TAP CHl TIM MACH HQC VIET NAM - SO 55 - 2010
Nong mang ngoai tim (ma cua so) bang bong qua da 6 benh nhan tran dich mang tim tai phat
Pham M(fnh Wing; Nguyen Ngoc Quang; Nguyen Hiiu Tuan; EHnh Huynh Linh (Vien Tim Mach - Benh Vien Bach Mai);
Le Van Cucmg (Benh Vien Ba Khoa Tinh Thanh Hda)
TOM T A T
Bat vdn de. Tran dich mang tim tai phat, nhat la ne'u co trieu chiing ep tim, co the lam nang them tinh t r ^ g benh ly san co ctia b | n h nhan. Tu tnrdc toi nay, phau thuat mo ciia so mang ngoai tim la bien phap duy nhat de dieu tri nhung benh nhan tran dich mang tim tai phat sau khi dan lim dich bang catheter theo phuong phap truyen thong. Tuy nhien, gan day, mot ki tiiuat mdi da ra doi, do la nong mang ngoai tim bang bong qua da co tac dung nhu mot viec mo ciia so co tiie la bi^n phap lua chon de dieu tri cho nhirng benh nhan bi tran dich mang tim tai phat.
Muc tieu. Budc dau danh gia hieu qua va tinh an toan ctia ki thuat nong mang ngoai tim bang bong qua da trong dieu tri cac benh nhan tran dich mang tim tai phat.
Doi tugng vd phuang phdp nghien ctiu. Chin benh nhan co tran dich mang ngoai tim tai phat dugc nong mang ngoai tim bang bong qua da. Trong do, ca 8 benh nhan c6 khoi u ac tinh di can gay tran dich mang tim, mot berth nhan tran dich mang tim v6 can. Cac benh nhan deu dugc nong mang ngoai tim bang bong ngoai bien (5 benh nhan) va bong Inoue (4 benh nhan), qua duong dudi mui tic.
Kei qud nghien cdu. Thti thuat dan luu thu$n lgi 6 ca chin benh nhan, khong co tai bie'n nang Uen quan de'n thii tiiuat. Cac bie'n chung nhe bao gom tran dich mang phoi so' lugng it, sau do tu tieu.
Trong thai gian theo doi tir 1 de'n 6 thang (trung binh 2,6 ± 1,5 thang), khong cd truong hgp nao tai phat tran dich mang tim, khong co ca ep tim ca'p nao phai nhap vien. Bo'n benh nhan tii vong, sau 1, 3,4 thang va sau 6 thang sau thii thuat, do benh ly ac tinh san co.
Kei ludn. Nong mang ngoai tim bang bong qua da la mot thu thuat don gian va hieu qua co the tiiay the'cho phuang phap mo ctia so mang tim, de dieu tri nhihig benh nhan tran dich mang tim tai phat so'luong nhieu, voi dp an toan cao va ti 1? bie'n chiing tha'p.
BAT VA'N B E t^'^o each truyen t h o n g (ong t h o n g nho) la k h a cao (13-50%), dac biet la n h u n g Nguyen nhan phobien nha't aia tran ^ ^ ^ ^ ^^^ ^,^^ ^i^j, ^„ y^.j u ac tinh dich mang tim tai phat la khoi u ngoai ^^ ggo^^jp] Q ^^^ ^ j , . ^ ^^.^ ^ i ^ ^ ^ g tim di can vao mang lim. Dich mang tim ^^^ pj, ,j_ p j ^ ^ ^ ^ ^^^^ ^g^ ^ ^^^^
thucmg la dich mau, va hay dan den ep ^^^^ ^^ ^.^ ^^ ^ i ^ ^ ^ ^ ^^^ ^^ ^^^
tim cap can phai dan luu cap cuu. Ti le ^^ ^^^ ^j,..^ ^.^ ^^ j ^ ^ . ^ ^^^ ^j,..j ^^^
tai phat tran dich mang tim sau dan luu y ^ ^ ^ ^ ^ ^ ^ ^ jj 2], phlu thuat mo
NGHIEN ClfU LAM SANG
Ctia so mang ngoai tim theo duong duoi miji tie [31, hoac phlu thuat boc tach mang ngoai tim [4]. Tuy nhien, nhung benh nhan tran dich mang tim tai phat thuong CO benh ly n&i nang, the trang yeu hay suy kiet. Vi vay, to't nhat la tranh nhiing can Ihiep phau thuat doi hoi gay me toan than. Palacios va cong su da de xua't Id thuat nong mang ngoai tim bang bdng qua da \a cho ke't qua kha quan [5].
Tir do, da co mgt so'bao cao tren the'gioi ve van de nay.
Tai Viet Xam, khi cac tnmg tam Tim maeh can thiep phat trioi manh, ben eanh nhung can thiep cac benh ly tim mach thuong quy (dpng mach vanh, van tim, tim bam sinh...), \iec can thiep benh ly mang tim con kha moi me. Do vay, chiing toi tieh hanh nghien ciiu nay nham muc tieu sau:
Muc dich nghien cuu:
"Ddnh gid tinh khd thi vd hieu qud cua phuang phdp nong mdng ngoai tim bdng bong qua da trong dieu tri benh nhan bi trdn djch mdng tim tdi phdt".
BOI TU0NG VA ?mM PHAP N6HEN CUTU 1 . Ddi tuvng nghien ciru
Theo trinh tu thoi gian, tir 2005 - 2010, chung toi da tieh hanh nong mang ngoai tim b ^ g bdng qua da cho 9 benh nhan. Bang 1 trinh bay nhirng dac diem lam sang aia 9 benh nhan. Trong ca 9 ca, nong mang ngoai tim dupc tieh hanh khi b^nh nhan co tran dich mang tim nhieu voi lri?u chiing lam sang va hinh anh
sieu am cua tinh t r ^ g ep tim cap. Co 4 tmong hgp tran dich nnang tun tai i ^ t gay ep lim cap sau khi da dugc dan luu dich mang tim trudc do.
Ve can nguyen gay tran dich mang tim, tam b^nh nhan co benh ly ac tinh duoc xac dmh (img thu phoX ung thu vii, da day) benh nhan con lai tran didi mau so'luong nhieu, tai phat, kel qua xet nghiem te'bao hgc chua khang dinh dugc nguyen nhan (bang 1),
2. Quy trinh kT thuat
Thti thuat duoc tioi hanh trong don vi tim mach can thiep. Sau khi gay te tai cho vimg da va mo duoi da, tiai hanh chgc tham do theo duong dirai miii lic dudi man huynh quang tang sang. Dua day dan (guide wire) 0.035 inch vao kho- ang mang tim va nit kim chgc ra. Dua que nong va catheter dan luu vao khoang mang tim qua day dan. La'y benh pham lam xet ngjiiem te'bao hgc \ a mo benh hoc Dan luu mpt ph&i dich mang tim de benh nhan do kho tho. Bom diuoc can quang qua catheter din luu de danh gia ro la thanh mang ngoai tim (Hinh 1). Sau do nit catheter ra, dua introducer 9-11 Fr vao. Dua bdng nong dpng maeh ngoai vi (duong kinh 20-25 nun, chieu dai 40 mm) vao qua guide wiie 0,038 inch ho?c dua bong Inoue da duoc lam cang vao.
Bong dugc dua vao khoang mang tim.
Bom bom tu tu, dam bao mang ngoai tim tao thanh mot eo 6 gjua bong (hinh anh mat kinh). Sau do bom bong cang deh Itic mat eo bong. Doi \oi bdng Inoue, bom eho nd dau xa, sau do keo ve mac vao
TAP CHi TIM MACH HOC VIET NAM - SQ 55 - 2010
mang ngoai tim (la thanh) va bom cang len cho no eo hoan toan. Sau khi nong xong, mpt ong dan luu kieu pitail dugc dua lai deTim de'n khi khi lugng dich con it thi nit. Toan bg thti thuat dugc tieh hanh duoi man tang sang. Tie'n hanh sieu am lai kiem tra sau khi da dan luu he't dich mang tim. Riit sonde dan luu khi he't dich mang ngoai tim (khi lugng dich con dudi 100 mL/24 gia trong 2 ngay). Ta't ca cac benh nhan deu dugc dimg khang sinh du phong bang cephalosporin the'he 1.
Bang 1: D^c diern ctia cac benh nhan nghien ciiu 1
2 3 4 5
Tuoi trung binh Gioi (Nam/Nir)
Ep tim cap tren lam sang phai choc cap cuu Nguyen nhin gay benh:
Benh ac tinh Khac
Thoi gian theo doi trung binh Loai bong dung;
Bong ngoai bien Bong Inoue
53 ±12 (37-75) 6/3 4 (44,5%) 8 (88,9%) 1 (11,1%) 2,6 ± 1,5 (thang)
5 (55,5%) 4 (44,5%)
Hinh 1. Hinh dnh cdc thi nong mdng ngoai tim bdng bong Inoue (hinh trdi Id thi nong bdng que nong; hinh giUa Id dua hong Inoue vd roi bam ddu xa roi keo ra cho mac mdng tim, hinh phdi Id bam bong Inoue cdng tdi da de'ma rgng mdng tim thdnh mgt cm so)
KET QUA NGHIEN ClIU
Vdi c^ 9 benh nhan, chi can tien hanh mgt Ian chpc tham do duy nha't. Vdi nhimg benh nhan nong bing bong ngoai bien, co
2 benh nhan nong mang ngoai tim thanh cong vdi Ian bom bdng dau tien, 3 benh nhan phai phai bom bong tu 2 - 3 lan. Vdi benh nhan dung bong Inoue, thuang bom bdng 2 lan cho ca 4 benh nhan.
NGHIEN CIJU LAM SANG
Ve thoi gian lam thu thuat, ca dau tien mat 60 phiit, nhiing ca nong mang ngoai tim sau do mat 20-50 phiit.
Ve dich mang tim, ta't ca cac truong h(7p deu la tran dich mau, tong luong dich 1000-2500 mL. Khi bom bong, cac benh nhan deu co cam giac dau, kho chiu.
Cam giac do mat di sau khi lam xep bong.
Hau het cac benh nhan deu co ep tim 6 cac miic do khac nhau, dat dan luu mang ngoai tim giiip benh nhan do kho tho. Ta't ca cac benh nhan deu dugc dan luu hel dich mang tim.
Khong CO bieh chiing nang sau thii thuat. Co 5 benh nhan co tran dich mang phot tiong vong 24-48 gio sau thu thuali trong do 4 truong hgp dich tu tieu het, mot titrcmg hgp phid chgc dan luu mang phoi. Thoi gian nit dan liru mang tim la t i i 2 - 7 n g a y
Cac bieh chiing nang lien quan dSi thii thuat nhu tir vong, rung that, tut hnvei ap... khong gap trong nghien cuu nay.
Da so cac benh niian dau, hie viing thugng vi khi bom bong nhung deu dung nap dugc.
Bang 2. Mot so ket qua thu dugc STT
1 2 3 4 5 6 7 8
Thong so'nghien cuu Ty le thanh cong ve ky thuat Cac bieh chung nang lien quan de'n thii thuat
Dau, tuc vimg thugng vi Tong so dich (ml)
Thoi gian liru ohg thong (pigtail) trung binh (ngay) Tai phat dich phai nhap vien de chgc Tir vong chung (sau 6 thang theo doi) Tijr vong lien quan deh tran dich tai phat
Gia tri 9 (100%)
0(0%) 9(100%) 1400 ±700 (100-2500)
3,4 ±2,5 (2-7) 0(0%) 4 (44,5%)
0(0%) THEU BUI THEU THffl GIAN
Trong thoi gian theo doi (1 d&i 6 thang), 4 benh nhan tii vong vi benh ung thu nen. Khong ed benh nhan nao tai phat dich mang tim, khong co ai bi ep tim cap phai nhap lai vien de chpc dich. Trong so 5 benh nhan con song (sau 6 thang), CO ngudi dugc theo doi tdi 1 nam, khong ai phai nhap vien vi phid xir ly benh ly mang tim, khong ai c6 trieu chiing ctia viem mang ngoai tim co thit.
BAN LIAN
Tran dich mang tim do benh ly ung thu di can thudng dan d & ep tim cap va CO ti le tai phat cao [11. Cac bien phap dieu tri tiuyati thohg, nhu bom thuoc gay xo hoac hoa diai vao khoang mang tim thuong gay kho chiu cho benh nhan va dg tai phat [2,6]. Phuong phap khac la phiu thu|t mo ciia so mang ngoai tim.
Han che'Ion nhat cua phau thuat la doi
TAPCHITIMMACH HOC VIET NAM - S6 55 - 2010
hoi gay me toan than, ne'u can md nguc de boc tach mang tim, ho^c md ciia sd mang tim-mang phoi. Vi the phau thuat CO rat nhieu nguy co, dac biet la 6 cac doi tugng th§' trang ye'u.
Kl thuat nong mang ngoai tim qua da theo duong dudi mui tie ed uu diem Idn la chi can gay te tai cho, ti le bie'n chiing thap, va co the lay dich mang ngoai tim lam benh pham xet nghiem [7]. Vi thC kl thuat nay dugc nhidu thay thuoc l\ra ehpn trong nhiing nam gan day, va tro thanh bien phap dieu tri cho nhung b^nh nhan tran dich mang tim tai phat nhieu Ian va co the trgng ye'u.
Trong so' loai bong dimg, bong Inoue (loai dung dd' nong van hai la) to ra than thien, de thao tac va hieu qua han ve mat thdi gian va ky thuat.
Nghien ciiu ctia chiing toi cho thay day la mpt thti thuat dem gian, an toan, it gay sang chan, co the tieh hanh 6 nhiing benh nhan n^ng hoac co tinh trang cap aiu (ep tim cap), vdi ti 1| bie'n chiing thap va it gay khd chiu cho ngudi benh.
Co che' dan luu dich khoang mang tim con chua ro rang. Ta^ ca cac benh nhan trong nghien ciiu deu cd tran dich mang phdi trai sau thti thu$t. Vi v^y chiing tdi cho ring dich mang tim da dugc dan liru ra khoang mang phoi. Mpt sd nghien cuu ciing dua ra gia thie't dich mang tim dugc thoat xudng o bung va ngam vao phiic macdetieudi[8].
Ndi chung, bieh chting ctia thti thuat nong mang ngoai tim qua da tirong tij
nhiing ea dan luu dich mang tim khac. Ki tihu$t chpc tham do tuong doi don gian va an toan, do benh nhan dugc lam thu thuat deu co tran dich so' lugng nhieu.
Trong nghien ctiu cua chiing toi, khong ed ca nao xuat hien sd't sau thii thuat, trai vdi mpt nghien ciiu khac [5]. Cd the do cac benh nhan deu dugc dimg khang sinh du phong bang cloxaeillin.
Tran dich mang phoi la bieh chting pho' bieh nha't, gap d mpi b?nh nhan vdi cac miic dp khac nhau. Miic do tran dich mang phdi cd the cd tuong quan vdi tinh trang benh ly phdi san cd ctia benh nhan, nhu khoi u cd di can mang phoi hay khong, chtic nang he vong ngi mo, hoac tien sir xa tri vung nguc tiudc do.
Theo mgt so' nghien ciiu, can tie'n hanh chgc dan luu dich mang phoi do lugng dich nhieu [5]. Tuy nhien ta't ca cac benh nhan cua chting toi, dich mang phoi deu tv tieu.
Nghien ciiu ciing cho thay, ki thuat nong mang ngoai tim bang bdng qua da cd the tie'n hanh thi dau nhu mgt thii thuat cap ctiu d nhung benh nhan tran dich mang tien co ep tim cap.
Lgi ich Itin nhat ciia thii thuat la ngan ngira nguy co tran dich mang tim tai phat va ep tim cap. Tinh de'n thdi diem nay, chiing toi chi tie'n hanh nong bdng mang ngoai tim d nhung benh nhan da cd tran dich mang tim tai phat. Ca 9 ca deu da dugc chgc dan luu mang ngoai tim trudc do, deu do benh ly ac tinh, va tai phat nhieu Ian.
NGHIEN CLfU LAM SANG
KET LUAN
N g h i e n a i u da b u d c d a u cho tha'y, n o n g m a n g n g o a i tim b a n g b d n g q u a da la m g t thti t h u a t k h a thi, d o n gian, an toan, ti le t h a n h cong cao va ti le bie'n chiing tha'p. K h o n g cd t r a n dich m a n g tim tai p h a t t r o n g m g t t h d i gian t h e o doi k h a dai. Tien l u g n g xa ciia b e n h n h a n p h u thugc c h u ye'u vao tinh t r a n g b e n h ly n e n san cd.
TAI UEU THAM KHAU
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