay cung tu'dng ty'. 6 nhu'ng benh nhan co TGTr cd nhT <
200ms thu'dng de xuat hien rung nhl va edn rung nhT thu'dng keo dai ket qua nay cung tu'dng ty' nhu' nghien ciTu cua Uhm JS nhan thay benh nhan rung nhT ben bi co TGTr cd nfiT ngan hdn d benh nhan rung nhT edn (p < 0,01)[7]. Nghien ciki ciia Daoud G tren 20 BN rung nhT edn cung nhan thay benh nhan co thdi gian trd cd nhT eang ngan thi nguy cd gay rung nhT va thdi gian rung nhT keo dai hdn d nhu'ng benh nhan co thdi
gian trd > 200ms[4].
Khi so sanh glu'a cac nhom tuoi vdi nhau, chiing toi thay d nhu'ng BN tuoi cang cao thi thdi gian trd cd nhT va cd that cang dai. Trong nghiSn cu'u ciia Chung toi, TGTr cd nhT d nhom > 60 tuoi dai hdn so vdi nhdm < 60 tuoi tu'dng iTng: 215,6
± 15,9ms va 198,7 ± 19,4ms (p < 0,05). Khi so sanh vdi nghien ciTu ciia Kitsler tren 58 benh nhan triet dot rung nhT cung thay TGTr cd nhTd nhom >60 tuoi dai hdn so vdi nhom < 60 tuoi (p
< 0,01). NhU vay, tuoi cang cao thi dan truyen trong tim canci giam, va thdi gian trd cd nhi tang hdn so vdi tuoi[5].
3.2.4. {>$c dli'm dl$n sinh / / hgc edn rung nhi:
* Dac dli'm di$n sinh iy edn rung nhid cae nhom tuoi:
Bing 8. Cac khoang dan truyen trong edn rung nhT d cac nhom tuoi Tiidng so < 60 tuoi
( X ± SD)
> 60 tuoi ( x ± S P )
So sanh Chung ( X ± SD) Khoang AA trung binh
(ms) 201.1 ± 35,7 194,7 ± 41,7 196,8 ± 39,5
Khoang AA ngSn nhat
135,6 ± 39,4 127,3 ± 33,4
Khoang AA dai nhat
(ms) 263,1 ± 51,5 249,8 ± 38,1 0,346 254,2 ± 42,9 Khoang W trung binh
imsi 543,7 ± 104,4 589,8 ± 107,8 574,4 ± 107,6 Khoang W ngan nhat
Jmsi, 350,0 ± 88,6 415,3 ± 102,2 0,049 393,5 ± 101,7 Khoang W dai nhat
JmsL 813,8 ± 191,5 827,6 ± 205,0 0,834 823,0 ± 198,4 Nhan xet chung ve cac khoanp dan truyen trong edn rung nhi chung toi thay: d benh nhan rung nh' vai trd cua dan truyen qua nut nhi that rat quan trong da iam^ giam dang ki xung dong ttf nhixuon^
that nen duy trl dddc tan so that trong khoang thich nghi. a nhiing benh nhan dan truyen qua nut nhi that tot dap uhg tan so that nhanh hdn dnhuhg benh nhan dan truyen qua nut nhi that kim hdn.
* Vi tringdai tam thu nhi khdi phat gay edn rung nhi:
Biiu do 3, T<i le phan bo vj tri khdi phat rung nhl
TMCT EO nhl Phil TMPn TMPDT TMPTP TMPDP TNT Eo nhl tril
Y HOC VIET NAM THANG 5 - SO 1/2015
Trong nghien ciTu nay, chung toi siT dung catheter chan doan Lasso 10 cy'c de ghi dien the 3 chieu trong buong tim nhan thay rang khi gay ngoai tam thu nhT bang ki'ch thfch sdm kfeh hoat edn rung nhT co tdi > 7 0 % ngoai tam thu nhT sdm gay rung nhT xuat phat tir lo tTnh mach phoi do ve nhT trai, dac biet co tdi 83,3% ngoai tam thu nhT khdi phat tii tTnh mach phoi trai tren trong khi chi c6 4,8% ngoai tam thu nhT khdi phat tiT nhT phai. Chiing toi cung ghi du'dc dien the sdm ciia ngoai tam thu nhT gay RN xuat phat d nhieu vj tri khac nhau cua cae tTnh mach phoi So ve nhT trai dong thdi. DiBu nay chiTng to cd che gay rung nhT la do nhieu 6 khdi phat ki'ch hoat nhieu vong vao iai nho duy tri RN keo dai.
Trong nghien ciTU ciia TakahashI va epng sy'tren 49 benh nhan rung nhT edn cung thay 112/117 vj tri ngoai tam thu nhT khdi phat rung nhi xuat phat tiT tTnh mach phoi, con lai cung ehi cd 5 ngoai tam thu nhT d vj trf khac. Trong nghien ciTu ciia Chang H.Y cung chi thay co 7,9% ngoai tam thu nhi khdi phat RN xuat phat tir nhT phai, chii yeu xuat phat tiT lo do vao nhT phai ciia tTnh mach chit tren[2]. Nghien ciTu tren 79 benh nhan RN edn, Chen S.A cung nhan thay cd den 88,8%
ngoai tam thu nhT xuat phat tu' lo do ve eua tTnh mach phdi gay RN. Chen S.A cijng ghi du'dc khdi ph^t ngoai tam thu nhT dong thdi d tinh maeh phoi trai va tTnh mach phoi phal[3].
IV. KIT LUAN
Qua nghien culj dac diem lam sang va dien sinh ly tim tren 42 benh nhan cd edn rung nhi kjch phat, chung toi rut ra mot so ket luan sau:
100% BN rung nhT edn deu cam thay hoi hop danh trong ngu'c. Cac trieu chiTng khac gom met moi chlem 7 2 , 1 % , dau ngifc chiem 69,3%, kho thd khi gang siTc chiem 41,9%. MiTc dp trieu chiTng ciia benh nhan theo thang diem EHRA la 3,19 ± 0,45. Cac khoang dan truyen nhu" thc(i gian chu ky nhjp xoang, dan truyen trong nhT, dan truyen nhT that, khiT cu'c that d benh nhan rung nhT kjch phat cung tu'dng t y nhu' d ngu'di binh thu'dng. Thdi gian t r d cd nhT, thdi gian ehu k/ cd ban, thdi gian phan ly nhT that d nhOng benh nhan tren 60 tuoi deu keo dai hdn nhom
benh nhan du'di 60 tuoi. Cac khoang dan truyen trong edn rung nhT nhu' khoang dan truyen trong nhT (AA) hay dan truyen trong that ( W ) trong edn rung nhT 6 benh nhan tren va du'di 60 tuoi cung khong co sy khac biet.
Ngoai tam thu nhT kfeh hoat edn rung nhT co tdi tren 7 0 % cac tru'dng hdp xuat phat tii lo tTnh mach phoi do ve nhT trai. Dac biet co tdi 83,3%
ngoai tam thu nhT khdi phat tiT tTnh maeh phoi trai tren trong khi chi co 4,8% ngoai tam thu nhT khdi phat tiT nhT phai. Nhu' vay, phan idn { > 7 0 % ) cae tru'dng hdp khdi phat rung nhT deu xuat phat tiT cac tinh maeh phoi do dd khi can thiep triet dot rung nhT hay phau thuat Maze viec co lap dien hpc glu'a tTnh maeh phoi va nhT trai giu" vai trd quan trpng dam bao thanh cong ciia cac phu'dng phap dieu trj.
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