- - . *f

WETMAM MEDICAL JOURHAL N'l - FEBRUARY - 2017

(r=0.1993, p<0.0335), giijB HDL-C vdi insulin (r=-0.2237, p<0.00157), giife HDL-C vdi HOMA - p (r=-0.2648), p<0.0044).

Nghien cull cua Tran Thj Thu'dng [5]^ cung cho thay Miang insulin d benh nhan cd roi loan lipid mau cao hdn d benh nhan kh5ng cd roi loan lipid mau, do nhay cua insulin giam nhieu d benh nhan tien DTO cd RLLP mau so vdi benh nhan Idiong r a loan lipid mau.

Le Oinh Tuan (2015) [2] cho thay chi so HOI^A-IR cua nhdm benh nhan DTO cd roi loan lipid mau thap hdn nhdm binh thu'dng cd y nghTa thong ke (p<0.05), chi so HOMA-IR cua nhom benh nhan benh nhan co chi so HDL-C, LDL-C va tryglycerid binh thu'dng thap hdn nhdm bSnh nhan co roi loan cac thanh phan lipid mau tren CO y nghTa tiiong ke (p <0.05). Tuy nhien, nghien cifu cua Do Oinh Tijng [1] va Nguyen Thj Thu Thao [ 3 ] chu^a thay moi lien quan gii?a cac chi so HOMA-IR va HOMA- p, HOMA-IS vdi cac thanh phan lipid mau.

Nghien cdu cOa chung toi, ty ie khang insulin d benh nhan hgi chuhg Cushing cd RLLM theo H0I^A2-IR la 53.97% cao hdn nhom khong cd RLLP mau la 31.82% (p > 0.05), t^ le giam do nhay cua insulin theo H0MA2-IS la 50.79%, cao hdn nhom khong co RLLP mau ia 27.27% (p <

0.05). Nhu" vay khong co sy" lien quan giiJa cac chi sff khang insulin, giam c h i i t nang te bao beta, d benh nhan hgi chiihg Cushing vdi RLLM mau. K§t^qua nay doi hoi can phai cd sir nghien cull cd mau ldn hdn de cd ket qua chi'nh xac hdn trong tu'dng lai. Cd s y lien quan giu:a do nhay insulin vdi roi loan lipid mau.

V . K E T LUAN

- Khong cd moi lien quan gida tuoi, BMI vdi chi so H0MA2-IR, HOMA-p, H0MA2-IS.

- Vong bung co tu'dng quan thuan, mii'c do nhe (r = 0.24, p < 0.05) vdi khang insulin; tutfng^

quan nghjch mii'c do nhe (r = - 0.25, p < 0.05)f vdi do nhay insulin.

- t y so eo hong (HWR) cd tu'dng quan thuan mu'c do vij^a (r = 0.32, p < 0.05) vdi khaiig Insulin, tu'dng quan nghich mii'c do viTa (r = - 0.32, p < 0.05) vdi do nhay insulin.

- Khong cd moi tu'tfng quan g\da vdng byng, ty so eo hdng vdi chii'c nang te bao beta.

- - . *f

T A I LIEU T H A M K H A O j 1. Do Dinh Tung ( 2 0 0 8 ) , "Nghien cuU chu'e ninfi,

te bao beta do nhay insulin qua mo hinh H0i4fiit d benh nhan DTD dian doan lan dau", Luan "hk Thac sy y hoc, Hoc Vien Quan Y.

z. Le Binh Tuan ( 2 0 1 5 ) , "Nghien cuV Hnh trsng khang insulin & hinh nhan dai tfiao du'dng typ 2' tai benh vien da Idioa tinh Thai Binh", Oe tai kHCN^2015, Dai hoc Y du'dc Thai Binh.

3. Nguyen Thj Thu Thao (2012), "Nghien cuU dSc diem iam sang va tinh trang l&iang insulin tren b^nii nhan dai thao du'dng typ 2 mdi du&e dian doan"

Luan an ti§n 3/ Y hoc, Hoc Vien C^an Y. r ^ 4. Tran Thj Thanh Ifoa (2009), "Nghien culiM

trang i^ang insuiin d benh nhan dai thao du&iim 2 CO gan nhiem md phat hlin lan daulaib&ihm Ngiti&", Luan an Ti&i ^ Y hoc, Dai hoc Y HN.

5. Tran Thj Thu'cfng, N g u y i n Vinh QuangI (2014), "Nghien ciru khang insulin va chu'e nang|l te bao beta d benh nhan tien dai thao duflng^f

Tap chi Y hoc Oiut hanh, tr. 1 3 8 - 1 4 1 . J i 6. Geloneze B., e t a l . (2009), " H O M A l - I R ^

H0r^A2-IR indexes in identifying insulin resistaff"

and metabolic syndrome: Brazilian l ^ e t a ^ Syndrome Study (BRAMS)", Arq Bras Endoc

Metaboi, 53(2), 281-7. ^^

7. Pivonello R., e a l . ( 2 0 1 0 ) , "PathophysislcM diabetes mellitus in Cushing's syndro^rt Neuroendocrinology, 92 Supp! 1, 77-81. '

HIEU QUA C O A PHU-aNG PHAP DO DIEN THE THAT SOM NHAM XAC DINH VI TRI DICH TRONG TRIET DOT NGOAI TAM THU THAT Ttr DU'O'NG RA T H X T PHAI

Phan Dinh Phong*, Tr4n Tu^n Vi?f*

'''' ,. ^VC Heu: NghlSn ciJu gia tri cua phirong p f i l S l?p ban do diSn hoc bSng do dien the that s4m (EATjl trang Wet dot ngoai tam thu thSt (NTTT) l<hcli phat t n duWng ra that phai. Doi tu'cfng va phu'dng p h a p i l Nghien CIHJ thtfc hien tren 73 benh nhan duHc chalil doan ngoai tam thu that ididi pliat tir duSlng'ra ttiM phai, duBc lam thu thuat triet dot bang nSng l u a H song CO tan so radio qua du'dng ong thong (dSt d l H l tai Vien Tim mach V i a Nam trong i<hoanq thdi oiaifOT 1/2015-11/2015. Qua trinh triet dot c6 sif dilOT

*Tn/dng Dal hoc YHi NSI

Oiiu trach nhiem chinh: Phan Dinh Phong.

Email: phong.vtm@gmaii.com.

Ngay nh§n bai: 12/10/2016 Ngay phan blen l<hoa hoc: 15/11/2016 Ngay duyet bai: 5/01/2017

TAPCHiY HOC Viei NAM TAP 451 - THAHG 2 - S 0 1 - 2017 jhUdng phap l|p ban do dien hpc b§ng tim (Ken thS

Jiat sdm (EAT) ket hdp vdi phuang phap tim vi tn 3i'ch bSng tao nhip. Ket qua: TSng s5 vi tri ISp ban do igi mac traiig phu'dng phap tim dien the that sdm bao 3om 170 vj tri. Trong do triet dot tiianh cong tai 59 vi [ri. Tai cac vj tri tii?t dot ttianh cong, th6i gian EAT irung binh la 26,0 ± 5,7ms, cao hdn so vdi tai cac vj tri triGt dot Ichong thanh cong la 21,3 ± 4,9 nis, khac biet CO y nghTa thong ke vdi p < 0,05. Tai di^m cut - off vdi EAT la 22,5 ms co gia tri du" bao du'dng tfnh la D,55, dp nhay la 0,71, do d^c hieu la 0,68. Ket luan:

Lip ban do dien hpc bang phu'dhg phap tim ^ e n the that sdm la mot phu'dng pliap hieu qua. Qua nghien diu nay, chung toi de xuat tiiet d6t d cac w tri dfchvdi EAT > 22,5 ms.

Tiy khda: ngoai tam thu that tu* du'dng ra that phai, )ap ban do dieh hoc bang tim dien the that sdm.

SUMIVIARY

ROL£ OF EARLY A O I V A T I O N MAPPING TECHNIQUE I N RADIOFREQUENCY

CATHETER ABLATION OF RIGHT VEI4TRICULAR OUTFLOW TRACT PREMATURE

V E N T R I C U U R CONTRACTIONS Objectives: This stiJdy aimed to assess the role of eariy activation mapping technique for localizing the origin of the right ventricular outflow tract premature ventricular contradions (RVOT-PVC). Patients and methods: 73 consecutive patients (15 male) with RVOT PVCs underwent successful radiofrequency catheter ablations at the Vietnam Heart Institute from 1/2015 to 11/2015. Early activation mapping and/or pace mapping were used in localizing the target sites for ablation. Results: At 59 of a total of 170 eariy activation mapping sites, the PVCs were successfully ablalEd. Mean eariy activation time (EAT) in 59 successful sites wassignificantiy higher than that o f l l l unsuccessful sites (26,0 ± 5,7vs21,3 ± 4,9, respedively, p < 0,05). Cut -,off point of EAT at 22,5 ms has a high sensitivity, spedficity and positive predictive value. Conclusions. Eariy activation mapping is an effective method in localizing tiie origin of RVOT-PVC. Based on the results of this study, we suggest that an EAT > 22,5 ms should be achieved in onjer to get good results.

Keywords: RVOT premature ventricular contractions, eariy activation mapping

I.

BAT VAN

o l

Ngoai tam thu that la mot dang roi loan nhjp tim thudng gap tren lam sang. Trong do co khoang 8 0 % NTTT khcrt phat td du'dng ra that phai [ 1 ] . Triet dot r n T T bang nang lu'dng song CO tian s5 radio ( I ^ ) qua du'dng 5ng thong dang dddc dng dung ngay cang rong rai [ 1 ] , [ 2 ] . Mac du ti le thanh cong trong dieu t n nhin chung la cao (tren 9 0 % ) , tuy nhien mpt so tru'dng hdp triet dot NTTT van con la mot thach thtfc [ 5 ] , [ 7 ] . Lap ban do dien hpc bang phu'dng phap tim dien the that sdm la mot phu'dng phap quan

trpng trong xac.djnh 6 khdi phat de tien hanh t r i k dot [ 2 ] , [3]," [ 4 ] . Nguyen !y cua phu'dng phap nay la neu dau ong thong dot d u ^ du'dc dung vao vj tri khdi phat PJTTT thi se ghi du'dc dien do that sdm nhat so vdi cac dien do con lai.

Nghien cdu ve do dien t h e that sdm giup dd bao Idia nang thanh cong cua thu thuat duci tren phu'dng phap nay. Tgi Viet Nam hien chuci co nghien cu'u sau ve hi$u qua phu'dng phap lap ban do dien hoc bang do dien tiie that sdm, do do chung toi tien hanh nghien cu'u vdi muc tieu:

Nghien cuV gia tri cua phu'dhg phap lap ban do dien hoc bang tim dien the Wat sdm tmng biet ddt ngoai tam thu thit tu" du'dng ra tiiat phai.

II. DOI TUONG VA PHU'CYNG PHAP NGHIEN CLTU 1 . Ooi tu'dng nghien cu'u: Benh nhan da du'dc chan doan WTH l<hdi phat tijr du'dng ra that phai.

Tieu chuan lu'a c h o n : Benh nhan du'dc Chan doan HTH khdi phat tu* du'dng ra that phai vffi cac dac diem dien tam do nhu' sau: phu'c bp NTTT CO dang block nhanh trai, true dien tim quay xuong du'di: phu'c b6 IMTTT cd QRS du'dng d D2, D3, aVF. Benh nhan du'dc chi djnh dieu trj I^TFTT trang nang lu'dng sdng cd tan so radio (RF) theo hu'dng dan cua ACC/AHA/ESC nam 2006.

Tieu chuan loai truf: Cac tru'dng hdp chong ciii djnh vdi thu thuat. Benh nhan khong dong y tham gia nghien cu'u.

2. Phu'dng phap nghien cuTu

* T h i e t k e nghien o J u : nghien culj can thiep khong doi chu'ng.

* Mau nghien c t h i : bao gom 73 benh nhan da du'dc chan doan NTTT khdi phat tiJ" du'dng ra that pliai va da du'dc dieu trj triet dot bang RF tai Vien n m mach Quoc gia ViSt Nam tij' thang 1/2015 den thang 11/2015.

* Cdch thuTc t i e n h a n h : tham do dien sinh

\<i theo quy trinh tai vien Tim mach Vi$t Nam.

Lap ban do dien hpc bang phu'dng phap do ^ e n the that sdm va/hioac tao nhjp. Triet dot bang nang lu'dng song c6 tian so radio. Ghi chep cac dac diem dien dfe cac phu'dng phap lap ban do dien hpc va cac thong so trong triSt dot.

* Phan tich sS l i e u : so li4u du'dc nhap, quan ly va phan tich tren phan mem SPSS 16.0.

* S 9 0 diu'c trong nghien c l h i : nghien culj du'dc thi/c hien tuan theo cac quy djnh ve dao du'c trong nghien culi y sinh hpc, Boi tu'dng tham gia nghien CU\J la hoan toan ^ nguyen va co q u ^ n nit khoi nghien arti bat ky luc nao. C^c thong tin ve dffl tui?ng nghien cuU du'dc ma hoa, duiJc giiJ* bi mat va chi phuc >ai muc dfdi nghien culi.

VIFTMAM MEDICtr JOURNAL N ' l • FEBRUARY - 2 0 1 7

., , la 20,2 ± 11,0%).

III. KET QUA i.s... „•/,, Ik Tren 73 binh nhan nghiSn ClJu, Chung tol dS Tu8i trung binh cua 5°''^J'"9 ! ? 9 " f ^ r ^ i S tiSn hanh lap ban do dien hoc Bm vi tri o kh^

43,8 ± 13,4 tuoi. Ba sS benh nhan ia nu' gitfi "^Jr",,,^;'„a. /, one ;,i fr! xmnn cR niv ri (chiem 79%), con iai la nam gidi (chiem 21%).

Thfli gian xuat hien trieu ehufng fl b$nh nhan t ^ 3 thang den 10 nam, trung binh la 2,9 ± 2,5 nim. Tren IcSt qua Hotter fflen tam do 24 gid, so iuUng MITT trung binh/24 gid ia 21167,3 ± 11639,8 hfTT/T (ty IS % I^ITTT trung binh/24 gid

Bang 1. So sanh dac diem BAT va cac thong sci triet dot Idiac tai vi tri thanh cong IdiSnq thSnh cSng

phat va triet dot d 206 vj tri. Trong so nay, co 170 vj tri lap ban dS npi mac bang phudng phap do EAT (CO hoac khong Icet hdp vdi phuttng phap tao nhjp). Ket qua: 59 vi trf triSt dot thanh cong vJ 111 vi tri triSt dot idiong thanh cong.

Thong SOI triet dot EAT (ms) Mapping bang tao nhip (so

chuyen dao gionq)

Mhi^t- i^r, l^r\

Nhiet do ("O Nanq luttnq (W) Thdi qian (giay) Bien trd (fl)

Vi tri thanh cong fn=59) 26,0 ± 5,7

11,6 ± 0,4 55,9 ± 5,3 32,0± 9,7

87, 2 ± 30,7

101,4 ± 12,2

Vi tri khong thanh conq ( n = l l l )

21,3 ± 4,9 10,9 ± 0,6 54,5 ± 6,5 31.2 ± 11,2 66.1 ± 35,7 103,5 ± 14,1

<0,05

>0,05

<0,05

>0,05

NhSn xet: EAT trung binh tai cac vj tri triet dot thanh cong la 26,0 ± 5,7 ms, idn hdn co y nghi.

so vdi (dc vj tri triet dot i<h6ng thanh cong ia21,3 ± 4,9 ms (p<0,05).

AUC: 0,741 p < 0,0001

Bieu do t. Bu'dng cong ROC bleu thf gia 111 tiSn lUtfng triet dci thanh cong cua phutm, phSp tim diSn the thai sdm (do EAT)

Nlian xeb Dien tich dudi du'dng cong = 0,741 vdi p < 0,0001 EhiJng to EAT co gia tri tot tron tien lu'dng i(ha nang thanh cong.

BSng 2. Bo nhay va do dac hieu qua cac ngddng gia tri cua EA T ^ EAT (ms)

19,5 22,5 25,5 28,5 34,5 43,5

Sd nhay 0,887 0,710 0,516 0,339 0,081 0,016

Do dac hieu 0,375 0,679 0,804 0,938 0,991 1,0

Gia trj du* bao du'dng tinh

0,44 0,55 0,593

0,75 0,833

1

Gia trj diT bao am tinh 0,857

0,80 0,75 0,719 -, 0,661 ; 0,547 ; NhSn xet: Thdi gian dien the that sdm do du'dc cang Idn thi gia trj dd bao diem dot thanh coi cang cao. Tai diem Cut - off vdi EAT = 22,5 cd dp nhay = 0,71 va dp dac hieu = 0,679 vdi gia trUt bao du'dng tinh la 0,55, gia trj dit bao am tfnh la 0,80.

IV. BAN LUiDiN

Trong nghien CLTU cua chung toi, co 170 vj tri lap ban do dien hpc bang tim dien the that sdm

nhat. Chi so EAT tai cac vj tri thanh cong la 26

± 5,7 ms, Idn hdn so vdi tai cac vj tri triet c

khong thanh cong (21,3 ± 4,9 ms) vdi p

TAP CHl Y HQC VigT NAM TAP 451 - THAHG 2 - S 6 1 - 2017

0,0001. Qanh gia gia tri ti€n lu'dng thanh cdng

cua phu'dng phap lap ban do dien hpc bang do dien ttie that s d ^ nhat du^ tren bieu do duidng cong ROC vdi dien b'ch di/dl du'dng cong AUC = 0,741, p < 0,0001. Tai gia tri EAT = 22,5 ms thi dp nhay la 0,71, dp dac hieu la 0,679, gia trj du*

bao Sm tinh la 0,8 va gia tri du" bao du'dng b'nh la 0,55.

Nhu" vay ket qua nghien cu\i cua chung tSi

cd sir tu'dng dong vdi cac nghiSn CIJ'U cua

Yokokawa hay cua Luker [5], [6]. Cac nghiSn cull ciJa cac tac g\h tren deu cho thay rSng EAT d nhdm triet dot thanh cdng cao hdn so vdi nhom tript dot khong ttianh cong. EAT cang ldn CO nghta la vj tri ong thong cang gan 6 khdi phat MTTT. Ben canh do, trong nghien ciili cua Luker [6] hay cua Fa - Po Chung [7] con cho thay rang cd moi lien quan giffa chi so EAT va ti le tai phat cua I^TTTT sau thii thuat, Nhdm tai phat I^TTTT cd chl so EAT thap hdn cd y nghTa so vdi nhdm cd chi so EAT Idn hdn. Dieu nay cung cd the du'dc glai thich rang khi triSt dot cang gan v| tri dich thi cang triet dot du'dc nhiSu cd chat hdn khien cho kha nang tai phat thap hdn. Neu vj tri triet dot chuci du gan vj tri dich khien cho ton tiiu'dng noi mac chu^ du sau va rpng de cat dut hoan toan cd chat khien cho ti le tai phat cCia NTTT cao hdn. €)ay cung la han che trong nghien culi cCia chung toi khi chu^ theo d5i du'dc b|nh nhan du dai de danh gia tu'dng quan giii^ EAT va kha nang tai phat sau thu thuat.

Tren thdc te, phu'dng phap lap ban do dlSn hoc bang do dien the that sdm CD nhieu uli diem so vdi phu'dng phap lap ban ban do diSn hpc bang tao nhip. Ooi vdi nhihig vung cd tim kem dan dien, hay nhiitig v£lng cd tim d gan sat du'di van dpng macti phoi se rat khd khan de ISp ban do bSng tao nhjp do cac vung cd tim khong dan dien ho|c phai kidi thich bang cu'dng dp dong dien Idn cd the dan t^i sai ISch ve hinh anh dien tam do. Tai nhihig vi tri nay phutfng phap lap ban do dien hpc bSng do dien thS that sdm td ra ulj viet hdn va cd gia trj hdn. Tuy nhien, nhu'dC diem cua phu'dng phap nay la khong thi/c hien du'dc d cac thdi diem ngoai 1am thu that xuat hien vdi tan so thda. Trong nhffng tru'dng hdp nay, phu'dng phap tao nhjp la phoi hdp can thiet de tim 6 khdi phat loan niilp.

Hien nay, trong cac hu'dng dan ve diSu trj RF

doi vdi NTTT dSu khuyen cao mu'c EAT tij" 10 - 60 ms [2], [3], [4]. DiSu nay cung da duWc chOtig minh qua nhiSu nghidn ciili ciia cac tac gia Ji Eun Ban, tac gia Kuhne hay Luker chd thay mii'c EAT deu nam trong gidi han nay. Qua nghien cihj chi3ng tfii de xuat mu'c EAT = 22,5 ms de tien hanh triet dot vdi gia trj dd bao du'dng tinh la 0,55, do nhay la 0,71, do dac hieu la 0,679.

V. KET LUJoiN

Lap ban do dien hpc bang phu'dng phap tim di$n thS that sdm trong triet dot |\nTT ttr du'dng ra tJiat phai la mpt phutfng phaphieu qua, dac biet CO uli diem vu'dt trdi trong nhihig tru'dng hdp NTTT khdi phat gan van dpng mach phoi, khd khan khi su" dung phutfng phap mapping bang tao nhip. Qua nghien ojli, chiing toi de xuat mu'c EAT >22,5ms de tien hanh triet dot v ^ Mia nang du* bao thanh cong cao.

TAI L I | U THAM KHAO

1. Yong-Mei Cha, et al.. Premature Vaitricuiar Cbntradion-Induced Cardiomyopathy. Qrculation Arrhythm Electrophysiology, 2012.5: p. 229 - 236. . 2. Jasmine Lamba, et al., Radio^uency

Catheter Walation for the Treatment of Idiopatiiic Premature Ventricular Contradions Originating from the Right Ventricular Outflow Tract: A Systematic Review and Meta-Analysis.

Electrophysiology, 2013. 37: p. 73 - 78.

3. David 3. Wilber, Douglas L. Packer, and Wiljiam G. Stevenson, Venti-icular Tachycanjia, in Catheter Ablation of Cardiac Arrhythmias: Basic Concepts and Clinical Applications. 2008, Blackwell. p. 274.

*». Callans, D.J., Ablation of Idiopathic Ventricular Tachycardia. TTie Joumai of Innovations in Canjiac Rhythm Management, 2012. 3: p. 16 - 23 3. Milci Yokokawa, et al.. Reasons fbr felled

ablation for idiopatfiic right ventricular out flow b^ct-Iike ventricular aniiythmias. Heart Rhytiim, 2013.10: p. U O I - 1108.

6. Jakob Ltiker, et al.. Automated template matcfiing correlates with earliest acHvation during mapping of idiopathic premature ventricular contractions*. UC Heart and Vessel, 2014. 4: p.

25 - 29.

7. Fa-Po Chung, et al.. Different characteristics and electrophysiological pnDperties between early and late recurrences after acute successful catheter ablation of idiopathic right ventricular out flow Iract an^ythmias during long-temi follow-up.

Heart Rhytiim, 2014.11: p. 1760 - 69.