TAP CHi Y HOC VIET KAM TJiP 450 - THAHG 1 - SO 2 - 2017
KET QUA S a M PHAU THUAT BENTALL TAI VIEN TIM MACH - BENH VIEN BACH MAI
T6MTAT
Myc tiiu: Danh gia ket qua sdm cua phiu thuat Bentall tai benh vien Bach Mai. Bdi tUdng va phu'dng phap: Nghien c i ^ hoi ciSu tren 44 benh nhln duWc thi/c hien phlu thuSt Bentall ddn thuan hole phoi hcfp vdi phiu thuat khac tai Benh vien Bach Mai tu* thang 1/2013 den thang 3/2016. Kit qua:
Tuoi tnjng binh 49,8 ± 13,8, nam gidi chi§m 72,7%.
Tang huyet ap la yeu to nguy cd gap nhieu nhat vdi ty le 45,5% va phan ldn benh nhan (72,7%) khi nhap vien CO NYHA I I I - IV. Thdi gian chay may tim phoi nhan tao la 110,30 ± 58,69 (phut) va tiidi gian cap dong mach diO la 64,46 ± 27,22 (phut). Thcfi gian nam vien trung binh la 15,16 ± 11,05 ngay vdi bien chijfng sau mo hay gap nhat la tran dich, tran khf mang phoi (22,7%). fu" vong tai vien la 9,1%. Kit luan: Doi vdi benh ly van va goc DMC, phau thuat Bentall la mot su" lite chgn hdp ly vdi ket qua sdm tot.
SUMMARY
SHORT - TERM RESULT OF BENTALL PROCEDURE I N V I E T N A M HEART I N S T I T U T E , BACHMAI HOSPITAL Aim of the study. To assess the early results of Bentall procedure at Vietnam Heart Institute - Bachmai Hospital. Metiiods and Objectives.
Retrospective analysis of records of 44 patients underwent Bentall procedure from January, 2013 to Mar, 2016. Results. The mean age was 49,8 ± 13,8 years, male patients were 72,7%. Hypertension was the major risk lactor (45,5%) and of these patients, 72,7% were NYHA I I I - IV. Mean CPB Ume was 110,30
± 58,69 (min) and mean aortic cross clamp time was 64,46 ± 27,22 (min). Average hospital stay time was 15,16 ± 11,05 (day). The most common complication postoperative was heamothorax and pneumothorax (22,7%.). Hospital mortality rate was 9,1%.
Conclusionr. Bentall pnDredure provided good short - temi results for treatment of diseases of aortic root at our hospital.
LDATVXNDE
Phinh tach dpng mach chu Stanford A Phau thuat thay goc dong mach chu (DMC) bang ong
* Viin Jim mach - Binh vien Bach Mai Oiju trach nhiem chinh: Du'dng Du'c Hung Email: [email protected] Ngay nhan bai: 15.10.2016 Ngay phan bien khoa hoc: 20.12.2016 Ngay duyet bai: 27.12.2016
Dirong Dire Hung*
mach nhan tao co gan van va cam lai cac Io vanh du'dc Bentall va De Bono mo ta fan dBu nam 1968 [ 1 ] . TlT do den nay p h i u thuat nay da du'dc ap dung rpng rai trong dieu tri nhieu loai benh khac nhau lien quan den van dpng mach chu, goc dpng mach chii va dpng mach chu len.
Ky thuat mo cung da co nhieu thay doi, cai tien de dem Iai hieu qua nhieu hdn cho benh nhan [ 2 ] . Tai Ddn vj Phau thuat Tim mach, Benh vien Bach |viai, phau thuat Bentall du'dc ap dung rpng rai trong vai nam t r d lai day. Vi vay, nghien cu'u hoi cull nay du'dc tien hanh nham muc dich danh gia ket qua sdm cua phau thuat tren.
IL o d l T y p W G VA PHU'OTMG PHAP NGHIEN CU\J Nghien ctfu hoi cu'u mo ta tren 44 benh nhan (BN) du'dc phau thuat Bentall tai Ddn vj Phau thuat tim mach, Vien Tim mach, Benh vien Bach Mai tii thang 01/2013 den thang 03/2016. So lieu du'dc xir ly bang phan mem SPSS 20.0.
Chi djnh ciia phau thuat Bentall bao gom: loc tach DMC type A co hd van DMC nhieu khong the bao ton du'dc; benh ly van DMC can phai thay van nhan tao co kem theo goc DMC gian rpng tren 45 m m ; benh ly van DMC va gian DMC len d nhiJng benh nhan co hpi chu'ng Marfan (goc DMC gian tren 55mm).
Ky thuat mo; theo quy trinh chuan da du'dc phe duyet bdi Hpi dong khoa hpc ciia Benh vien.
III. KET QUA
3.1. Dac die'm chung cua cac benh nhan Tuoi trung binh la 49,8 ± 13,8.
Tuoi benh nhan tre nhat la 20, gia nhat la 73.
Phan Ictn benh nhan la nam gidi vdi ty le 72,7%.
Cac yeu to nguy cd: phan ldn benh nhan co tang huyet ap (45,5%), 6,8 % co dai thao du'dng, benh ly mach vanh kem theo la 9,1 %, tien su* benh ly Marfan la 6,8%.
Trong so cac benh nhan ciia chung toi co 14 benh nhan (31,8%) du'dc mo cap cdu, 30 benh nhan (58,2%) mo cap cu'u co tri hoan.
yiETMAM MEDICAL JOURNAL m - JANUARY - Z017
Bang 1 Oac diem binh legale BMC vi van BMC
Oac diem 1 N ("/ol
Benh Iv qoc CMC
Gian sau hep 1 Phinh goc OMC do xd vifa | Gian OI^C do hoi chu'nq Marfan
Loc tach BMC cap
Loc tach BMC man [ Bu'dng ki'nh cho ronq nhat cua qoc BMC (mm±SB) |
6 (13,5) 5 (11,4) 13 (29,5) 12 (27,3) 8 (18,2) 51,62 ± 12,17 Bgnh Iv van DMC
WS van BMC Bo I (hoac Idionq hd)
B o l l Bo III Bo IV Van BMC CO 2 la van
5 (11,4) 5 (11,4) 3 (6,8) 31 (70,5)
8 (18,2) Benh ly van tim khac
Van hai la Van ba la
8 (18,2) 4(9,1) 3.2. Bac diem irong md
Bang 2 Cic thonq so ve ky thuit trong md.
Dac diem
Vi tri canuie dong mac BMC len
BM nach phai BMdui
N (»/o)
^l
22 (50,0) 19 (43,2) 3 (6,8) Thdi gian tuan hoan ngocii cd the
Thai gian chay may (phutiSD) Thdi qian cap BMC (phiitiSD) Thdi gian ngu'ng tuan hoan (phutiSB)
Cach Ichau van Khau mui. rdi co don
Khau mui vat
110,30 ± 58,69 64,46 ± 27,22 26,94 ± 15.30
(n=17) 27 (61,4) 17 (38,6) Phau thuat icem theo
Siia van hai la Thav van hai la Su'a van ba la Bac cau chu vanh Thay ban quai OMC Thay toan bo quai BMC
7 (15,9) 2 (4,5) 3 (6,8) 6 (13,6) 15 (34,1) 2 (4,5) Thdi gian chay may nhanh nhat la 51 phut, lau nhat la 370 phut
Thdi gian cap DMC nhanh nhat la 28 phiit, lau nhat la 169 phut
Co 17 BN phai ngifng tuan hoan de sifa chu^ quai hoac ban quai vdi thdi gian ngirng tuan hoan nhanh nhat la 9 phiit, lau nhat la 66 phiit.
4.3. Ket qua sdm sau mo Bang 3 KSt qua sdm sau md
Ketqua Tir vonq Nqay nam vien trunq binh
Ch§ pham mau dung tronq v Khdi HC
Khoi TC may Khdi plasma
N {Wo) 4(9,1) 15,16 ± 11,05 a sau mo
6,10 ± 4,24
1,93 ± 3,03
4,12 ± 2,81
TAP CHi Y HOC VlgT NAM TAP 450 - THANG 1 - SO 2 - 2017
Bien chu'ng sdm sau mo ( Mo lai do chay mau
Mo do nquyen nhan khac Block nhT that cac mu'c do i Suy than phai loc mau
Suy da tanq Tran dich, tran khi manq phoi V Nhiem triing vet mo
Nhiem trunq xu'dnq u'c Nhiem triinq huyet
Nhiem triing phoi Tai bien mach mau nao
n=421
0 (0,0) 1 (2,3) 0 (0,0) 2 (4,5) 2 (4,5) 10 (22,7) 3 (6,8) 1 (2,3) 1 (2,3) 3 (6,8) 2(4,5) Co 4 BN tif vong do hpi chu'ng giam cung
Iifdng tim ngay sau mo (3 BN) va do suy da tang (1 BN). 4 BN tren co dac diem chung khac la phai thifc hien ciJng luc nhieu phau thuat: 2 BN phai tJiay ban quai DMC, 1 BN thay quai DMC va 1 BN bac cau chu vanh. 1 BN phai mo do co tu mau Idn quanh wB. choc dpng mach canh tay gay dien ep. Tran didi/tran khi mang phoi phai dan lull la bien chutig hay gap nhat vdi ty le 22,7%.
IV. BAN LUAN
Hdn 4 thap ky tru'dc (1968), Bentall va De Bono lan dau tien mo ta phu'dng phap thay toan bg goc DMC trong nhutig tru'dng hdp phinh goc aS kem theo van DMC bi gian. Cac tac gia (^
khau ong mach nhan tao vao vdng van cua mpt chiec van bi Starr c3 13 roi thay goc DMC bang ca cum nay. Cac Io vanh du'dc khau vao thanh cua ong mach nhan tao va dau xa cua ong mach nay du'dc noi vc^ DMC len [1].
Ilia chpn loai ong mach cd gan van cd hpc hay van sinh hpc de thay cho benh nhan pliu thupc vao nhieu yeu td nhu": tuoi, nguyen vpng Wiong diing thuoc chong dong hoac chong chi djnh diing thuoc nay. Tren thj tru'dng Viet Nam hien nay md] chi cung cap loai ong mach nhan tao CO gan sin van cd hpc cac cd khac nhau ma chii^ o5 loai ong mach gin san van sinh hpc. De giai quyet van de nay, cac trung tam da tif che ra ong mach nhan tao co gan van sinh hpc (khau van sinh hpc vao ong mach nhan tao) roi su' dung cho b^nh nhan. Theo nghien cifu cua Etz CDj Bischoff MS, va cong su" tren 597 BN du'dc phau thuat Bentall cho thay ty le sif dung dng van sinh hpc chiem nhieu hdn vdi 307 BN trong khi 290 BN dting ong van cd hpc [3]. Cf nghien ciiXi ciia chung tai co 4 BN (9,1%) diing ong van sinh hpc (ty che): 3/4 ia BN tren 65 tuoi va 1 BN nu* CO nhu cau sinh nd.
Mpt trong nhijlng phan ky thuat chinh ciia phau thuat Bentall la each khau vong van nhan tao vao vdi vdng van DMC. Hau het cac tac gia
deu thong nhat each sif dung mui khau rdi vdi chi det 2.0 co kem manh don va khau kieu tif ngoai vao (everted) de cho vdng van nhan tao du'dc dat nam trong vdng van DMC (intra- anulus) [1]. Tai benh vien chung toi, ngoai ky thuat khau rdi nay, trong mot so tfi/dng hdp ma mo vdng van khong qua miin nat, chung toi thut hien ky thuat khau vat vdi duy nhat mpt sdi chi Polypropylene 3.0. Ldi ich ciia ky thuat nay la rut ngan thdi gian khau va buoc chi, qua do rut ngan thdi gian .cap dpng mach chu (59,82 ± 30,22 phut) cung nhu" thdi gian chay may tuan hoan ngoai cd the (98,41 ± 44,59 phut). Ap dung ky thuat nay da lam giam thdi gian cap DMC va thdi gian chay may rat co y nghTa trong lam sang mac du chu^ co y nghTa thong ke. Mpt BN trong nghien cdu nay du'dc sif dung ky thuat khau vat cd thdi gian cap DMC la 28 phut. Trong nghien cuXi cua Etz CD va cong sif tren 597 benh nhan, thdi gian chay may va cap DMC lan lu'dt la 252 ± 60 phut va 176 ± 49 phut [3]. Tac gia Hyun-Chel J vdi nghien cu'u gom 218 benh nhan trong vdng 28 nam cung cd ket qua tu'dng tu' (210 ± 78 phut va 146 ± 51 phut) [4]. De rut ngan du'dc nhu'ng thdi gian tren, ngoai viec co ky nang thuan thuc ciia phau thuat vien cung nhu' kfp mo thi viec thay doi nhOtig ky thuat cu cung gdp phan quan trpng. Tuy nhien de danh gia day dil Idi ich va bien chifng cua ky thuat nay, can c6 nhu'ng nghien cifu du'dc thiet ke chi tiet hdn du'dc tten hanh trong thdi gian tdi.
Ky thuat quan trpng nhat trong phau thuat
Bentall la lam mieng noi lo vanh vao ong gan
van. Cach noi 2 lo vanh de nguyen ca thanh ong
DMC vao ong mach ma Bentall va De Bono thifc
hien lan dau (Inclusion technique) gid da khorig
con du'dc SLf dung nu^ do kha nang bj gia phong
mieng noi DM vanh, dac biet d nhij'ng BN Marfan
[4]. Thay vao do !a ky thuat cai tien ciia
Kouchoukos va cong si/ nam 1991 la cat rdi hoan
toan hai lo vanh thanh hai num (open button
technique) roi phau ti'ch tu" do ra khoi to chifc
VIETHAM MEDICAL JOURNAL N°2 - JANUARY - 2017 lien ket xung quanh de noi vao dng gan van. Day
ciing la ky thuat t i r tru'dc den nay duUc^^ap dung cho t§it ca cac benh nhan du'dc phau t h u | t Bentall tai trung tam ciia chung t o i . Npoai ra, doi vdi nhOtig tru'dng hdp da tutig co phau i i i u a t tai goc DMC, khi hai lo vanh khong the phau tich rdi ra, chiing toi sif dung ky thuat Cabrol: khau 2 lo vanh vao vdi mpt dng mach nhan tao so 6, rBi noi ong nay vao ong gan van [ 2 ] . Trong nghien cutJ nay, chung toi khong gap bat cd bien chu'ng sdm nao lien quan den van de mach vanh nhu"
nhoi mau cd tim sau mo, ro mi$ng noi lo mach vanh - dng van... De danh gia ket qua lau dai, nhutig benh nhan trong nghien cu'u nay van du'dc chiing toi tiep tuc tham kham va theo doi mpt each lien tuc.
Chay mau sau mo trong phau thuat Bentall doi hdi phai m6 lai la mpt bien chutig khong hiem gap. Ty le nay khoang 3 , 4 % - 9,6% d cac trung tSm khac nhau [ 3 ] [ 4 ] [ 5 ] . Vdi viec sir dung keo sinh hpc gia co cho du'dng khau trung t i m , du'dng khau lo vanh va dau xa vdi DMC mot each he thong da han che toi da bien chutig ehay mau d trung tam cua chiing toi: khong cd benh nhan nao phai mo lai vi chay mau sau mo.
Trong nhiJng nam gan day, mpt sd ky thuat mdi gpi la bao ton van DMC du'dc phat trien de ap dung trong nhutig tru'dng hdp cd gian gdc DMC hoac Ioc tach DMC nhutig la van van c h u ^ b| hong. U'u diem ciia phu'dng phap nay la tranh viec phai sd dung thuoc chong dong de han che nhO'ng bien chifng ciia no [ 6 ] . Tuy nhien ky thuat nay tu'dng doi phifc tap va doi hdi stf thuan thuc cua phau thuat vien nen anh hu'dng nhieu den thdi gian mo cung nhu' ket qua lau dai sau mo. De so sanh ket qua lau dai giu^a hai phtfcSig phap, nghien cutj cong gpp ciia Benedetto va epng stf gom 11 nghien cifu vdi 1385 benh nhan co hpi ehutig Marfan du'dc phau thuat hoac theo ky thuat Bentall hoac theo ky thuat bao ton da du'de tten hanh. Ket qua cho thay ty ie tuyen ti'nh phai can thiep lai d nhom bao ton cao gap 4 lan d nhdm Bentall (1,3%/nam so vdi 0,3%/nam). Ngu'dc lai, bien CO do xuat huyet d nhdm bao ton tiiap hdn so vdi nhdm Bentall (0,3%/nam so vdi 0,7%/nam, p
= 0,01) [ 7 ] . Ly^ chpn phu'dng phap nao trong nhutig phuirfng phap tren cho tiitig tru'dng hdp cu the van la van de con tranh cai r 2 ] [ 6 ] [ 7 ] , tuy nhien vdi mu'c do an toan ciia phau thuat, kha nSng thuan thuc ky thuat cung nhu' ky vong lau dai, Chung toi chpn ky thuat Bentall trong phan Idn nhO'ng benh nhan co chi dinh d trung tam eua minh.
Ty le tor vong sdm sau phau thuat Bentall du'dc bao cao khoang 1,9% - 7,3% tuy tifngftac gia. Mac dii co nhieu khac biet ve dac diem bgnh nhan giO^ cac nhom nghien cu'u nhutig hau het cac tac gia deu thong nhat ia co sif khac biet giu'a nhom mo cap cu'u va nhom theo ke hoach [ 3 ] [ 5 ] . 0 nghien cifu cua chiing toi, ty le tu'vong la 9 , 1 % (4/44) trong d d ed den 3/4 la mo cap cull do loc tach DMC. T y le tii* vong nhu' vay la chap nhan du'de va cung tu'dhg dong vdi cac nghien cifu khac. Vdi ket qua sdm tot, cho*den nay phau thuat Bentall van la lifa chon dau tay trong dieu trj benh ly van va gdc DMC khong nhUng d benh vien ciia chung tdi ma con 6 nhiJng trung tam Idn khac.
V . KET LUiBiN
Doi vdi benh Iy van dpng mac chii phoi hdp vdi doan gdc dpng maeh chu, phau thuat Bentall la mpt liJa ehpn hdp ly va cho ket qua bu'de dau kha quan neu du'dc tien hanh tai cac trung tam cd ed sd trang thiet b| t o t va cd dpi ngu chuyen gia giau kinh nghiem.
T A I LIEU THAIVI K H A O
1 . Bentall H, De Bono A. "A technique ter complete replacement of the ascending aorta".
Thorax. 1968;4:338-9.
2. Kouchoukos NT, Wareing TH, Mutphy SF, Perrillo JB. "Sixteen-year experience with aortic root replacement. Results of 172 operations" Ann Surg 1991;214:308-18.
3. Etz CD, Bischoff MS, Bodian C, Roder F, Brenner R, Griepp RB, Luozzo GD. 'The Bentall procedure: is it tiie gold standard? A serief- of 597 consecutive cases" J Ihorac C^nliovsk.
Surg. 2010;140(6S):64-70. '
* i . Hyun-Chel J , Byung-Chul C, Young-Nam S, KyungOong Y, Lee S. "Clinical experience witii the Bentall procedure: 28 years". Yonsei Med 1 2012;53(5):915-923.
3. Svesson LG, Crawford ES, Hess KR, Coselll J%
Safi HJ. "Composite valve graft replacement of the proximal aorta: compariSOT of techniques in 348 patients" Ann ThoracSurg. 1992;54:427-37.
6. HagI C, Strauch JT, Spielvogel D, Galla JD, Lansman SL, Squitieri R, et a l . "Is the Bentall procedure for ascending aorta or aortic val'l^
replacement ttie best approach for long-tei#
evet-free survival?" Ann Thorac SQrsa
2003;76:698-703. '*
7. Price J , Magruder JT, Young A, Grimm JC, Patel ND, Cameron DE, et a l . "Long-temi outcomes of aortic root operations for Marfan syndrame: A comparision of Bentall versus aortic valve-sparing procedures" J Thorac Cardiovasc.
Surg. 2016;151(2):330-6.
