JOURNAL OF 108 - CLINICAL MEDICINE A N D PHARIVIACY Vol.12 - N°4/2017
Tinh trang hoat dong cua cac van tim o^ benh nhan tir chung Fallot nguoi Ion duffc phau thuat sua chua toan bo
The functional status of heart valves in adult tetralogy of Fallot patients underwent complete surgical repair
Dinh Tien Dung*, * B^nh vipn Tim Hd Noi Ngo Van Hoang Linh** ** Hgc vien Qudny Tom tSt
Muc tiiu: Danh gia tinh trang boat ddng chUe nang eCia ele van tim t r i n b i n h nhan tU chUng Fallot ngudi tdn dupcmosUachUa toan bp. Do/fupngvap/iupng p/jdp; Nghiin eUu m d t l tren 95 benh nhan til chUng Fallot ngUdI Idn dupe md sUa ehUa toan bp tai Vien tim H I Not tU t h i n g 4/2009 d i n t h i n g 12/2015.
Ket qud; Tudi trung binh la 24,4 ± 8,1. TrUdc md khdng cd tinh trang hep cle van tim trU hep van/vdng van ddng mach phdi v l 91,6% cd hd nhe van ba I I . Ngay sau md cac van tim deu hoat dpng binh thUdng, chi cd 1,1% edn hdvan b a l l nhe. Tuy nhien sau m o i t h i n g b i t dau xuat hien tinh trang hd eae van tim va den 36 thang sau md thIy: 53,1% hd van ba I I , 28,6% hd van hai la, 40,8% hd ddng mach chu, dac biit co tdi 100% hd van dpng mach phdi. Kef/uan; Sau md sUa ehUa toan bp tU eh Ung Fallot ngudi Idn cd t y ' l i kha cao hd ele van tim, nhat la hd van dpng maeh phoi. Day la van di can duoc t i i p tuc nghiin cUu, nhat la viec chi djnh thay van ddng maeh phoi trong md sda chUa toan bp tUchUng Fallot ngudi Idn.
Tdkhda: Binh nhan tU chUng Fallot ngudi Idn, tinh trang hoat ddng cua cae van tim, phau thuat sUa chUa toan bp.
Summary
Objective: To evaluate the functional status of heart valves in adult tetralogy of Fallot patients underwent complete surgical repair. Subject and method: Descriptive study w/as performed on 95 adults with tetralogy of Fallot underwent complete surgical repair in Hanoi Heart Hospital from April 2009 to December 2015. Result Mean age was 24.4 ± 8.1. Before operation, there was no stenosis of heart valves except pulmonary valve/anulus and tricuspid regurgitation in 91.6% of patients. Early after operation, no heart valve disfunction was seen but mild tricuspid regurgitation (1.1%). 1 month postoperatively, the regurgitation of heart valves began to rise, and up to 36 months after repair, 53.1% had tricuspid regurgitation, 28.6% had mitral regurgitation, 40.8% had aortic regurgitation, and especially 100% had pulmonary regurgitation, Conclusion: There were relatively high rates of regurgitation of heart valves after complete surgical repair of adult tetralogy of Fallot patients, especially the pulmonary regurgitation. More studies are needed, especially the indication for pulmonary valve replacement in complete surgical repair of adult tetralogy of Fallot patients.
Keywords: Adult tetralogy of Fallot patient, functional status of heart valves, complete surgical repair oftetralogy of Fallot.
Ngdy nhgn bdi. 04/01/2017. ngdy ckdp nhdn ddng: 17/02/2017
Nguaiphdn hoi: Dinh Tiin DUng, Email: txhungl08@gmail com - Benh vi^n Tim Hd Noi
TAP CHl Y DUOC LAM SANG 108 Tap 12-564/2017
I . D a t v a n d l
TU chUng Fallot (TCF) la benh tim bI'm sinh, t^ le gap khoing 3 - 5/10.000 tre sinh ra cdn sdng [1], [4], [10]. Bdn bat thudng dIetrUng eua benh la: Thdng lien that rdng; hep dUdng thoat that p h l i ; ddng mach chCi cUdi len vach l i i n that v l phi dai that phai. NhUng bat thudng g i l i phau thUcthe nhuvay I n h hUdng nang n i d^n hoat ddng chUe nang eua ele van tim, nhat la trong ele trudng hpp mang benh keo dai do khdng dupe dieu trj phau thuat siJa ehUa toan bd sdm fTCF ngudi Idn). Tmh trang nay I n h hudng khdng nhd den viee chan doan cung n h u ket q u i d i i u trj phau t h u l t sUa chUa toan bd TCF ngUdi 1 ^ .
Xuat p h l t tU tinh hlnh t r i n , chung tdi tien hanh n g h i i n cUu nay nham Ddnh gid chi tiet tinh trgng hogt ddng cua cdc van tim trudc vd sau mo sda chda todn bd TCF ngudi Idn.
2. Doi tupng va phUimg phap 2.1. Ddi tugng
Gdm 95 benh n h i n (BN) (46 nam, 39 nU) dugc chin doan la TCF, tudi t r i n 15, duae phau t h u l t sCfa chUa toan bd TCF tai Benh v i i n Tim Ha Ndi tU t h i n g 4 nam 2009 den t h i n g 12 nam 2015.
2.2. Phuang phdp Nghien eUu m d t l , tien cUu.
P h l n tich cae thdng tin ve tinh trang boat ddng ehUe nang eOa cae van tim thdng qua t h I m k h I m s i i u I m tim trudc, ngay sau md (trude khi ra v i i n ) , sau md 6 t h i n g , 12 t h i n g , 24 t h i n g va 36 thang.
Qua dd rut ra nhdng nhan x i t v i tinh trang boat ddng ehUe n l n g eua eac van tim d cac giai doan trudcvasau md.
2.3. Quan lyva xdly sdliiu
N h i p v l q u I n ly sd lieu bang phan mem MS Office Excel 2007, xii ly sd lieu bang phan mem IBM SPSS Statistics 20.0.
3. Ket qud
Bdng 1 . Dac di^m chung Cac trieu chumg lam sang
Gidi ti'nhi
Tuoi
Nam NO 1 5 - 1 9 t u 6 i 2 0 - 3 9 tuoi 4 0 - 5 9 tuoi Tuoi trung binh
So benh nhan 46 49
T > l e % ( 9 5 = 1 0 0 % ) 48,4 51,6
31 32,6 58 61,1 6 6,3
24,4±8,! 05-53) Nhdn xit €)a sd benh nhan (61,1%) d nhdm tudi 20 - 39 tudi. T^ l i nUtUong duang nam.
Bdng 2 . Tinh trang cac van tim tren sieu am tim trUdc md Cac bat thudng khac ve van tim
Hdvan ba la
Hd van dong mach chO Hdvan halla
1/4 2/4 3/4 1/4 2/4 1/4 Hep van hoac/va vonq van dong macli phoi
So benh nhan 61 24 5 20 3 13 47
T y l e % (95 = 100%)
64,2 25,3 5,3 21,1 3,2 13,7 49,5 Nhdn xet Cd tdi 94,8% sd b i n h nhan bj hd van ba la d eae mUc dp khae nhau. Ngoai hep van/vdng van dpng mach phdi khdng ed van tim nao khIe bj hep.
JOURNAL OF 108 - CUNICAL MEDICINE AND PHARMACY
Bdng 3. Cac ky thuat siia chita doi vdi cac van tim trong mo
Ky thuat sAa chOa doi vdi van tim Rach qua vong van dpng mach phoi - Lam mi^ng v^ xuyen vong van dpng mach phpi
Tao hinh van dpng mach phoi mpt la (monocusp) Khau cung c6 van ba la
Sira van hai la bj hd
So b§nh nhan
39 41 11 2
T J I 6 % (95 = 100%)
41,1 43,2 11,6 2,1 Nhdn xet Cd 43,2% benh nhan dugc tao hinh van ddng maeh phdi mdt I I . 11,6% dupe khau cCing ed van ba la (khau khep mep trUdc v I c h van ba la) d u phdng h d van ba I I ; 2,1 % dupe sUa van hai I I bj hd.
BSng 4. Ket qud sieu am tim Iciem tra d giai doan sorm sau md
Tinh trang cac van tim Hdvan ba la nhe
Hd hoac hep van hai la Hd hoac hep van dong mach chi!i Hd hoac hep van dpng mach phoi
So b4nh nhan 1 0 0 0
T J I c % (95 = 100%)
1,1 0 0 0
Bdng 5. Dien bien tinh trang her cac van tim or cac thdi gian sau mo
Thdi diem l(ham
Sau mo 1 thang Sau mo 6 thang Sau mo 12 thang Sau mo 24 thang Sau mo 36 thang
SfiBN Itham
95 (100%)
95 (100%)
86 (100%)
81 (100%)
49 (100%)
Tinh trang cac van tim HA3ia
1/4 2/4 76 19 (80,0%) (20,0%)
76 (80,0%)
37 45 (43,0%) (52,3%)
51 (63,0%)
26 (53,1%)
H d a i a 1/4 76 (80,0%)
76 (80,0%)
34 (39,5%)
24 (29,6%)
14 (28,6%)
Hddong mach chij 1/4 19 (20,0%)
19 (20,0%)
39 (45,3%)
20 (40,8%)
ild dong mach phoi 1/4 2/4 25 70 (26,3%) (73,7%)
34 61 (35,8%) (64,2%)
37 45 (43,0%) (52,3%)
39 42 (48,1%) (51,9%)
11 38 (22,4%) (77,6%) Nhdn xet: Sau mo 1 thang bat dau xuat hien hd cua cac van tim (100% h d ba la, 80% h d hai la, 20% W dpng mach chij (SMC) va 100% h d dong mach phoi (BMP)). Tinh trang tren tiep dien cho den sau mo 36 thang v I n thay: 53,1 % hd ba la, 28,6% hd hai ia, 40,8% hd DMC, dac biet co tdi 100% hd van BMP.
TAP CHf Y Dyjqc LAM SANG 108 Tapl2-S64/2017
NgaySM SMlth SM6th SM12th SM24tti SM36tti Hinh 1 . Dien bien tinh trang hd van ba la va van hai 11 theo thdi gian sau md
™ NgaySM SMlth SM61h SM121h SM24th SM36th Hinh 2. Dien bien tinh trang hd cle van BMP va DMC theo thdi gian sau md
4.1. Ddc diem chung
Lda fuD/:Tudi trung binh la 24,4 + 8,1 (15 - 53 tudi), nghia la 6 lUa tudi thanh n i i n t r i , ed eau true t h ^ lUe cua ngudi Idn ddng thdi cd tuoi b i n h TCF la "gia".
Gidi tinh: Ty le nam gan tUdng dUOng vdi nU (48,4% so vdi S1,6%). K i t q u i n l y eung tUdng tU nhu d h l u het eac nghien cUu ve b i n h TCF ndi ehung 6 trong nude^eung n h u t r e n the gidl [1], [2], [10]...
4.2. Tmh trgng cdc van tim trddc mo Cd 49,5% bj hep van va/hoac vdng van ddng maeh phdi (OMP) trong khi do chi thay cd h d ehU khdng ed trudng hpp nao hep d cae van t i m khIc.
Cu the la hau het benh nhan (94,7%) ed h d van ba la mUc dp tU nhe den n l n g , gan mpt phan t u sd benh i h i n (24,3%) cd h d van ddng mach ehu (BMC) mUe Jd nhe hoae vUa va 4,2% h d nhe van hai I I . Cd the ldi tinh trang cae van tim trude md la k h i dien hinh :ho b i n h TCF ndi chung, do la: Hep van/vdng van DMP k i m hd van ba la d e l e mUe dd khac nhau do j l l n that p h l i .
4.3. Cdc can thiep doi vdi van tim trong mo Rgch qua vdng van DMP vd Idm mii'ng vd xuyin vdng van DMP: Chung tdi chi djnh rach qua vdng van va m d rdng vdng van BMP bang mieng v l xuyen vdng van khi g i l trj Z vdng van < -2 hoac khi ngUng tuan hoan ngoai co t h i ' x l c djnh thay chenh I p tdi da that phai/BMP > SOmmHg. Cd 41,1% phai rach qua vong van OMP va lam mieng va x u y i n vdng van BMP de g i l i q u y i t tinh trang hep d van/vdng van OMP. T;^ le lam mieng va xuyen vdng van BMP nay nam d mUe trung binh so vdi cac nghien cUu trong nudc d TCF tre em: Cao hon so vdi n g h i i n eUu eua Nguyen Sinh H i i n (38,70%) [1] nhung thap hOn so vdi n g h i i n cUu eua Hoang Hiep va CS (67,69%) [2]
h o l e Le Quang ThUu (75,18%) [4]...
Cd the thay viec xU ly hep vdng van/van OMP trong n g h i i n cUu eua ehung tdi cung tuang tU nhU cae t i e g i l khac trong nudc d TCF tre em. Tuy n h i i n trong n g h i i n cUu ve phau t h u l t TCF ngUdi idn eua c l e t i c gia nude ngoai, viee ehi djnh thay van OMP eho c l e trUdng hpp vdng van/van DMP bj hep hay mat ehUe n l n g nang da dupe thUc hien ngay cang rdng rai: Christine H. Attenhofer Jost va CS d Mayo
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JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol.12-N°4/20I7
Clinic t r i n 52 b i n h n h i n TCF ngudi Idn (40 - 68 tudi) dupe md sUa chUa toan bd cd ty le thay van DMP la 19% [7], Fernando AA va CS (2004) tren 39 benh nhan TCF ngudi Idn ( 1 8 - 6 7 tudi) cd ty le thay van OMP trong md sUa chUa toan bp TCF I I 7,7% [9]... Ly do chinh eua xu hudng nay I I : Odi vdi cae trudng hpp vdng van/van BMP bi hep hay mat ehUe nang n l n g thi viee m d rpng vdng van bang m i i n g va xuyen vong van va/hole tao hlnh van OMP mdt la khdng dam bao ket q u i lau dai vi tinh trang bj h d van OMP ludn tien trien theo thdi gian sau md, nhanh ehdng dan tdi tinh trang p h l i md lai de thay van OMP. D l y eung la mdt van de can dUpe quan tam nhieu hon trong md sUa chUa toan bd TCF ngUdi Idn d nUde ta hien nay.
Tgo hlnh van DMP mot Id (monocusp): Chi djnh tao hinh van DMP mdt la (monocusp) khi vdng van OMP qua hep, phai rach qua vdng van OMP ve phia pheu that p h l i > 5mm hole khi phai c^t bd la van OMP bj mat ehUc nang nham dU phdng tinh trang hd DMP ngay sau mo. Cd 41 trudng hpp (43,2%) dupe tao hinh van DMP mdt I I . Ty' l i ed tao hinh van BMP mdt fa trong nghiin eUu cua ehiing tdi tuang duong vdi mpt sd nghien eUu khIc trong nude tren benh nhan TCF ndi ehung: Cua Nguyen Van Mao va CS la 50% [3], eua Nguyen HUu l/de va CS la 50% [5]...
Sda van ba Id: Cd 11 trudng hop (11,6%) dUpe khau CLing CO k h i p mep trUde vach van ba I I de dU phdng hd van ba I I sau md (vi mep trudc vIch van ba la thudng bj k i o gian nhieu bdi dung cu v i n van ba I I trong sudt thdi gian phau thuat). Trong phau thuat cle b i n h nhan TCF t r i em theo phuang p h I p khdng md that phai va diing dung eu ven van ba la, mdt sd t i e g i l cdn chCi trucmg khau eung ed khep mep trudc vIch van ba II cho t i t e l ele benh n h i n de dU phdng triet de tinh trang hd van ba la sau md [1 ].
Sda van hai Id: Cd 2 trudng hpp (2,1%) dupe khau sCra vdng van hai I I qua dudng m d vIeh lien nhi d ^ dieu ehlnh tinh trang hd van hai la. T^' l i ed sUa van hai I I bj hd trong nghien eUu nay cd phan cao hon so vdi mpt sd n g h i i n cUu trong nude dTCF t r i em: Cua Nguyen Sinh Hien la 0,64% [1], eua Nguyen Van Mao va CS la 1,6% [3]...
Trong n g h i i n cUu eCia ehung tdi khdng gap cac bat thudng t i m mach khae d mUc dp can p h l i xCftrf nhU: Hd OMC, tuan hoan ben nang...
4.4. Ket qua sieu am tim kiem tra tinh trgng cac van tim trddc khi ra vien
Kix qua kiem tra s i i u I m tim sau md (trudc khi ra vien) eho thay tinh trang hoat ddng ehUe nang eua ele van tim deu trong gidi ban binh thUdng: Cac van tim (van hai la, van OMC, van OMP) khdng bi hd hay hep, rieng van ba I I cd 1 trUdng hpp bj hdnhe (1,1%). N h U v l y nhin chung ket qua kiem tra siiu Sm tim trudc khi benh n h i n ra v i i n eho thay c l ve hinh thai va ehUe n l n g hoat dpng cCia tim deu d tinh trang g i n nhu binh thudng, dieu nay cd nghia la ve CO b i n viee phau thuat sCfa ehijfa toan bd TCF d nhdm b i n h n h i n n g h i i n cUu cCia ehung tdi da clat dupe y i u cau dieu trj.
4.5. Diin bien hogt dgng cOa cdc van tim theo thdi gian sau m6
Van ba id: Sau m d 1 t h i n g t y l i hd van ba la la 100% (80% h d mUc dp 1/4 va 20% hd mUc do 2/4), sau md 6 t h i n g la 80% (tat e l deu h d mUe do 1/4), sau m d 12 t h i n g la 95,3% (43,0% hd mUc dd 1/4 va 52,3% h d mUc dp 2/4), sau m d 24 t h i n g la 63,0% va sau md 36 t h i n g la 53,1% (tat ca deu hd mUc do 1/4). Nhu vay cd the ndi: Tinh trang hd van ba la ludn di kem vdi b i n h TCF c l trUde va sau md: Mac du ngay sau md ty ie hd van ba la ehi edn 1,1%
nhung sau md 1 t h i n g gan n h u toan bd b i n h nhan bat d i u cd tinh trang hd van ba I I , tinh trang nay keo dai eho den sau m d 12 t h i n g d dai da sd binh nhan (80 - 95,3%), sau dd cd g i l m dl nhUng den thdi gian sau md 36 t h i n g ty le nay van edn d hon mot nUa sd b i n h nhan (53,1 %).
Von hai Id: Ty le h d van hai la sau md 1 thing la 80%, sau m d 6 t h i n g la 80%, sau md 12 thing la 39,5%, sau md 24 t h i n g la 29,6% va sau md 36 thang I I 28,6% (tat ca deu hd mUe dp nhe). NhUvay, tinh trang h d van hai la bat d i u xuat h i i n sau m61 t h i n g d dai da sd b i n h nhan (80%), sau do c6 xu hudng g i l m : Sau md 12 thang ehi cdn d 39,5% va sau md 24 t h i n g d^n 36 t h i n g duy tri d t^ l i 29,6%
va 28,6%.
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TAP CHl Y DUOC LAM SANG 108 Tapl2-S6 4/2017
Van DMC: Jy le hd van OMC sau m d 1 thang la 20%, sau md 6 t h i n g la 20%, sau md 12 thang la 45,3%, sau md 24 t h i n g I I 0% va sau md 36 t h i n g la 40,8% (tat e l deu h d mUc dp nhe). Nhu vay tinh trang hd van OMC bat dau xuat hien sau md 1 t h i n g vdi ty' le 20% sd b i n h n h i n , sau d d ed xu hudng t i n g l i n d mUe 45,3% sau m d 12 t h i n g va 40,8% sau m d 36 thang.
Van DMP: Ty le h d van DMP trUdc m d va ngay sau md deu la 0%, tuy nhien ehi sau m d 1 t h i n g ty l i hd van DMP da la 100% (26,3% h d mUc dp 1/4 va 73,7% h d mUe dp 2/4), sau m d 6 t h i n g la 100%
(35,8% hd mUe dp 1 /4 va 64,2% h d mUc dp 2/4), sau md 12 thang la 95,3% (43,0% h d mUc dp 1/4 va 52,3% hd mUe dp 2/4), sau md 24 t h i n g la 100%
(48,1% hd mUe dp 1/4 va 51,9% h d mUc dp 2/4), va sau md 36 t h i n g ty l i hd van OMP la 100% (22,4%
hd mUc dp 1/4 v l 77,6% hd mUe dp 2/4). Cd the nhan thay mpt v I n di kha rd r i n g d day la: Tmh trang hd van OMP bat dau xuat h i i n sau md 1 t h i n g tren toan bd sd b i n h n h i n , sau dd t i i p tue duy tri va ed xu hudng tien trien theo thdi gian. O l y la mot van de can p h l i quan t i m nghien cUu tiep tue vdi sd luong b i n h nhan n g h i i n eUu nhieu ban de ed the cd nhufng ket luan va de xuat b i i n phap theo ddi va dieu tri phf] hpp.
Khuyen cao nam 2010 cua Hdi Tim Mach Viet Nam ve x U t r i benh t i m bam sinh d ngUdi Idn - Phan II cung ed nhan manh: "Van de phd bien nhat thudng gap d b i n h nhan trudng t h l n h sau phau t h u l t (TU chUng Fallot) la h d van BMP. Oieu nay thudng xuyen bj bd sdt qua t h I m kham lam s i n g vi am thdi thudng ngan, kin dao v l h d van BMP cQng thudng bi bd qua tren sieu am t i m " , khuyen e l o cung de nghj: "Khi phau thuat sUa chUa hoan toan diiigc thUe hien d ngUdi trudng thanh, thay van OMP cd the can thiet neu van OMP tU nhien khdng edn nguyin ven" [3].
Cd the nhan djnh chung ve tinh trang c l e van tim sau m d TCF la: Ngay sau mo hau h i t ele van t i m J i u hoat ddng hoan toan binh t h u d n g (ehi 1,1%
b i n h nhan ed hd van ba la mUc 66 nhe), tuy nhien sau md 1 thang b i t dau xuat h i i n tinh trang h d d cac mUe dp khac nhau vdi eae X')/ l i k h I e nhau cCia e l e van t i m , t r o n g d d ed 100% b i n h n h i n cd h d van ba la, 80% ed h d van hai la, 20% ed h d DMC va 100% ed h d DMP. Tmh trang h d eae van ndi t r i n tiep tue dien bien va eho den sau m d 36 t h i n g van thay t d n tai vdi cac t y l i k h I e nhau:
5 3 , 1 % ed h d van ba la, 28,6% ed h d van ha; la, 40,8% ed h d van OMC va d i e biet ed t d i 100% sd benh n h i n ed h d van OMP vdi 77,6% h d van BMP mUe dp 2/4. Day la t i n h trang can chu y n g h i i n cUu sau hpn nUa. Hang loat nhUng n g h i i n cUu gan day eua eae tae gia nude ngoai n h u Alessandro Frigiola (2006) [6], Elliot A Shinebourne (2006) [8], Kirklin JW [10]...deu nhan manh d i n t i n h trang h d van OMP t i i n tri^n sau md sUa chUa toan bp TCF va khuyen cao t r o n g m d sCfa chUa TCF nen ehi djnh thay van BMP khi t h l y van nay da bj t d n t h u a n g nang v l mat chUe n l n g , n h d dd ed t h i ' t r i n h dupc viec p h l i md lai de thay van DMP sau nay.
5. K4t luan
Qua n g h i i n eUu tinh trang hoat ddng cOa eac van tim d 95 b i n h nhan TCF ngudi Idn (tudi trung binh 24,4 ± 8,1} dugc phau thuat sUa ehUa TCF triet de tai Vien Tim Ha Npi ed the rut ra mdt sd k i t q u i sau:
TrUde md chi gap hep d van/vdng van dpng mach phdi, cdn d cac van tim khac khdng gap hep ma ehi thay cd the hd mUe dp nhe, trong dd h l u het b i n h n h i n (91,6%) cd h d nhe van ba I I . Ngay sau md, toan bd c l e van tim deu hoat ddng binh thudng, chi ed 1,1% bj h d n h e van ba I I .
Tuy nhien sau md 1 thang bat dau xuat hien tinh trang hd eua eac van tim (100% hd van ba I I , 80% h d van hai la, 20% hd dpng mach ehu va 100%
hd dpng maeh phdi). Tinh trang nay cd bien ddi theo thdi gian nhUng den sau m d 36 t h i n g van thay:
53,1% hd van ba la, 28,6% h d van hai la, 40,8% hd ddng mach ehu, d i e b i i t cd tdi 100% h d van OMP.
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Bay la van de can dupe tiep tue n g h i i n cUu, nhat la viec chi djnh thay van ddng mach phdi trong mo sUa ehUa toan bd TCF ngudi Idn.
Tai lieu tham khao
1 Nguyen Stnh Hien (2012) Nghiin cdu dieu trj phau thudt sda chda todn phdn binh td chdng Fallot.
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