Y HQC VigT NAM THANG 9 • s6 OAC BlgT<2012
DIEU TR| NHjP TIM NHANH THEN THJiT BANG SdNG RADIO CAO T £ N 01 TRE EM
Nguyen Thanh Hfii*, NguySn Minh Virtfug*
TOMTAT
Nhjp hm nhanh tren that la roi loan nhjp tim hay gap nhat d tre .em. Oieu trj cdn nhjp nhanh tren that bSng dot triet du'dng dan truyen bat thudng gay cdn nhip nhanh bSng song radio 1^
phuUng phap dieu trj hi$u qu^, an toan va du'(?c lya chpn dau hen. Chung toi bao cao 3 trui&ng hdp nhjp nhanh vao lai nhT that va nhip nhanh vao lai nut nhT that duijfc dieu hi ttianh oong l^ng phu'dng phap dot trj$t vdi song radio cao tan.
Tit khia: Dot bSng song radio; nhip nhanh tren that; tre em; Wolff-Parkinson-White.
ABTRACT
Radiofrequancy ablation in treatment of supraventricular tachycardia in children
Supraventricular tachycardia are the most common an-hythmias in pediatric patients.
Radkifrequency ablation has become first-line therapy for supraventricular tachycardia in all age groups. We report first three cases succeeding in radiofrequancy ablation in treatment of atriovenWcular reentry tachycardia and atrioventricular reentry nodal tachycardia.
Keywords: Radiofrequency ablation;
supraventricular tachycardia; Woiff-Parklnson- White; pediatric
I.Oi^TVANOI
Nhjp tim nhanh trto that Id loai rSi loan nhip liay g$p nhSt ti tre em voi ti 1? drxcfc rxtic tmh khoang 1 trong mSi 250 tre kh6e (1).
Con nhjp nhanh trta th4t thucmg tai dien nhiju l&i gay anh hucmg din cu0c s6ng, sinh
» Khoa Tim mach, B$nh vien Nhi TW
hoat vi c6 thi gay nguy hiem din tinh mang diia tr6. P h ^ Idn ccm nhjp nhanh trdn thAt \i nhip nhanh vdng vdo iai nhT th4t vi nhjp nhanh do vdng via lai nut nhT that. Hi§n nay, dot tri$t bSng sdng radio cao tin \i phuong phdp du9C lua chpn dau txin cho hai ioai loan nhjp. Ddy Id phucmg phdp dieu tri hi?u qud, an todn (2). Trong khi vi$c dieu tri bdng cac thu6c ching loan nhip ddi b$nh nhan phdi dimg thudc k^o ddi, tdc d\ing han che, nhieu tdc dung phy vd chi phi diiu trj cao hcm(3,4).
TrSn thi gidi phuang phdp diiu tri ccm nhip nhanh tren that d tre em bdng dit tri^t bit ddu dupfc bdo cdo vdo nhiing ndm dau cua thdp nien 90 thi id trudc. Tai Vi?t Nam van chua cd bdo cdo ndo ve van de ndy d txi em.
Chiing toi bdo cdo 2 trudng hijp ddu tiSn tai B^nh vign Nhi Trung uong.
II. B A O C A O TRUdNG H(?P Trirdmghf/pl:
Tre trai, 14 tuoi, nhdp vi?n vi ngit tdi diln nhilu. Trong 2 ndm tre dot ng$t cd nhihig con tim dap nhanh, dau tiic ng\rc, khd thd, hoa mdt chdng mjt cd khi ngdt. Con keo ddi vdi phiit vd tv kit thuc. Tiin sut: 2 tuli diiu hi viem mang nao mil, mpi thdnh viSn h-ong gia dinh khde . Diiu tej d^ng kinh tai bfnh vi?n tinh 2 ndm nhung vin tdi phdt com.
Trd din khdm teong tmh trang lam sdng hodn toan binh thudng ngoai ttvr gidm vdn dpng niia ngudi phdi nh? do di chiing viem mdng nao mu. Dien tdm dd hinh thai WPW diln hinh. Holter di$n tim 24 gid: Sdng delta lien
C H U Y S N Bi: Hpl NGHj KHOA HQC N O A N H NHI KHOA T O A N QUiiC L A N THCI IX
tyc; khdng cd con nhjp tim nhanh hoJc bdt thudng khde. Ciu tn5c vd chiic n&ng tim binh thudng khi siSu dm ti kilm tra. Di^n ndo dl khdng thiy hoat d$ng cCia sdng d$ng kinh.
Dupc chin dodn xdc djnh Id hOi chiing Wolff-Parkinson-White vd diiu ttj bdng cordarone liiu 7,5 mg/kg/ngdy bdng uing rii duy tri vdi liiu 5mg/kg/ngdy. Trong 6 thdng ding thulc khdng cd bilu hi^n tdi phdt con.
B$nh nhi dupc dimg thuoc ching loan nhjp mOt thdng trudc khi dupc thdm dd difa sinh 1^ vd can thi^p dieu trj. Thil thujt thdm dd di^n sinh 1^ dupc th\TC hifn tai phdng can thifp di?n sinh ly trong khi bfnh nhdn dupc gdy mf. Bin catheter chin dodn dua qua dudng tinh mach diii hai bf n vd tinh mach cdnh trong phdi vdo cdc vi tri; xoang vdnh.
mdm thit phdi, nhi phdi vCmg cao vd viing lii His. Xdc djnh dudng din truyin phy ben pliii (hinh 2) vd kich thich dl ddng tao con nhjp nhanh vdo lai nhT thit (hlnh 3). Dua catheter dit dudng kinh SF qua dudng tinh mach diii trdi vdo nhT phdi dd tim quanh vdng van ba id, xdc djnh vj tri dudng phy d vimg sau bh phdi van ba Id (hlnh 3). Sau bdt mdy dit 3,2 gidy vdi kilu dit kilm sodt nhift 60°C, sdng tiin thit bien mit d$t ng$t, tilp t\ic duy tit nhift dO d ngudng dd djnh trong vdng 60 gidy. Dimg dit vd kich thich kilm tra, khdng cdn bdng chiing dudng phy. Dit ciing cl lin 2 trong 90 gidy d cimg ngudng nhift d? ban diu. Kilm tia lai lin culi sau hnyln isupiel khdng cdn bdng chiing dudng phy. Thii thi^l thdnh cdng khdng cd bit ki biin chiing.
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Trudng hfp 2:
Bfnh nhin nam, 7 hioi, cdn njng 23 kg.
Trifu chiing: nhilu ccm dau hie ngyc vd ddnh h-Ing ngyc, khdi phdt d$t ng^t, kto ddi tir 5- 10 phiit. Difn tim hinh thdi WPW vd sifu Sm tim ciu hnic tim binh thudng. Thdm dd difn sinh 1^ dupc tiin hdnh tuong ty nhu trudng hpp 1 gdy con nhjp nhanh vdo lai nhT thit
chilu xudi vd xdc djnh vj tri dudng phy tliit ndm ndm ciing vdch lien nhT.
catheter dit qua dudng finh mach ddipUi vdo nhT phdi vd thit phdi. Dd tim vj tri phy dya vdo hinh dnh tren mdn Iilnh Xi 2 bmh difn (hinh 4) v4 tifu chuin vj tii tren difn tim ghi dupc t»i diu catheter«
Khi xdc djnh vj tri dich b$t may dit vdi nhifl
Y HQC VigT NAM T H A N G 9 • s 6 BAC 8161/2012
J$ 60°C tiin kich thich thit biin mdt dpt ngpt vd hodn todn sau 13 gidy, tilp tyc dot d cCmg ngudng nhift dp trong 60 gidy. Sau dit lin mOt khodng 5 philt, sdng delta va tien kich thich thit xuit hifn trd lai. Dd tim lai vj tri dudng phy vdi diu catheter dit kio vl phia sau dudi ciia vdng van 3 id vCmg vdch lifn nliT Idiodng 2mm. Tai day khdi dilm ciia sdng V (thdt) ghi dupc tai diu catheter dit ludng eye sdm hom ichdi dilm cua sdng delta 12 mill gidy vd difn tim don eye tai diu catheter dit cd hlnh dnh QS. Bat mdy dit vdi nhift df 70*'C , sdng delta vd tiin kich thich
thit bien mit dot ng^t (hinh 3) sau 2,1 gidy vd tilp tuc duy tri dit d cimg ngudng nhift df du 60 gidy. Theo ddi sau dot lin thii hai trong 30 phiit khdng thay hifn tupng tien kich thich thit xuit hifn trd lai. Dit cdng cl them 2 lin djch diu catheter dit vf phia sau dudi vd trudc trf n. Truyin isuprel kich thich thit vd nhT khdng gdy ccm nhip nhanh vd thiy din truyen nhT thit hodn todn binh thudng.
Ket thiic thu thudt. Kilm tra lai difn tim, sifu dm tim, chyp Xquang tim phii cimg vdi thdm khdm ldm sdng sau 1 ngdy ididng thdy bit ki diu hifu tdi phdt vd tai biin hodc hiln chiing.
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Hlnh 3:Hinh anh duimg phv nhlthSt bi triit bosau dSt 2,1 gidy; Nhip tim Hinh 4: Hlnh anh Xauang vi tri thiy nhat vattiuf hai con hinh anh song delta ImOi ten), tir nhip thu't.atrcf dot da-cmg phu nhithat vitng dis6ng s6ng Q thay cha vi trisong delta. vdch sau bin phai
Trudng hfp 3:
Bfnh nhdn nam, 8 tuli, cdn ndng 25 kg.
Con nliip nhanh tdi phdt nhilu lan vdi hifu hifn dot ng^t danh trdng ngyc, tile ngyc trdi, 'khd thd, hoa mdt vd chdng mjt. Tai benh 'vifn tinh bfnh nhdn dupc chin dodn nhjp 'nhanh kjch phat tten thit va dupc diiu hj
•bing cordarone. Tuy nhifn vin phdi nhdp 'bfnh vifn tmh nhilu lin teong 2 ndm vi con inhjp nhanh. Trd dupc chuyin khdm tai Bfnh
•vifn Nhi TU, tiidm khdm Mc tdi vifn khdng
phdt hifn diu hifu ldm sdng bdt thudng. Cdc xet nghifm nhu difn tdm do,holter difn tim, sieu dm vd cdc x6t nghifm khde ciing khdng thiy diu hifu bit thudng. Khdng cd bit ki bdng chiing difn tdm dd cua ccm nhjp tim nhanh dupc ghi lai. Ccm nhjp nhanh dupc kilm soat bdng flecainide vdi liiu 3mg/kg/ngdy chia 3 Idn teong 8 tiidng teudc khi dupc can thifp diiu tri. Thdm dd difn sinh ly dupc thyc hifn nhu vdi trudng hgp bfnh nhdn trfn. Kich tiilch tun bdng tao nhjp
C H U Y S N Bi: Hpl NGH| KHOA HpC N G A N H NHI KHOA T O A N QU6"C LAN T H O IX
de ddng gdy vd cdt con nhjp tim nhanh. Phdn tich djc dilm difn sinh 1;^ ciia hf thong din teuyin khi kich tiiich, cdch khdi phdt vd kit thuc con nhip nhanh, djc dilm con nhjp tim nhanh xdc djnh con nhjp nhanh do vdng vdo lai mit nhi thit thi diln hlnh (hinh 5 ). Dua catheter dit qua tTnh mach ddi Ifn nhT phdi vdo tilit phdi rii tiiao tdc dd tim vj tti dudng chjm dudi sy djnh hudng mdn hinh Xquang vd difn tim ghi dupc tai diu catheter dit. Sau
khi xdc djnh vj tri dich tiieo tifu chuin sinh 1;^ vd gidi phiu dudng chjm. Bjt dit kilm sodt nhift d$ d ngudng 60°C t khi theo ddi sdt cdc hifn tupng biin dii sinh 1;^ nhdm phdt hifn hie thi cdc diu:
tin thuorng ndt nhT thit. Sau mSi lin dit 1 thich nhT vd thit nhdm ddnh gid cdc tifu thdnh cdng. Sau 3 lin dit cdc tifu cb thdnh cdng dupc khdng djnh.Thil tiiujt th cdng khdng cd biin chiing.
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Hinh S: Kieh thieh that gay eifn nhjp nhat^ Difn Um ngoii (I, II, 111) v&i bliu hiin: tSnatS? ISn/phut, Q S fifft Ui&ij tkSysingP.OIintlmer HIS-tl: trlnhtvkhueve H-V-A, khoang V-A S2m.
III. B A N LUijiN
Thdm dd difn sinh ly tim Id phucmg phdp chin doan xdm nhjp nhdm ddnh gid djc tinh vd chiic ndng cua hf tiling dan tiuyln, nguyfn nhdn vd co chl gdy con nhjp tim nhanh. Hon nOa sy kit hpp tiidm dd difn sinh ly cimg vdi dot teift bdng sdng cao tin Id phuong phdp diiu tii teift dl vd hifu qud doi vdi hiu hit cdc loai nhjp tim nhanh ttfn tilit vd nhip nhanh thit (5).
Trong khodng mft thjp nifn ted l?i ddy vdi sy hiiu biit ve gidi phlu cimg nhu co chl bfnh sinh, cing vdi tiidnh tyu cila khoa hpc cdng nghf. Hifu qud dieu tei con nhjp nhanh
bdng dot teift ngdy cdng nang cao vd ti hiln chiing njng ngdy cdng gidm (2, 6). fi vdi dit dudng din truyin ciijm teong a nhjp nhanh vdo lai nut nhT tilit tid ti if thii cdng id 97% (7), ti If biin chUng block a tilit hoan toan 0,8% (7). Cdn dii vdi d dudng phy nhi that trong diiu trj con nil nhanh vdo Ifii nhi thit till ti If tiidnh cdng 92%, tdi phdt 7% vd khdng cd biin chUr nguy hilm (8).
Chl djnh diiu trj con nhjp nlianh ti tilit bdng phucmg phdp ddt trift dang ngi cdng 14 phuong phdp dieu tri dupc lua tm diu tay dii vdi tit cd cdc nhdm tuli. MOts
Y HQC VigT NAM T H A N G 9 - stf P A C 6167/2012
nghign cihi so sdnh gSn dSy da chi ra rang hi?u qud dieu trj cua phucmg phdp cd ve ti 1?
thanh cong cung nhu ti 1? bien chiing Id nhu nhau giiia nhom doi tupng Id tr6 nhd so vdi tre 16n hodc b^nh nhan ngu6i Idn (9,10).
IV. KlT LU$N
Voi vi^c trien khai thdnh c6ng kT thu|t di^u tri corn nhip nhanh tren th^t bfing dot tri^t du6ng dan truyen bk thudng gdy con nhip nhanh b i n g s6ng radio sg md ra hudng diSu tri mdi cho trd em Vi^t Nam bj roi Io?in nhip tim nhanh.
TAI UEU THAM KHAO
1. Losek JD, Endom E, Dietrich A, et al.
Adenosine and pediatric supraventricular tachycardia in the emergency department:
multicenter study and review. Ann Emerg Med. 1999;33(2):185-91.
2. Kugler JD, Danford DA, et al. Pediatric radiofrequency catheter ablation registry success, fluoroscopy time, and complication rate for supraventricular tachycardia:
comparison of early and recent eras. J Caidiovasc Electrophysiol. 2002;13(4):336-41.
3. Chang PM, Silka MJ, et al. Amiodarone versus procainamide for the acute treatment of recurrent supraventricular tachycardia in pediatric patients. Circ Arrhythm Electrophysiol. 2010;3(2):134-40.
Manole MD, Saladino RA. Emergency department management of the pediatric patient with supraventricular tachycardia.
Pediatr Emerg Care. 2007;23(3): 176-85.
Blaufox AD, Felix GL, Saul JF.
Radiofrequency catheter ablation in infants
</=18 months old: when is it done and how do they fare?: short-term data from the pediatric ablation registry. Circulation.
2001;104(23):2803-8.
Triedman JK. Procedural innovation and ablation of pediatric SVT. J Cardiovasc Electrophysiol. 2009; 20(6): 643-4.
Hwang HK, Wolff GS, et al. The most common site of success and its predictors in radiofrequency catheter ablation of the slow atrioventricular nodal pathway in children.
Pacing Clin Electrophysiol. 2008; 31(10):
1300-6.
Lee PC, Hwang B. et al. The results of radiofrequency catheter ablation of supraventricular tachycardia in children. Pacing Clin Electrophysiol. 2007; 30(5): 655-61.
Aiyagari R, Saarel EV, et al.
Radiofrequency ablation for supraventricular tachycardia in children < or =15 kg is safe and effective. Pediatr Cardiol, 2005; 26(5):
622-6.
]. Anand RG, Rosenthal GL, et al. Is the mechanism of supraventricular tachycardia in pediatrics influenced by age, gender or ethnicity?
Congenit Heart Dis. 2009; 4(6): 464-8.
