Thye quan ciia Dong Chay Qua Van Hai La Nhan Tao loai Sorin Bicarbon Dac diem Sieu Am Doppler tim qua Thanh Ngyc va Qua

TAP CHi TIM MACH HQC VIET NAM - S6 56 - 2010. Dac diem Sieu Am Doppler tim qua Thanh Ngyc va Qua Thye quan ciia Dong Chay Qua Van Hai La Nhan Tao loai Sorin Bicarbon BS: Vii Quipth Nga' CS, TS. Nguyen Uin Viet**. TdM TAT Nghien ciiu dac di&n sieu am - Doppler tim qua thanh ngyc vk qua thuc quan ciia van co hoc Sorin Bicarbon 6 96 benh nhan. Hinh anh v ^ dpng dong md ciia van cd the quan sat ca tren sJeu am tim qua thanh ngyc va qua tiiyc quan. Chinh ap toi da qua van (Gmax) la 10,0 ± 3,0 mmHg va chinh ap trung binh (G mean) la 4,1 ± 1,3 mmHg. Dientichvan hai latiieophuong phap PHT la 3,0 ± 0,5 cm2. Khong co su khac biet cd y ngjiia thdng ke eua cae thdng so nay 6 cac co van khac nhau. Cac gia tri chenh ap qua van do tren sieu 5m qua thye quan tha'p hon do tren thanh nguc nhung dien tich van cung nhu thdi gian ban giam ap lyc do qua 2 phuong phap khac nhau khong co y nghia thohg kl. Silu am thye quan phat hi|n dong ho tiong van d 100% cae bfnh nhan trong khi sieu am qua thanh ngyc chi phat hien dupe 6 81,1%. Trin sieu am qua thye quan, eo thi' quan sat thay 3 dong hd trong van, vdi chieu dai trung binh ciia dong ho Idn nhat la 20,2 ± 5,2 (mm), chieu rpng trung binh 2,3 ± 0,5 (mm) va dien tieh dong hd trtmg binh la 1,3 ± 0,5 (mm).. BAT VAN B £ Tir sau ca phau thuat dau tien tren the' gidi cua Starr thay van hai la nhan tao d vi tri van hai la vao nam 1961, sd' lugng b?nh nhan dugc thay van tim nhan tao ngay mdt nhieu. Cdng ngh§ che' tao van ciing dugc phat trien khdng ngimg de tao ra nhiing the'he van mdi ed nhieu ini diem ve huyet ddng va han che' eae bieh ehiing: van bi, van mpt eanh, van hai canh, van sinh hpe, van ddng loai. Van Sorin Bicarbon (Sorin Biomediea, Italy) la mot loai van eo hge the' he mdi cd hai earth dugc sir dyng tren the'gidi tir 1990 va duge sir dung kha nhieu d Vi?t Nam trong nhung nam gan day. Day la van co hgc the'he 3 dugc thiet ke' gdm 2 eanh van hinh ban nguyet hoi eong duge. * Benhvien tim Ha Ngi **Vien Tim mach quoc gia. gan trong 1 khung hgp kim Titan. Khung va canh van duge phii 1 Idp Carbofilm de giam nguy eo tao huyet khoi tren be mat van. Cae la van duge lam bang hgp chat pyrolytic carbon. Ca'u tnic ban le d|e bi^t ciia van vdi cae ranh nhd cho phep kiem soat duge dong mau tiao nguge ngay ea khi van ddng. Cae ddng mau nay ed tae dyng h^n che'sy tap thanh cae cue mau ddng tren van nen con gpi la "ddng nia" (washing jets). Khi md, cae canh van tao mpt gdc 800 vdi mat phang vong van tao nen 3 Id de ddng mau qua. Cae eanh van hoi eong eho phep dong mau ehay can bang giira ddng trung tam va 2 ddng ben. Tuy nhien, eae benh nhan mang van tim nhan tao, nhat la van eo hpe, deu cd nguy eo nhat dinh cd eac bie'n chiing nhu huyet kho'i. NGHIEN CLfU LAM SANG gay ket van, viem ndi tam mac nhilm trung, xuat huyet... Vi vay \iec theo doi cac benh nhan sau phau tfiual la rat quan trpng de de phdng ciing nhu phat hien sdm cac biwi chiing CO the xay ra giiip dieu tri kip fhdi. Sieu am Doppler tim da tid thanh ky thuat Ihudng qui co ban trong theo ddi cac berth. nhan mang van tim co hgc. Dac diein sieu am ciia mdt loai van co hgc eiing nhu dane ddng diay qua van khac nhau theo timg load \ an dugc sii dimg. Vi vay, vdi mdi loai van can cd mdt gia tri. Hinh 1: Van Sorin Bicarbon. LEFT ATRIUM. Flow. Closed LEFT VErjTRICLE Open HhOi Z- So do hoat dong cua van co h^c 2 canh tham khao ve hinh thai sieu am - Doppler de CO the phat h i ^ sdm cac bieh chiing nia chting. Di co mpt so nghien ciiu danh gia hoat dong binh thuong cua mot vai loai van nhan tso 6 1 nhom b«nh nhan nhat djnh tren. the gioi ciing nhu 6 Viet nam [1], tuy nhien chua CO nghien ciiu nao tien hanh tren van Sorin Bicarbon. Xghien o i u cua chiing toi nham danh gia dac diem sieu am Doppfel binh thucmg dia van Sorin Bicarbon hai canh. TAP CHi TIM MACH HOC VIET NAM - SO 56 - 2010 d cae benh nhan dugc phau thugt thay van. 30 (Nhgt Ban). hai la tai benh v i | n tim Ha Npi nham mue. Sieu am 2D dugc sii dung de quan sat. dich dua ra mgt so thong so' danh gia hoat. hoat dpng ciia van va cae ca'u tnic lan can. dgng binh thudng ciia van Sorin Bicarbon. d cae m | t cat khae nhau. Su dyng sieu am. sii dung sieu am - Doppler tim qua thanh. Doppler mau d mat cat 4 buong tir mdm. ngyc ciing nhu qua thuc quan. de xac dinh ddng ehay tii nhl trai xud'ng. DOI M N G VA PHIftfNG PHAP NGHIEN CffU:. that trai va ddng hd van. Ciia so Doppler lien tuc duge dat d trung tam ddng chay,. Odr tLPang nghien ci>u. thang hang vdi trye eua dong mau qua van.. Tu thang 10/ 2008 den thang 9/2009 da ed 96 benh nhan phau thuat thay van hai la dem thuan bang van Sorin Bicarbon dugc dua vao nghien ciiu. Chiing tdi loai khdi nghien ciiu eac b?nh nhan dugc thay dong thdi ca van hai la va van ddng maeh chii, hoac cd kem cae ton thuang tim khae nhu cd benh mach vanh, cd eae di tat tim baim sinh ... , eac b?nh nhan ed tinh trgng huyet dpng khdng dn dinh, cae b^nh nhan tir ehd'i khdng thuc hi?n sieu am tim qua dudng thye quan. Tat ea cac benh nhan dua vao nghien ciiu deu khdng cd ton thuong dang ke ciia van ddng mgch chii eiing nhu van dpng maeh phdi.. Chpn phd Doppler ro rang va eo van td'c eao nhat. Chenh ap to'i da va trung binh qua van dugc do ty ddng tren may theo phuong trinh Bernoulli don gian sau khi vien kin pho Doppler qua eiia dong chay qua van hai la nhan tao. Thdi gian ban giam ap lye duge do theo Hatle va cpng sy, tir dd tinh dupe dien tich Id van hi^u dyng theo cdng thiic S (van hai la) = 220/PHT trong dd S(VHL) la di?h tieh Id van hai la do bSng em2; PHT la thdi gian ban giam ap lye tinh bSng ms. Cac chi so' dugc la'y trung binh tii 3 lan do ne'u benh nhan ed nhip xoang va 5 lan do ne'u benh nhan bi rung nhT. Dong. Thidt k& nghien cu'u Nghien CLPU m d ta,. hd van hai la dugc danh gia dua tren hinh. ti§n CIJU.. dang, mau sae (ddng mau kham hay dong. Cac benh nhan deu dupe kham lam sang,. nha't), miic dp lan xa trong nhi trai.. cae xet nghiem dien tam do, chup phim tim phdi, lam sieu am - Doppler tim trong vdng 1-2 tuan sau phau tiiuat, khi tinh trgng huyet dpng da dn dinh. Sieu dm - Doppler tim Sieu am 2D va Doppler tim qua thanh ngue dugc thye hien tren may TOSHIBA Nemio 30 Nhat Ban) hoac may GE VIVID 3 (My). Sieu am tim qua dudng thye quan dugc thye hien tren may TOSHIBA Nemio. X i r ly sd lieu. Tat ca eae sd'lieu thu dugc se dugc sii ly theo eae thuat toan thd'ng ke y hpe vdi phan mem SPSS 15.0. Cac ket qua duge trinh bay dudi dang trung binh ± dp l#ch chuan. Test 't' student va x^ dugc sti dung de so sanh ket qua sieu am giiia 2 nhdm dd'i tugng. Sy khac biet dupe coi la cd y nghia thd'ng ke khi p <0,05.. NGHIEN CLfU LAM SANG. van ba la dong thdi khi thay van hai la.. KET QUA NGHEN CSU D^c diim Chung cua nhdm nghien ciru Cac benh rihan cd tuoi trung binh la 44,4 ± 11,2 (tir 16 deh 66), tiong dd cd 70 nu (66%) va 36 nam (34%). BSA tnmg binh 1,48 ± 0,17 (m2)- 27 benh nhan (28%) cd nhip xoang va 69 benh nhan (72%) bi loan nhip hoan toan do rung nhi. Cd 64 benh nhan (67%) dupe siia. O 96 benh nhan n ^ e n ciiu, ki'ch thudc eac van Sorin Bicarbon dugc sii dtrng la hi 25 deh 33, trong dd cae cd van dugc sii dung rihieii nhat la 29 va 31 (Bang 1).. Bdng 1: Ty le cae cd van dugc sir dung So luong benh nhan. Ty le %. 25. Cac CO van. 6. 6,1. 27. 13. 13,4. 29. 29. 29,9. 31. 35. 36,1. 33. 12. 12,4. Tren Sieu am - Doppler tim qua thanh ngirc, dong qua van dugc ghi lai 6 tat ca cac benh nhan; Chenh ap toi da qua van (Gmax) la 10,0 ± 3,0 mmHg (tir 5 den 16,5minHg) va chenh ap trung binh (G mean) la 4,1 ± 1,3 mmHg (tit 2,0 deh 9,0 mmHg). Khong co su tuong quan nao gifta chenh ap toi da ciing nhu chenh ap trung bmh voi cac co van tii 27 deh 33 ( r - - 0,003 va r - - 0,08 vol p khong CO y nghia thong ke). Chiing toi ding khong tim thay moi hrong quan giiia thoi gian ban giam ap lire (PHT) cung nhu tich phan van toe dong chay (VTl) nia dong qua van hai la voi co van. Bang 2: Cac thong so Sieu am - Doppler tim qua thanh ngvtc Trung binh. Gia tri nho nha't. Gia tri Ion nha't. 10,0 ± 3,0. 5,0. 16,5. Chenh ap trung binh (Gmean) (mmHg). 4,1 ± 1,3. 2,0. 9,0. Dien tich VHL theo PHT (cm=). 3,0 ± 0,5. 2,2. 5,0. PHT(ms). 73,63 ± 12,8. 3. 100. VTl(cm). 29,3 ±5,6. 18. 46. Chenh ap toi da (Gmax) (mmHg). TAP CHi TIM MACH HQC VIgT NAM - SQ 56 - 2010. Hinh 1: Hinh anh phd Doppler ddng qua van hai la co hpe Khi nghien eiiu cae thdng sd'sieu am - Doppler tim ciia ddng chay qua van hai la theo co van, chiing tdi khdng tha'y ed su khac bi$t ed y nghia thd'ng ke ctia cac thdng so' nay d cae ed vem khae nhau. Sy khac bi?t nay chi co y nghia thd'ng ke khi so sanh ehenh ap td'i da va trung bmh ciia van sd'25 vdi cac logi van khac (p= 0,018). Tuy nhien, PHT va dien tich van tinh theo PHT d eac cd van khac nhau khong ed y nghia thd'ng ke (Bang 3). Bdng 3: Dae diem huyet ddng ctia van Sorin Bicarbon theo sd'van. (mmHg). Gmean (mmHg). Dien tich van hai la (theo PHT) (cm^). 25. 14,1 ± 3,0. 5,2 ± 1,0. 2,9 + 0,3. 77,3 ± 7,7. 31,2± 7,2. 27. 10,5 ±2,9. 4,2 ±0,9. 3,0 ±0,5. 72,7 ±11,1. 28,8 ± 6,8. So'van. Gmax. PHT (ms). VTI (cm). 29. 9,3 ±2,8. 3,7 ±0,8. 3,1+0,6. 74,0 ±13,5. 28,2 ±5,6. 31. 10,5 ±3,9. 4,5 ± 1,7. 3,0 ±0,4. 69,7 ±20,8. 29,5 ±4,9. 33. 9,6 ±2,1. 3,9 ± 1,0. 3,0 ± 0,4. 73,7 ±13,0. 30,8 ±4,3. Hd van nhan tgo: ddng hd trong van quan sat dugc d 78 b?nh nhan (81,1%). Ty le ddng hd la tuong tu nhau d cae ed van khae nhau. Cac ddng hd nay rUid tien sieu am qua thanh ngyc thudng rat nhd, mau xanh nhat, dong. nha't, thudng khdng lan xa trong nhi tiai Tren sieu am Doppler tim qua dudng thue quan, van ddng ctia eanh van hai ia ddng md duge qu^m sat rd hon. Chenh ap toi da va trung binh qua van tren sieu am qua thuc quan tha'p. NGHIEN CIJU LAM S A N G. hon tren sieu am qua thanh ngirc ( p < 0,01), tuy nhien PHT va dien tich van tren PHT tren sieu a qua thanh nguc va qua thuc quan khac nhau khong co y nghia thong ke (Bang 4). Bdng4: Cac thong sd'sieu am Doppler tim qua dirong thuc quan Qua thuc quan. Qua thanh ngirc. P. Chenh ap toi da (Gmax) (mmHg). 9,1 ± 3,0. 10,0 ± 3,0. 0. Chenh ap trung binh (Gmean) (mmHg). 3,9 ± 1,6. 4,1 ±1,3. 0. Dien tich VHL theo PHT(cm=). 3,7 ± 0,65. 3,0 ± 0,5. 0,09. PHT(ms). 61,7 ± 11,8. 73,63* 12,8. 0,1. Cae ddng hd trong van dugc quan sat rd rang d tat ea cae benh nhan (1(K)%). Cd 3 ddng ho tiong van, 1 ddng hd trung tam va 2 ddng ngoai vi. Tuy nhien, khdng phai d benh nhan nao ciing quan sat tha'y ea 3 ddng hd tren eiing 1 mat eat. Day la 3 ddng hd nhd, va ddng hd cd kidi thude Idn nhat thudng la ddng hd ngoai vL Chieu dai trung binh oia ddng hd Idn nhat la 20,2 ± 5,2 (mm) (tit 12 de'n 34,5 mm), chieu rpng trung binh tir 1,3 deh 3,6mm (2,3 ± 0,5) va dien tich ddng hd trung binh la 1,3 ± 0,5 mm (0,6 den 3,7).. Hirth 2: Sieu am qua thye quan. Hinh trdi: dong mau qua van hai la co hoc. Mnh phM: 3 dong ho sinh ly trong v. TAP CHi TIM MACH HQC VIET NAM - S6 56 - 2010. BAN tUAN: Tren sieu am hai chieu, cd the tha'y ro hinh anh ddng - md etia van ca hoc 2 eanh nhip nhang trong chu ehuyen tim [2]. Hinh anh nay cd the quan sat duge qua sieu am tren thanh nguc va ea sieu am qua thye quan. Doppler mau eiia ddng chay xudi dong tu nhl trai xudhg that trai gdm 3 ddng ed dam dp va kich thude tuong dd'i gidhg nhau, quan sat dugc ea tren sieu am qua thanh ngyc va qua thye quan. Dac diem nay phii hgp vdi ca'u tao ciia van Sorin Bicarbon: Van ed 2 eanh cong cho phep khi md se tgo ra 3 Id nho tuong dol bang nhau [3,4]. Chenh ap tdi da qua van eiia chiing tdi trung binh la 10,0 ± 3,0 mmHg va khdng o6 trudng hpp nao cao hon ISmmHg. Gia tri nay khdng khae so vdi ket qua nghien ctiu ciia Banado [3] nam 1997 (llmmHg). Khi so sanh vdi ket qua chenh ap tdi da qua van cCing tiong ngjiien ciiu nay, Banado Ihay chenh ap qua van cd xu hudng gjam khi sd'van tan^ tuy nhien sy khac biet chi 00 y nghia thohg ke khi so sanh van sd'25 vdi cac so'van khac Ket qua ciia chiing toi cung cho tiiay sy khae biet ve chenh ap tot da qua van khdng ed y nghia thdng ke vai cac van tu sd'27 deh 33 (p = 0,2). Chenh ap tnmg binh ctia ddng diay qua van trong nghien ctiu oia chiing tdi la 4,1 ± 1,3 mmHg. Khdng cd trudng hpp nao cd chenh ap > SmmHg. Gia tri nay eung tuong ty ket qua tim. Masters va, cac gia tri ehenh ap tdt da, ehenh ap tnmg binh tuong ling la 9,43 ± 3,96 mmHg va 4,15 +1,46 mmHg, cae ket qua thu dugc cua ehiing tdi khac biet khdng cd y nghia thdng ke ( p> 0,05) tiic la ehenh ap qua van Sorin Bicarbon va van St Jude Masters la tuong ducmg. Trong nghien ciiu eiia ehiing tdi, khi so sanh giiia cac so'van khae nhau, chenh ap tdi da va ehenh ap trung binh qua van ciing nhu dien tieh Id van hieu dyng d cac so' van khae nhau khdng cd y nghia thdhg ke, dieu nay ed y nghia tren lam sang khi e&i diing b^nh nhan 1 van ca hgc sd'nhd. Ddng hd nhd "sinh ly" la 1 dgc diem thudng thay d van co hpe logi 1 hogc 2 eanh. Tren sieu am Doppler eac ddng hd nay nhd, nam trong vdng van, dong nhat ve mau sac bieu hien ddng ehay cd van to'c thap (2,6,7). Trong rihdm nghien ciiu eiia ehiing tdi, ty le berth nhan quan sat thay ddng hd "sinh ly" tren sieu am qua thanh ngue la 81,1%, cao hon so vdi ty le ddng hd tiong nghien eiiu ctia Banado nam 1997(12%), cd the la do thanh ngyc d ngudi Viet nam mdng hon va the'he may sieu am sau nay ed dp nhgy cao hon. Tren sieu am tim qua thye quart, eae ddng hd nay dugc quan sat rd rang hon ea ve so' lugng va kieh thude.. KET LUAN:. duge eua 1 so' tac gia nude ngoai cung ve van Sorin Bicarbon d vi tri van hai la nhu Banado [3] (4mmHg)va Reisner 15] (4 ±1,1 mmHg). TnaTgi^iien eiiu nay, dien tidi 16 van hi?u dung trung tanh flieo phuong phap PHT la 3/1 ± 0,5 cm2 tuong ty ket qua ciia Reisner [^ (2,9±0,4cm^). Khi so sanh vdi eac ket qua tiong nhien cihi cua Nguyen Hdng Hanh [1] tren van St Jude. Nghien eiiu ciia ehiing tdi eung ea'p mdt so gia tri huyet ddng cua dong ehay qua van hai la nhan tao loai Sorin Bicarbon do dugc tren sieu am Doppler tim qua thanh ngyc va qua thye quan. Day la nhiing gia tri eo ban giiip theo ddi hieu qua sau phau thuat d eac benh nhan duge thay van hai la co hpe logi Sorin Bicarbon ciing nhu phat hien cac bie'n chiing ed the xay ra d cae berth nhan nay.. N G H | £ N CLfU LAM. SANG. ABTRACTS Doppler echocardiographic diaractertistics of normally functioning Sorin Bicarbon in the initral valve position were prospectively assessed in 96 patients operated from 10/ 2008 to 9/ 2010, The dose and open movement of the protheses were observed on both transthorade and transesophageal echocardiography The f»eak transprosthetic gradient were 10,0 ± 3,0 (mmHg) and the mean transprosthetic gradient were 4,1 ± 1,3 (mmHg).These parameters were not significatiy difference in different prothetie sizes Ihe gradients measured on transesophageal ediocardiography were lower than that measured on transthoraac echocardiography, but prosthetic area and pressure half time measured by two methods were similar On transthoracic study, 81,1% patients with a Sorin Bicarbon valve in the mitral valve showed minunal transprosthetic leakage. On transesophageal study, all patients showed transprosthetic leakage whose the everage length was 20,2 ± 5,2 (mm),, the everage width at the origin was 2,3 ± 0,5 (mm) and the everage area was 1,3 ± 0,5 (mm).. TAI LIEI THAM KIIA8 1.. 2. 3.. 4.. Nguyen Hong HanK Nghiin ciiu boat dong tanh thuong ciia van hai la nhan tao loai Saint Jude Masters tren sieu am Doppler tim. Luan \'an tdt nghiep bic sy npi tni benh \'ien 2005. J Barbetseas, WA Zo^bi. Evaluation of prosthetic valve fimction and assodated complications. Cardiology clinics 1998; 16(3): 505-530. L Banado, R Mocchegiani, D Bertoli et aL Normal ediocardiographic characteristics of the Sorin Bicarbon bileaflet prosthetic valve in the mitral and aortic position. J Am Soc Echocardiogr 1997; 10:632-43. 1 Goldsmittv Y.H Lip, R L PateL Evaluation of the Sorin Bicarbon bileaflet valve in 488 patients ( 519 protheses). Am J Cardiol 1999,83:1069-1074-. S A Reisner, D Harpaz, R Skulski et al. Hemodynamic f»erformance of foiu mechanical bileaflet prosthetic valve in the mitral position: an echocardiographic study. European J Ulh-asound 1998; 8:193-200. H Drissa, F Ben Salah, RM Zaowali. Evaluation by Doppler echocardiography of hemodynamic profil of mitral bileaflet prothesis. Report on 90 cases. TUNIS Med, Jul 1,2004,82 (7), 648 - 55 (Abstract). FA Flaehskampf, JL Guerrero, JP CTshea. Pattems of normal transvalvular regurgitation in mechanical valve prostheses. J Am Coll Cardiol 1991; 18.1493-1498..