D A O T A O L I E N T U C k.
Triet dot roi loan nhjp tim bang nang ifldng sdng cd tan so' radio qua dfldng catheter
TTiS. Phan Dinh Phong - TS. Pham Quoc Khanh V/ien Tim mach Viet Nam
MAD£U
Trilt ddt cic rdi loan nhip tim sfl dung ning Ifldng sdng cd tan sd radio qua dfldng dng thdng tim (radioirequency catheter ablation - thfldng gpi ii ddt dien) dfldc xem la mpt trong nhiing thanh tflu ndi bat nhat cua chuyen nganh rdi loan nhip trong hdn ba thap nien qua. Tfl mpt ky thuat mang tinh thfl nghiem vao nhflng nam 80 aia t h i ky trflde da phat trien nhanh chdng thinh phfldng phip dilu tri dfldc Ip dung rdng rai d cie trung tim tim m?tch tren pham vi toin t h i gidi 10 nam sau dd va hien nay li Ifla ehpn hang diu trong dilu tri nhieu loai rdi loan nhip tim khic nhau.
Ky thuit ddt diln di;fa tren ed sd sfl dung nhiing dng thdng (catheter) chuyin bilt ludn vao trong eic budng tim de triet bd dinh khu cac cau true tim mach can thilt cho vile khdi phit va duy tri cie rdi loan nhip tim.
Trong nhflng nam diu d giai doan mdi phit trien ky thuit, dot diln sfl dung ddng diln mpt chieu vdi hi?u di|n t h i cao phdng trfle tilp vio cac eau true tim maeh (DC shock)
vdi nhilu han chi vl mat ky thuit vi ti le biin chu!ng cdn cao. Sau dd, nang Ifldng tin sd radio (radiofrequency energy) da dfldc sfl dung de thay the ddng dien mpt chieu va trd thanh loai nang Ifldng phd bien trong cac thu thuat ddt diln hiin nay. Bin canh ning Ifldng tin sd radio, cic loai ning Ifldng khac nhfl silu im (ultrasound), vi sdng (microwave), nhiet lanh (cryothermal enery), tia lazer... cung dang dfldc nghien cflu flng dung tiong dilu tri rdi loan nhip tim.
Cd sd vlt ly eua ddt diln la nang Ifldng sdng radio cac vdi dao ddng tan sd rat cao (khoang 500 KHz tflc 500 000 dao ddng/ giiy) di vao vung md tim tiep xue vdi diu dng thdng, eac ion trong rad tim se dao ddng theo vi sinh nhiet do ma sit gly ting nhilt dp. Khi nhiet dp tang Iln tdi 60-70 dp C se glytdn thfldng protein khdng hdi phue va do viy giy mit die tinh sinh hoc cua md tim, diy la cd sd cua vile triet bd cac d ngoai vi hole cic dfldng dan truyin bit thfldng ddng vai trd la cd chit giy rdi loan nhip tim. Cic nghien cflu eho thiy, chinh vi dao ddng vdi tin sd rat nhanh nen nang lupng tan so radio khdng TAP CHi TIM MACH HOC VIET NAM - 5064.20131 61
A DAO TAO LIEN TUC
kich thich tim gay cac rdi loan nhip vi khdng giy cam giic dau cho ngfldi benh. Die tinh gly ndng md bang ma sit do dao ddng cua cic ion chfl khdng phli truyen nhiet trfle tilp qua dau dng thdng cho phep khu tru tdn thUdng md tim trong vdng vii milimet dfldng kinh va dp siu nen vile triet ddt rit dac hilu vi an toan. Qua trinh ddt diln dfldc kilm soat bdi ddng thdi nhieu thdng sd nhfl cfldng dp nang Ifldng dot, nhiet dp va dien trd md... he thdng ngat ttf ddng se dfldc kieh hoat neu cic thdng sd nay vfldt qua ngfldng an toin dfldc cai dat. Thfldng thi cfldng dp nang Ifldng ddt thay ddi tfl 10-50 W, nhiet dp dau dng thdng ddt dfldc duy tri khoing 60-70 dp C vi trd khang md dao ddng tii 80-120 Ohm.
Hinh 1: LUi^c dS md td dUdng kinh vd d^ sdu tdn thUOng md tim gdy ra do ndng lUdng tdn so radio. Dudng kinh ton thuang: S-10 mm, viing cd tim bj dot nong nhdt co dd sdu khodng 1 mm.
62 ITAPCHiTiMMACH HOC VIET NAM-$064.2013
DAO TAO LIEN TUC 1^
Hien nay, dot dien dfldc ehi dinh cho phan Idn eic rdi loan nhip tim nhanh. So vdi dilu tri npi khoa kinh dien vi cac phfldng phip khic, ddt diln l i dilu tri mang tinh triet dl, an toin va cd Idi ve tinh chi phi-hieu qui, die bilt vl mat dii han.
CHi DjNHVACHONB CHi DINH
1. Chi dinh
Chi dinh chi tiet cua thu thuit ddt dien se dfldc d l cap trong tflng chuyin d l cu t h i trong cudn sich nay. Chi dinh dot dien trflde hit diia tren tinh hieu qua - nguy cd cua thu thuit va tiep dd la sfl Ifla chon cua benh nhan trong trfldng hdp dilu tri thudc van cd kit qui.
Hiin nay, cd ba chi dinh dtidc xip logi I (khuyin cdo dp dung):
Cdc cdn tim nhanh trin that (supraventricular tachycardia) co trieu chdng do cdc cO chi.
- Tim nhanh vao lai nflt nhl thit.
- Tim nhanh vao lai nhi that qua dfldng din truyin phu (hpi chflng WPW)
- Tim nhanh nhi mdt d khdi phat - Cudng nhi (d|c bilt cudng nhi diln hinh b i n phii)
Rung nhl gdy trieu chting vd khong dap dng vdi it nhdt mot thuoc chdng rdi logn nhip tim, bao gdm hai ky thudt:
' Cd lap eic tinh mach phdi kit hdp vdi cic ky thuat triet ddt khic frong nhi trai/phii.
- Cat ddt bp ndi nhi that nham khdng che tin sd that.
Tim nhanh thdt co trieu chiing, bao gom:
• Tim nhanh thit vd can
- Tim nhanh that tren nIn benh tim thUe tdn: trong trfldng hdp dieu tri ndi khoa khdng hi^u qui hole b^nh nhin khdng dung nap dfldc
thudc chdng rdi loan nhip hoac d benh nhan d l ciy may pha rung tfl ddng (ICD) nham giim sd Iln phai shock diln.
Cdc tnidng hdp khdc co thi chi dinh dot diin:
- Nhip xoang nhanh giy trilu chflng vi khdng dip flng vdi dilu tri ndi khoa.
- Ngoai tim thu thit hole nhi gly trilu chflng, inh hfldng din chit Ifldng cude sdng.
- Nhip nhanh bp ndi cd trieu chflng Cdc chi dinh dang diidc nghien cdu:
- Tim nhanh that da hinh thii - Rung that
2. Chdng chi dinh:
Cdc chdng chi dinh chung cua cdc thu thugt tim mgch can thiep khdc:
Nhiem trung tien trien, b?nh ly ndi khoa nang, rdi loan ddng mlu nang...
Mgt so chdng cht dinh dgc thu:
- Huylt khdi trong nhl trii, thit trii li chdng chi dinh ciia ddt diln trong cac budng tim ben trai.
- Van nhan tao la chdng chi d;nh vdi eac ky thuit ddt diln can phai dfla dng thdng qua van.
- Phu nfl cd thai (vi nguy cd nhilm tia X cho me va con).
CHUAN BIGENH NHAN
Chuan bi binh nhin trflde thu thuat eung tfldng tfl nhfl thu thuat tham dd dien sinh ly hpe tim. Benh nhin dfldc tham khim llm sing, ghi diln tam dd 12 chuyen dad, xet nghilm cdng thflc mau, ddng miu cd ban, sinh hda mau (chflc ning thin, dien giii dd...), Iim silu am tim va eac tham dd can thiet khic.
B|nh nhin phai ngflng cac thudc chdng loan nhip hole ed inh hfldng tdi dac tinh diln sinh ly tim it nhit 5 Hn thdi gian bin huy cua TAPCHITIMMACH HOCVIET NAM-SO 64.20131 E
A DAO TAP LIEN TgC
thudc trflde thu thuat.
Ngflng eie thudc chdng ddng hole dilu chinh Ueu vl gjdi han an toin nhim tranh nguy ed ehiy mau.
B|nh nhin cd t h i In nhe vio bfla In trflde gid Iim thu thuat trfl trfldng hdp eIn phii gay me toin thin (ddt rung nhi...).
Benh nhin phai ky giiy cam kit trflde khi tiin hinh thu t h u i t
Vd cim ehi can giy te tai chd bang Udocain.
Giy me toin thin tiong trfldng hdp b?nh nhan la tri nhd hoac trong mdt sd thu thuit ddt diln keo dai nhilu gid (nmg nhi, tim nhanh thit).
KYTHUAT
Thu thuit ddt diln dfldc tiin hinh trong phdng thdng tim (catheterization laboratory) vdi eic trang thilt bj chuyen dyng nhfl may chup mach vdi man ting sing, he thdng tham dd diln sinh ly hpe tim va miy phat ning Ifldng tan sd radio.
Thdng thfldng, dot diln se dfldc tien hinh ddng thdi vdi thu thuit tham dd diln sinh ly hpe tim.
2 d i n 5 dien eflc chan doin (diagnostic catheter) se dfldc dfla vio eic budng tim qua dfldng tinh mach dui ben phii va tinh maich dfldi ddn ben trai. Cie vi tri dat diln eflc chin doin bao gdm: dien ctfc vung cao nhi phii, vung mdm thit phii, diln cflc bd His, diln cflc xoang vanh.
Cung vdi dien tim dd b l mat 12 chuyin dao thdng dung, viec ghi cic diln do tiong budng tim va kich thich tim theo chfldng tiinh cho phep chan doan chinh xie cd che, bin chit cac rdi loan nhip tim vi die bilt l i cae cd chit gay rdi loan nhip (substrate), dd cd t h i li mdt d ngoai vi d tam thit hoic tim nhi hoaic cd the la mpt dfldng dan truyen bit thfldng.
Khi ed chat eua rdi loaji nhip da dfldc xac dinh, mdt loai dng thdng khic se dfldc sfl dung la cac dng thdng ddt (ablation catheter), dfldc thiet k l die bi|t de vfla cd the ghi dfldc eac diln dd vfla dfla ning Ifldng tan sd radio vio eac md tim ndi dau diln cflc tilp xue. Die tinh cd thi gap dudi dfldc (steerable) cua dng thdng cho phep cic bic si can thilp ed t h i ludn dng thdng ddt vao cie vi tii khic nhau trong cic budng tim ndi ed ed chit gay loan nhip d l triet ddt.
Hmh 3: Mdy phdt ndng luong tdn sd radio, vdi cdc nut dieu chinh vd mdn hinh hiin thi cdc thdng so triet dot:
nhiet do, trd khdng mo, thdi gian ddt.
64 ITAPCHITIMMACH HOCVIET NAM-S664.2013
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Hmh 4: Dau dng thdng ddt (ablation catheter), bdn diin cUc ddu xa co do ddi 4 hogc 8 mm, Id noi tiip xue vdi mo tim duoc triet ddt
Ong thdng tri?t dot trong cac budng tim b i n phli thfldng dfldc dfla qua dtfdng tinh mach dui b i n phii. Ong thdng trilt ddt trong cac budng tim b i n trii ed the dtfa qua dtfdng dpng maeh dui trai di ngtfdc ddng vao thit trai qua dpng mach ehu hole qua dfldng ehpe xuyen vach liln nhi.
1. Trilt dot dfldng dan truyen phu trong Hdi chntng WolfF-Parkinson-White (WPW) va cdn tim nhanh v i o lai nhl thlit.
Hdi chflng WPW Uen quan tdi sfl tdn tai mdt dfldng din truyin bit thfldng (dfldng din truyin phu - accessory pathway) ndi Uen tam nhi va tam that b i n canh dfldng din truyin binh thfldng qua nut nhi that. Trong trfldng hdp dien hinh, dfldng dan truyen phy cd the dan truyin xung dpng theo chieu xudi tfl nhl xudng that hoac ca hai chieu, di|n tam do be mat die trflng bdi khoang PR ngin (< 120 ms), phflc bd QRS gian rpng (> 120 ms) va sdng delta d diu phflc bd QRS. Dfldng din truyin phu chi din theo chieu ngfldc tfl that len nhi gpi li dfldng In (concealed accessory pathway).
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Hinh S: Di$n tdm do be mat cua hdi chdngWPW diin hinh vdi dudng ddn truyen phu d vung trUdc vdch bin phdi.
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Bilu hien llm sing cua hdi chflng WPW l i cic cdn tim nhanh vao lai nhi-diat thdng qua dfldng din truyin phu. Binh thfldng xung dpng phit ra tfl nut xoang gay khfl cflc hai t i m nhl trflde sau dd di qua nflt nhi that gay khfl cflc tam that rdi tfl t i t Khi tdn tai dflcftig d i n truyin phu, xung ddng niy se di ngfldc qua dd, vio lai tim nhl gly ccfti nhip nhanh vdi tan sd ti^ 140-220 ck/ph. Mat khic, hpi chflng WPW die bilt nguy hiem trong trflcflig h<^ rung nhi, cie n m g dpng tan sd rat cao tfl tam nhi se di qua dflcftig din truyin phu xudi^ khfl ctfc tim that lam tam that d i p rat nhanh (co the Iln tdi 300 ck/ph) giy tut huyet ip, ed khi tfl vong.
u j a a a x j a X u a j j a j j j U ! ^ ^
Hmh 6: Can tim nhanh vio lai nhi thdt (AVST). 0 chuyen dao VI nhm ro sdna P din truyen nguifc di sau phdc bd QRS vdi RP<PR.
Ky thuit triet dot dudng dan truyen phu diJa tren viec dua dan ong thong dot tSi tiep luc v « mot diem tren vong van hai la hoac ba la ndi co dudng d i n truyen phu di qua. Tiep can vong van ba la bing d u t o g tinh mach dui, tiep can vong van hai 14 bang dudng ngUOc dong dpng mach chu qua dong mach dui hoac qua dudng xuyen vach hen nhi. Dudng dan truyen phu duoc djnh vi (mapping) dUa vao cac dien do trong buong tim trong luc nhjp loang, trong luc con tim nhanh vao lai nhi t h i t hoac trong luc tao nhip that va dUa v i o hinh anh giai phau trin X quang.
I I TAP CHi TIM MACH HOC VIET NAM-$064.2013
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Hmh 7: Vt tri cdc ong thdng tren hinh dnh X quang trong triet ddt dudng ddn truyen phg: NP: diin cUc cimg cao nhi phdi, His: di$n cUc vi tri bo His, XV: dien aXc xoang vdnh, TP: di$n cUc mom thdt phdi, Abl:
diin aic tnit ddt duoc dUa vdo thdt trdi ngUOc chii'u qua van dgng mgch chd vd cam vdo vong van hai la ndi CO dudng ddn truyen phu nhi-thdt di qua.
Hmh 8: Triit dot dudng ddn truyen phu dien hinh trong luc nhip xoang. Kit qud xudt hiin ngay sau 372 ms (hit hinh dnh WPW), diin do vi tri dich (trong d vudng do) co song nhi di trUdc vd trdn Idn vdi song thdt.
TAPCHITIMMACH HOC VIET NAM-5064.20131 67
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Hmh 9: Triit dot dudngd&n truyin phu dim hinh trongluc tgo nhip thdt phdi. Kit qud xudt hiin ngay sauS40ms (xudt hien hinh dnh phdn ly thdt-nhi), diin do vi tri dich (trong 6 vudng do) cd song thdt di trUdc vd song nhi di ngay sdt sau song thdt
Ti 11 thinh cdng efla phfldng phap ddt dien trong hpi chiing WPW cd t h i dat tdi 90-95%, ti le tii phit thfldng thap < 5%.
2. Cdn tim nhanh do vong vao lai vflng not nhi that
La loai tim nhanh kich phat tren that thfldng gap nhat tren lam sing. Cd chat cua rdi loan nhip niy li sfl tdn tai dfldng din truyen kep d vung nut nhi thit vi rad nhi lin can bao gdm mdt dfldng dan truyin nhanh (fast pathway) v i mdt dfldng din truyin ehim (slow pathway). Khi ed dilu kiln thu|n ldi ve diln hpe (nhfl ed ngoai tim thu), xung ddng di qua dfldng ehim cd the quay lai dfldng nhanh khep kin mpt vdi^ vio lai gly cdn tim nhanh vctt tan sd tfl 120-240 ck/ph.
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Hinh 10: Diin tdm do be mat cua can tim nhanh vdo hi nh thdt kieu chdm-nhanh. Khdng thdy ro Unh dnh sdng P do bi Idn vdo phdc bp QRS.
68 I TAP CHi TIM MACH HOC VIET NAM - 5064.2013
DAO TAO LIEN TUC fc.
Dieu tri cdn tim nhanh vio lai nut nhi diat dfla trin cd sd viec triet dot mot trong hai dfldng d i n truyen qua nut nhi that, dfldng nhanh hole dfldng cham. Ngay nay, hau het cac trung tam tim mach tren t h i gidi deu ddng thuan vi$c triet bd dfldng ehim vi cd ti le thanh cdng cao hdn vi it biin chflng gay bloc nhi that hdn. (3ng thdng ddt se dfldc dfla qua tinh mach diii tdi vi tri trilt ddt dfldng din truyin cham d vung md nhi phai nam gifla bd van hai la vi Id xoang finh mach vinh, cich nut nhl that khoang 1-2 cm (edn gpi la vflng diy tam giac Koch). Xac dinh vi trf dfldng cham dfla vao dien dd ghi dtfdc tai dau diln cflc ddt vi hinh anh giai phiu tiin X quang.
Hinh 11: Vi tri cdc dng thdng trin hinh dnh X quang trong tri^t dot dudng chgm d tU thinghiing trdi 30 do (trdi) vd nghiingphdi 30 d$ (phdi): NP: diin cUc cung cao nhl phdi, His: diin cue vi tri bo His, XV:
dien cue xoang vdnh, TP: diin cUc mom thdt phdi, Abl: diin aic triit dot dupc dUa vdo viing day cua tam gidc Koch, dudi vi tri diin aic bo His khodng 2 cm vd ngang mdc vdi lo xoang vdnh.
Htnh 12: Triet dot dudng chgm. Diin do vi tri dich (trong d vudng do) hinh dnh song nhi nhieu thdnh phdn, bien dd thdp di trUdc song thdt, tl le hiin do song nht/thdt Id 1/5. Kit qud triit dot dudng chgm thdnh cong the hiin bdng sU xudt hiin nhip bg noi gta toe ngay sau khi phdt ndng lUdng tdn sd radio.
TAP CHi TIM MACH HOC VIET NAM - SO64.2013!
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Tl le thinh cdng cua phfldUg phap ddt dien trong trfldng h ^ nay co the len tdi 98-99%, biin chflng bide nhi that rat hiem gap (khoing 1%).
3. Cuong nhi va tim nhanh nh! ddn 6
Cd chi II do ele vdng vio lai trong cd nhl hoic cic d ngoai vi bat diflcAig d nhi trii hoac nhl phai Ddt diln cic rdi loan nhip niy dfla trin cd sd cat dut eic vdng vio lai hoic triet bd cac 6 ngoai vi. Triet ddt trong nhi phii dfldc thflc hien bing each du^ dng thdng dot qua dfldng tinh mach dui, trilt dot troi^ nhi trii can phii chpc vich Uln nhi hoac hion dng thdng tfl nhl phli qua Id bau due Hien nay, ddt dien dieu tii cic edn cudng nhi (nhat l i cudng nhl khdng dien hinh) v i tim nhanh nhi dfldc difle hien di ding hdn nhd he thdng lip b i n dd diln hpe vi giii phau ba chieu cic budng tim (CARTO, En Site...). He thdng se tii tao die dilm gili phiu tim nhi eiing nhfl trinh tflho^t hoi diln hpe trong cdn nhip nhanh, do viy giup cho vile xac dinh cd chat giy rdi loan nhip mpt each chinh xie. Cac tdng kit tfl nhieu trung tim cho thiy, hien nay ti le thanh cdng cua ddt diln tiong dieu tri cudng nhi diln hinh dat tdi 90-95%.
Hinh J 3: Vitri cdc dng thong trin hinh dnh Xquang trong triit dot cudng nhl dtin hinh: NP: dien cUc cdng cao nhl phdi. His: dien cUc vi tri bo His, X\': diin cue xoang vdnh, HALO: dipt cUc trong budng nhtvdi nhieu cap diin ctic, Abl: diin cUc triit dot dUOc dUa vdo vung eo van ba Id (ishmus) ndm d viing day nhi phdi
70 ITAPCHiTiMMACH HOCVIETNAM-S664.2013
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4. Tim nhanh that ddn dang va ngoai tam thu that
Phin Idn ed ngudn gdc tfl dfldng ra that phii hoaie d vich Uen that b i n tiii, thfldng xly ra trin nhiing ngfldi khdng cd benh ly tim mach thflc tdn. Cdn tim nhanh that cd ngudn gdc tfl dfldng ra thit phii bieu hien trin diln tim dd vdi QRS ed dang bide nhinh trii vi true dien tim quay xudng dfldi, cdn tim nhanh that cd ngudn gdc tfl mat trii vach hen thit cd diln tim do vdi dang bide nhinh phai va true diln tim htfdng Ien tren. Ngoai ra, tim nhanh that/ ngoai tim thu thit vd can edn ed t h i khdi phat tfl nhflng vj tri khie nhfl xoang Valsalva, tren van ddng maeh phdi, vdng van ba ll, vi tii canh bd His, vdng van hai la...
Trilt dot cie edn tim nhanh thit dfldc thflc hien bing cich dfla dng thdng ddt vao trong cac budng thit qua dfldng tinh maeh hole dpng mach dui hole qua dfldng xuyen vach lien nhi. 0 ngoai vi dflde xie dinh bang vi tri ghi dfldc diln the hoat hoa npi mac sdm nhat (earliest activation mapping) hoae bang phfldng phip tao nhip (pace mapping).
Hinh 14: Vi tri cdc dng thdng tren hinh dnh X quang trong triit dot ngogi tdm thu thdt khdi phdt tii dudng ra thdt phdi tren goc nghiingphdi 30 dd:
Pig: dng thdng Pigtail chup buong thdt phdi, Abl: diin cUc triit dot du^c dua vdo viing dUdng ra thdt phdi, ngay dudi van dong mgch phoi
TAPCHITIMMACH HOC VIET NAM-5064 20131 71
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Hmh IS: Triet ddt ngoai tdm thu thdt khdi phdt titdudngra thdt phdi Xac dinh vi tridkhdiphdt bdng phuong phdp tao nhip thdt (pace mapping). Ddu dim cue dot da dot dung vdo d ngoai vi nen khi too nhip qua dim cue dot segdy ra duac cdc phdc bo QRS giong vdi ngoai tim thu xudt him tii phdt 12/12 diuyen dao.
Hmh 16: Vl tri cdc ong thong tren hinh dnh X quang trong triit ddt ngoai tdm thu that khdi phdt td xoang VaMva trfe goc nghieng trdi 30 do: XV: diin cue xoang vdnh. Pig: ong thing Pigtail chup xoam.
Valsalva, AU: dim cue tnet dot duac dUa vao trong long xoang Valsalva U vdnh trdi, phiu tren iLdm 1
cm la to xudt phdt cua thdn chung dong maeh vdnh trdi. *
72 I TAP CHI TIM MACH HOC VIET NAM - 5064.2013
DAO TAO LIEN TUC k
Hinh 17: Triit ddt ngogi tdm thu thdt khdi phdt tii xoang Valsalva Id vdnh trdi. Xdc dinh vi trio khdi phdt bdngphUdngphdp ghi dien the sdm nhdt. Diin thi thdt ghi dUdc d vi tri ddu diin cue ddt sdm hdn phdcbd QRS tren dien tdm do be mat SI ms.
Hien nay, ti le thanh cdng efla ddt diln ddi vdi cie cdn tim nhanh thit ddn dang/ ngoai tim thu that vd can vao khoing > 90%.
Ddi vdi cie cdn tim nhanh that tiin nen benh tim thilu miu cue bd, do ed chit gay loan nhip phflc tap, Uen quan den ele vung ed tim thieu mlu hole td chflc seo sau hoai tfl cd tim nen ky thuat triet ddt thfldng quy nhfl tren gap khd khan va cd ti I? thanh cdng thap. Hi|n nay, sfl dung he thdng lap b i n do dien hpe vi giii phau ha chilu se xac dinh vung cd tim hda seo
d tam thit giup dinh hfldng eho thu thuit Hinh 18: Hinh dnh tdi tgo tren khonggian ba chieu bdn . -i^ j ' l . i-" - „• ™,,^-us« ^.,«i, *.-i« do sidi phdu-dien hoc buong thdt trdi vdi viingseo cOtim tn^t dot, tiep can ngoga mac ben canh tiep £ f ; > , ,r^ ,. ^ ,... . ' ,.
^ d vung trUdc rong (mau do), la cO chat gay ra con tim can ndi mac da giup ning cao ding kl ti ll ^}^^^^ ^^^^^ ^flc cham mdu do Id cdc dUm triet dot xung thanh cdng. quanh viing td chiic seo.
TAP CHi TIM MACH HOC VIET NAM - 5064.20131 73
-* DAO TAO LIEN TUC
5. Rung nhi
Ky thuit ddt dien trong rung nhl dfla tren ed sd tii tao hinh inh giii phlu ba chilu tim nhl trai vi cie tinh maeh phoi, viec kit hdp ky diuat tai tao dfla tren catheter vdi hinh Inh ehup cit Idp vi tinh da dly (MSCT) giiip tii tao hinh anh giai phlu chinh xac va chi tilt hdn.
Ddt diln dfldC chflng minh hilu qui cao nhat ddi vdi cae cda rung nhi kich phat Cd chit chfl yeu l i eie d ngoai vi nim troi^ eie tinh mach phdL Ky thuat triet dot dfla trin cd sd cat dflt cac sdi cd tim ndi Uln gifla tim nhi vi cic tinh mach phdi de cic d ngoai vi khdng the phat xung dpng Ian vao tim nhi triL
Triet dot trong tam nhi trii thfldng sfl dung cic dng thdng vdi eic Id b i n d l truyen dich lam lanh md nhi (irrigated catheter hay cool-flow catheter), cdng nghe niy giup cho nang Itfdng tin sd radio cd the truyen dfldc siu hdn vio md nhi giy nIn cie tdn thfldng xuyen thanh (transmural lesion) nhd viy ed the cd lip dfldc triet d l hdn cac finh maeh phdi. Ben canh dd ddt diln ket hc^
tfldi lanh giup Iim giim ding ke ti le bien chflng thflng tim nhi.
Htnh 19: Ddu dng thong ddt vdi cdc IS bin ditUdi dich lam Ignh mo (irrigated ablation catheUr), catheter ndy CO thi giup dUa duOc ndng luOng tdn sd radio thdm sdu hon, tgo nin nhang tdn thuong xuyin thdnh tdm nht
Tl le thinh cdng cua thu thuit ddi vdi rung nhi kich phit theo tdng kit tfl cic trung tam la khoing 70-85%.
Ddi vdi rung nhl dai ding va man tinh, ben canh cae d ngoai vi, Cd chat cdn cd Sfl tham gia eua cac vung md d nhi tiii, ky thuit tiiet dot thfldng phii ket hdp them cac dfldng ddt cd lip khac trong nhi trii gidng nhfl phiu thuat Maze (Unear ablation) vi/hoac tiiet ddt cae vung md nhi ed phflc bp dien hpe phan minh phflc tap (CFAE hay CAFE).
74 I TAP CHi TIM MACH HOC VIET NAM - 5064.2013
DAO TAO LIEN TUC h.
Hinh 20: Hinh dnhtdUgobatrinlchdng gian ba chii'u tdm nhi trdi vd 4 tinh mgch phoi. Ky thudt triet dot rung nhi kjch phdt du trin cd lap 4 tinh mgch phoi bdng cdc dudng dot dien Uen tiip nhau (cdc cham mdu dd).
Ti 11 thinh cdng efla ddt di|n ddi vdi rung nhi mstn tinh thap hdn (khoang 50% hoac thap hdn). Khoang 25% sd benh nhan can 2 hoac nhieu hdn sd lan lam thu thuat mdi cd the duy tri nhjp xoang hieu qui. Mac du da ed rit nhieu tien bd vl ky thuat vi cdng nghe ddt diln, rung nhi man tinh van edn 11 mdt thich thfle Idn vi ddi hdi tilp tuc ed nhflng nghien cflu eli tien ky thuit tiong tfldng lai.
BIENCHUfNG
Bien chflng n|ing cua dot dien gap tiong khoing 3% sd ca thu thuit vi tiiy thupc nhieu vao loai chi dinh. Ti le bien chflng cao hdn d cac thfl thu|t dilu tri rung nhi, tim nhanh thit vi nhin ehung rat thap d eac trfldng hdp tim nhanh tren thit. Trong dd, tai biin tac mach, huyet khdi chilm khoang 1%, tfl vong chiem khoang 0,1-0,2%.
1. Cac biin chflng tai tim:
- Block nhi thit dd cao
- Thung tim giy tiin mlu ming tim (cao nhat d thu thuat dot diln rung nhi: khoing 3-6%).
- Tac dpng maeh vanh, co that ddng mach vanh - Viem mang ngoai tim
- Tdn thfldng van tim 2. Bien chflng mach mau
- Chly miu vio phuc mac - Tu mlu chd chpc mach - Tdn thfldng ndi mac mach mau - Tai biin mach nao - Tut huylt Ip
- Tie mach do cue mau ddng hay do khi 3. Bien chflng phoi
- Tang i p ddng maeh phdi, ho mlu do hep tinh mach phdi (sau ddt diln rung nhi)
- Tran miu mang phdi (thfldng Uln quan den chpc tinh maeh dfldi ddn)
TAP CHi TIM MACH HOC VIET NAM - SO 64.20131 75
- DAO TAP LIEN TUC
4. Cac bien dning k h i c - Nhiem trung tai \ i tri chpc mach - Dd nhi trii - thflc quin (die biet trong ddt - Rdi loan nhip tim
mng nhi) 5. Nguy cd n h i l m xa
- Kich dng da. diy - Nguy cd nhilm xa cua thu thuit ddt dien - Liet cd hoanh nhin chung li thap.
-Bdng da do tia X
TAI LIEU THAM KHAO
1. David J. Wilber, MD, Doagjas L. Packer, MD, William G. Stevenson, MD (2008)
Catheter Ablation of Cardiac Arrhytiimias-Basic Concepts and QiniailAp>pIiciafions. Third Edition. Blackwdl Futura publishing company.
2. Francis D. Mnrgatroyd (2002)
Handbook of Cardiac Electrophysiology - A practical guide to invasive EP studies and Catheter Ablation.
Remedica Pulishing.
3.IgorSinger(l997)
Interventional Electrophysiology. Williams-Vfilkins publishing company.
4. Mohammad Shenasa, MD, Gerhard Hindricks, MD, Martin Borggrefe, MD, Gonter Breithardt MD(2009)
Cardiac Mapping. Third edition. TA^ey-BlackweU publishing company.
5. Roberto De Ponti, MD (2008)
From Signals to Colours: A Case-based Atlas of Electroanatomic Mapping in Complex Atrial Arrhythmias.
Springer.
76 ITAPCHITIMMACH HOCVIET NAM-SO64.2013