NGHIEN Ciru LAM SANR
Cay may tao nhip vinh vien a tre so sinh thap can bi block nhi that bam sinh qua dudng giiia duoi miii tic
ThS. Nguyen Thanh Hai, ThS. Nguyen Ly Thinh Truong, TS. Pham Hull Hoa.
Khoa Tim mgch, Benh vien Nhi Tnmguang, Hd noi.
Dien thogi: 0936S08889, Mail hai-numwtmaiLcom
TiM
TAT:Chiing toi bao cao 2 truong hop tre so sinh bi block nhi that hoan toan bsm sinh (BNTHTBS) CO suy tim nhip cham giam cung luong. Ca hai deu duoc cay may tao nhip vinh viin (CMTWV) dien cue thuong tam mac (DCTTM) qua mpt duong giua duoi mui lie (DGDMU) voi may phat xung (MPX) nim truoc la sau bao co thing bung.
Tie khoa: Block nhi that; Xhip tim cham; May tao nhip tim; Tre so sinh
l i t VAN BE
Chi dinh CMTW\' la chi dinh bit bupc tren nhung tre so sinh BNTHTBS co nguycohtvongcaobao gom: Phil bao thai, de non can nang tha'p, suy dinh duong bao thai, nhip that diam, suy tim giam cung lupng. Doi voi cac truong hpp nay, cac thuoc dieu tri loan nhip nhu atropine va isoproterenol thuong kem hieu qua [1].
KJ thuat CMTWV vdi DCTTM 6 tic so sinh va dac biet tre thap can that su la mpt van de thadi thiic do su bat tuong hpp giiia giai phau va kich thuoc MPX. Mac dil mpt so' ki thuat da dupc mo ta, tuy nhien mot \i tri li tuong de tao 6 chiia MPX van con la mot de tai tranh luan. Cho deh nay da co mpt so'bao cao ve hieu qua cua phuong phap CMTXW cho tre so sinh voi tXTFTM chi bSng mgt
duong mo, mgt trong cac phuong phap do la DGDMlf co o chiia MPX nam giua CO thing bung va ban sau can co thing bung. Hau het cac bao cao nay la cac ca benh hoac vai ca benh, tuy nhien rat hian truong hgp la tre so sinh thap can[2-31.
Chiing toi bao cao 2 trudng hpp ap dung phuong phap nay tren tre so sinh thap can bi BNTHTBS.
KfTIUATCAYMAY
Phiu thuat dupc tieh hanh tai phong mo, gay me ngi khi quan. Benh nhan nam ngua, long nguc va bung tren dupc uon ngua bang mie'ng dem ke lung.
Ducmg mo dgc giira keo dai khoang V4 tren giira mui lic va roh. Mang ngoai tim dupc boc Ig sau khi mom xuong uc dupc tach dgc giiia, mo mang ngoai tim. Dien
TAP CHi TIM MACH HQC VIgT NAM - S6 55 - 2010
Hinh 1: Vi tri dat mdy phdt xung [Nguon • Theo Benjacholamas V vd cs (2003)][2]
cue ludng cue thugng tam mgc (Myo- Dex™ Epicardial Lead, Model 1084T, dai 35cm, hang san xuat St. Jude Medi- cal, Inc.) dugc xoan cd' dinh vao co tim vung budng td'ng that phai each dgng mgch lien that trudc khoang 1cm, sau do khau 3 mui chi khong tieu cd' dinh dia dien cue vdi lop ngoai co tim. Dung may lap trinh kiem tra nguong kich thich, nguong nhan cam va trd khang dien cue.
Md dgc mep trong ciia ban trudc can ca thang bung trai, bde taeh phan ca thang bung ra khdi ban la sau, tie'p tuc bdc tach sang ben giiia co eheo bung trong va co ngang bimg cho de'n khi o chiia MPX du rgng de chiia may (hinh 1). Ke't nd'i dien cue vdi MPX logi VVIR (Microny II SR+2525T, trgng lugng 12.8 gam, the ti'ch 5.9cm3, day 6mm, hang St Jude Medi- caL Inc.), kie'm tra hogt dgng cua may, dgt MPX vao 6 chiia may vua tgo, phan day dien cue con trung dugc tao thanh vdng trong khoang mang tim. Khau lgi mang ngoai tim va ddng Igi thanh bung theo phan Idp giai phau.
BAO CAO TRIfflfNB H0P 1.
Tre so sinh nhap vien liic 12 gid tuoi, ehuyen d a i tu benh vien tinh. Tien sii san khoa: thai du thang 39 tu&i, de thudng, suy dinh duong bao thai nang, can nang lue sinh 1800 gam, khdng nggt. Sau de thd nhanh, khdc ye'u dan, tim khi khdc, phai thd oxy va nam long ap.
Tmh trgng luc nhap vien: Khdc yeii, thd nhanh ndng khong deu 70 Ian/phut, tim Sp02 86%, nhip tim chgm khong deu 45 Ian/phut, gan to 3 cm dudi bd sudn phai, huye't ap dgng mach xam nhap tha'p 60/26mmHg, ton thuong da dang Lupus so sinh toan than chii ye'u d vung tran va tti chi.
XQ tim phoi bdng tim to (hinh 2), dien tam do phan ly nhi that hoan toan, sieu am tim thdng lien nhi thii phat dudng kinh 6,8 mm va cdn ohg dgng mach nhd 2.8x4.5mm. Xet nghiem cdng thtic mau:
bgch cau 13.200 bc/pl, thie'u mau Hb 12.6 g/dl, tieu cau 43.000 tc/^il. Xet nghiem sinh hda: nhiem toan chuyen hda ma't bu pH 7.25, acid lactatic tang cao 10.2mmol/l, tang ure mau 11.8 mmol/lit, creatinin 56.4
|j.moI/lit, AST va ALP trong gidi hgn binh thudng, CRP< 6 mg/I. Rdi logn dong va ehay mau: ngoai tieu cau giam nang, ti le prothrombin 19%, INR 3.98, fibrino- gen 0.75 g/I/ APTT keo dai gap ddi so vdi chuan. Cac xet nghiem khac: test coombs true tie'p va gian tie'p am tinh, xet nghiem tim SSA/Ro va SSB/La ciia me khong cd dieu ki^n lam.
NGHIEN Cl>U LAM S A N G
Hinh 3: Phim chup tim phoi sau cdy may
Tre dugc dieu tri b ^ g thd may, duy tri huye't ap bang dopamine va adrenalin, lasix tinh mgch, tmy&i tieu cau va plasma tuoi hang ngay, tiem vitamin K, khang sinh phdng bgi nhiem va nudi duong finh mach. Ca'y may tao nhip phai tri hoan deh ngay thti 8 khi cae xet nghiem dong
\-a ehay mau d miic eho phep. Kiem tra di?n arc b5ng may lap trinh trudc khi cd
dinh dien axe: trd khang d i ^ cue 420 Q, nguong nhan cam 6 thai > 7.2 mV, nguong kich tiiich 0.8 V vdi do rgng xung 0.31nis, tan so kich thich 150 Ian/phut. Phau thugt keo dai 60 phiit, khong cd bioi ehiing.
Sau phau thugt tre tiep tuc thd may, khang sinh finh mgch, truyen khoi tieu cau, nudi duong bang dudng tinh madi.
Huye't dgng on dinh, bai rueu binh tiiuong va he't phii, cac thuoe van mach dugc cit ngay sau mo. Ngay thii had sau md: khong cdn tinh trgng nhiem toan, add lactic tro ve gjdi hgn binh tiiuong, XQ tim phoi di?n tim trd ve kich thudc binh thudng (hinh 3), sieu am mang ngoai tim khdng cd djdi va chiic nang co bdp tha't trai trong gioi han binh thudng. D ^ ngay thti ba sau mo vet md van kho saeh, khdng cd bieii hi§n viem nhiem hogc tir mau.
Tuy nhien, ngay thii 4 sau mo tre bat dau tinh trgng viem phdi: xua't tie^ dudng thd, nghe phoi li dgng, XQ phoi cd hinh anh ton thuong viem Ian tda. Dien biai tie'p ttjc xa'u dan, suy ho hap tieh trial, shock nhiem khu&i, suy than va rdi loan ddng mau nang. Tre hi vong khi 21 ngay tudi do nhiem trung mau va suy da tgng kei qua ca'y mau Klebsiella Pneumoniae da khang khang sinh.
BAD CAO TRirtfNG H0P 2
Tre trai, nhap vien 20 ngay tuoi, vao vien vi li do khd thd va bii kem. Tien sii san khoa: thai dii thang 38 tuan, md de yi sa day rau, suy dinh duong bao tiiai, can nang Iiic sinh 2.3 kg. Kham lue nhgp vien: Can nang 2.6 kg, khde yeu, da tai,
TAP CHl TIM MACH HOC VIET NAM - SO 55 - 2010
Sp02 82%, tho nhanh 60 lan/phiit, thong khi phoi deu, nhip tim cham khong deu khoang 60 lan/phiit, gan 3cm duoi bo sudn phai.
Hinh anh bong tim to tren phim X- Quang tim phoi, dien tam do hinh anh block nhl that hoim toan, sieu am dm ca'u tnic tim binh thuong, nhilm toan chuyen hoa con bii (pH 7.39, BE -10.5, HC03- 14.5, pC02 24 mmHg ). Dien giai do, ure va creatinin trong gioi han binh thuong.
Tre dupc ca'y may tao nhip dien cue thuong tam mac cap cihi, cupc mo keo dai 60 phiit Test dien cue truoc khi co dinh:
dien tro 355 n , bien do song R 8.53-8.77 V, nguong kich thich 1.3 V vol dg rpng oia xung la 0.31 ms, tan so'phat nhjp 140 Ian/
phiit, khong co bie'n chiing trong va sau mo. Sau ca'y may, tre dupc nit 6'ng npi khi quan sau mpt ngay, tir ngay thii ba bii tot va dupc xuat vien sau mgt tuan. Tai kham khi 5 thang tuoi: phat trieh binh thuong, can n^ng 6.5 kg, trp khang dien cue va nguong kich thich gan nhu khong thay doi, khong co trieu chiing bat thudng lien quan de'n may tao nhip.
BAN LOAN
BLNTHTBS duge phan thanh hai tiie lam sang: the ket hgp vdi cac benh tim bam sinh ehie'm khoang 50% [4]; the don thuan lien quan de'n cac tu khang the trong cac rd'i loan tu mien ngudi me vdi ca'u tnic tim binh thudng. Tan xua't mac benh BLNTHTBS dugc udc tinh vao khoang 1:11.000 - 1:20.000 tire de soiig [5-6]. Ti le tii vong thay ddi theo timg nhdm nguy co
va timg giai doan tuoi khoang 11-100%, cac ye'u to nguy co Hen quan deh ti 1$ hi vong la: de non, tre so sinh tha'p can, phu bao thai, nhip thai cham, tim bam sinh [1, 4, 7-9]. Phan Idn tre bi BLNTHTBS duge ca'y may sdm, trong nghien cihi eiia Glatz va cs 54% cac trudng hgp nay dugc ca'y may ngay trong 24 gid dau sau sinh[l].
Hien nay ph&i Idn cac trung tam tim mgch ap dtjng ki thuat CMTNW bang cac phuong phap 2 dudng mo. Mgt dudng md dimg cho tie'p can va eo dinh dien cue, duong thii hai de tgo d chiia MPX. Phuang phap DGDMLT, gidiig nhu cac ki thugt mgt dudng md da dugc mo ta (dudng mo dudi bd sudn; md long nguc dat MPX ngoai mang phd'i; dgt MPX giiia co hoanh), tranh phai thuc hien dudng mo thii hai. Hon niia, vi tri dgt MPX trong ki thuat nay giup cho may dugc bao ve chac chan giiia cac lop co thanh bung va khdng de ep de'n cac tgng ben trong long nguc va o bung. Phuang phap nay cdn tgo dieu kien de dang va it xam nhap hon khi thay the'MPX so vdi cac phuong phap khac [10-13],
Ngoai cac uu diem tren, phuong phap dudng vao miii lic cdn cd uu diem vugt trdi niia la don gian de thi^c hi?n, thoi gian phau thuat ngan, do an toan cao va de dang thay ddi vi tri co dinh di$n cvc khi do tim vi tri thfch hgp. Tuy nhien phuong phap nay cd the bi hgn che khi dgt DCTTM nhi phai, hogc trong trudng hgp phai dat dien cue that trai. Do vay phuang phap nay chi nen ap diang vdi tre so sinh va tre bu me cd chi dinh tao nhip mgt buong 6 that phai[2].
NGHIEN CLTU L A M SANG
TAI UEU TIAM KIAO
1. Glatz A C GaynoT JW, Rhodes LA, et al.
Outcome of high-risk neonates with con- genital complete heart block paced in the first 24 hours after birth. J Thorac Cardio- vasc Surg 2008;136(3):767-73.
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3. Cohen ML Bush DM, Vetter VL, et al.
Pennanent epicardial pacing in pediatric patients: seventeen j-ears of experience and 1200 outpatient visits. Circulation 2001 ;103(21 ):2585-90.
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5. Siren MK Julkunen H, and Kaaja R. The increasing incidence of isolated congeni- tal heart block in Finland. J Rheumatol 199825(9):1862-4.
6. Michaelsson M and Engle M A Congeni- tal complete heart block: an international study of the natural history. Cardiovasc Clin 1972;4(3):85-101.
7. Schmidt KG, Ulmer HE, Silverman XH, et al. Perinatal outcome of fetal com- plete atrioventricular block: a multi- center experience. J Am Coll Cardiol
1991;17(6):1360^.
8- Groves AM, Allan LD, and Rosenthal E.
Outcome of isolated congenital complete heart block diagnosed in utero. Heart 1996;75(2):19a4.
9- Jaeggi ET, Hamilton RM, Silverman ED, et al. Outcome of diildren u i t h fetal, neo- natal or childhood diagnosis of isolated congenital atrioventricular block. A sin- gle institution's experience of 30 years. J Am Coll Cardiol 2002^9(1 ):130-7.
10. Takabayashi S, Ito H, Shimpo H, et al Emergent permanent pacemaker implan- tation in a premature 1,502 g neonate. Jpn J Thorac Cardiovasc Surg 2005p3{4):199- 201.
11. Agarwal R, Krishnan GS, Abraham S, et al. Extrapleural intrathoracic implan- tation of p)ennanent pacemaker in the pediatric age group. Arm Thorac Surg 2007;83{4):1549-52.
12. Roubertie F, Le Bret E, Thambo JB, et aL Intra-diaphragmatic pacemaker implan- tation in very low weight premature neonate. Interact Cardiovasc Thorac Surg 2009,-9(4):743^.
13. von Schnakenburg C Fink C Peuster M, et al. Permanent pacemaker implanta- tion in a 1,445 g preterm neonate on the first day of life. Thorac Cardiovasc Suig 2002;50(6)363-5.