VIETHAM MEDICAL JOURHAL N°1 - JANUARY - 2017 outcome of infective endocarditis in the 21st
century: the International Collaboration on Endocarditis-Praspective Cohort Study", Ardi Intem Med, 169(5), tr. 463-73.
S. J. Head, M. M. Mokhles, R. L Osnabnigge.
(2011), "Surgery in cun-ent therapy for infechVe endocarditis'; VaseHea0iRiskManag, 7,tr.255-63.
H. Grubitzsch, T. Christ, C. Melzer et a l . (2016), "Surgery for prosthetic valve endocarditis:
associations between morbidity, mortality and costsdagger" Interact Cardiovasc ThoracSurg.
A. Dodge, M. Hurni, P. Ruchat et al. (1995),
"Surgery in native valve endocarditis: indications,
results and risk factors" Eur J Cardiothorac Surg, 9(6), tr. 330-4.
P. Tornos, B. I u n g , G. P e r m a n y e r - M i r a l d a i ^ al. (2005), "Infective endocanjitis in Europe:
l^sons fi-om the Euro heart survey'; H^it, 91(5), tr. 571-6.
S. Ragnarsson, J . Sjogren, M. Stagmo et al.
(2015), "Clinical Presentation of Native f^ilral Valve Infective Endocarditis Determines Long- Term Outcome after Surgery" J CanI Surg, 30 (9), tr. 669-76.
T. Raychaudhury, A. Faichney, E. W. Cameron et al. (1983), "Surgical management of native valve endocarditis" Thorax, 38(3), tr. 168-74.
TIM HIEU NGUYEN NHAN KHif N BENH N H A N P H A I TAI NHAP VIEN DIEU TRI N O I T R U SAU KHI P H A U THUAT THAY VAN TIM NHAN TAO
v A DE XUAT MOT SO GlAl P H A P
Do PhiTffng Anh*
T O M TAT
MifC tiiu nghien cdu. tim hieu nguyen nhan khien benh nhan mang van tim nhan tao phai nhap wen dieu tri noi tru va de xuift mot so giii phap. Dor tifdng ngiiien cdu. tst ca cac benh nhan c6 mang van tim nhan tao vao nam dieu tri ngi tru tai Vien Tim mach Benh vien Bach Mai trong thdi gian 1 nam tu"
1/2015 d§n 12/2015. PhUdng phap nghiSn ahr. hoi ci!ili, ph3n tich mo ta. Kit qua: trong 1 nam co 312 benh nhan phai nhap vien dieu trj n5i tr6, s6 benh nhan td vong la 18 (5,8 % ) . Trong do co 162 b§nh nhan nhap vien trong thdi gian 1 nam dau tien sau phau thuat (cfii^m 20% tong s5 cac binh nhln phau thuat); s6 benh nhan tuf vong la 12 ngifcfi (7,4%). Cac bien chiing hay gap nhat la: qua lieu thuoc chong dong (41,3%), trong s5 do co den hdn 40,74% cac benh nhan bj xuat huyet 6 cac mu'c do khac nhau, nang nhat la xuat huyet nao dan den tu" vong. Cac bien chuYig khac nhu': rot loan nhjp tim (16,7%), suy tim (15,17%); thai san, chan thu'dng hay phau thuat ngoai tim co chay mau keo dai, benh ly kem theo:
t3ng huyit ap, dai thao dU&ng... fi4,9%). Cac bien chCfrig g^p vdi ty- le it hdn la: nhiem tmng (5,98%), thuyen tac mach (3,98%), bien chtftig cd hoc (2,24%), tan mau (0,75%), cac bieu hien than kiiih sau mo (0,75%). Kit luan: Ty l i benh nhan mang van nhan tao phai nhap vien dieu tn ngi tru sau phau thuat kha cao (20% so benh nhin mo trong nam dau
* l^e/7 77m mach - Benh viSn Bach Mai Chju trach nhiem chinh: Oo Phu'dng Anh Email: [email protected] Ngay nhan bai: 8.11.2016 Ngay phan bien khoa hoc: 13.12.2016 Ngay duyet bai: 27.12.2016
tiin). Cac blen co hay gap nhat la roi loan dong rpau, xu§it huyet nang, suy tim, roi loan nhip tim. Trang:d6 qua lieu tiiuoc chong dong mau la nguyin nhan ph6 bien hang dau va la nguyen nhan, gay tu" vorig QO nhat. Be han che bien chiJng do chung toi de Mjat mgt so giai phap: xay di/ng mo hinh phong kham' khang dong vdi may Coagucheck, ca the hoa dieu tri vdi lieu phap gen, phat the ID card ve tinh trang siy dung chong dong cho benh nhan.
SUIVIIVIARY
C O M P L I C A T I O N S OF PROSTHETIC HEART VALVES I N PATIENT HAD REHOSPITALIZED AFTER OPERATION:
CAUSES A N D SOME SOLUTION Aim of the study, to find out tiie cause of patients with prosthetic heart valves were hospitalized after tJie operation and suggest some solutions.
Subjects, all inpatients w/ith prosthetic heart valves at the Institute of Cardiology of Bach I^ai Hospital during 1 year from 1/2015 to 12/2015. Method.
retrospective, observed analysis. The result, in one year 312 prosthetic heart valves patients had hospitalized, the 18 patients died (5.8%). Of whicii 162 patients admitted during the first 1 year after surgery (20% of the total number of surgical patients); the number of patients who died was 12 (7.4%). The most common complications are:
overdose of anticoagulants (41.3%), of which there are more tiian 40.74% of bleeding patients in different degrees, is the most severe brain hemorrhage leads deatii. Other complications, such as cardiac arrhytiimia (16.7%), heart failure (15.17%), oOier complications such as maternity, trauma or surgery in addition to prolonged bleeding heart, patliology
148
Tjj* CHi Y HQC VIET NAM TAP 450 - THANG 1 - S 6 1 - 2017 atbiched; h^ertension, diabetes ... (14.9%).
Complications encountered with lesser rate: infection (5.98%), embolization (3.98%), medianical complications (2.24%), hemolysis (0.75%), neurological symptoms after surgery (0.75%).
Conclusions: The proportion of patients carrying the ariifldal valve to inpatient hospitalization after surgery is high (20% of surgical patients in the first year). TTie most common events are coagulopathy, major bleeding, heart fellure, an-hythmias.
LDATVANDE
Thap tim hay con gpi la thap khdp cap hoac sot thap khdp du'dc coi la mpt trong nhulig benh cua he miln djch, mo lien ket hay thupc he ttiong tao keo, Cho tdi nay, benh van kha thu'cfng gap d cac nu'dc dang phat trien (trong -do CO Viet Nam) va la nguyen nhan hang dau
cua bSnh van tim d ngu'cfi tre tuoi. Viet Nam la mot trong nhiJng nu'dc co ty le benh nhan thap
^ c a o tren the gidi. Do hau qua cua nhieu nam Chien tranh va ddi song kinh te khd khan de lai, hien tai diung ta dang phai chu'a cho mot lu'dng tdn cac benh nhan van tim hau thap. Trong dd phau thuat thay van tim nhan tao la mot trong nhutig bien phap dieu tri triet de nhat va la giai phap cuoi cung cho cac benh nhan ed ton thuUng nang van tim do thap va gay anh hu'dng nhieu den huyet dpng. Tuy nhien nhutig benh nhan mang van tim nhan tao se phai su* dung thuoc chong dong mau lau dai. Viec theo doi va
^ u chinh thuoc chong dong mau cung la mot thach thu'c Idn trong dieu kien thifc te hien tai d nude ta. Ngoai ra cac benh nhan nay cung gap mpt so bien chutig nhu" : suy tim, nhiem triltng, roi loan hoat dpng cua van nhan tao, roi loan nhjp tim, tan mau...
Trung bmh moi nam Vien Tim mach Viet Nam phau ttiuat khoang 800 benh nhan thay van nhan tao. Tuy nhien so lu'dng cac benh nhan tai nhap vien dieu trj sau phau thuat kha Idn. Chung toi tien hanh ghi nhan so lieu cua cac benh nhan nham mucdfch:
Tim hieu cac nguyen nhan khien benh nhan nhap vien,
- Bu'de ^ u de xuat mot so giai phap han die cac bien chu'ng do.
II. Ddt TU'QNG VA PHU'aNG PHAP NGHIEN COU Chung toi ghi nhan tat ca cac benh nhan mang van tim nhan tao nhap vien dieu trj npi tru
tai Vien Tim mach Benh vien Bach Mai trong khoang thdi gian ttT 1/2015 den 12/2015. Cac b$nh nhan du'dc lay theo trlnh ttr thdi gian.
Phu'dng phap nghien ciJu: hdi cdu, phan tich, mo ta. Cac thong tin ve benh nhan du'dc thu thap theo mau benh an cu the bao gom; tuoi , gidi, tinh trang lam sang, tinh trang theo doi va lieu thuoc chong dong, ty' Ie INR, eac bien co khien benh nhan nhap vien, thdi gian tiJ" luc mo thay van va loai van du'de thay. So lieu du'dc the hien du'di dang cac bang, bieu do.
III.KETQUA
3.1.Thdng tin chung cua nhdm benh nhan nghien cuii.
Trong vong 1 nam ehung toi ghi nhan eo 312 laenh nhan mang van tim nhan tao da phai nhap vien dieu trj npi tru. Ty le benh nhan nam la 56,2%, so benh nhan nff la 43,8%, dp tuoi tmng binh 55 ± 17. Ty le benh nhan mang van nhan tao cd hpc la 85,36%, so benh nhan mang van nhan tao sinh hpc la 13,64%.
Trong tong so benh nhan noi tren so benh nhan nhap vien trong vdng 1 nam dau sau pliau thuat la 162 (52,27%), sau 1 nam la 150 (47,73%). Nhif vay neu ti'nh tren so trung binh moi nam mo 800 ca thay van nhan tao thi co 20% so benh nhan phai nhap vien vi nhutig bien
CO ngay trong nam dau tien sau mo.Trong so 312 ca nhap vien cd 18 benh nhan tir vong (5,8%). Oac biet so benh nhan tu" vong trong nhom nhap vien trong nam dau tien la 12 benh nhan (7,4%) cao hdn han so vdi nhutig benh nhan nhap vien sau 1 nam dau (4%).
3.2. Ty le cac bi^n chitng chung.
Chi^m ty" le cao nhat la cac bien co lien quan den qua lieu thuoc chong dong mau: 41,3%,
Cac bien chutig khac lan lu'dt la: rdi loan nhjp tim: 16,17%; suy tim 15,17%; nhiem trung 5,72%, thuyen tac mach 3,98%, ket van 2,2%, tan mau 0,75%, cac bien chiiYig nao: 0,75%.
Cd mpt nhdm cac bien chu'ng khac cting xuat hien vdi ty le kha eao (14,9%) la cac bien co khac tuy nam ngoai tim nhutig cung lien quan den tinh trang su" dung thudc chong dong mau nhu*: SLf cd ve thai san, chay mau keo dai sau ehan thu'dng hay sau cac phau thuat khac ngoai tim, va mpt so tru'dng hdp la cac benh Iy tim mach khac nhu" tang huyet ap, dai thao du'dng...
3.3. Cac bieu hien trong nhdm bien chutig qua lieu thudc chong dong mau.
Bieu do 3.1. Cac bieu hi|n trong nhdm qua lieu thudc chong ddng mau
o - * ) — — <
I a QLCEJ
: • XH d a , n i e m m g c I Bi T h i e u m a uXH n a o •;
XH t i e u h o a XH t i e t n i # u j at XH o b i j n g
QLCD: gua lieu thudc chdng dong thehien bang ty ie INR cao, XH: xuat huyet
3.4. O nhom benh nhan thay van cd hoc
bien chutig hay gap nhat la cac bien c±iutig co lien quan den tinh trang thuoc chong ddng khong dat lieu trong do doi vdi cac benh nhan mang van sinh hpc bien <£ chu yeu khien benh nhan phai nhap vien dieu trj la suy tim va roi loan nhip.
Vdi cac benh nhan nhap vien trong narti dau tien sau phau thuat bien co nliiem triJng va ket van cd hpc gap nhieu hdn han so vdi cac.beiili nhan nhap vien sau thdi gian 1 nam. Cac bien chutig khac gap d 2 nhdm vdi ty le tu'dng du'dng.
3.5. Theo doi trong vong 1 ngm dau sau mo thi ty le xuat hien cac bien chtfng lan lu'dt la:
Bien chifng Roi loan niijp tim_
Ty le (%/ngu'dinam) 3,02%
-J^t tim 3.12%
Qua lieu thuoc chong dong _
5,53%Xuat huyet _ Thuyen tae mach_
2,26%
0,84%
+Nhiem trung _Bien chutig cd hoc
Cac_bien chu'ng khac
0,6%Tan mau 2,6
0,15%
Cae bieu hien bat thu'dng than kinh 045%
IV. BAN LUAN
Theo thong ke tren y van the gidi sau mo thay van nhan tao benh nhan thu'dng gap mot so bien chutig lien quan den van nhan tao. f y le bien chutig gap noi chung la vao khoang xap xi 3%/ nam. NhU vay neu so sanh vdi thong ke cua ehung toi cac bien chutig xuat hien d 20% sd benh nhan trong nam d^u tien sau mo ma chung toi ghi nhan du'dc thi ty Ie cua chung toi la tu'dng doi cao,[l-5]
Tren mot nghien cuti gpp da trung tam tren 5837 benh nhan thay van dpng maeh chii sinh hpe ty le cac bien chu'ng hay gap nhat la huyet khdi tren van, thuyen tae mach, xuat huyet, roi loan chut nang van ed hpc khong do huyet khdi vdi t/ Ie lan Iu'dt la 0,03%; 0,87%; 0,38%;
0,38%/ngu'di nam. [6]
Mpt nghien cu\j khac tren 440 benh nhan mang van hai la nhan tao St Jude ty cac bien ehutig thuyen tac mach, huyet Ichdi tren van, xuat huyet lan lu'dt la 0,7%; 0,2%; 1%/ngu'di nam. [7]
Trong thong ke cua chiing toi ty le cac benh
nhan gap bien co qua lieu thudc chdng dong va
xuat huyet vdi ty Ie kha cao. Day la nguyen nhan
hang dau khien benh nhan phai nhap vien dieu
tri npi tru va cung la nguyen nhan gay tif vong
pho bien nhat. Cac thudc chdng ddng loai khang
vitamin K du'dc sd dung cd viJng gidi han dieu trj
kha hep va nong dp cua thudc trong ed the lai
thay doi rat nhieu do cac tac dung cua ehe dp
an. Mae du da co cac khuyen cao phai theo d6i
sat va chat che ty le INR de dieu chinh lieu thudc
chdng ddng dinh ky 2-4 tuan/1 ian, tuy nhien
tren thu'c te do cac dieu kien khach quan dieu
nay khdng phai de dang tiitfc hien du'dc. Mot
phan do dieu kien kinh te cua cac benh nhan da
phan cdn kha kho khan, khong cd du dieu kiSn
de thu'dng xuySn tai kham. M?ng lu'di y te tuy§n
ed sd hoac md hinh y te gia dinh, dac biet d cac
dja phu'dng vung sau vung xa, cting chu^ du
phat trien de cd the gop phan theo doi va tu" van
chat che ve su" dung thuoc chong ddng cho cac
benh nhan nay. Chinh day la mpt trong nhu'ng
TAP CHi Y HQC VIET NAM TAP 45Q • THAHG 1 • SO 1 - 2017 han ehe Idn khien cho cac bien cxi ve qua lieu
thudc chdng ddng va xuat huyet tren cac benh nhan cua chung toi gap vdi t y le cao hdn dang ke so vdi cac bao cao da ghi nhan tren the gidi. [1,2]
Suy tim va cac roi loan nhjp sau phau thuat cung la nhutig bien chutig phd bien thtr hai hay gap. Suy giam chu'e nang tam thu that trai sau md CO Itie lien quan den cac yeu t d sau: suy GhCrc nang that trai chu phau keo dai hoac nang hdn len sau m d , nhijtig ton thu'dng thieu mau ed tim trong qua trinh m d , t o n thu'cing cac van tim khae nang hdn, roi loan hoat dpng cua van nhan tao, cac benh tim khac piioi hdp nhu' benh ly mach vanh , tang huyet ap. £)ac biet trong thdng ke cua ehung tdi eac benh nhan nhap vien vi cac rdi loan nhjp tim cGng gap vdi t / le kha ldn. Dieu nay co the mpt phan do eae benti nhan sau md chu'a du'de theo doi va quan Iy chat che.
Chung toi cung nhan thay co mpt sd cac benh nhan mang van nHSn tao khi dang su'dung thuoc chdng ddng phai nh$p vien vi cac bien cd kh6ng lien quan den cac b^nh ly tim maeh n h u ' : mang thai ngoai y muon, ehan thu'dng hay phau thuat khac ngoai tim gay chay mau keo dai.
Nguyen nhan d i n den tinh trang nay ed Ie do benh nhan khi nhap vien do cac irenh ly khac da thieu thdng tin y t e ca nhan can thiet (dac biet la tinh trang dang dijng thudc chdng dong mau) de du'de XLf ly kjp thdi.
Ngoai ra cac bien chu'ng khae ma chung tdi ghi nhan trong thdng ke cua minh cung la nhu'ng bien chutig kinh dien da du'dc nhac den trong y van nhu'; thuyen tac macli h$ thdng, nhiem hTjng, ket van nhan tao do huyet khdi hoac do pannus, viem ndi tam mac nhiem trung van nhan tao....[l-5]
Nliu" vay cd the thay neu so vdi nhutig bien chu'ng cua benh nhan mang van nhan tao hay gap da du'dc bao eao thi md hinh benh ly 6 Viet Nam ma chung tdi ghi nhan du'dc cd mot vai diem khac biet. Chung tdi gap nhieu nhat-nhutig bien chutig ed lien quan den tinh trang su" dung thude chdng ddng mau khdng phi!i hdp va day cung la nguyen nhan phd bien nhat gay tLf vong cho benh nhan. Ngoai ra cae bien cd rdi loan nhjp tim va suy tim sau m d cung kha thu'dng gap, Dieu nay cd le do dac diem
De gdp phan khac phuc cae bien chifng nay, chung tdi xin de xuat mpt sd giai phap:
- Cd ehu'dng trinh quan ly benh nhan sau md thay van nhan tao.
- Thiet lap cac ddn vl khang dong, dieu chinh cac rdi loan ddng mau vdi cac du'dng day
ndng, khuyen khieh benh nhan su' dung may thif ddng mau tai nha ( Coagucheck).
- Tang cu'dng hieu biet cho cac benh nhan mang van nhan tao va silf dung thudc khang ddng du'dng udng (sach v d , truyen thdng...)
- Cd the ID cho benh nhan mang tiieo ngifdi ve tinh trang mang van nhan tao va cd sd dyng thudc khang ddng de dung khi benh nhan can cae can thiep y te khae.
V . KET L U A N
Qua ghi nhan sd lieu trong vdng mot nam tij"
cae benh nhan sau mo thay van nhan t?o phai nhap vien dieu tri npi trti chung tdi thay: ty le gap cac bien chu'ng va td vong kha cao. 2 0 % cac benh nhan sau phau thuat phai nhap vien dieu tri ndi tru trong vdng 1 nam dau tien sau md, trong sd dd t y le tu" vong la 7,4%. Cac bien cd hay gap nhat la roi loan ddng mau, xuat huy€t nang, suy tim, rdi loan rihjp t i m . Trong d d qua lieu thudc chdng ddng mau la nguySn nhan phd bien hang dau va la nguyen nhan gay td vong cao nhat. De han che bien chu'ng dd chung tdi de xuat mdt so,giai phap: xay dtfng md hinh phong kham khang ddng vdi may Coagucheck, ca the hoa dieu trj vdi lieu phap gen, phat the ID card ve ti'nh trang siJ dung chdng ddng cho benh nhan.
TAI UEU THAIVI KHAO
1. Vongpatanasin W, Hillis LD, Lange RA. "RosUiEte heart valves". N BigiJ Med 1996; 335:407.
2. Hammermeister KE, Sethi GK, Henderson WG, et al. "A comparison of outcomes in men 11 years after heart-valve replacement with a mechanical valve or bioprosthesis. Veterans Affairs Cooperative Study on Valvular Heart Disease." N BnglJ Med 1993; 328:1289.
^ . Bloomfield P, Wheatley DJ, Prescott EU, Miller HC, 'Twelve-year comparison of a Bjork- Shiley mechanical heart valve with porcine bioprostheses" N EngiJ Med 1991; 324:573.
4. Yacoub M, Rasmi NR, Sundt T M , et aL
"Fourteen-year experience with homovital homografls for aortic valve replacement". J
Thorac Cardiovase Surg 1995; 110:186.
5. O'Brien MF, Stafford EG, Gardner MA, et al.
"Allograft aortic valve replacement: long-term follovi/-up". Ann Thorac Surg 1995; 60:565.
6. Puvimanasinghe 3P, Steyerberg EW, Takkenberg JJ, et al. "Prognosis after aortic valve replacement with a bioprosthesis:
predictions based on meta-analysis and microsimulation". Orcuiadon 2001; 103:1535.
7. Remadi JP, Baron O, Roussel C, et al.
"Isolated mitral valve replacement with St. Jude medical prosthesis: long-term results: a follow-up of 19 years". Circulation 2001; 103:1542.
