Y HOC VIET NAM SO DAC BIET - THANG 11/2010
DANH GIA CAC YEU TO KY THUAT CUA PHlfOfNG PHAP TAG NHjP VUNG VACH DU^OTNG RA THAT PHAI
To Hirag Thuy*, Bui Dire An Duy*, Nguyen Ciru Loi*
TOM TAT
Md dau: Tao nhip tii' mdm that phai la phu'dng phap truyen thdng nhUng khdng sinh ly doi vdi tim. Tao nhip tii' vung vach dUdng ra that phai dUdc gidi thieu gan day da chiTng td cd nhieu Uu diem hdn
Pol tu'dng va phu'dng phap: PhUdng phap mo ta cat ngang, hoi eu'u nhiJng trUdng hdp tao nhip til' viing vach dUdng ra that phai thUc hien tai Trung tam Tim mach Benh vien Trung Lfdng Hue tir thang 12/2009 den thang 7/2010
Kit qua: 35 benh nhan cd chi dinh dat may tao nhip vTnh vien va dUdc dat dien cUc that vao vung vach dUdng ra that phai, tud'i trung binh 71
± 15,3 gdm 17 nii'va 18 nam.
Chi dinh tao nhjp gdm: 13 trUdng hdp bloc nhi that cap 3, 1 trUdng hdp bloc nhT that cao do CO Ventricular standstill, 5 trUdng hdp rung nhl cham, 14 trUdng hdp hdi chu'ng nut xoang benh ly, 2 trUdng hdp tao nhjp mdm trUdc dd bj nhilm trung chuyen sang tao nhip vach dUdng ra that phai. Thdi gian cd dinh dien cUc la 21 ± 21,8giay vdi thdi gian phat tia tUdng dnq la 17 ± 16,9 giay; thdi gian dUa dien cUc qua van ba la len OM phdi 12 ± 18,6 giay vdi thdi gian phat tia tUdng ifng la 10 ± 14,4 giay; thdi gian keo dien cUc tii DM phd'i den khi cd djnh vao vach dudng ra that phai 10 ± 4,8 giay vdi thdi gian phat tia tUdng LJiig la 7 ± 3,7 giay. Do nhan cam 12,5 ± 5,9 mV ngay sau khi cay dien cUc; trd khang trung binh la 712 ± 172 ohms; ngUdng trung binh ngay khi van vi't vao vach cd that la 1,077 ± 0,34 V/0,5 ms va giam nhanh sau 15 phiit la
Kit luan: Tao nhjp td vung vach dUdng ra that phai la ky thuat de thUc hien, nhanh chdng.
It kha nang gay ra cac bien chu'ng, sinh ly hdn vdi boat ddng hai that, vdi cac thdng sd tao nhjp trong gidi ban chap nhan.
ABSTRACT
EVALUATION OF TECHNICAL ASPECTS OF PACING FROM RIGHT VENTRICULAR OUTFLOW
TRACT SEPTUM
Background: RV apical pacing is the traditional method of permanent pacing but not physiological for ventricular activity. Pacing from RV outflow tract septum has recently been introduced w/ith more advantages.
Method and materials: retrospective study on cases with pacing from RV septal outflow tract at Hue Cardiovascular Center from Jan. to July, 2010.
Results: 35 patients (17 female and 18 male) were implanted with a PM for AV block, AF with slow ventricular respond, sick sinus syndrome and replacement of PM (2). Total time from right atrial entrance of electrode to electrode fixation to RV outflow tract septum was 21 ± 21.8sec with respective radiation time 17 ± 16.9; time of advancing the electrode from the tricuspid valve to the pulmonary artery was 12 ± 18.6sec with respective radiation time 10 ± 14.4 sec; time of pulling the electrode out of the PA and fixation to the RV outflow tract septum was 10 ± 4.8 sex with respective radiation time 7 ± 3.7 sec. Sensitivity just after the fixation of
CHUYEN DE: P H A U THUAT TIM MACH VA LONG NGLTC VIET NAM
fixation of electrode were respectively 1.077 ± 0.34 V @ 0.5 ms and 0,638 ± 0,17ms (p<0,0001).
Conclusions: RV outflow tract septal pacing with specifically-fashioned conventional stylet is a relatively easy, safe and not time-consuming technique with favorable pacing parameters.
I. Md oAu
Tao nhip d mdm that phai {right ventricular apical pacing: RVA pacing) la phuong thiic tao nhip dugc ap dung tu khi ky thuat tao nhip ra ddi each day ban 50 nam.
Tuy nhien, kieu tao nhip nay tao nen hudng khu cue khdng sinh ly vi di ngugc tu mdm mdm tim len. Ngoai ra, hudng khir cue nay cQng gay ra dang bloc canh trai (LBBB), hix ddng bd CO bdp (dyssynchrony) giUa hai thSt, giiia vung vach va thanh ben that trai. Cd nhieu nghien ciiu cho thay tao nhip RVA anh hudng xau len chiic nang ca tim va huy6t ddng cQng nhu gay hd hai la, rung nhT.[l][2][3][4][5][6][7][8][9][10]. Do dd
trong nliung nam gan day, tao nhip d vuni:
vach lien that trd thanh phuong thiic lua chon cua da sd cac nha tao nhip tim. Tuy nhien, van de dat ra la phai chgn vi tri thich hgp cua vach lien that, ky thuat cam dien cue \'ao vach an toan ciing nhu cac thdng sd tao nhip phai dam bao chiic nang tao nhip dn dinh.
Chiing tdi ap dung phuang phap tao nhip vung vach dudng ra that phai tai Trung tam Tim mach Hue tu cudi nam 2009 bang each ap dung ky thuat be lui sau phSn dSu stylet theo phuong phap Hary Mond.
Muc tieu cua nghien ciiu ndy nhdm:
1. Danh gia thdi gian thuc hien ky thuat tao nhip viing vach dudng ra that phai bSng phuang phap udn cong stylet thdng thudng qua cac thdng sd: thdi gian cd dinh dien cue vao vach dudng ra that phai tinh tir khi dien cue that vao nhT phai, nam trude van ba la va thdi gian phat tia tuong iing.
2. Danh gia cac thdng sd tao nhip: trd khang (impedance), do nhan cam (sensing) va ngudng (threshold) liic cay dien cue.
Hinh 1. Tuong quan vi tri dudng ra that phai tren hinh anh flouro [8]
Y HOC VIET NAM SO DAC BIET - T H A N G 11/2010
' LAO
Hinh 2: Vi tri ciia dien cue dudng ra that phai tren 3 nhat flouro: nghieng trai 40°, sau trude va nghieng phai 40° .
II. OOI TUqJNG VA PHUdNG PHAP NGHIEN CCfU
2.1. Doi tu'o'ng nghien ciiu: cac benh nhan cd chi dinh tao nhip mdt budng theo MODE VVI hay VVIR.
2.2. Ky thuat cam dien cue that vao vach duoTig ra that phai : Ky thuat cam dien circ dugc thuc hien bdi bac sT chuyen khoa tao nhip tim dugc dao tao chinh quy va cd kinh nghiem. Sir dung dien cue cd dinh chu ddng bang vit vdi stylet thdng thudng vdi doan dau dugc udn cong va be lui phia
sau sau. Dien cue dugc cam vao vimg vach ciia dudng ra that phai theo phuang phap ciia Harry Mond. Dac diem chinh ciia Mond stylet (FDA da cdng nhan) gdm doan gan dugc udn cong nhieu tao nen hinh dang niia dudng trdn va doan xa 2 cm dugc udn quay lui sau. Cd the sir dung stylet thdng thudng va udn cong theo hinh dang nay. Trong nghien cim nay chung tdi chi sir dung dien cue ciia 2 cdng ty ldn la Medtronics va St Jude.
Hinh 3: Stylet dugc udn cong doan
xa vdi dau xa duac be ra sau
Posterior angulation2.3. Ky thuat: Dien cue cd stylet da dugc udn cong dua qua van ba la bang 2 each:
a) Dhu dien cue cathode nam trude van ba la: Dua dm dien cue cathode di qua van
dudng ra that phai sau dd day dien cue len ddng mach phdi.
b) Phan than dien cue nam trude van ba
la: phan than stylet udn cong nam ngay
CHUYEN DE: P H A U THUAT TIM MACH VA LONG NGUC VIET NAM mach phdi. Khi dien cue da nkm d ddng
mach phdi, da\' stylet vao trd lai sau do keo dien cue xuong tii' tir ca vao ndn ddng mach khi dien cue di qua mao tren that tren that crest supra\'entricularis se roi vao vimg ca be vach thanh (septoparietal trabeculation). Ngudi dat se cd cam giac dien cue nhay nhe va rai vao tiii CO be. Da}' la vi tri cd dinh dien cue.
2.4. Tinh thdi gian co djnh dien cue:
sau khi dien cue that dugc dua dugc vao nh!
phai. udn cong stylet dua vao lai trong long dien cue. Tii' da\' bat dau tinh thdi gian dua qua van ba la len ddng mach phdi (thdi gian 1) sau dd keo lui dien cue den khi cd dinh dien cue vao \ach dudng ra that phai (thdi gian 2). Tinh thdi gian phat tia trong thdi gian cd dinh dien cue.
Xac diiih dien cue nam d vimg vach dudng ra that phai bang 4 nhat chup: sau tm'dc (PA), chich trai 40° (LAO 40°) nghieng trai 90° (LL) chich phai 40° (RAO 40°) trong dd nhat chich trai 40 rat quan trgng de xa dinli dien cue vao vach. Ngoai ra dien cue cd dinh vao vach dugc chap nhap khi cac thdng sd tao nhip nam trong gidi ban chap nhan dugc.
Xcic dinh cd kich thich ca hoanh d cudng do lOV (diaphragmatic pacing) hay khdng.
Theo ddi cac bien chirng tran dich mang tim. tran khi mang phdi cua thii thuat tao nhip gay nen tren lam sang va chup X quang tim phdi thang ngay thir 1 sau tao nhip. Lam sieu am tim kiem tra neu nghi ngd tran dich mang ngoai tim.
2.5. Xac djnh cac thong so tao nhjp: Sir dung chuong trinh pacing system analyzer ciia Medtronic de danh gia cac thdng sd nhu trd khang (impedance), do nhan cam (sensing) \a ngudng (threshold). Do tra khang tir 300 den 1200 ohms, do nhan cam
ciia sdng R > 5 mV. ngudng < 1,25 V la gia tri chap nhan dugc.
2.6. Xir ly so lieu: Theo phuong phap thdng ke y hgc
- Gia tri trung binh: X ± 2SD .
- Student's /-test dugc diing de so sanli 2 trung binh. Cd y nghTa thdng ke khi p < 0.05.
V. KET LUAN
Chiing tdi tien hanh nghien ciru hdi cim tren 35 benh nhan cd chi dinh dat may tao nhip vTnh vien va dugc dat dien circ that vao viing vach dudng ra that phai tai Trung Tam Tim Mach Hue tir thang 12 nam 2009 den thang 7 nam 2010. Tudi trung binh la 71 ± 15.3 (tir 7 tudi den 84 tudi), trong dd co 17 nu va 18 nam.
Chi dinh tao nhip gdm: 13 trudng hgp bloc nhT that cap 3, 1 trudng hgp bloc nhT that cao do cd Ventricular standstill, 5 tmdng hgp rung nhT cham, 14 trudng hgp hdi chiing niit xoang benh ly, 2 trudng hgp tao nhip mdm trude dd bi nhiem triing chuyen sang tao nhip vach dudng ra that phai.
3.1. Thoi gian co djnh dien cue: Thdi gian cd dinh dien cue trung binh la 21 ±21,8 giay, ngan nhat la 15 giay va dai nhat la 125 giay. Thdi gian phat tia trung binh la 17±16,9 giay. Thdi gian dua dien cue qua van ba la len DM phdi trung binh 12 ± 18,6 giay lau nhat la 100 giay, nhanh nbSt la 5 giay. Thdi gian phat tia trung binh tuong img la 10 ±
14.4 giay. Thdi gian keo dien cue tir DM phdi den khi cd dinh vao vach dudng ra that phai la 10 ± 4,8 giay, nhanh nhat la 7 giay lau la 25 giay. Thdi gian phat tia trung binh tuong img la 7 ± 3,7 giay (Bang 1).
Y HOC VIET NAM SO D A C BIET - T H A N G 11/2010
Bang 1. Thdi gian cd dinh dien Moc thdi gian
Thdi gian tien hanh (giay) Thdi gian phat tia (giay)
cue va thdi gian phat tia.
Qua van 3 la len OM phoi 12 ± 18,6 10 ± 14,4
Keo tit OM phoi xuong 10 ± 4,8
7 ±3,7
Tong 21 ± 21,8 17 ± 16,9
3.2. Cac thdng so tao nhip
3.2.1. Dp nhdn cdm: Do nhan cam trung binh la 12,5 ± 5,9 mV ngay sau khi ciy dien cue vdi Medtronic analyzer.
3.2.2. Tr& khdng: Trd khang trung binh la 712 ± 172 ohms. Trd khang trung binh cua Medtronic 5076 (N = 14) la 743.2 ±261,6 ohms va cua St. Jude Tendril 1688 TC (N = 21) la 714,9 ±76,7 ohms, p = 0,64.
3.2.3. Ngw&ng kich thich: Ngudng trung binh ngay khi van vit vao vach ca thk la 1,077
± 0,34 V @ 0,5 ms (cao nhSt la 2 V thap nhat la 0.5 V) va giam nhanh chi sau 15 phiit cd dinh 0,638 ± 0,17ms vdi p<0,0001.
Bang 2. Cac gia tri ngudng va trd khang trung binh theo timg loai dien cue
Medtronic 5076 Tendril 1688 TC
p value
Op nhan cam (V) 13,6 7,0 13,2 ± 5,2
0,85
Trd khang (Ohm) 743,2±261,6
714,9±76,7 0,11 Bang 3. So sanh gia tri ngudng ngay khi cay
Ngay say cay Sau cay 15 phut P value
Ca 2 dien cUc 1,077 ± 0,34 0,638 ± 0,17
< 0,0001
tien cue va sau 15 phiit Medtronic 5076
0,98 ± 0,34 0,58 ± 0,18
0,0007
Tendril 1688 TC 1,13 ± 0,34 0,67 ± 0,15
0,0001
0.8 0,7 0.6 0.5
-; - : r
;
•
:
m
\
\ \
\ \ \ \
1
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- a Medtronic 5076-58 - Tendril 1688 TC/58
CHUYEN DE: P H A U THUAT TIM MACH VA LONG NGUC VIET NAM
IV. BAN LUAN
Trong nghien nay ty le thanh cdng ky thuat cam dien cue vao vimg vach la 100%.
Khdng cd trudng hgp nao that bai hay bien chimg. Trong thdi gian dau ty le thanh cdng ciia Harry Mond va cs. la 97%. Trong khi dd ky thuat udn dien cue theo each ciia tac gia Vlay (khdng cd dau be lui sau) thi ty le thanh cdng chi 61 %. Khdng cd cd bien chimg rai dien cue. Ket qua cua nghien cim nay ciing tuang tu nhu ket qua cua Hary Mond \'a cs.
Chiing tdi su dung bdc Id tTnh mach dau (cephalic vein) trong 32/35 trudng hgp nen giam thieu nguy co bien chiing tran khi mang phdi. ehen ep dien circ (crushing syndrome) giua phan trong xuang ddn va xuang sudn 1 do chgc kim tTnh mach dudi ddn. Neu dien cue cd dinh diing vao vi tri vach thi se tranh dugc bien chimg tran mau mang tim (cd the xay ra neu cd dinh dien cue vao thanh tu do that phai). khdng gay thiing DM lien that trude cd the xay ra trong trudng hgp cd dinh dien ciic vao thanh trude that phai.
Thdi gian trung binh cd dinh dien cue vao vach khdng cao, neu khdng mudn ndi la ngan 21 ±21.8 giay. Trudng hgp thdi gian cd dinh dien ci.rc lau ban 120 giay la do dua dien cue qua \an ba la gap khd khan mat ban 90 gia\. Dua diiSn cue qua van ba la khd thudng gap trong cac trudng hgp hd van ba la nhieu (gap trong cac benh ly van tim, rung nhT. tim phai ldn).
Cac thdng sd ve tao nhip nhu do nhan cam sdng R trung binh 12,5 ± 5,9 mV cd gia tri tren > 5 mV. Ket qua nay ciing tuang duang \di gia tri nhan cam sdng R trong nghien ciai cua HaiT)' Mond la 10,9 ± 0,40 mV.
Tra khang trung binh la 712 ± 172 ohms, tuang tu nhu kit qua ciia tac gia Han-y
Mond va cs. la 732 ± 150 ohms. Tro khang ciia Medtronic cao ban tra khang dien cue ciia St.Jude ( p = 0,01).
Gia tri trung binh ciia ngudng kich thich la 0,638 ± 0,578 V @ 0.5 ms (do \kn thir hai trude khi quyet dinh ndi dien cue vdi may).
Day la gia trj ngudng chap nhan dugc \';i tuong duang nhu ket qua ciia tac gia Mond va cs.( 0.84 ± 0,40 V) Dilu dang ghi nhan a day la gia tri ngudng ngay khi vira dm dien cue vao vach cd the hai cao 1.077 ± 0,34 V
@ 0.5 ms (cd trudng hgp 2 V) nhung se giam ngay trong vdng 10 den 15 phiu (p< 0.0001).
Dieu nay cd gia tri thuc tien giiip cac nha tao nhjp khdng qua lo neu ngay tir dau ngirong cao nhung khdng vugt qua 2 - 2,5V. Co thi chd 10 den 15 phut de ngudng giam xuong, trong thdi gian dd cd the dat dien cue nhT, hay budc cam mau TM dau hoac cd the buoc cd dinh sleeve.
V. KET LUAN
Tao nhip viing mdm cd anh hudng khdng sinh ly len huyet ddng, tai cau true va chuc nang that trai da dugc chiing minh tir lau. Tao nhip viing vach da va dang la mot hudng di mdi. Phuang phap tao nhip tii' viing vach dudng ra that phai sir dung phuang phap udn stylet theo each Harry Mond da chirng td la cd nhieu uu dilm: de thuc hien, an toan, thdi gian ngan, thdi gian phat tia it.
cac thdng sd tao nhip trong gidi han cho phep. Can cd nghien cim theo ddi lau dai hon ve su dn dinh cac thdng sd tao nhip ciing nhu anh hudng len huyet ddng va chii'c nang that tiii.
TAI UEU THAM KHAO
I. Barold SS. Adverse effects of ventricular desynchronization induced by long-term right
Y HOC VIET NAM SO D A C BIET - T H A N G 11/2010
ventricular pacing. Am J Cardiol 2003;
42:624-626.
2. Barold S.S; I. Eli Ovsyshcher. Pacemaker- Induced Mitral Regurgitation. Pacing Clin Electrophysiol. 2005;28[5j:357-360.
3. Dixit, Marchlinski. Electrocardiographic Patterns of Superior Right Ventricular Outflow Tract Tachycardias; Distinguishing Septal and Free-Wall Sites of Origin. / Cardiovasc Electrophysiol, Vo\. 14, pp. 1-7, January 2003
4. Haoying Shi, Fang Wang. Improved left ventricular mechanical synchrony and systolic performance during right ventricular outflow tract pacing versus apical and low septum. Heart Rhythm, Vol 3, No 5, May '' Supplement 2006. r'3-43.
5. Harris, Gammage. Alternative right ventricular pacing sites — where are we going? Europace (2000) 2, 93-98
6. Karpawich PP, Rabah R, Haas J£. Altered
cardiac histology following apical right ventricular pacing in patients with congenital atrioventricular block. Pacing Clin Electrophysiol 1999; 22:1372- 1377.
7. Kaye, Stampler, Yee. Search for the Optimal RV Pacing Site: Design and Implementation of Three Randomized Multicenter Clinical Trials. PACE 2009;
32:426-433
8. Lieberman, Mond, Gammage. Selective Site Pacing: Defining and Reaching the Selected Site. PACE 2004; 27[Pt. II]:883-886
9. Marsh va Gammage. Benefits of right ventricular septal over apical lead placeinenet after 18 months of pacing: implications for echocardlographlc assessment of leff ventricular function. Heart Rhythm, Vol 3, No 5. May Supplement 2006. P3-44.
10. Michael O. Sweeney, MD; Anne S. Hellkamp, MS. Heart Failure During Cardiac Pacing.
Circulation. 2006; 113:2082-2088.