Gia Phuong

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NGHISN CO'U LAM SANG

Danh Gia Ket Qua Som Gia Phuong Phap Nong Van Hai La Bang Bong Inoue Trong Dieu Tri Benh Hep Van Hai La Khit Tai Phat Sau Nong.

Tran Lan Anh*; Bo Boon Lai"; Pham Manh Hiing"; PhamNgoc Oanh*"

TOM TAT

Dat van de: Nong van hai la b3ng bong Inoue ngay nay da dugc ap dung rong rai trong nuoc va tren the gioi. Cling nhu sau phSu thu^tt tach van hai hai, sau nong van bang bong, mgt so b?nh nhan xuat hi§n h?p khit tro led. Lieu ehiing ta eo the nong lai van hai la cho nhiing doi tugng nay hay khong la cau h6i cho de tai nay. Muc tieu: Danh gia ket qua som cua phuong phap nong van hai la bang bong Inoue trong dieu tri hep van hai la khit tai phat sau nong va mpt so' yeii to anh huong. Dot tUgng va phuong phdp nghien cuu: nghien eiiu mo ta cat ngang, theo trinh tu thoi gian, co so sanh doi chiing.

Nghien ciiu tieh hanh tren 70 benh nhan tai hep van HHL khit, co chi dinh va dugc NVHL (nong lai van hai la) bang bong Inoue, co so sanh ghep cap vdi 70 bfenh nhan dupe NVHL ISn dau, thoi gian tir thang 4/2009 den 8/2010. Ket qud: ty 1? thanh cong ve ky thuat cao (100%), ty le tharUi cong ve ket qua 6 miic kha cao (78,6%), khong co cac bie'n ehiing nang (hi vong, tac mach, ep tim eS'p...), eai thien ve lam sang, huyet dgng va dien tieh 16 van la rat dang ke (p < 0,001). Di^n tich 16 van hai la truoc nong la 0,98 ± 0,20 cm', sau nong dat dugc 1,74 ± 0,34 cm^( p < 0,001) va chenh ap trung birth qua van giam tii 13,65 ± 2,92 mmHg xuong con 6,92 ± 2,89 mmHg. Co 2 truong hgp HoHL nang sau nong (chiem 2,9%), 12 b?nh nhan (chieml7,l%) sau nong van MVA <1,5 cm^. Kei luan: Nong van hai la b5ng bong Inoue CO the tie'n hanh va kha thi cho cac benh nhan bi tai hep van hai la sau nong ma eo hinh thai van con phii hgp. Chiing toi nhan tha'y eo mgt so yeu to anh huong deh ket qua nong van hai la nhu: diem Wilkins cao (> 8 diein), van hai la bj caici hoa nang, co rung nhi truoc nong van, co HoBL nhieu truoc nong van, co HoC kem theo truoc nong van va diem Padial > 10 co gia tri du bao nguy co HoHL tang I6n sau nong van.

BAT V A N BE

Nong van hai la bang bong INOUE ngay nay da dupe ap dung rgng rai tiong nuac va tren the'gioi. Sau nong van, mgt so'benh nhan xuat hi?n hep khit tra lai vai tri|u chiing suy tim nang. Nhieu nghien eiiu theo doi ket qua trung h?n va dai han eua NVHL da ghi nhan ty 1? tai h?p la 4 - 39%>, xuat hien khoang 6 ± 2 nSm sau NVHL lan dau. Nhimg benh nhan

(•|:B^\^CoSainiPault

('•): Vi^ Tim M?ch - Benh Vien Bach Mai (•••): B ^ Vi?n Da Khoa Diic Giang

nay mgt so' dugc NVHL lai, so' khac dugc mo thay van, hoac dieu tri bao ton. Theo mgt so nghien eiiu tren the'giai, ty 1? thanh eong oia lan NVHL nhae lai cho nhiing benh nhan nay dat duge la 77 - 100%. Theo danh gia so bg, NVHL lai cho nhimg benh nhan tai hep sau nong la hoan toan kha thi va dem lai ket qua tot 6 nhimg benh nhan co hinh thai van phii hpp [1,2, 4,5,6, 7, 8, 9,10,11,12]. Lieu NVHL nhae lai co mang lai Ipi ieh cho nhimg benh

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TAP CHi TIM MACH HOC VIET NAM - S6 57-2011

nhan tai hep hay khong? Chiing toi tieh hanh de tai nay vol hai myc tieu:

1. Ddnh gid ke't qud som cua phuong phdp nong van hai Id bang bong Inoue trong dieu tri hep van hai Id khit tdi phdt sau nong.

2. Khao sdt mot so' yeu to' co the dnh huong den kei qud nong van hai Id o cdc benh nhan hep van hai Id khit tdi phdt sau nong.

flO'l TirCfNG VA PHiriTNe PHAP NGHIEN CUfU

Ddi tiro'ng nghien CLPU:

140 benh nhan HHL khit da dugc hpi chan, CO ehi dinh va dugc NVHL bang bong hioue tai Vien Tim mach - Benh vien Bach Mai tir 4/2009 deh 8/2010

- Nhom A; 70 b#nh nhan (co tien sii NVHL) - Nhom B: 70 benh nhan HHL khit dugc NVHL lan dau

Moi benh nhan nhom B dupe lay ngay sau mpt benh nhan nhom A.

* Tieu chuan lua chgn benh nhan - Benh nhan HHL khit (dien ti'ch 16 van tren sieu am < 1,5 cm' va eo trieu chiing co nang tren lam sang (NYHA > 2),

- Mpt so'trucmg hgp dac biet khi phai NVHL cap ciiu hoac benh nhan mang thai eiing dupe dua vao nghien ciiu va duoc theo doi dac biet.

* Tieu chuan loai trie benh nhan

- Hinh thai van qua kem (voi hoa nhieu, bie'n dang, day ehang ngan...) voi diem Wilkms > 12 diem.

- Co huyet khoi trong nhi trai.

- Co bieu hien tae m?ch moi xay ra trong thoi gian 3 thang truae thii thuat mae dii tren sieu am tim khong tha'y hinh anh huyet khoi.

- Co kem HoHL va/hoac HoC miie dp nhieu (> 2/4) va da anh huong deh huyet dpng that trai.

- Benh nhan tir choi NVHL.

- Berth nhan dang eo eac benh nhiem trimg tie'n trien hoac mpt so' benh ly nang khac ma can phai giai quyet cac benh ly do truoc.

Phipcng phap nghien ciJu:

M6 ta cat ngang, theo trinh tu thai gian, co so sanh doi chiing. De dam bao tinh khaeh quan, moi benh nhan nhom B dupe lua chgn bang each lay ke'tiqs ngay sau moi benh nhan eua nhom A.

Nong van hai la bang bong theo phuong phap Inoue tai phong Thong tim chup m?ch oia Vien Tim mach Quo'c gia Viet Nam - Benh vien Bach Mai. Xii ly so' lieu bang iphan mem SPSS 10.0 KET QUA NGHIEN ClTU

Dac d i l m cliung cua nhom benh nhan Tuoi trung binh: 43,35 +11,0, eae berth nhan tie tuoi ehie'm da s6^ do tuoi gap nhieu nhat tii 41 deh 50 (31,4 - 44,3%). Nu ehiem da so (> 83,6%).

Bdng 1. Cac thong so'chung eiia benh nhan

Thong so Tuoi trung binh (nam) Gioi nii (n) (%) NYHA trung binh Dp II Doin DoIV

Nhom chung (n=140) 43,35 ± 11,0

117 (83,6) 2,31 ±0,52 101 (72,1%) 35 (25%) 4 (2,9%)

Nhom A ( n = 7 0 ) 42,69 ± 0,52

56 (80,0%) 2,26 ±0,5 54 (77,1%) 14 (20,0%) 2 (2,9%)

NhomB ( n = 7 0 ) 44,01 ±11,58

61 (87,1%) 2,36 ± 0,54 47 (67,1%) 21 (30,0%) 2 (2,9%)

P*

>0,05

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NGHIEN CCfU LAM SANG

Rungnh5(n)(%) Diem Wilkins HoHL 0 1 2

56 (40%) 8,52 ±0,99

33 (47,1%) 8,61 ± 0,94

23 (32,9%) 8,44 ±1,04 16 (11,4%)

104 (74,3%) 20 (143%)

7 (10%) 54 (77,1%)

9 (12,9%)

9 (12,9%) 50 (71,4%) 11 (15,7%)

>0,05

p* la gia tri khi so sanh giiia 2 nhom A va B Nhu vay, eac dae diem lam sang ehung eiia hai nhom la tuong tu nhau. Day la tieu chuan quan trpng de ehiing toi tieh hanh so sanh ket qua sau can thiep giiia hai nhom.

K i t qua chung

- Thanh cong ve mat ky thuat dat dupe 100% 6 ca 2 nhom. Thanh cong ve ket qua (hie la dien ti'ch 16 van sau nong > 1,5 em^ va khong CO bie'n chiing nang xay ra nhu HoHL nang >

2/4...) 6 nhung benh nhan da thanh cong ve ky thuEit noi tren dat dugc a 55/70 benh nhan

(78,6%.) 6 nhom A va 59/70 benh nhan (84,3%) a nhom B, su khac biet nay khong co y nghia thong ke (p > 0,05). Trong do 2 nguyen nhan chinh la dien tieh 16 van sau nong < 1,5 cm^ va bi bieh chiing HoHL nhieu (HoHL > 3/4) sau thii thuat. Nhom A eo 2 benh nhan va nhom B CO 3 benh nhan eo ha hai la sau nong miie dp nang (> 3/4). Ca 3 benh nhan nay deu dung nap tot voi dieu tri npi khoa.

Bdng 2. Thay doi eae chi so' lam sang, can lam sang va huyet dpng ca ban ciia cae 1 nhom A sau nong van

Thong so NYHA

Duong kinh nhi trai (mm) ALDMP tam thu (mmHg) Poppler) MaxVG (mmHg)

MVG (mmHg) MVA tren sieu am 2D (on^) MVA(PHT)(cm=)

ALDMP tam thu (mmHg) (thong tim) ALDMP trung binh (mmHg) (thong tim) Ap Itrc r\hi trai tam thu (mmHg) (thong tim) Ap luc niu trai trung binh (mmHg) (thong tim)

Truoc NVHL 2,26 ±0,50

47,4 ±7,9 49,2 ±9,7 23,35 ±5,40 13,65 ±2,92 0,98 ±0,20 1,02 ±0,21 49,11 ±11,0 34,8 ± 10,11 28,9 ± 7,61 22,07 ±6,80

Sau NVHL 1,23 ±0,46 44,0 ±8,0 33,7 ±9,6 12,88 ±4,12

6,92 ±2,89 1,74 ± 0,34 1,76 ±0,34 37,48 + 8,8 27,2 ±9,47 19,6 ± 5,87 21,85 + 7,89

P

<o,a5

<0,05

< 0,001

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TAP CHi TIM MACH HOC VIET NAM - S6 57 - 2011

Bdng 3. Thay doi cac chi so'lam sang, can lam sang va huyet dpng eo ban ciia cac berJi nhan nhom B sau nong

Thong so N Y H A '

ALDMP tam thu (mmHg) (Doppler) MaxVG (mmHg)

MVG (mmHg) MVA trgn sieu am 2D (cm^) MVA (PHT) (cm')

ALDMP tam thu (mmHg) (thong tim) ALDMP trung binh (mmHg) (thong tim) Ap luc nh! trai tam thu (mmHg) (thong tim) Ap luc nhi trai tnmg binh (itunHg) (thong tim)

Tnioc NVHL 2,36 ±0,56 48,1 ±11,4 22,79 + 8,0 13,49 ±4,9 1,02 ±0,22 1,04 + 0,21 48,9 ±16,0 33,58 + 13,15

30,3 ±8,7 21,85 + 7,89

San NVHL 1,24 + 0,52

32,8 ± 8,4 12,64 + 4,5 5,84 ± 1,74 1,93 ±0,41 1,96 ±0,38 36,35 ±11,69 24,57 ± 9,03 19,2 ± 6,3 13,8 ±5,7

P

<0,05

< 0,001

<0,01

< 0,001

< 0,001 Bdng 4. Mgt s6' yeii to' eo the anh huong de'n ket qiia NVHL

Yeu to Rung nhi

Co HoC di kem muc dp < 2/4 Co HoBL di kem miic do > 3/4 Diem Wilkins > 8

OR 4,13 7,8 6,3 5,8

95% CI 1,1 -14,6 1,6 - 37,9 1,2 - 32,2 1,2 - 28,2

P

<0,05

<=7diem(ii-8) SOiim (n = 20) 9di£iii (n >36) >=]Omeiii (D=6) Bieu do 1. Tuong quan giiia diem Wilkins va dien tieh 16 van sau NVHL

" phan loai suy tim theo Hpi Tlni M^ch (New York Hean Association)

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NGHIEN CUU LAM SANG

BAN LUAN

Dac diem nhom nghien CLPU

* Tuoi va giai: Cae b e n h nhan tre tuoi ehie'm da so". Tuoi trung binh la 43,35 ± 11 (tuoi). Nii ehiein 83,6%. Giiia 2 nhom khong CO su khac biet ve tuoi trung binh, gioi ( p > 0,05).

* Tieh s^nong van hai Id onhom tdi hep O nhom tai hep, dning toi thay trung binh thoi gian tai phat sau NVHL la 6,1 ± 3 nam (ngan nhat la 1 nam, dai nhat la 16 nam), va so' lan benh nhan phai can thiep VHL trung binh la 1,16 ± 0,37 lan (it nhat la 1 lan, nhieu nhat la 2 lan). Ket qua nghien ciiu ciia chiing toi eiing tuong ti^ nhu 6 mpt so' nghien ciiu khac [3,4,8].

* Diem Wilkins: co 74 b$nh nhan co dian Wilkins > 8 (chiem 52,86%)

K6t qua NVHL tren 2 nhom nghien ci>u Thanh c6ng ve ky thuat dat dupe la 100% a ea 2 nhom. Thanh eong ve ket qua dat duge 78,6% 6 nhom A va 84,3% 6 nhom B. Khac biet khong co y nghia tho'ng ke 6 miie p >0,05. Hai nguyen nhan co ban ban che'ty le thanh cong la dien ti'ch 16 van sau nong < 1,5 cm' va bi bie'n ehiing HoHL nang sau nong van. Ket qua nghien eiiu eua chiing toi cung phu hpp vdi nhieu tac gia khac tren the gioi [3, 4, 5, 7, 8]. Sau NVHL, chiing toi CO ty le nho con ton luu thong lien nhi (4,3% a nhom A so vai 5,7% 6 nhom B voi p > 0,05). Lo thong Hen nhi nay thuong rat nho va khong de lai hau qua Ion nao ve huyet dpng eung nhu lam sang. Chiing toi kh6ng gap truong hpp nao co bie'n chiing nang ne phai dimg thii thuat nhu: tii vong, tkc maeh ea'p, ep tim cap...

Chiing t6i kh6ng tim thay su khae biet CO y nghia tho'ng ke nao ve Dd, Ds, %D, EF,

duong kinh that phai truoc va sau nong van (p deu > 0,05).

Cae thong s6' thu dupe trong nghien eiiu ciia chiing toi (bang 3.2 va bang 3.3) eho tha'y eo mgt su eai thien rat manh va rat som cac thong so' do dac dixoc ca tren sieu am tim va tren thong tim. Trong do , dang ehii y nhat la eae thong so' ve dien tieh 16 van va cae th6ng so' huyet dong ve chenh ap qua van hai la, ap luc dpng maeh phoi.

Dieu nay cho phep khang dinh hieu qua cua NVHL doi voi kh6ng chi ve mat giai phau (miic dp hep van ve dien tich) ma eon ve mat huyet dpng, giiip benh nhan dung nap tot hon voi gang siie.

Mot so' yeu to dnh huang den ket qud NVHL a nhom benh nhan tdi hep: Diem WUkLns cao (> 8 diein), van bi ealei hoa nang, CO rung nhi truae nong van, co HoBL nhieu truoc nong van, co HoC kem theo truae nong van, diem Padial > 10 du bao nguy ea HoHL tang len sau nong van.

Bieu do 3.1 cho tha'y diem Wilkins cang Ion, ket qua cang han ehe'. Trong thi^c hanh lam sang thuong ngay, nhiing benh nhan CO hinh thai van qua toi, voi hoa va to chiic duoi van kem thi ket qua NVHL kh6ng tot.

Do vay, vai benh nhan co van hai la qua toi voi diem Wilkins > 10 diem, thi nen eo ehi djnh mo thay van hai la. NVHL eo the la p h u a n g phap lua ehpn tam thoi cho nhiing benh nhan nay khi ma nguy co cho cupe mo truoc m^t qua cao. Diem Wilkins > 8 co kha nang d u bao HoHL vai RR = 2,89 (0,91 - 9,22); p < 0,043.

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TAP CHi TIM MACH HOC VIET NAM - S6 57 - 2011

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