TAP CHi V - Diroc H9COUAWSySO5-2014
THAY VAN BONG MACH CHCI B X N G VAN CO HOC SO NHO:
TAI SAO LL/A CHON VAN SORIN BICARBON SLIMLINE?
B$ng Hanh Son*; T j Hoang Tuan'; Trin Thanh Binh"
TOM TAT
Nghien cCru 73 b6nh nhan (BN) dupc dilu tn phlu thuat thay van ding mach chu (DMC) loai Sorin Bicarbon Slimline cd 17 va 19 tpi Binh vipn Tim HP Npi tCr 01 - 2009 din 12 - 2010.
Kit qua: ty Ip ter vong 2/73 BN (2J%). Chay mau sau mo 4/73 BN (6,4%), nhiim treing vet m i 3/73 BN (4,1%). Biln chCrng liSn quan den van nhan tpo. tan mau gSp 1/73 BN (1,4%), h i canh van nhan tao 3/73 BN (4,1%). NYHA sau phlu thuat 1 nSm- khing co BN nao NYHA III - IV.
Gia tn NYHA trung bInh sau phlu thuSt 1,3 ± 0,5 so vdi tru'dc phlu thupt 2,3 ± 0,5, khpc biet ci y nghTa thing kP (p < 0,001). Cherc nang thit trai thay dii khong c i y nghia thong k i so vpi trudc phlu thuat, trudc khi ra vipn va sau phlu thuat 1 nam.
Kit lupn: phlu thuPt thay van BMC bing van nhSn tao co hpc IP phiu thuSt thudng quy vi an toan vdi t} Ip td vong, t} IP bien chiing chung va ty Ip biln chCrng lipn quan den van nhan tao thip. Bat tuong hpp van - BN (PPM) la vin d l cln luu tam khi thay van BMC, dpc biet vdi van nhan tao s i nho. Van Sorin Bicartjon Slimline (SB Slimline) s i nho (si 17 vP 19) c i ty Ip PPM thap va kit qua lam sang sau phlu thupt tit nPn c i thi dupc ser dgng tit cho BN Vipt Nam.
• Ter khia: Thay van dpng mpch chu; Van co hpc; Van Sorin Bicarbon Slimline.
AORTIC VALVE REPLACEMENT BY SMALL-SIZED MECHANICAL VALVE: WHY IS SORIN
BICARBON SLIMLINE CHOSEN?
SUIVIMARY
73 patients were admitted for aortic valve replacement by Sorin Bicartionat Slimline at the size of 17 and 19 at Hanoi Heart Hospital from 01 - 2009 to 12 - 2010
Results: Mortality: 2/73 (2.7%), post-operative bleeding 4/73 (5.4%), infection 3/73 (4.1%), artificial valve-related compilations- hemolysis in 1/73 cases (1.4%), paravalvutar leak in 3/73 cases (4.1%). NYHA 1 year after operation, no NYHA 111 - IV patients. NYHA post-operative average value was 1.3 ± 0.5, compared to pre-operatlve value (2.3 ± 0.5), statistically significant difference (p < 0.001). Change of EF has no statistic meanings compared to the time prior to surgery, time of discharge and one-year post-operation.
Conclusions: Aortic valve replacement with mechanical prosthesis is normally safe witti low rate of mortality, general complications and complications related to artificial valve.
PPM should be taken into consideration in replacement of aortic valve especially, for small- sized one Because Sorin Bicarbon Slimline (17 and 19) small-sized valve has low PPM and positive post-operative clinical results, it Is good for Vietnamese patients.
* Key words: Valve replacement; Aortic; Mechanical valve; Sonn Bicarbon Slimline valve.
' Binh viin Tim Hi Nil
" Binh viin QuSn y 103
Ngu^i phin hdi (Corresponding): D^ng Hanh San ([email protected]) Ngiy nhan bii: 10/03/2014; Ngiy phin biin danh gii bii bio: 28/03/2014
Ngay bit bio duac ding: 20/04/2014 136
TAP CHi V - DVOC HOC OUAN SIT Sd' 5-2014 DAT VAN OE
B i t tuong hprp van - BN (Patient- Prosthesis IWismateh: PPIVI) vi ving van BMC nho la 2 v i n d l can quan tSm trong phlu thult thay van BMC. N l u khing giai quyit tript d l se d i n d i n tang chenh ap qua van, chpm hoi phgc cherc nang thit trai va anh hu'dng khing t i t d i n ket qua sdm cung nhu' k i t qua ldu dai sau phlu thuat. M|t trong nhung bipn phap giai quyit v i n d l vong van BMC nho la ser dgng van nhan tao co hpc vdi thiet ke hipn dpi giup cai thipn huyit ding. SB Slimline dup'c gidi thieu nam 1998 da co nhCrng cai tiln trong thiet ke giup tang dipn tich lo van va eai thipn huyit dOng qua van.
Hipn tup'ng PPM xay ra khi di^n tich van nhan tpo qua nhd so vdi dipn tieh co t h i cua BN. Thyc te cho thiy, hau h i t van nhan tao d i u khdng dpt dipn tich IS van ly terdng nher van t y nhien. PPM gay tang chinh ap qua van, nhung viec PPM CO anh hydng d i n qua trinh h i i phgc eo that trai hay khong thi v i n ehua thong nhit. Trong khi mot s l tac gia ghi nhan mii lien quan giCra PPM vdi qua trinh h i i phgc CO thit trai [1,4,5], mpt s6 khac cho rang PPM khing anh hudng d i n qua trinh nay cung nhu tien lupng bpnh [2].
Chijng t i i thyc hipn nghien cuu nay nham: Danh gia higu qua cua van SB Slimline doi veil BN thay van DMC so nho (17mmvi 19 mm).
BOI TUpNG VA PHUONG PHAP NGHliN cCru 1. f)di lu'p'ng nghien ci^u.
73 BN d i l u trj phau thu^t thay van DMC CO hpe cd 17 mm vi 19 mm tai Benh vipn Tim Ha N i l t y 01 - 2009 den 12-2010.
2. Phu'o'ng phap nghien cipu.
* Thiit ki nghien ciru:
- Nghien cuu hoi cuu, m i ta cat ngang.
- BN dupe kham va theo doi tai Khoa Kham bpnh, Bpnh vipn Tim Ha Npi bing kham lam sang va sieu am tim.
• NQI dung nghien ciru:
- Dpc dilm iam sang; gidi, tuli, di$n tieh CO the (BSA), phan dp suy tim theo NYHA (Hpi Tim New York).
- Sieu am tim' t i t ea BN d i u dupe sieu am tim' M - mode, 2D, Doppler. Moi BN dupc sieu am tim it nhit 2 Iln do 2 bae sy dpc lap (iam tpi eae thdi dilm: trudc phlu thu^t, sau phlu thupt, thyc hien trudc khi ra viin va 1 nam sau phlu thuat) there hien.
•'• Tinh khii lypng co thit trai theo cong thu'c Devereux:
LVM = 1,04 X [(LVDd + IVSD + PWD)»
-LVDd']-13,6.
+ ChI so khoi lupng co thit trai (LVM index);
LVM index = LVM/BSA.
+ Tieu chuin danh gia phi dpi co that trai: nam ^ 134 g/m^, nu 3:110 g/m^.
+ Chu'c nang thit trai dupc coi la binh thudng n l u EF £ 50%.
+ Danh gia hoat d i n g eua van co hpc dya tren hopt dpng cua canh van (binh thudng hay han ehe), hd canh van, chenh ap t i i da qua van, chenh ap trung binh qua van, eh! so dipn tich hCru dgng (EOA index = EOA/BSA).
- Danh gia cac biln chung lien quan d i n van nhan tao theo hudng d i n eua Hipp hpi Phiu thuat Long nguc Hoa Ky doi vdi ty Ip t y vong vi biln ehung sau phau thuat van tim.
137
TAP CHi y - DVOC HOC OUAN SIT S6' S-2014 - Phuong phap phlu thupt: thyc hipn phlu thuat qua dudng md dpc giO'a xuong ire vdi t u i n hoan ngoai co the va khing ha nhiet d i co t h i . Bao vp co tim bing dung dich mau I m xuii dong hope tn,rc flip qua Id d|ng mpch vanh. Truyen nhac Ipi dung dieh bao v« co tim sau m i l I'S phut. Van nhan tpo dype c i djnh bang cac mOi chO U khing cd miing d$m, ch!
su dung miing dpm n l u cd v i i hoa vong van. Hepann tTnh mpch lien tgc bat dau 6 gid sau m l n l u khong cd chay mau. Sau 48 gid, cho BN dIJng thuoc chong ding dydng uing (sintrom) nham dpt ch! s i INR:
2 - 3 n l u thay van DMC don thuan ho§c 2,5 - 3,5 nlu cd thay van hai la phii hpp.
- Phuong phap thing k i va xu iy s i lipu:
+ Thu thpp so lipu tpi thdi diem trydc khi ra vipn va sau 1 nam.
+ XCr ly s l li^u bang phin m i m Epi info 7.0.
KET QUA NGHIEN CLfU 1. Mpt s l d | c d i l m trirdc p h l u thuat.
S i BN trong nghien ceru; 73 BN; ty 1$
nam/nu: 22/51; t u l i trung binh;
44,7 ± 10,3 (16 - 63 tuoi); NYHA trung binh; 2,3 ± 0,5; EF > 50%/EF < 50%;
10/63 BN, dien tich co t h i trung binh.
1,41 ± 0 , 1 3 m ^
Bang 1: Chi s6 sieu am tim trudc mo va CO van Sorin sy dgng.
cHis6sieuAM TRUOC M6 Chenh ap toi da {mmHg) Chenh ap trung binh (mmHg)
CS VAN SORIN SCl DUNG 17
28,3 ±12,7
16,7 ±7.3 19 23,1 ±9,5
12,7 ±5,3
Vach lign \hit (mm) Thdnh sau thSt trdi (mm) Chi s6 kh6i cff th4t trdi
ChiJc nang th4t trai (EF:%)
11.0±2,0 12,8 ± 2,6
79,2 ± 30,4
61.8 ±5,6 12,1 ±2,5 137 ±2.9
96,2 ± 36,4 58,7 ± 8,5
2. eac d i l m p h i u t h u | t .
S l BN thay van 17 mm; 12 BN; s l BN thay van 19 mm: 61 BN; thay van DMC don thgin: 10 BN; thay van BMC + van hai la: 63 BN; tao hinh van ba la; 44 BN;
thdi gian cpp DMC trung binh: 87,3 ± 28,6 phut; thdi gian chpy may trung binh:
107,3 ± 33,5 phut.
* Ty lg tCr vong va bien chirng phiu thuit:
Trong nhdm nghien cuu cd 2 BN tii vong (2,7%). Nguyen nhan tir vong do suy tim va giam cung lypng tim. Chay mau sau phlu thuat: 4 BN (5,4%), nhiem treing v i t mo; 3BN(4,1%).
* Biin chirng lien quan din van nhan tgo:
Tan mau gap 1 BN (1,4%) va ty hit sau 48 gid, hd canh van nhan tao; 3 BN (4,1%), nhO'ng BN nay van dupc theo doi npi khoa do mere dp hd duy tri 1/4 - 2/4.
Theo doi NYHA sau phau thuSt 1 nam khong cd BN nao NYHA III - IV. Gia trj NYHA trung binh sau phau thuat 1,3 ± 0,6 so vdi trudc phlu thupt la 2,3 ± 0,5, khac biet cd )i nghTa thong kS (p < 0,001).
Trong ca 2 nhom BN, thay van co hpc s i 17 va s6 19 tai 3 thdi diem (trydc phlu thuat, trydc khi ra vipn va sau 1 nam), Chung t i i t h i y cd sy khac biet v l thay doi chdc nang thit trai, nhung nhu'ng thay doi nay khing cd y nghia thong ke (p > 0,5).
TAP CHi V • pifgc H9C OUAN sir s6' s-2014
BAN L U A N
Khai nipm PPM dypc Rahimtoola d l elp Iln d i u tien nam 1978, tuy nhien, den nam 1996, Pibarot la ngudi d i u tien dua ra tidu chuin danh gia mere dp bit tuong hop va dypc da s l cae tae gia tren t h i gidi cing nhan. Theo dd, khi ch! s6 PPM
< 0,85 dypc eoi la co PPM, tu' 0,85 - 0,95; mere d i nhp, t u 0,65 - 0,85: mu'c dp vera, < 0,65: mere dp npng. Tren thyc t l , vdi cac lopi van nhSn tao hipn co, khing lopi van nao dpt dypc dipn tich heru dgng va chenh ap qua van nhu van t y nhien.
Theo mpt s i tac gia tren the gidi, PPM muc do vera gap 19 - 70% cae trudng hpp sau phlu thupt thay van DMC, PPM mere dp npng g | p 2 11% [1]. Trong nghien eeru eua chung toi, 2 BN co PPM mere dp nhp (2,7%) d i u dypc thay van co hpc s i 17.
Hpu qua cua PPM la lam tang chenh ap qua van nhan tpo, chpm hoi phyc khii CO thit trai, eh|m eai thi#n chu'c nang thit trai, anh hudng d i n k i t qua lau dai, lau dan d i n den suy chere nang thit trii va BN CO t h i t y vong do suy tim. Tuy nhien, cho den nay chya co sy thing nhit giu'a cac tac gia tren the gidi ve anh hydng eua PPM den k i t qua sau phlu thupt va hoi phuc khoi co that trai cung nhu cai thipn cherc nang thit trai. Theo Imanaka, vdi nhyng trydng hp'p thay van s i 19 va 21, cho dij c i n t i n tpi chinh ap qua van nhan tpo va dipn tich hCru dgng khing nhu mong muln, nhyng BN v i n e i t h i CO k i t qua tot sau phlu thupt, ngay ca khi chenh ap toi da qua van > 40 mm Hg, dipn tieh hyu dung < 1 cm^ va ch! s l dipn tich hu'u dung < 0,7 cm^/m^ [2]
Trong nghien ceru eua chung t i i , sy khac
bipt v l hoi phgc khii co thit trai va eai thi$n cherc nang thit trai khing c i y nghTa thong ke. Dieu nay ed t h i giai thich vl 2 1^
do: thy nhat, bpnh ly van DMC trong nghien ceru nay khing phai la hpp don thuin (hpp hd van DMC phoi hpp hope b$nh ly van DMC kem van hai la) nen chenh ap qua van cung nhy hipn tupng phi dpi CO thit trai trydc phlu thupt khing ro ret. Thu' hai, cH c i 2 BN c i PPM sau phau thupt nhung d mere d i nhp.
Theo nghien cyu eua mot s l tae gia tren t h i gidi, van nhan tpo co hpc s i nho ( s i 16, 17 va 19) thydng e i chenh ap qua van Idn hon, ch! s i dien tich hu'u dgng nhd hon cac van s i Idn (> 21), nhung sy h i i phgc khii eo that trai va cai thi^n chCrc nang thit trai cung nhy biln chyng sau phlu thupt va k i t qua lau dai khac nhau khing co y nghTa thing ke giira cae nhdm [3]. Trong nghiSn ceru cua Chung t i i , chirc nang thit trai thay d i i khing c i y nghTa thing ke khi so sanh trudc phlu thupt, trydc khi ra viin va sau phlu thuat 1 nam.
D l khic phuc hien typng PPM, c l n can nhac vipc lya chon loai van. Tren thyc t l , van sinh hpc loai khong c i vong van CO huyet d i n g qua van tot hon van sinh hpc CO ving van, van co hpc 2 canh CO huyit ding qua van t i t hon van dTa.
Neu vdng van BN nho, co t h i phai md rpng vong van d l sCr dgng van s i ldn hon. Tuy nhien, ky thuat nay doi hoi phlu thupt vien c i kinh nghiem, do biln chiing chay mau tai dydng khau md rpng ving van DMC. Van nhan tao co hpc SB Slimline la lopi van 2 canh e i nhilu eai tiln trong thiet ke giup eai thipn huyit dpng qua van [7, 9] Theo thdng s l ky 139
TAP CHi V - Diroc HOC OUfiN SI/ SO 5-2014 thuat Xir nha san xuat, chi s6 dien tich h&u dgng trung binh cua van so 17 va s6 19 trong nghien ci>u ciaa chung toi lan lu-otla 1,13 ± 0,13 va 1,44 ± 0,12 cm^/m^.
V^i BN Cf chau Au va chau MJ, do dien tich CO t h i Ion nen van so 19 du-cc coi 1^
nho, thgm cht con du-oc khuyen cao khong nen dijng van nho hen s6 21. Tuy nhien, vdi d^c die|n di?n tich co t h i nho, BN ngu'O'i chau A noi chung va BN ngu-oi ViQt Nam ndi rieng v i n co the sii dyng van s6 17 [6, 8, 10] D i l u nay giai thich tgi sao trong tong s6 73 BN, chi co 2 BN co PPM mO'C dO nhe. Chenh ap t6i da va chenh ap trung binh qua van nhan tgo co hpc Sorin trong nghien cu'u cua chung toi tuong ty so v6i cac loai van khac cua cac tac gia tren the gioi [7, 8, 10].
K^T LUAN
Qua nghien cii'U chung toi nhgn thay phlu thugt thay van OMC bang van nhan tgo CO hpc la p h l u thugt an to^n vol ty i^
tu vong, ty 1$ bien chii'ng chung va ty 1$
biln chu-ng lien quan d i n van nhSn tgo thSp.
B i t tu-ong hp'p van - BN ia v i n d l c l n luu tam khi thay van OMC, dac bl#t voi van nhan tgo s6 nho. Van nhan tao co hpc SB Slimline la logi van 2 canh co huyet dong qua van tit. Van SB Slimline s6 nho (so 17 va 19) CO ty I? PPM t h i p va k i t qua lam sang sau phlu thugt tot, co the SU' dgng tot cho BN nguai Viet Nam.
TAI LIEU THAM KHAO 1 Hernandez Vaquero D. Uosa YC, Diaz R. The problem of patient-prothesis mismatch after aortic valve replacement concept and clinical impact Biological and Biomedical Report 2012, 2, pp.70-77.
2. Kazuhito Imanaka. Shinichi Takamoto.
Akira Fumse. Favorable results in patients with small size Carbomedics heart valve in the aortic position. Ann Thorac Surg. 2001, 7, pp.150-154.
3. Eduardo Otero, Jose L Pomar, Jose M.
Revuelta, Juan J. Rufilanchas. Comparative evaluation of small size Sonn Slimline and SJM HP heart valve prosthesis Ann Thorac Surg. 2005, 79,pp 1284-1290.
4. Efstratios Apostoiakis, Nikolaos G Baikoussis. Nikolaos A. Papakustantinou.
Patient - prosthesis mismatch and strategies to prevent it during aortic valve replacement.
Hellenic J Cardiol. 2010, 52, pp.41-51.
5. Eugene H. Biackstone, Deles M, Cosgrove, WR Eric Jamieson. Prosthesis size and long-term survival after aortic valve replacement. J. Thoracic Cardiovascular Surgery.
2003, 126, pp.783-792..
6 Raghavedra Vijayanagar, Gary Chan, Rao Musunuru, Narendra Sastry. Aortic valve replacement without annular enlargement in patient with small aortic root Asian Cardicvasc Thoracic Annals. 1998, 6, pp.279-284.
7. Andrea Garatti, Francesca Mon, Francesco Innocente, Alberto Caziani. Aortic valve repiacememntwith 17 mm mechanical prosthesis:
Is patient-prosthesis mismatch a revelant phenomenon. Ann Thorac Surg. 2011, 91, pp.71-78.
8. Tohru Takaseya, Takemi Kawara, Shigehiko Tokunaga, Michitaka Kohno. Aortic valve replacement with 17 mm SJM prosthesis for a small aortic root in elderly patients. Ann Thorac Surg, 2007. 83, pp 2050-2053.
9. Yoshio Misawa, Tsutomu Saito, Hiroaki Konishi, Shin-ichi Oki. Clinical experience with the Bicarbon heart valve prosthesis.
J Cardiothoracic Surg. 2007, 2, pp 1-8
10. Giovani Minardi, Carta Manzara, Vittorio Creazzo, Daniele Maselli. Evaluation of 17 mm SJM regent prosthetic aortic heart valve by rest and Dobutamin stress echocardiography.
J Cardiothoracic Surgery. 2006, 1, pp.i-27 140
