JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY V o n 2 - N'4/26f'
Tim hiiu gia tri cua sieu am tim trong danh gia cac tdn thuong cua thong lien nhT 16 thu hai co d6i chieu voi kSt qua thong tim
The role of echocardiography in assessment of atrial septal defects ostium secundum in comparison with results of cardiac catheterization
Pham Thai Giang*, *Binh vien Trung uang Qudn dgi 108 Nguyin Thi Thu Thuy** **Benh vien Tim Hd NQI
Muc tieu: Nghien cUu danh gia vai trd cua s i i u am tim qua thanh ngUc va sieu am tim qua thi/c q u I n trong v i i c xae djnh cae tdn thuong eCia thdng l i i n nhT 16 thU hai ed doi chi^u vdi k^t q u i thdng tim, phan tieh mdt so yeu t d I n h hudng den k h i nang danh gia tdn thuong thdng lien nhT cCia sieu am. Doi tugng vd phUOng phdp: Thdi gian nghien cUu tU t h i n g 01/2015 den het t h i n g 12/2016, dot tuong nghien cUu gom 68 benh nhan chan doan thdng lien nhT 16 thU hai cd chi djnh bit bang dung cu. Ket qud: Sieu am tim qua thanh ngUc va sieu am tim qua thUe quan hd tro nhau va ddng vai tro quan trong trong danh g i l cac tdn thuong thdng lien nhT quyet dinh ehi djnh d i i u tri. Tuy nhien sieu am tim qua thUc q u I n cho hinh I n h ro net, ket q u i d i n h g i l chfnh x l e hon so vdi sieu am tim qua thanh ngUc. Dudng kinh 16 thdng l i i n nhT do d cac mat cat tren siiu am tim qua thanh ngUe tUOng quan tuyen tinh chat che vdi ket q u i thdng tim (r a 0,7), dudng kinh 16 thdng lien nhi do t r i n siiu am tim qua thUc q u I n tuong quan tuyen tfnh rat chat che v l sat n h l t vdi ket q u i thdng tim (r £ 0,9). Mat e l t 4 budng tim tU mdm va mat cat dudi mui Ue tren sieu am tim qua thanh ngUc cd y nghTa hdn cl trong viee danh g i l c l e t d n thuong eCia thdng lien nhT Id thU hai./fet/udn: Siiu I m tim qua thanh ngUe va sieu am tim qua thuc quan la nhUng phuong phap chan doan chinh xac giup chi djnh can thiep bit thdng l i i n nhT bang dung cu qua da.
Tdkhda:Th6ng lien nhT, sieu am tim.
Summary
Objective: To evaluate the role of transthoracic and transesophageal echocardiography m assessment ofthe lesions in ASD ostium secundum in comparison with the parameters achieved during percutaneous closure. Some factors affecting to ability of echocardiography in assessment of ASD were also analysed. Subject and method: From January 2015 to December 2016, 68 patients with ASD ostium
Ngdy nhdn bdi: 11/01/2017, ngdy chdp nhdn ddng: 13/03/2017
Ngumphdn hoi: Pham Thdi Giang. Email: [email protected] - Benh vien Trung uang Qudn doi 108 14
TAP CHl Y DUOC LAM SANG 108 Tapl2-S6 4/2017
secundum who should be candidates for percutaneous closure were entered into the study. Result TTE and TEE were assisted mutually, played important roles in assessment of atrial septal defects and in decision of treatment. However, TEE showed dearer images and more accurate results than what of TTE.
Diameters of the ostium measured on the sections of TTE were closely linear correlative to the results seen in percutaneous closure and relatively closely correlative to the results achieved in percutaneous closure (correlation coefficient: r > 0.7). The results of TEE had very close linear correlation with the results observed in percutaneous closure (r > 0.9). Four chamber apical section and subcostal section on TTE had more significance in defects assessment of the ASD ostium secundum. Conclusion: TTE and TEE are good tools for assessment o f t h e ostium secundum before intervention.
Keyworc/s: Atrial steptal defect, echocardiography.
1 . Dat v l i n de
Thdng lien nhT (TLN) I I mpt t r o n g nhOng benh t i m bam sinh thUdng gap, chiem 5% - 10% cae dj tat bam sinh d tre so sinh, 30% cac dj tat bam sinh d ngUdi Idn [3] t r o n g d d TLN kieu 16 thU hai chiem 60% - 70% c l e t r u d n g hpp TLN [3], [5]. Viec d i n h g i l chfnh x l c d u d n g kinh, vj t r i , hinh dang 16 TLN, c l e g d eCia 16 TLN v l nhUng thucfng t d n di kem (phlnh vach lien nhT, bat t h u d n g tTnh mach phdi, tTnh mach ehu h o l e cae dj tat phdi hpp khae...) cd ^ nghTa rat Idn de quyet d m h lUa chpn p h u o n g phap dieu trj d d n g 16 TLN bang d u n g eu hay phau t h u l t va 16 TLN ddi vdi benh nhan TLN 16 thU hai. Sieu I m tim qua thanh ngUe (SATQTN) giup sang Ipe, phat h i i n benh nhan TLN, xae dmh cae t d n t h u o n g TLN, nhung cdn mdt sd mat han che nhU 6 eae benh n h i n cd thanh ngUc day, cd benh phoi man tinh...
thi hinh anh s i i u am t h u d n g m d , khd danh gia. Sieu I m t i m qua thUc quan (SATQTQ) khae phuc nhufng nhupe diem cCia SATQTN, d i n h gia chinh xae ele ton thUdng eUa TLN, ehuan bj t d t eho viee bit 16 t h d n g bang d u n g eu [1], [3].
T r i n thUe te SATQTN va SATQTQ eho ket q u i d u n g d u p c den dau khi ddi chieu vdi ket q u i t h d n g t i m va phau t h u l t va nhOfng yeu t d nao I n h hudng d^n k h i n l n g danh gia t d n t h u o n g TLN eua SA? Qi t i m hieu van de nay, chung t d i tien h l n h n g h i i n cUu nham muc t i e u Bdnh gid vai trd cua sieu dm tim qua thanh ngUc vd siiu dm tim qua thUc qudn trong viec xdc dinh cdc ton thuang cua thdng lien nhi Id thd hai cd ddi chieu vdi dddng kinh lo thong do bdng bdng khi can thiep.
2. Doi tUcfng va phUOng phap 2.1. Doi tugng
68 benh n h i n dupe chan d o l n TLN 16 thU hai dieu tri tai Benh vien Tim Ha Ndi tU t h i n g 01/2015 den het t h i n g 12/2016 cd chi dinh ddng Id TLN bang dung cu.
2.2. PhUc^g phdp
Nghien eUu tien cUu, md t l , eat ngang.
2.3. Dung cu, phUcfng tien
M I y sieu I m Doppler mau XARtO eua hang TOSIBA MODEL SSA - 660 A vdi dau d d SATQTN va dau dd SATQTQ.
Thude: Lidocain 10% (dang xjt), Xylocain 2%
Jelly, midazolam human.
2.4. Dia diem: B i n h vien Tim Ha Ndi.
2.5. XCf ly so liiu: Cac sd lieu dupc xCr ly theo phuong phap t o l n thong k i .
3. Ket qud
3.1. Dgc diem chung ve tuoi, gidi
Tuoi trung binh la 30 (10 den 68), trong do cd 66,3% I I nU. Nhdm benh n h i n dupe chan doan trude 16 tudi ehi chiem 18,2%, dp tudi chiem ty le eao nhat la tU 16 - 39 tudi (61 %).
3.2. Bieu hien Idm sang cua nhdm benh nhdn TLNlothiJfhai
40,6% benh nhan phat hien b i n h mdt each tinh ed, NYHA II chlem 68,8%, met (48%), dau ngUe (21%).
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JOURNALOF 108 - CLINICAL (WEDICINE AND PHARMACY V0I.I2-N''4/2017
NhUng dau hieu lam sang dien hinh: Tieng thdi t i m thu 6 khoang l i i n sUdn II t r l i (chiem 92,6%), T2 tach ddi cd djnh d khoang lien sUdn li trai (63%).
3.3. Kit qud ddnh gid ton tht/ong TLN tren SATQTN vd SATQTQ doi chieu vdi thdng tim
Bdng 1 . So sanh dtfcmg ki'nh TLN Id thuf hai tren SATQTN va SATQTQ
STT
1 2 3
M i t c i t
4 buong True ngSn Du6i mui ijfc
OUcmg kinh IS TLN (mm) (n = 68) SATQTN 25,1 ±4,1 22,3 ±3,8 24,8 ± 3,5
SATQTQ
25,9 ± 2,1 P
>0,05
<0,05
<0,05
Bdng 2 . So sanh dadng Itinh TLN 16 thuf hai do Xtkri SATQTN va do bang bong trong luc thong tim
Nhgn xet Dudng kfnh 16 TLN trung binh do t r i n SATQTQ Idn hon do d c l e mat cat tren SATQTN. SU Wile biet cd y nghTa thdng ke (p<0,05) d mat cat true ngan va mat e l t dUdi mui Uc, mat eat 4 budng cho ket q u i sat vdi SATQTQ (khdng cd sU khae bret cd y nghia thdng k i , p>0,05).
STT
1 2 3
Mat c i t
4 buong True ngan DU6i mui<}c
Di/dng kinh lo TLN (mm) (n = 68) SATQTN 25,1 ±4,1 22,3 + 3,8 24,8 ±3,5
Thong tim
26,9 ±2,2 P
<0,05
<0,05 Nhdn xet DUdng kinh 16 TLN do tren SATQTN nhd hon dUdng kinh 16 TLN do bang bdng khi thong t i m . Khae b i i t ed ^ nghTa thdng ke (p<0,05).
Bang 3. So sanh dUdng kinh TLN lo thiif hai tren SATQTQ va do bSng bong khi thong tim DUdng kinh I& TLN (mm) (n = 68)
SATQTQ 25,9 ± 21
Thdng tim 26,9 ±2,2
P
<0,05 W/idn xet; Dudng kfnh trung binh eua 16 TLN tren SATQTQ nhd hOn dUdng kfnh trung binh cua 16 TLN do khi cang bdng (p<0,05).
3.4. M6i tuang quan giiJfa ket qud SATQTN, SATQTQ vdi thong tim
3.4.1. Tuang quan gida dUdng kinh TLN d mat cdt bon buong (SATQTN) vd ket qua thdng tim
„ HOI quy tuy^n tinh El9tncgy95%
DKTLNmStcat4bu6ng[mm)
Bieu do 1. Tuong quan giUa dudng kfnh TLN d mat c i t 4 budng va thdng tim
Nhdn xet Dudng kfnh 16 TLN do 6 mat eat bdn budng tim t r i n SATQTN ed tUPng quan tuyen tfnh chat c h i vdi ket q u i thu dupe t r i n thdng tim (he sd tuang quan r = 0,87).
TAP CHl Y DUOC L A M S A N G 108 Tap 1 2 - 5 6 4 / 2 0 1 7
3.4.2. Tuang quan gida dUdng kinh TLN do d mat cat true ngdn qua van ddng mgch chd (DMC) (SATQTN) vd ket qud thdng tim
Max eat true ngan qua van DMC t r i n SATQTN eho ket q u i dudng kinh 16 TLN cd moi tUong quan tuyen tinh chat che vdi k i t q u i t h u dupe tren thdng t i m (he sd tUOng quan r - 0,76). Phuong trinh bieu dien mdi tuong quan ed dang y = 0,76x + 11,95.
3.4.3. Tuang quan gida dUdng kinh TLN d mat cot dudi mui dc (SATQTN) vd ket qud thdng tim Phuong trinh bieu dien cd dang y = 0,75x + 10,56, h i sd r ^ 0,69.
3.4.4. Tuang quan gida dUdng kinh Id TLN tren SATQTQ vdi ket qud thdng tim
. H6i quy tuy^n tinh B6lino5y95%
DK TLN trSn SATQTQ (mm)
B i e u d o 2 . T u o n g q u a n g i Q a d u d n g k i n h T L N t r i n S A T Q T Q v d i t h d n g t i m
Nhdn xet Dudng kfnh 16 TLN d o tren SATQTQ tuong quan tuyen tfnh chat che n h l t vdi k i t q u i t h u dugc khi d o bang bdng Aga tren thdng t i m (he sd tUOng quan r = 0,97). Phuong trinh bieu dien mdi t u o n g quan y
= 1,07x + 0,76.
4. Ban luan
4.1. Dgc diem chung cua nhom nghien cufu Dgc diem chung ve tuSi, gidi: 68 benh nhan tudi til 10 den 68, tudi t r u n g binh la 30 trong do cd 66,3% la nuf. T;^ le nU/nam trong nghien eUu I I 1,96 xap xl nghien eUu cCia eae tac g i l khac trong va ngoai nUde [1], [2], [4], [7]. Nhdm benh nhan dUgc chan d o l n trUde 16 tuoi chi chiem 18,2%, d p tudi chiem X^ le eao nh^t la tU 16 - 29 tudi.
Bieu hiin Idm sdng cua nhdm benh nhdn TLN 16 thd hai: 40,6% b i n h nhan p h l t hien benh mdt each tinh cd, nhufng benh nhan khIc trieu ehUng ca nang t h u d n g khdng dien hinh, xuat hien mudn, t h u d n g gap la khd t h d khi gang sUe (NYHA II chiem 68,8%), met (48%), dau ngue (21%). NhUng dau hieu lam sang dien hinh: T i i n g thdi tam t h u d khoang lien sudn II trai (chiem 92,6%), T2 tach ddi cd djnh d
khoang lien sUdn II trai (63%), k i t qua nay eung phu hpp vdi n g h i i n cUu eCia Nguyen Lan Hieu [1].
4.2. Ket qud ddnh gid ton thuang TLN tren SA TQTN vd SA TQTQ doi chieu vdi thong tim
DUdng kinh 16 TLN trung binh d o tren SATQTQ Idn hon d o d cac mat e l t tren SATQTN. SU khae biet CO y nghta thdng k i (p<0,05) d mat e l t true ng^n qua van DIVlC v l mat eat dUdi mui Uc. Cf mat cat true ngan qua van DMC dd khac biet trung binh la Idn nhat. DUdng kinh 16 TLN do tren SATQTN d mat cat 4 budng t i m khdng ed sU khae biet ed y nghTa so vdi k i t q u i do tren SATQTQ (p>0,05), k i t q u i nay cung phu hpp vdi tac gia Nguyen L l n Hieu [1].
Dudng kfnh 16 TLN do t r i n SATQTN nhd hdn dudng kinh 16 TLN d o bang bdng khi thdng t i m . Khae b i i t ed y nghla thdng k i {p<0,05). Mat eat true ngan qua van DMC dp khIe biet trung binh Idn nhat (trung binh dudng kinh 16 TLN d o d mat e^t nay nhd 17
JOURNALOF 108-CLINICALMEDICINE AND PHARMACY Vo[.12-N''4/2017
hon dudng kinh e I n g bdng khi thdng tim 7,23mm, c h i n h lech 26,8%). 6 mat cat 4 budng dp khae biet trung binh nhd nhat.
DUdng kinh trung blnh eua 16 TLN t r i n SATQTQ nhd hpn dUdng kinh trung binh cCia 16 TLN do khi cang bdng nhung dp khIe biet trung binh gliJfa do bang phuong p h I p SATQTQ vdi ket q u i thu dupe trong qua trinh thdng tim thi nhd hdn nhieu so vdi dp khac biet trung binh giUa do bang phuong phap SATQTN vdi thdng tim.
V l y cd the nhan thay tren SATQTN mat eat 4 budng tim eho k i t q u i s i t vdi k^t q u i SATQTQ, vdi ket q u i thdng tim so vdi eae mat eat edn lai.
4.3. I\/I6i tuang quan giUfa ket qua SATQTN, SATQTQ vdi thong tim
Tuang quan gida dUdng kinh 16 TLN do trin SATQTN vdi ket qud thong tim
Ludn ed mdi tucfng quan tuyen tinh giUa dudng kfnh 16 TLN do t r i n c l e mat eat t r i n SATQTN vdi k i t q u i thdng tim nhung d eae mUe dp khac nhau. Ket qua d mat cat bdn budng tim tren SATQTN tuong quan tuyen tfnh chat che nhat vdi thdng tim, s i t vdi ket qua thdng tim nhat, sU c h i n h lech eung ft hpn so vdi eac mat eat edn lai. Mat eat true ng^n qua van DMC (SATQTN) cung cho ket q u i tuong quan tuyen tfnh r^t chat che vdi thdng tim (r > 0,7) nhung v I n chenh lech dang ke vdi ket q u i thdng tim. Mat eat dUdi mui Uc cho ket q u i tuong quan tuyen tfnh kha chat che vdi thdng tim (r < 0,7).
Su chenh lech d mat eat nay la nhieu hon vdi he sd tuong quan r nhd hon so vdi eae mat c^t khae. Mdt so t i e gia khIe: Faletra F, Chen C eung nhan thay r i n g kfch thUde 16 TLN tren s i i u I m deu nhd hOn kfch thudc udc tfnh eua phau t h u l t vien [5], [7].
Tuang quan gida dUdng kinh Id TLN do trin SATQTQ vdi ket qud thdng tim
Dudng kfnh 16 TLN do t r i n SATQTQ tUOng quan tuyen tfnh chat e h i nhat vdi k i t qua thu dupe khi do bang bdng t r i n thdng tim, ket qua thu dupe kha sat vdi ket q u i thdng tim, sU chenh lech it hon so vdi khi do d eac mat cat khac nhau t r i n SATQTN. Tac gia Durongpisitkul K va cdng sU trong n g h i i n eUu eua minh eung nhan thay ket qua dUdng kfnh 16 TLN do tren SATQTQ tuong quan rat chat che vdi ket q u i do bang bdng khi thdng tim [5], [6].
SATQTN va SATQTQ ho t r p l l n nhau va ddng vai trd quan trpng trong viec danh gia cac tdn thuong eua TLN 16 thU hai. SATQTQ la phuong phap cho hinh I n h rd net, danh gia chfnh xae hon kieh thi/dc 16 thdng so vdi SATQTN. DUdng kinh 16 TLN do d cac mat eat t r i n SATQTN va SATQTQ ed mdi tuong quan tuyen tinh t h u I n rat chat vdi ket q u i thu dupc trong q u i trinh thdng t i m .
Tai lieu t h a m khcio
1. Nguyen Lan Hieu (2008) Wg/i/^/ioiU dp dung phi/ong phdp bit 16 thdng liin nhi qua da bang dung cu Amplatzer. Luan an t i i n sy y hoc. Dai hpc Y Ha Noi.
2. Aear P, Dulac Y, Roux D, Rouge P, Duterque D, Aggoun Y (2003) Comparison of transthoracic and transesophageal three-dimensional echocardiography for assessment of atrial septal defect diameter in children. Am J Cardiol 91 (4): 500-502.
3. Chen C, Krem P et al (1987) Usefulness of anatomic parametes derived from two - dimensional echocardiography for estimating magnitude ofleft- to - right shunt in patients with atrial septal defed.
Clin Cardiol 10(6): 316-402.
4. Chiang CW, Lee YS, Hsieh MZ, Fun-Chung (19B5) Early postoperative echocardiographic studies of atrial septal defect Japsnese Heart Journal 26(3);
391-402.
5. De Dios Ana Maria S, Granja M, Damsky BJ, Trentacoste L, Zarlenga B, Kreutzer E, Ackerman J, Fischman E, Flores E, Orence V (2004) Follow-up in closing of atrial septal defect by catheterism with transesophageal echocardiography (TEE) guidance.
Echocardiography 21(2): 213.
6. Durongpisitkul K, Tang NL, Soongswang i Laohaprasitiporn D, Nanal A (2004) Predictors ol successful transcatherter closure of atrial septal defect by cardiac magnetic resonance imaging.
PediatrCardiol 25:124-130.
7 Faletra F, Searpini S et al (1991) Color Doppfe echocardiographic assessment of atrial septal defeo size: Correlation with surgical measurements. J An' Soc eehocardiogr 4(5): 429-434.
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