JOURNAL OF 108 - CLINICAL MEDICINE A N D PHARMACY Vol.12 - N'S/IOI?
Danh gia kSt qua phlu thuat sua van hai la trong benh van tim thoai hoa
The result evaluation of valve repair for degenerative mitral valve disease
Le Quang Thihi*, Nguyen Dire Hien*, *Benh vien Trung ucmgHui Nguyen XuSn Hung*, Tr5n Tbanh Binh** *'*Benh vien Qudn y 103
Muc tiiu: Oanh gia ket qua dieu tri phau thuat sda van hai I I do benh van tim t h o l i hoa tai Trung tam Tim mach - Benh vien Trung uong Hue. Doi tugng vd phUang phdp: Mau nghien cdu gom 41 benh nhan duoc chan doan hdvan hai la do t h o l i hda va dupc dieu trj phau t h u l t sda van hai I I tai Trung t i m Tim mach - Benh vien Trung dOng H u l t d t h i n g 12-2013 den t h i n g 8 - 2015./Cef qud;Tu6i trung binh 39,5 ± 15,9 tuoi. Mdc dp hdvan hai la 3/4 chiem 58,5%, hd4/4chiem41,5%.T6n thUPng thudng gap la sa la van, chiem 92,7%. CIc ky thuat sda van: Dat vdng van nhan tao (82,9%), cat v l khiu mo van (39%), dong c h i l l van (19,5%), ddng mep van (17,1%). K i t q u i sau mo: Hdvan hai la < 1/4 chiem 82,5%, phan suat tdng mau trung binh tang l^n 60 ± 6,4% (so vdi trUde md, p<0,05). Biin chdng sau md: Chly mau (2,4%), tran djch mang ngoai tim (14,6%), t d vong (0%). Kit ludn: Phau thuat sda van hai la d i l u trj benh van tim t h o l i hda la phuong p h I p d i l u trj hi^u q u i eho k i t q u i khi quan.
Tdkhda: Sda van hai I I , benh van tim thoai hda.
Summary
Objective: Evaluate the outcomes of degenerative mitral valve disease at the Cardiovascular Center of Hue Central Hospital. Subject and method: 41 patients, diagnosed with degenerative mitral valve disease and treated by valve repair surgery at Hue Central Hospital from December 2013 to August 2015.
Result: Mean age was 39.5 + 15.9 yrs. The grades of mitral valve regurgitation: Grade 3/4 accounted for 58.5%, grade 4/4 accounted for 41.5%. Common damage of mitral valve regurgitation was valve prolapse, accounting for 92.7%. Valve repair techniques included inserting artificial valve (82.9%), cutting and sewing valve tissue (39%), closing and chopping valve leaves (19.5%), and dosing valve edges (17.1%). Postoperatively, the mitral valve regurgitation grade of s 1/4 accounted for 82.5%, and the average ejection fraction (EF) increased to 60 ± 6.4% (compared to preoperative, p<0.05). Some postoperative complications were bleeding (2.4%) and pericardial effusion (14.6%); no mortality was seen. Conclusion: Valve repair surgery is effective method in treatment of degenerative mitral valve disease with satisfactory results.
Keywords: Valve repair, degenerative mitral valve disease.
1 . Oat van de nguyen nhan gay ra HoHL, nhung cd the chia thanh Hd van hai la (HoHL) x l y ra khi mau c h l y t d that ^ " ^ ^ " ^ " 9 ^ ^ ^ " " ^ ^ " ' ' ^ ' " ^ '^ '^^ ^ ^ " ^ * " ^ ^^''"
trai v l nhT t r l i trong thdi ky tam t h u . Cd nhieu ' ^ ^ " ' ' ' ^ " ^ * ' ^ ^ ^ ° " 9 ^'''^'^ ^ ^ ^ ^^ ' ' ^ " ^ ^ ' " *""
t h o l i hda [5]. Benh ly van tim t h o l i hda I I nguyen nhan ehd yeu dan den t h o l i hda van tim, anh hUdng
Ngdy nhdn bdi- 28/11/2016, ngdy chap nhdn ddng: 08/12/2016 khoIng 4% din SO, ting len d nhdm ngddi cao tu^i.
Ngum phdn hSi: Trdn Thanh Binh. g^^^ ,y ^3^ hai 11 do tholi hda chiem khoing 2%
Email [email protected] - Benh vien Qudny 103 84
TAP CHlYDl/OC LAM SANG 108 Tap12-S6 5/2017
d i n sd [4], ve lau dai ed t h l gay bien doi chdc nang tim n g h i l m trpng va c l e nguy eo t i m mach khac.
B6nh t i i n trien t d t d , g l y ra tinh trang ton t h d o n g ele I I van va bp m I y dddi van, bao gdm c l t o n thuong gian h o l e ddt day chang. Viec dieu t n ndi khoa suy tim do HoHL da ddpc chuan hda: Sd dung thudc giam hau tai (dc e h l men chuyen, hydralazine) dupe sd dung dau t i i n , ed the diing them ldi tieu hoac digitalis. Tuy nhi&n, theo Wisenbaugh T, dieu t n ndi khoa du bang dc che men chuyen khdng g i l m ddpc tien trien eua benh. Do do tot nhat van I I phau t h u l t sda van h o l e thay van.
Trong dieu trj phau t h u l t , phau t h u l t thay van hai I I cho d i n nay van la mpt phdong phap d i l u trj hieu q u i cho cac trudng hop ton thddng van hai I I da qua nang. Tuy nhien, phau thuat sda van cd nhieu du diem hon so vdi thay van nhan tao, n h d I I b i o ton duoc chdc nang t h i t t r l i , t r i n h dugc t i e dung phu do p h l i dung thuoc chdng ddng, t>' I I t d vong h l u p h l u thap, b l n h nhan on djnh l l u dai sau mo [3], [6], [7], [83- t)a ed mpt vai tac gia trong nude nghien edu ve phau thuat sda van hai I I ndi ehung eung nhu tren mpt sd ddi tdpng ndi rleng, nhdng chua cd t i e g i l n I o tai Viet Nam nghien cdu va de cap ve van de sda van hai I I do benh van tim t h o l i hda. Chinh vi vay, nhdm n g h i i n edu chdng tdi t i i n hanh nghien cdu de tai t r i n vdi muc tieu nham Ddnh gid kit qud dieu tri phau thudt sda van hai Id do binh van tim thodi hda tgi Trung tdm Tim mgch - Binh viin Trung uang Hue.
2. Doi tdgrng va phaong phap 2.1. Doi tugng
Nghien cdu 41 benh n h i n dddc chan doan hd van hai I I do thoai hda va ddpc dieu trj phau t h u l t sda van hai la tai Trung t i m Tim mach - Benh vien Trung uong Hue t d t h i n g 12 - 2013 den t h i n g 8 - 2015.
2.1.7. Tiiu chuan lUa chon
Bdnh nhan ddOc c h i n doan h d van hai la do t h o l i hda trUde md (dUa t r i n k i t q u i sieu I m tim) v l trong mo (dUa tren danh g i l ton thdong phat hien trong mo).
Phdong p h I p d i l u trj: Sda van hai la.
2.1.2. Tiiu chuan logi trd
B l n h nhan duoc chan doan h d van hai la nguyen nhcin do thap tim (tien sd ed viem khdp, x l c djnh cd y l u t d thap...).
Phuong p h I p dieu tri: Thay van hai I I . 2.2. PhWcmg phdp
2.2.1.Thiitki
Nghidn edu hdi edu, md t l eat ngang.
Benh nhan dugc kham, chan d o l n v l dieu trj phau t h u l t tai Trung tam Tim mach, Bdnh vi^n Trung uong H u l .
2.2.2. Ngi dung
Mpt sd dac diem chung: Tudi, gidi, mdc dp suy tim theo NYHA...
£)ac diem sieu am t i m : Tat e l benh nhan deu duoc lam sieu am tim: M-mode, 2D, Doppler qua t h l n h ngdc (trUde v l sau mo), s i l u am qua thUc q u I n (trong md), nham xac djnh kich thddc buong that t r l i , d i e diem ton thuong bd m I y van hai I I , d e ton thddng ket hop.
Cac ky t h u l t sda van hai la.
D i n h gia thdi gian phau t h u l t (thdi gian kep dpng mach ehO, thdi gian chay tuan hoan n g o l i eo the), d e bien chdng sau mo.
Phuong phap phau t h u l t : Phau t h u l t ddpc thUe hien qua dudng m d dpc gida xdong dc vdi t u i n hoan n g o l i eo the, ha than nhiet 32°C. Bio v l ca tim bang dung dich m l u I m xudi ddng, dung djch b i o ve CP tim ddpc truyen nhac lai sau moi 15 phut. T i l p can van hai la qua dddng m d nhT t r l i h o l e vach lien nhT. Oanh g i l ton thUOng van hai I I trong md, thde hien d c ky thuat sda van hai I I : Odng mep van, chuyen day chang, thu ngan d l y chang, c i t va k h I u mo van, ddng che I I van, dat vdng van n h i n tao. Sda van 3 la (khi hd van ba I I t d 2 - 2,5/4 t r d ISn) bang Bandalette h o l e theo phdPng p h I p De Vega.
Phdong p h I p thong ke va x d ly so lieu: So liSu dugc thong ke v l x d ly bang phan m I m SPSS for Window phien ban 13.0.
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3. Ket q u i Bdng 5. Dac diem t 6 n thUcfng van hai la
BSng 1. Mot so dac diem chung Dac diem chung
Tuoi trung binh Cao nliat Tiiap nhat Nam/Na
NYHA
ECG 1 II III Nhjp xoang Rung nhT
Thong so 39,5 ±15,9 (tudi)
73 (tuoi) 14 (tuoi) 48,8%/51,2%
2,4%
51,2%
46,3%
85,4%
14,6%
Bang 2. IVIdt so dac diem that trai tren sieu am trUdc mo
Kich thudc buong that trai (mm)
Tam thu T i m truong Phan suat tong mau (%)
Trung binh 40,3 ± 6,0 57,1 + 6,2 54,7 ± 5,6
Nho nhat 29 45 45
Ldn nhat 54 73 65 Bang 3. Mot so dac diem van hai la
sieu am tim tnidc md Dac diem
Kfch thudc vdng van Op dai la trudc Mdc do hd van hai I I
3/4 4/4
Thong so 36,5 ±4,9 (mm) 28,0+ 2,8 (mm) 58,5 (%) 41,5 (%) Bing 4. IVIot s6 ton thiTOng k^t hop Ton thuong
Hdvan bala
1/4 2/4 3/4 Ap tuc dpng mach phdi Huyet khdi nhitr^i
Thong so 9,8 (%) 26,8 (%) 63,4 (%) 35,8±10,7mmHg
2,4%
Loai ton thuong Dan vong van Co che la van Sa la van hai la
La trade La sau D i ^ day chang
So luong 13
2 23 15 12
TJI6%
31,7 4,9 56,1 36,6 29,3 BSnge .Ky thuat sCr:
KTthuatsCravan Dong mep van Mep trade Mep sau Chuyen cordage Thu ngSn day chang C^t va khau mo van Dong che la van Dat vong van nhan tao
C3 vong van 26 28 30 32 Kich thudc vong van trung blnh
van hai la So iifong
7 4 3 4 4 16 8 34 6 13 14 1
28,6 ±
i
TJISWll 17,1 S 9,8 '' 7,3 '' 9,8 9,8 39,0 19,5 82,9 14,6 31,7 34,1 2,4 1,6 Bitng 7. Ky thuat s^a van ba la phdi hop
Sda van 3 la phdi hpp Bandalette (tang cUdng vdng van b i n g dai m I n g tim) De Vega
SdlUtfng 7
6
1
•rmnM 17,0 J i
J
14,6 . 2,4
f'
BSng 8. ThcTi gian phau thuat (phtit) Thdi gian
phau thuat Thdi gian tuan h o l n ngoai cothe Thdi gian kep dong mach ehd
Trung binh 77,4 ±21,1
48,9 ±15,5 NgSn nhat 37
20 Dal nhat 138
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TAP CHl Y Dl/pC LAM SANG 108 Tap 12 - So 5/2017
Bang 9. Mot sd chi sd sieu am tim trade, trong va sau phau thuat
Mac do hdvan hai la
0/4 1/4 2/4 3/4 4/4 Dien tich md van (cm^) Phan suat tong mau trung binh (%) Dudng kfnh that trai tam trUdng (mm)
Dudng kfnh that trai tam thu (mm) PAPS (mmHg)
TrUdc mo
58,5 (%) 41,5 (%)
54,7 ± 5,6 57,1 ± 6,2 40,3 ± 6,0 35,8 ±10,7
Trong mo 46,3 (%) 34,1 (%) 19,5(%)
2,56 ±0,34 54,5 ± 6,6
Sau mo 40,0 (%) 42,5 (%) 17,5(%)
2,51 ± 0,35 60 ±6,4 45,8 ±4,3 30,9 ±4,2 25,6 ±1,7
P
<0,05
<0,05
<0,05
<0,05
Bang 10. Cac bien chihig sau md Bien chihig
Chay mau sau mo Tran dich mang tim Tavong Nhiem trung vet mo
So iuong 1 6 0 0
Tan suat (%) 2,4 14,6 0,0 0,0 4. Ban luan
4.1. Ve dgc diem chung cua nhdm benh nghien cvtu
Tudi trung blnh eua nhdm benh la 39,5 ± 15,9 (tuoi), khdng cd su khac biet ve gidi tinh trong nhdm benh nghien cdu. Khi vao vien, benh nhan ddpc chan doan va p h l n loai d e thUPng ton van hai la dUa tren phan loai eua A. Carpentier [2]:
Type 1 - ed ddng binh thudng cCia d e I I van, dan vdng van h o l e bi thung I I van;
Type II - sa la van do thieu day chang, ddt hoac keo dai d l y chang hay eo nhu;
Type 111 - han che cd dpng d c I I van h o l e bp may dudi van.
V l thdi diem phau thuat, tUPng t u nhu tac g i l Vahanian A va tac g i l Bonow RO [1], [9], chung tdi chi dinh phau thuat cho nhdng benh nhan ed trieu chdng suy t i m , chdc nang that trai giam, that trai gian, rung nhT tien trien h o l e tang ap dpng mach
phoi. Trong nhdm benh nhan nghien edu cua chung tdi, cd tdi 40 trudng hop (97,6%) NYHA II - III, rung nhT 6 trudng hop (14,6%), phan suat t d n g mau that t r l i trung binh la 54,7 ± 5,6%, ap Idc dpng mach phoi trung blnh 35,8 ± 10,7mmHg.
4.2.Veky thuat phau thuat
Cae ky t h u l t sda van hai I I kinh dien cCia A.
Carpentier cdng ddpc chung toi ap dung trong q u i trinh d i l u t n [2], tuy nhien, ddi vdi d e ton thuong sa la van sau ehung tdi sd dung ky t h u l t cat hlnh tam g i l e v l t d giac (theo kinh dien) d la sau. Sau khi ddpc cat hlnh tam g i l c d n vdi day I I bd tU do cua la van v l dinh tam g i l e quay v l phia vdng van, md la van se dupe k h I u lai vdi ehl 5/0, k h I u vat hai lucft de dam b i o tinh ehae chan. Chung tdi thde hien tren 16 trudng hpp (39%). Ky t h u l t nay k h i ddn gian, de thuc hien, b i o tdn ddpc mo la van tot, d i m b i o dupe tinh on djnh lau d l i cua k i t q u i sda van [6], [7].
Ky thuat ddng mep van (ky thuat Alfieri) d vi trf A l P l , A3P3 eung ddpc chung tdi thUe hien tren 7 trddng hpp (17,1 %). Dung chi 5/0 khau dinh vung sa la van trUdc vdi la van sau d v| trf ddi dien tuong xdng, dung dddng khau vat 2 lucft. Oay la mpt ky thuat ddn gian, de thuc hien, kiem tra sau mo cho den nay eho k i t qua tdt, khdng hep van va chi cdn hd nhe.
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JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol.12-N'S/SOI?
N g o l i ra chung tdi thUe hien ky thuat c h u y i n d l y chang 4 trddng hdp (9,8%), thu ngan day chang 4 trudng hpp (9,8%). Trong nghien edu chung tdi khdng thde hi^n ky t h u l t Edge-to-Edge nham tranh nguy ca hep van hai I I sau sda van.
Viec sd dung vdng van n h i n tao trong sda van hai I I n h I m giup lay lai hlnh dang vdng van da bj bien dang, t h u hep vdng van bj d i n ve kieh thddc blnh thudng, t i n g dien tiep xue hai la van v l ngan ngda tinh trang dan vdng van tien trien ve sau [3], [4]. Chung tdi da sd dung vong van n h i n tao kieu hd va nda cdng cho 34/41 trudng hop (82,9%), nham dam b i o tinh dn djnh k i t q u i sda chda. Qua theo ddi den nay, tinh trang van hai la van on djnh chda thay hd van tai phat cung nhd bien chdng hep van x u l t hien.
Tai Trung t i m Tim mach - Benh vien Trung Udng Hue, trong qua trinh phau t h u l t chung tdi b i o ve CO tim bang dung djch m l u am va ed ha than nhiet 32°C. Thdi gian cap dpng mach chu trung blnh 48,9 ± 15,5 phut, t h d i gian chay m I y trung blnh 77,4 ±21,1 phdt.
4.3. Vi kit qua phdu thuat
Nghien edu cho thay sd c l i thien rd ret va cd y nghla ve d c trieu chdng ngay sau md eung n h d trong q u i trinh theo ddi so vdi Idc trddc mo (Bang 9,10). Khdng cd trddng hpp n I o t d vong benh vien, X^ I I b i i n chdng phau t h u l t thap bao gom: 1 trudng hop c h l y mau can md lai (2,4%); 6 trudng hpp t r i n dich mang ngoai t i m (14,6%), khdng ed nhiem trung v l t md. Kiem tra trudc khi ra vien eho thay 82,5% trddng hpp ehi cdn HoHL nhe hoac khong d i n g ke. Cdn lai I I HoHL mde do vda, khdng ed trudng hpp nao HoHL nang va rat nang. Khdng cd hep van hai I I , vdi dien tich m d van trung binh sau mo la 2,51 ± 0,35em'.
Sau mo chdc nang that trai ddpc d i thien.
Phln suat t d n g mau that t r l i t i n g t d 54,7 ± 5,6%
trddc m d l l n 60 ± 6,4% sau mo. Kfch thudc budng that t r l i eung thu nho lai tren c l hai thi tam thu va tam trdong. N g o l i ra, ap Idc dpng mach phdi cung giam xudng, t d 35,8 ± 10,7mmHg trUde md xudng cdn 25,6 ± l,7mmHg sau mo.
5. Ket luan
Phau thuat sda van hai la dieu trj b l n h van tim t h o l i hda I I phdong p h I p d i l u trj hieu q u i cholc^
q u i k h i quan. Tuy nhien, do thdi gian nghien ciiu eon ngan, sd lUpng benh n h i n nghien cdu cdn chi/a n h i l u n I n can p h l i nghien cdu them nda de co the ed k i t q u i lau d l i tren b l n h nhan.
Tai lieu tham k h i o
1. Bonow RO et al (2008) Focused update incorporated into the ACC/AHA 2006 guidelines for tt\e management of patients with valvular heart disease:
A report of the American College of Cardiology/American Heart Association TaskForceon Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease).} Am Coli Cardiol 52:1-142.
2. Carpentier A, Brizard C (2006) Congenital malformation of the mitral valve in surgery for congenital heart defect John Wiley&Sons, Ltd:
England: 573-590.
3 Dan Spiegelstein et ai (2010) Midterm results of mitral valve repair: Closed versus open annuloplasty ring. Ann thorae surg 90:489-496.
4. Enriquez-Sarano M, Akins CW, Vahanian A (2009) Mitral regurgitation. Lancet 373:1382-1394.
5. Giovanni BP, Francesco FF, Giuseppe V,Tiziano M (2010) Mitral regurgitation. SwissMedWkly 140(3- 4): 36-43.
6. Kristopher MG, Tomislav M, Marc GA (2009) Triangular resection for posterior mitral prolapse:
Rationale for a simpler repair. The journal of heart valve diseasel8:119-121.
7. Leo MG et al (2007) A simplified approach to degenerative disease: Triangular resection of the mitral valve. Ann thorae surg 83:1658-1665.
8. Nguyen Van Phan (2008) Tong quan diiu trj ngogi khoa binh iy van tim. Tap chf Y hpc Viet Nam, so 2.
9 Vahanian A et dl (2007) Guidelines on the management of valvular heart disease: The taskforce on the management of valvular heart disease of the European society of cardiology. Eur HeartJ 28: 230-268.
