DAI HQI HOI NGOAI KHOA VN LAN THtf XII VA HQl NGHj KHOA HOC NGOAI KHOA TOAN QUOC LAN THtf XIV
KINH NGHIEM TO CHlTC PHAU THUAT CAP CLOJ SLf DUNG MAY TIM PHOI NHAN TAO TAI BENH VIEN VIET DLTC
Nguyin Hun l/ffc*, Vu Ngoc Tii*
T O M TAT
Muc di'ch: Oanh gia trien khai md' cap citu cd sif dung may tim phd'i nhan tao tai Benh vien Viet Diic trong nam 2011.
Ddi t&dng va ph&dng phap nghiin c&u: Md ta 16 tru'dng hdp du'dc trien khai md' cap cu'u cd sii* dung may tim phoi nhan tao tai Benh vien Viet Diic trong nam 2011.
Kit qua: Trong 16 benh nhan dUOc tien hanh phau thuat, cd 8 trUdng hOp loc tach ddng mach chii type A; 3 trUdng hOp ket van hai la cO hgc; 1 chan thu'dng vd cac buong tim; 1 nhoi mau cd tim cap, hep vanh; 1 vet thu'dng mat sau qua! dgng mach chii; 1 u nhay nhT trai; va 1 rdi du bit thdng lien nhT. Cd 12/16 benh nhan ra vien vdi ket qua tdt.
Kit luan: Mo cap ciTu may tim phoi nhan tao la mdt kT thuat kho trien khai, ddi hdi phai cd stf to chu'c tot, nhan Idc du'dc dao tao bai ban, chuyen sau. Benh vien Viet Diic da thiic hien ky thuat khd nay nhu" mot cap CLTU thu'dng qui, ke ca 6 ngoai phdng mo tim, vdi thdi gian trien khai cd the chi trong vdng 30 phut, vdi ket qua sdm sau mo kha tdt.
SUMMARY
EXPERIENCE I N EMERGENCY SURGERY USING CARDIOPULMONARY BYPASS I N VIETDUC
HOSPITAL
Objective. Review emergency procedures using cardiopulmonary bypass at Vietduc hospital in 2011
Material and method: Description of 16
* Benh vien Viet D&c
cases of emergency procedures using cardiopulmonary bypass in 2011
Results: V/e haves 16 patients: 8 type A aortic dissections, 3 mechanical mitral valve thrombosis, 1 heart trauma, 1 acute myocardial infarction, 1 penetrating injury of aortic arch, 1 myxoma of left atrium, 1 amplatzer septal occluder in right atrium. 12/16 patients are good outcome.
Conciusion: Urgent operations using cardiopulmonary bypass i:i a difficult technique, requiring good organization, personnel are advance trained. We has dor^e this technique as routine emergency, including outside the heart operating room in minimum 30minutes. Outcome is good.
I. T O N G Q U A N
Tir khi ra ddi, may tim phdi nhan t^o da md ra mot ki nguyen mdi eho chuyen nganh phau thuat tim va la mdt phuong tien khdng the thieu de phuc vu cho md tim hd [1],
Tuy nhien, khdng chi cd linh vuc phau thuat tim hd, cung vdi su cai tien ve cau true va hoat ddng, tim phdi nhan tao cdn dugc chi dinh eho nhieu phau thuat khac, chu yeu la eae phau thuat ldn, phirc tap: phau thuat cac maeh mau ldn, cac phlu thuat tiet nieu, tieu hda cd nguy co chay mau ldn hoac huylt khdi ldn...Da ed nhieu nghien cuu tren thi gidi eho cac ket qua dang khich le vh cac phlu thuat nhu tren [2]. Nhimg tinh cho ted thoi didm nay, d Viet Nam, tridn khai dugc
224
NGOAI KHOA SO DAC BIET 1,2, 3/2012
nhimg phau thuat nhu vay, dac biet la khi phau thuat cap cuu, vin cdn nhieu khd khan vdi nhieu li do khde nhau: thieu ve nhan luc chuyen sau, thieu ve trang bi may moc, khd khan khi md vao ban dem ....
Benh vien Viet Dure da trien khai md tim hd tir nhOng nam dau thap ki 70, la noi md tim hd dau tien tai Viet Nam, va toi cudi nhiing nam 90, da trd thanh phau thuat thudng qui. Dac biet, trong nhimg nam trd lai day chung tdi da ap dung thanh cdng phlu thuat sir dung may tim phdi nhan tao nhu mot cip cim thudng qui vdi nhiing ket qua rat dang khich le.
IL OOI TUONG VA PHUONG PHAP NGHIEN COU
Md ta tat ca cac trudng hgrp dugc triln khai md cap cuu ngoai gid lam viec thdng thudng (ban dem hoac ngay nghi) cd su dung may tim phdi nhan tao tai Benh vien Viet Dire trong nam 2011. Sir dung cac phan m8m toan hgc de thdng ke.
III. KET Q U A
Trong nam 2011, chung tdi da thuc hien tat ca 16 trucmg hgp phau thuat cd sir dung may tim phdi nhan tao cap ciru. Ket qua duge md ta cu the trong bang dudi day.
Benh li Loc t i c h DMC type A Ket van nhan tao Nhoi mau cd tim cap U nhay nhT trai
Rdi du sau bit thonq iien nhT Chan thu'dnq, vet thu'dnq tim
Tong so
So lu'dng benh nhan 8 3 1 1 1 2 16
TuT vong sdm 3 0 0 0 0 1 4
Hai tmcmg liop chiing toi pliai quyet dinh tri6n Idiai su dung may tim phoi ngay trong mo (Uiong co dir liiSn triroc m6). Hai truong hop nay ia cac truong hop chan thuong, vet thuong tim. Thai gian trien Ichai may tim ph6i nhan tao trong nhung truong hop c4p cuu ngSn nhat la 30 phiit. Thoi gian phlu thuat trung binh la 6 gio. Trong 4 truong hop tit vong, c6 2 truong hop la suy da tang sau m6, hai truong hop la mat nao sau mo.
IV. BAN LUijlN
Ket qua som sau m6.
Cdc loai benh li duac tiin hanh phdu Ihugl cdp cuu. Trong so cac benh nhan nghien cuu, co tai 50% la benh 16c tach dpng
mach chii type A cap (theo Stanford). Diiy la loai benh li cip ciiu ngoai khoa tuyet doi, co ti Ie tu vong trong vong 48 gio dau Ien tdi 50%, va trong nhimg gio tiep theo tang Ien 1% m6i gio [3]. Chinh vi vay, phau thuat cap ciiru cho loai benh li nay can phiii dugc tien hanh cang som cang tot. Diing hang thu hai trong khi m6 vai tim phoi may nhan tao la benh li ket van nhan tao. Day la dieu phii hop vol tinh hinh phau thuat tim mach tai Viet Nam hien nay. Trong khi co nhieu trung tam phau thuat tim ho dugc xay dung, so lugng benh nhan dugc thay van tang ien nhanh chong, thi chS do theo doi, tu vin va dieu tri chdng dong cho benh nhan sau mo lai chua theo kip. Chinh vi vay s6 lugng benh nhan phai dSn vien mo cap ciiu vi benh li nay van
225
DAI H 6 | HOi NGOAI KHOA VN I^N THtf XII VA Hpi NGHI KHOA HOC NGOAI KHOATOAN QU6c LAN THtf XIV edn nhieu. Ngoai ra chiing tdi ciing da cd
gang trien khai duge phau thuat cap cim cho nhiing benh nhan cd the "tri hoan" dugc, nhu u nhay nhT trai, roi dii sau bit thdng lien nhi ... de han che nhiing bien chimg nang cho hg.
Thdi gian va each thiic trien khai may tim phoi nhan tao. Ddi vdi da phan cac trudng hop, do cd du kien trudc, chiing tdi trien khai phau thuat tai phdng md tim hd nen van de trang thiet bi va kT thuat khdng ed nhieu khd khan. Tuy nhien, cd hai benh nhan chan thucmg, vet thuong tim chiing tdi bat huge phai quyet dinh trien khai may tim phdi nhan tao ngay trong md, vi vay cd rat nhieu khd khan. Trudc het, khdng the du kien dugc may tim phdi cap euru eho nhung trudng hgp nay vi cae benh nhan deu vao vien trong tinh trang tdi cap cuu, shock mat mau nang, phai dua benh nhan thang vao nha md nen khdng ed thdi gian chuan bi va cung khdng ed dieu kien de lam chan doan trudc md. Sau khi md nguc, danh gia dugc tdn thuong thi mdi quyet dinh phai diing may tim phdi nhan tao.
Trong khi dd, benh nhan lai dugc md tai nhiing phdng md thudng qui, khdng cd san may tim phdi. Cho nen trien khai md tim phdi nhan tao cho nhimg benh nhan nay, vira ddi hdi het sire nhanh, nhtmg ciing ddi hdi rat nhieu d kinh nghiem ciing nhu su sang tao eua toan bd kip md.
Ti le vd nguyen nhan tu vong. Cd 4/16 benh nhan tii vong (hoac gia dinh xin ve de tiir vong). Trong sd nay ed 3 benh nhan la Idc tach DMC type A (trong tdng sd 8 benh nhan loai benh nay). Theo da phan cae nghien eihi g4n day, ti le tir vong ciia benh li nay sau phau thuat la 10 - 20% [4]. Ddi chiSu vdi cac ket qua nghien curu nay, ket qua tir vong ciia chung tdi cd cao hon. Cd the giai thich su khac biet nay vdi nhiing li do sau. Thii nhat trong sd 3 benh nhan tir vong, ngoai 1 benh
nhan cd cac chi sd xet nghiem binh thudng, hai benh nhan cdn lai ddu da cd bieu hien suy than trudc md. Thii hai, do trien khai md cap ciiu ban dem, thieu eac che pham de cam mau (tieu cau may, plasma . . . ) , lam keo dai thdi gian md, d l suy da tang sau md. Con truong hgp tir vong cdn lai la do benh nhan bi mat mau trudc md qua nang do vet thuong tim, huyet ap thap keo dai, dan den mat nao sau md, dii trien khai may tim phdi chi trong 30 phiit.
Cd s& ha tdng, trang thiet bi, may moc.
Do \iiet Nam van cdn la nude dang phat trien, de dau tu trang thiet bi day du de phuc vu eho mc tim hd, ma cdt loi la may tim phoi nhan tao, la mot van de khdng he don gian ddi vdi eac benh vien. Vi vay, tuy bit dia trien khai phau thuat tim hd tir nhihig nam 1970, nhung phai mai den nhiing nam cuoi eiing' eua thap ky 90 thi phlu thuat tim hd mdi trd thanh thudng qui tai Viet Nam. Va tinh cho den thai diem hien nay, nhiing trang tam md tim hd moi chi tap trung chinh d cac thanh phd ldn la Ha Ndi va thanh phd Hd Chi Minh. Nhu vay, rd rang phau thuat tim hd vdi chi phi cao, may mde dat tien chinh Ik mdt nguyen nhan quan trong lam giam kha nang trien khai phau thuat nay tai nhieu noi trong ca nude. Tuy nhien, ke ca d nhiing noi tap trung nhieu trung tam md tim hd nhu Ha Ngi, viec trien khai nhirng phau thuat tim hd cap cuu vSn la mdt khd khan thuc su. Cdn tai benh vien Viet Dire, dii chiing tdi hjen dang la mdt trung tam md tim cii nhat, du t^i nhung phdng md khdng dugc trang bi san may tim phdi nhan tao, ehiing tdi vin trien khai dugc phdu thuat tim ho c&p eiiu ngay trong dem. Vi thd, li do chinh dk triln khai phlu thuat nay nam nhieu hon d nhung vSn de lien quan den su td ehiie cung nhu trinh do dpi ngii nhan luc.
226
NGOAI KHOA S6 BAC BlgT 1, 2,3/2012 Van de to chuc, so luong va trinh do
ciia doi ngu n h a n luc
Ra ddi tir nhiing nam 1950, md tim hd da cd nhieu thay ddi ldn, ke ca ve may mdc ciing nhu ky thuat phau thuat. Tuy nhien, mpt dac tnmg ciia md tim hd v^n khdng he thay ddi, dd la ngoai may tim phdi nhan tao, ludn ludn phai cd su ket hgp nhan nhuyen cua nhieu e kip, bao gdm phau thuat vien, bac sT gay me, dieu duong phdng md va kT thuat vien chay may. Dieu ddng dugc het sd nhan luc nay ngay trong dem la mdt khd khan rat ldn, vi nhieu ngudi d xa benh vien ca chuc km. Chua ke vdi chinh sach dai ngd, tiln luong nhu hien nay, huy ddng dugc ea mot e kip md tim hoan thien la dieu rat khd khan. De khac phuc dugc khd khan nay, chiing tdi ludn ed thudng true san sang tat ca nhimg thanh phan can thiet cho mdt cas md tim hd. Khi ed chi dinh md tim hd cap cim la ho ed mat l^p tire, khdng phai huy dgng mgi ngudi tir nha den vien.
d day, chic cd nhidu ngudi dat ra cau hdi: "Tai sao d benh vien Viet Diic ludn ludn thudng true mdt e kip md tim hd, va chi de md tim hd? Lieu cd lang phi khdng?" Tai benh vien Viet Dire, mdt sd lugng Idn dieu dirong, y ta la nhung ngudi da hoac dang tham gia thanh thao phau thuat tim hd hang ngay, la thanh vien cua nhiing tua true cap cuu. Hon nGa, trudc khi thanh phlu thuat vien, bac si gay me, dieu duong, kT thuat vien phau thuat tim hd, hg da thuc hien thanh thao nhiing nghiep vu cip cuu ngoai khoa ndi chung. Cho nen phkt ldn thdi gian di true, hg tham gia c i p eiiu ngoai khoa chung, khi can thilt, dpi ngu nay chuydn sang lam phau thuat tim hd ma khdng ed trd ngai gi ldn.
Nhtmg dii sip x6p ed tinh hop li tdi da nhu vSy, neu khdng cd mdt sd lugng nhan vien cd trinh dp chuyen sau dii ldn thi cung khdng
the rai deu nhan lire eho eac ngay trong tuftn.
Day cd le hi mdt khac biet ldn nhat ma cac trung tam Idiac khdng dap iing dugc, nen khdng the trien khai cae phau thuat tim hd cap cim trong dem. 6 benh vien Viet Diic, ed dem chiing tdi da trien khai dugc hai ca md tim hd cap cuu. Trong dd, ngoai trang thiet bi, sd lugng va ddi ngu nhan vien chuyen nghiep, cdn cd ca su say me, trach nhiem va day nhiet huyet vdi cdng viec.
V. KET LUAN
Md cap c i n cd su dung may tim phdi nhan tao la mot phau thuat thudng qui tai Benh vien Viet Dire. Nam 2011, chung tdi da trien khai dugc 16 trudng hgp phau thuat cap cim nhu vay vdi ti le tdt khi ra vien rSt kha quan. De tien hanh duge ngay trong dem nhung phau thuat phiie tap nay, ngoai dieu kien trang thiet bi, chimg tdi ludn ludn sin sang mdt dpi ngu phau thuat vien, bac sT gay me, kl thuat vien chay may va dieu duong chuyen khoa sau, dugc td chirc tdt, cd day dii trinh do chuyen mdn, dugc dao tao bai ban va nhiet huyet vdi cdng viec.
TAI UEU THAM K H A O .
i . Kirklin JW, Barratt-Boyes, History of cardidac surgery. P 24-26
2. Fry RA, Middleton N. Cardiopulmonary bypass and circulatory arrest for partial hepatectomy. Anaesth Intensive Care. 1989 Feb;17(l):117.
3 . Anagnostopoulos CE, Prabhakar MJ, Kittle CF: Aortic dissections and dissecting aneurysms. Am J Cardiol 1972; 30:263.
4 . Bruno C , Marc S., Early and late outcomes of acute type A aortic dissection: analysis of risk factors in 487 consecutive patients, European Heart Joumal (2005) 26, 180-186
227
