DANH GIA KET QUA PHAU THUAT THAY VAN TIM NHAN TAO TAI VIEN TWQD 108 - BIEN CHUYJG VA CAC YEU TO LIEN QUAN T0I
VIEC sur DUNG THUOC CHONG DONG
TOM TAT
Md dau: Benh van tim mac phai la nhom benh pho bien tai Viet Nam. Oa so benh nhan den kham thudng 6 giai doan nang va so benh nhan phai thay van nhan tao chiem ty le con cao.
Vi vay, viec theo doi ket qua phau thuat thay van tim nhan tao cung nhU tim hieu cac bien chu'ng ciia viec dieu tri chong dong la riit can thiet.
Muc tieu: Chiing t6i nghien ciru danh gia ket qua phau thuat, cac bien chii'ng ciia viec diing thudc chong dong tren 168 benh nhan dUdc thay van tim cd hgc tai Vien trung Udng quan dgi 108, td nam 2005 den nam 2009.
PhUdng phap: Hoi ciTu m6 ta. Oanh gia cac ket qua sdm trong mgt thang sau md. Ket qua dai ban qua theo doi djnh ky moi thang sau md, cac bien chu'ng chung sau mo. Danh gia cac tai bien ciia thuoc chong dong va cac yeu to lien quan: Cac tai bien huyet khoi, cac tai bien chay mau. Cac yeu to nguy cd lien quan den tai bien thudc chong dong: Tudi, gidi, nghe nghiep, trinh dp van hoa, kinh te, thoi quen sinh boat, che do an...
Ket qua: Trong thdi gian td nam 2005 den 2009, chiing toi tien hanh phau thuat thay van tim cd hgc cho 168 benh nhan. Tudi trung binh:
38,57 ±11,59. Trong do 60,1% benh nhan dUdc thay van hai la, 14,3% thay van dgng mach chii, 25,6% thay hai van. Ket qua sau mo ty le benh nhan NYHA III trUdc mo giam td 47,6% xuong con 21,7%. Sau 3 thang, 6 thang va 1 nam khong co benh nhan nao co NYHA I I I . Benh nhan NYHA II cung giam dan, td 52,4% trUdc mo xuong 23,1% sau mo 1 nam. Sau 1 nam, sd benh nhan co NYHA I la 76,9%.
Hoang Quoc Toan, Ngo Vi Hai, Ngo TuSn Anh, Nguyin Quoc Hung(*)
Ty le td vong sau mo la 1,2%. Cac bien chii'ng hay gap la: chay mau phai mo lai (6%), tran dich mang phoi phai chgc hut dich (9,5%), rung nhT mdi xuat hien (3,6%). Mgt so bien chiitig it gap nhung nang la: vd that (0,6%), viem ngi tam mac nhiem triing (0,6%), tan huyet (0,6%).
Bien chu'ng lien quan den thudc chong dong gap 20,2% trong qua trinh theo doi sau mo.
Trong do ty le bien chu'ng xuat huyet la 19%.
Bien chu'ng huyet khoi gay ket van nhan tao la 1,2%. Mgt so yeu to gop phan lam tang ty le bien chu'ng lien quan den thudc chdng dong la ndi d ciia benh nhan (viing nong thon) (75%), khong uong thuoc deu theo hUdng dan (68,8%), khong kham lai thudng xuyen (62,5%).
Ket luan: Phiu thuat thay van tim cd hpc tai vien 108 da dUdc tien hanh thudng quy va vdi ket qua tot. Bien chu'ng lien quan thuoc chong dong trong qua trinh theo doi sau mo con tUdng doi cao (20,2%), vi vay benh nhan can dUdc theo doi sat va kham lai dinh ky tai cac cd sd chuyen khoa.
SUMMARY
The result of heart valve replacement by mechanical prothesis in 108 center Hospital. Anticoagulant comlications and
relational factors.
Back ground: Heart valve diseases are usual disease in Viet Nam. Most of the patient was late diagnosed and need to replace mechanical valve prothesis.
Aim: Evaluate the result of heart valve raplace (mitral and aortic valve) and (*) Khoa Phdu llnidl Tim mgch, henh vien TWQD 108.
106
anticoagulant complications in 108 center Hospital.
Method: Prospective study is performed to evaluate the short term and long term result, the complications after surgery. Anticoagulant complications: thrombosis and bleeding complications. Relational factor: age, gender, education level, economy...
Result: There are 168 patients who have heart valve replace by mechanical valve prothesis. Mitral valve replacement: 60%. Aortic valve replacement: 14.3 %.
Mitral and Aortic valve replacement: 28%.
The numbers of patient with NYHA III decrease from 47.6% to 21.7% post operation and there is no patient having NYHA III after 03 months, 06 months and 01 year. After 01 year, the rate of patient with NYHA I: 76.9%. The mortality rate is 1,2%. The comon complications are: bleeding need reexploration (06%), pleural effusions require thoracentesis or chest tube drainage; atrial firillation:
03%, left verticular rupture 0,6%, endocarditis:
0,6%; hemolytic anemia 0,6%. .
The rate of anticoagulant complications is 20.2% follow up long term, hemorrhage is 19%.
Valve obstruction due to thrombosis: 1.2%. The rate of patient having irregular anticoagulant drug is 68.8%, irregular follow up examinations: 62.5%.
Conclusion: The surgery of heart valve replacement in 108 center hospital is routine and has good results. The anticoagulant complications is high. Therefore the patient need to close follow up and regular examination.
I. OATVANOI
Trong nhung nam gan day ty le ciing nhu so lugng benh nhan mac benh tim mach a nudc ta dang c6 xu huo'ng tang nhanh. Trong do cac benh van dugc coi la benh tim truyen th6ng cua cac nuac dang phat trien nhu thap tim van chiem ty le dang ke, ban 90%. Di§u tn ngoai khoa cac benh ly van tim tai nuac ta chil y^u la thay van tim nhan tao va sii'a \an.
Ciing vai nhu'ng ti6n bg moi trong phau thuat
tim mach giiip cho cac phuong phap sira \'an dugc phong phu va dat dugc nhung kk qua rat thuyet phuc, gdp ph4n lam giam bien chirng ciing nhu ty le tir vong sau m6. Tuy nhien, thay van tim nhan tao van chilm ty le cao do benh nhan thuang d§n mugn. ton thirong da van va dieu kien cung nhu trinh do phau thuat a cac trung tam phlu thuat khong giong nhau. Tai vien tim thanh pho H6 Chi Minh, CO tai 90,7% benh nhan dirge thay van vai henh ly ton thuang da van [2].
Doi vai benh nhan dugc thay van tim nhan tao hoac sira van co sir dung vong van nhan tao, viec theo doi va dieu tri sau mo het sire quan trgng, dac biet theo doi hieu qua va bien chirng ciia thuoc chong d6ng . Day van la kho khan va thach thuc chinh cua benh nhan c6 mang van tim nhan tao cung nhu ciia thay thuoc. '' ' '
Tai benh vien TWQD 108 da tien hanh phau thuat tim ma tir nhii'ng nam 1998.
Trong d6 thay van chiem ty le chu yeu, ben canh do chung toi ciing tien hanh sii'a van tim va da dat dugc nhQ'ng ket qua buac dau dang khich le. Tuy nhien cting nhu cac trung tam phau thuat tim mach khac, van de tai bien thuoc chong dong van con la mgt thach thuc.
Hien nay chua c6 mgt nghien cuu toan dien ve ket qua sau phau thuat thay van tim va cac bien chung sau mo, nhat la bien chirng cua thuoc chong dong.
Vai ly do tren, chimg toi tien hanh nghien ciru de tai " Danh gia ket qua phau thuat doi vai benh nhan thay van tim hoac sira van co sir dung vong van nhan tao, cac bien chirng va cac yeu to lien quan doi vai viec dieu tri chong dong" vai muc dich:
1. Ddnh gid kel qud phdu thugl doi vdi cdc benh nhdn md thay van tim nhdn tgo.
2. Ddnh gid bien chung vd cdc yeu td lien quan cua viec dieu tri thuoc chong ddng.
II. OOI TUONG VA PHUONG PHAP NGHIEN COU 2.1 Doi tuong nghien ciru:
2.1.1. Doi tuffng, thdi gian, dia diem nghien ciru: Gom 168 benh nhan thay van tim nhan tao tai khoa Phau thuat Long nguc - Tim mach benh vien Trung U'ang quan dgi
108. Thai gian tir nam 2005 d6n 9/2010.
2.1.2. Tieu chudn chgn benh nhdn:
Cac benh nhan dugc phau thuat thay van tim nhan tao tai benh vien Trung uang Quan dgi 108. Sau mo dugc theo doi va kham lai dinh ky theo hen. Moi lan kham lai, benh nhan dugc kham lam sang, lam cac xet nghiem sieu am tim, dien tim do va INR.
Tieu chuan loai trir: Cac benh nhan mat theo doi, khong den kham lai.
2.2. Phuo'ng phap nghien cihi: Nghien cim m6 ta cat dge, phoi hgp hoi cim va tien cuu.
Ddnh gid ket qud phdu thudt:
• Ket qua som trong mgt thang sau mo.
• K6t qua dai han qua theo doi dinh ky moi thang sau mo.
• Cac chi s6 theo ddi: Muc do suy tim, danh gia chi s6 NYHA. Cac chi so tren sieu am tim: EF, Ap luc dgng mach phoi tam thu, do ha van nhan tao, chenh ap qua van.
• Danh gia cac bien chimg chung sau m6: Va th4t, huy6t khoi, xuat huyet, viem noi tam mac nhiem khuan. Tran dich mang tim, mang phoi phai chgc hut dich. Rung nhT. Roi loan dan truyen.
Ddnh gid ede tai bien eua thude chdng ddng vd eac yeu td lien quan:
• Cac tai bien huyet khoi.
• Cac tai bien chay mau.
• Cac yeu to nguy ca lien quan den tai bien thuoc chong dong: Tuoi, giai, nghe nghiep, trinh do van hoa, kinh te, thoi quen sinh boat, che do an...
2.3. Xu- ly so lieu: Xir ly theo thuat toan th6ng ke. Cac so lieu dugc xvr ly theo phan mlmSPSS 12.0
III. KET QUA NGHIEN CCfU 3.1 Tuoi, gioi.
3.1.1 Tudi: Tuoi trung binh: 38,57 ±11,59. Cac benh nhan cua chiing toi da so la trong tuoi trudng thanh trong do benh nhan nhd tuoi nhat la 16 tuoi, cao nhat la 65 tuoi.
3.1.2. Gidi: (Bang 1)
Nam Nu' Tong
Sd benh nhan 99 69 168
Ty le o/o 58,9 41,1 100
Ty le nam chiem 58,9 %>, nir chiem 41,1 %>. Su khac biet khong c6 y nghia thong ke (p>0,05).
3.2 Cac benh van tim duoc phau thua(
Benh ly
Benh van hai la (phau thuat thay van hai la) Benh van OMC (phau thuat thay van OMC) Benh van hai la va van DMC (thay 2 van) Tong
(Bdng 2)
So benh nhan 101
24 43 168
Ty le o/o 60,1 14,3 25,6 100
108
Nhom benh hay gap nhit cua chiing toi trong so cac benh nhan thay van la benh van hai la, chiem 60,1%. Thay van DMC don thuan chiem ty le thSp nhit, 14,3%.
3.3 Ket qua trung va dai han:
3.3.1 Muc dp suy tim: (Bdng 3) NYHA
NYHAl NYHA 2 NYHA 3 NYHA 4
Tru'dc md SdBN
0 88 80 0
Tyle 0 52,4 47,6 0
Sau mo 1 thang So BN 46 84 36 0
Tyle 27,7 50,6 21,7 0
Sau md 3 thang SdBN
124 44
0 0
Tyle 73,8 26,2 0 0
Sau mo' 6 thang Sd BN 120 40
0 0
Ty le 75 25 0 0
Sau mo' 1 nam SdBN
100 30
0 0
Ty le 76,9 23,1 0 0 Danh gia ve ket qua trung va dai ban dua tren chi so NYHA {New York Heart Association), chiing t6i thay cac benh nhan truac mo diu c6 bi6u hien NYHA II-III. Sau md 1 thang, ty le benh nhan NYHA III truac mo giam dang kk, tii' 47,6%) xu6ng con 21,7%. Sau 3 thang, 6 thang va 1 nam khong co benh nhan nao c6 NYHA III. Tuong tu cac benh nhan NYHA II cung giam dan, tir 52,4%o truac mo xu6ng con 23,l%o sau m6 1 nam. Ben canh do s6 benh nhan NYHA I trudc mo la 0 benh nhan, con so nay tang dan vai thai gian sau mo va sau 1 nam, ty le nay la 76,9%).
3.3.2. Sieu dm tim: (Bdng 4) Chi sd
EF Paps
Dd Ds
Tru'dc mo' 53,2 40,7 55,7 37,8
Sau mo 1 thang
57,6 37,0 53,4 38,6
Sau md 3 thang
55,7 36,1 52,1 37,1
Sau mo' 6 thang
56,3 35,8 51,8 39,6
Sau md 1 nam
54,2 35 52,4 38,4 Theo ddi ve cac chi so tren sieu am, chiing toi thay chi so phan so tong mau (EF) co tang hon sau mo, ap luc dgng mach phoi tam thu (paps) co xu hudng giam dan, tuy nhien su khac biet con chua co y nghia thong ke.
3.4. Cac bien chung chung sau mo (I Bien chu'ng
Vd that
Tran dich manq phdi phai chgc hut dich Tran dich manq tim
Chay mau phai mo lai cam mau Viem noi tam mac nhiem khuan Tan mau
Huyet khoi
lang 5)
Sd benh nhan 1 16
4 10
1 1 0
Ty le o/o 0,6 9,5 2,4 6 0,6 0,6 0
Xuat huyet
Rung nhT mdi xuat hien Rdi loan dan truyen
Bien chu'ng khac (hong hoc cd hgc, hien tupng pannus...)
1 6 0 0
0,6 3,6 0 0
Trong nghien ciru cua chung toi, cac bien chimg hay gap nhat la: tran dich mang phoi phai chgc hiit dich (9,5%)), chay mau phai mo lai chiem 6%o. Ngoai ra cac bien chimg khac it gap hon nhung nguy hiem do la vd that: 1 benli nhan (0,6%)). tan huyet: 1 benh nhan (0,6%), viem ngi tam mac nhiem trung: 1 benh nhan. S6 benh nhan co rung nhT mai xuat hien: 6 benh nhan (3,6%)). Co hai benh nhan tii' vong sau mo (ty le l,2%o):l benh nhan va that, 1 benh nhan tan mau, suy than.
3.5. Lieu thuoc chong dong benh nhan thuong diing (thuoc sintrom): (Bang 6) Lieu sintrom /ngay
Lieu 1/8 vien Lieu V4 vien Lieu 3/8 vien
Lieu V4 va 3/8 vien xen ke Lieu V^ vien
Lieu %
Lieu y^ va % xen ke Tong
Sd benh nhan 8 24 72 50 8 2 2 166
Ty le o/o 4,8 14,3 42,9 29,8 4,8 1,2 1,2 100
Nghien cim ve lieu thuoc sintrom benh nhan thuang diing, chiing toi thay da so benh nhan dugc dimg lieu 3/8 vien mdi ngay (42,9%o), tiep den la lieu '/4 xen ke 3/8 vien moi ngay (29,8%). Co 8 benh nhan (4,8%)) chi diing lieu 1/8 vien, va 2 benb nhan (1,2%)) dimg lieu VA vien.
3.6. Cac bieu hien ciia bien chung lien quan den thudc chong dong:
Trong qua trinh theo doi, co 34 benh nhan c6 bien chiing lien quan den thuoc chong dong, chiem 20,2%). Trong do co 32 benh nhan bieu hien xuat huyet (98,8%o), 2 benh nhan huyet khoi gay ket van nhan tao, chiem l,2%o. Benh nhan xuat hien bien chirng xuat huyet cu the nhu sau: (Bdng 7)
Xuat huyet Xuat huyet dUdi da Chay mau niem mac mui,
mieng Xuat huyet tieu hda Xuat huyet dUdng nieu
Xuat huyet nao Tong
Sd benh nhan 10 12 4 2 4 32
Tyle 31,3 37,5
12,5 6,3 12,5
100
Trong s6 benh nhan co bieu hien xuat huyet hay gap nhat la chay mau niem mac mui mieng (37,5%), xult huyet duoi da (31,3%o). So benh nhan bi xuat huy6t nao la 4 benh nhan.
chilm 12,5% trong so cac benh nhan bi bien chiing xuat huyet, nhung benh nhan nay diu tir vong sau do.
Trong so 2 benh nhan co bien chimg ket \m nhan tao, chung toi tien hanh mo cap cim. tuy nhien chi' co 1 benh nhan dugc cim thoat con 1 benh nhan tu vong (do suy than nang sau m6).
3.7. Lieu thuoc chong dong va muc INR khi co bien chiing xuSt huyit (n=32) 3.7.1. Liiu thudc chdng ddng (Bdng 8)
Lieu sintrom / n g a y Lieu < 1/4
Lieu 3/8 vien hoac Lieu V4 va 3/8 vien xen ke Lieu > l / 2
Tong
Sd benh nhan 4 24
4 32
Ty le 12,5
75 12,5
100
3.72. Muc INR (Bdng 9)
I N R
<2,5 2,5-3,5
3,5-5
>5 Tong
So benh nhan 0 1 4 27 32
Ty le (O/o) 0 3,1 12,5 84,4 100
Tim hieu ve lieu thuoc sintrom va mirc INR khi benh nhan c6 bien chirng xuat huyet, chiing toi thay da so gap d benh nhan dang dimg lieu 3/8 vien hoac % xen ke 3/8 vien, chiem 75%. Mirc INR khi xuit huyit da s6 la > 5 (84,4%o).
3.8. Mot so dac diem ve djch tl d6i vdi benh nhan co bien chung xuat huyet do dung thuoc chong dong (n=32)
3.8.1. Tudi (Bdng 10) Nhdm tudi
< 20 tuoi 20-30 tuoi 30-40 tuoi 40-50 tuoi 50 -60 tudi
>60 tuoi
Sd benh nhan 0 4 6 10
8 4
Tyle 0 12,5 18,8 31,3 25 12,5
3.8.2. Gidi (Bang 11) Gidi
Nam Nu'
Sd benh nhan 12 20
Tvie 37,5 62,5 3.8.3 Nghe nghiep(Bdng 12)
Nghe nghiep Lam ru6ng
Can bo, cong chirc
Nghe khac (kinh doanh, buon ban nho...)
d
So benh nhan 20
6 6
' Tyle
62,5 18,8 18,8
3.8.4 Dia du (Bdng 13) Dia dU
Thanh pho N6ng th6n
Sd benh nhan 8 24
Tyle 25 75 3.8.5 Muc dp udng thudc thudng xuyen theo hudng ddn (Bdng 14)
Udng deu theo hUdng dan
Udng thudc khong deu theo hUdng dan (co lan quen khong udng thudc, khong udng do
bet thudc)
Sd benh nhan 10 22
3.8.6 Khdm lgi theo dinh ky (Bdng 15) Kham lai thudng xuyen theo hen
Khong kham lai thUdng xuyen theo hen
So' benh nhan 12 20
3.8.7 Thdi gian tir khi ed bieu hien eua Men chung do diin
^uffc khdm vd dieu tri tgi eff sd ehuyen khoa (Bdng 16) Thdi gian
< 1 ngay 1-2 ngay
> 2 ngay
Sd benh nhan 24
6 2
Tyle 31,3 68,8
Tyle 37,5 62,5
g thude ehong ddng tdi khi
Tyle 75 18,8
6,3 Tim hieu mgt so dac diem ve dich te ciia
benh nhan c6 bien chung xuat huyet chiing toi thay benh nhan gap hau het cac lua tuoi, trong do nir gap nhieu hon so vdi nam (62.5% so vai 37,5%)). Gap chu yeu trong
nhom benh nhan c6 nghe nghiep lam ruong (62,5%)). Tuy nhien c6 tai 25%o benh nhan d thanh pho. Dang chii y, trong s6 cac benh nhan co bien chiing xuat huyit, co 68,8%
benh nhan uong thuoc khong deu theo hudng
112
dan cua thiy thudc va 62,5 % benh nhan khong dugc kham lai dinh ky. Da s6 cac benh nhan dugc dua din kham va dilu tri tai ca sd chuyen khoa ngay khi co bien chung (75%o).
Tuy nhien cQng con tdi 25 %> benh nhan sau hon 1 ngay mai toi dugc ca sd dieu tri.
IV. BAN LUAN
4.1. Tudi, gidi. Vi Trong 5 nam (2005-2009), chiing toi tiln hanh phlu thuat thay van ca hgc cho 168 benh nhan, cac benh nhan co tuoi trung binh la 38,57. Ket qua nay ciing tuong tu so vdi cac nghien ciin khac a trong nuac. Theo Lam Trilu Phat, tai vien Tim thanh pho Ho Chi Minh la 42,16. Tai benh vien Chg Riy, theo tac gia Tran Quyet Tien thi tuoi trung binh la 40,2. So vdi tuoi trung binh cua benh nhan thay van ca hgc tai benh vien Thong Nhat la 49,3 thi nhom tuoi benh nhan cua chiing toi thap han. [1,3]
Ty le nam trong nghien ciin cua chiing toi chiem cao hon vai 58,9%). Tuy nhien su khac biet nay khong co y nghia thong ke.
Trong nghien cii'u 54 ca thay van cua tac gia Do Kim Que, thi ty Ie nu lai chiem ty le cao hon vdi 63,9%). C6 thi trong nhom nghien ciiu cua chiing toi ty le nam cao hon do benh vien chiing toi la benh vien quan dgi, 4 nam ve trudc ddi tugng dieu tri la bg dgi van la phan nhieu, 2 nam gan day, da ma rgng cho tat ca cac doi tugng benh nhan (chu yeu bao hiem y tl).
4.2. Cae benh van tim duffephdu thudt:
Benh ly van hai la chiem ty le cao nhat 60,1%. Dilu nay phu hgp vdi mo hinh benh ly van tim d nuac ta. Hep ha van hai la la nguyen nhan chinh ciia thay van hai la. Theo D6 Kim Qui, 66,7%) cac truong hgp thay van hai la do benh hep hd van hai la. Hep hd van
hai la da so do nguyen nhan thip, vi vay rdt kho c6 kha nang sira van.[l]
4.3.Ket qud trung vd ddi hgn:
Danh gia ket qua phau thuat dua tren cac chi s6 lam sang nhu NYHA, mgt s6 chi so sieu am nhu EF, ap luc dgng mach phoi tam thu, Dd, Ds chiing toi nhan thSy da s6 cac benh nhan truac mo co tinh trang suy tim NYHA 2 va 3. Sau m6 1 thang, ty le benh nhan NYHA 3 giam tir 47,6%) truac md xuong con 21,7 % va sau 3 thang, khong con benh nhan nao co bieu hien suy tim vdi NYHA 3. Ngugc lai, s6 benh nhan c6 NYHA I tang dan, tir 0 benh nhan co NYHA 1 truac mo, sau 1 thang tang len la 27,7 Vo va sau 3 thang la 73,8%), sau 6 thang la 75%o va sau 1 nam la 76,9%.
Ben canh do cac chi so EF c6 tang hon sau mo va ap luc dgng mach phoi tam thu c6 xu huong giam dan (Bang 4). Ket qua nghien cim nay ciing phii hgp vdi mgt so nghien cim trong va ngoai nudc [1,7]. Trong thi cat bo van hai la, chiing toi co gang bao ton toi da mo van va day chang la sau, giiip cho giii dugc cau triic tim va ban che suy tim sau mo.
Ton thuong do thap thuong lam day la van, chiing tdi giiJ lai la sau bang each hoc, lot to chiic viem xa cua la van a mat nhT, tir vong van tdi bd tu do cua van, nham giir lai toi da day chang va nhu mo van. Theo Do Kim Que, trong 54 benh nhan thay van hai la, c6 24 benh nhan co NYHA 3 trudc mo, sau 1 thang chi co 10 benh nhan va sau 3 thang khong CO benh nhan nao NYHA 3. Cac chi so EF va Paps ciing cai thien dan sau m6.[l]
4.4.Cdc bien chdng sau mo:
"Ve cac bien chiing som sau mo thay van ca hgc chiing toi gap 9,5%) truong hgp co tran dich mang phoi phai chgc hut dich. Bien chimg nay kha pho bien sau mo, Theo tac gia Joanna Chikwe co tdi 50%) benh nhan co tran
dich mang phoi sau phau thuat tim. Tuy nhien da so chi can dieu tri ngi khoa la dii, chi khi CO tran dich so lugng nhieu anh huang den ho hap can chgc hut dich hoac dat dan luu.
So benh nhan phai mo lai do cha}' mau chimg toi gap 10 benh nhan (chiem 6%). Ty le nay tuong doi cao so vai mgt so tac gia khac. Theo William A.Baumgartner thi t}' le nay <2%. Theo J. Chikwe & T. Athanasiou ty le nay la 1-2%) [7,8]. Chay mau sau mo chil yeu chay mau sau xuang u'c. Ty le benh nhan bi chay mau phai m6 lai ciia chiing toi con cao co the do so lugng benh nhan mo moi nam ciia chiing toi chua nhieu, viec theo doi dieu tri bao ton khi co bien chung chay mau con chua co kinh nghiem, vi vay ty le phai mo lai cam mau con tuang doi cao. Gan day, vai viec day manh so lugng benh nhan mo len (1-2 benh nhan moi ngay) thi ty le nay da giam ro ret.
Chiing toi gap 1 benh nhan (0,6%)) co bien chiing va that. Day la bien chimg nang va CO ty le tir vong cao. Theo mgt so tai lieu tren the gidi, ty le va that trai sau thay van tir 0,5-1,2% va ty le tir vong la 65-100%. Tai benh vien Tim Ha Ngi, ty le nay duai 1 % [4].
Khi gap bien chiing nay, doi hoi phai tien hanh mo cap cim rat khan cap, tuy nhien ty le tii' vong van rat cao. Benh nhan ciia chiing toi xuat hien va that ngay dau sau mo tai khoa hoi sire, dugc tien hanh mo lai cap cim nhung khong ket qua. Ngoai ra. chiing toi gap 1 benh nhan co bien chimg viem ngi tam mac nhiem triing. Theo tac gia J. Chikwe & T.
Athanasiou thi ty le nay la 0,2-0,5%o trong 30 ngay dau sau mo. va tang len 2%o trong 5 nam [7]. Day cung la bien chimg nang doi hoi dieu tri rat tich circ va lau dai.
Cac bien chirng khac chiing toi gap do la tran dich mang tim (2,4%)), rung nhT mai xuat
hien (3.6%) tu>- nhien cac biln chirng nay deu nhe va chi can dieu tri ngi khoa.
4.5. Cdc bidn chung lien quan thudc chdng ddng.
Cac benh nlian ciia chimg toi khi ra vien diu dugc huong dan ty my ve each diing thuoc va hen ngay kham lai. Da so benh nlian dugc dimg lieu sintrom (vien 4mg) 3/8 vien hoac /A xen ke 3/8 vien moi ngay (73,7%) tuang duong vai lieu tir l-l,5mg/ngay. Day la lieu trung binh. Trong 168 benh nhan thay van. chimg toi gap 32 benh nhan c6 bien chirng xuat huyet (19%)). Ty le ciia chiing toi Cling tuong tir mgt so tac gia. Theo Bloomfield va cong su nghien cim tren 575 benh nlian dugc thay van nhan tao thi gap bien chung nay trong 12 nam la 19%o doi vdi van ca hgc [7]. Day la van de cam go doi voi benh nhan mang van tim nhan tao. Co the noi sau mo thuoc chong dong gan lien vai eugc doi ciia nguai benh. Trong dieu kien ciia nuac ta, van de theo doi doi vdi benh nhan sir dung thuoc chong dong gap rat nhieu kho khan. Trong cac bien chirng xuat huyet, chung toi hay gap nhat la xuat huyet dudi da (31,3%o), xuat huyet niem mac mui, mieng (37,5%o). Day la bien chiing tuong doi nhe va de nhan biet, vi vay thuong benh nhan den kham kip thai. Mgt so bien chirng xuat huyet nang hon do la xuat huyet tieu hoa (12,5%), xuat huyet dudng nieu (6,3%)). Cac bien chirng nay thuong kem theo thieu mau nang, vi the benh nhan can dugc chan doan va dieu tri kip thdi tai cac ca sd chuyen khoa. Ngoai ra, mgt bien chii'ng xuat huyet dang sg va gay ty le tir vong cao d6 la xuat huyet nao. Chung toi gap 4 benh nhan (12,5%)), cac benh nhan nay sau do deu tu vong do xuat huyet dien rgng. Cac benh nhan nay kiem tra INR khi co bien chirng deu co muc INR cao (>5).
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Ngoai ra. Chung toi gap 2 benh nhan (chilm 1,2%) CO biln chirng huyit khoi gay ket van nhan tao va phai tien hanh mo lai.
Theo tac gia Gerard P Aurigemma va cong sir thi ty le ciia biln chirng nay thay doi tir 0,03 din 5,7%, hay gap d6i vai van hai la nhan tao va cac benh nhan dugc kiem tra xet nghiem d6ng mau thi c6 den 70%o benh nhan khong dat lilu ch6ng dong thich hgp. Nhiing benh nhan nay cdn dugc nhanh chong den ca so chuyen khoa, c6 the phai tien hanh phau thuat cap ciru [7]. Trong hai benh nhan ket van nhan tao ciia chiing toi deu tien hanh mo cap cim thay lai van (mgt benh nhan ket van hai la, mgt benh nhan ket van dgng mach chil) thi CO 1 benh nhan tir vong do suy than khong hoi phuc sau mo.
4.6. Lieu thudc chdng ddng vd muc INR khi cd bien ehurng xudt huyet-Mpt sd dge diem ed lien quan.
Khi benh nhan c6 bien chu'ng xuat huyet, chiing toi thay da so benh nhan van dang diing lieu trung binh (l-l,5mg sintrom/ngay).
Tuy nhien, xet nghiem mirc INR thi c6 84,4% trudng hgp co INR>5. Dieu nay cho thay trong qua trinh dieu tri co the benh nhan da khong tuan thu dung lieu thuoc da huong dan, nhu co benh nhan uong nham lieu thuoc, uong bii lieu ngay hom trudc... Hon nira, thuoc khang vitamin K con phu thuoc kha nhieu vao che do an. Tim hieu trong so cac benh nhan co bien chung xuat huyet, chung toi thay da so gap nhu'ng benh nhan song d vimg nong thon (75%)), va c6 31,3 %) benh nhan uong thuoc khong deu theo hudng dan.
Ben canh do con co tai 37,5%o benh nhan ivhong kham lai thuang xuyen theo hen. Day la nhirng ylu td gop phan lam tang ty le bien chiing lien quan din thuoc chong dong. Ben canh do, khi xay ra biln chung do thuoc chlng dong, thi viec mau chong dua benh
nhan den ca sd chuyen khoa la quan trgng nhat. Trong nghien cim cua chung toi, con 25%) benh nhan dugc den dieu tri sau 1 ngay.
Tir thuc te tren, rat can thiet c6 su theo doi mgt each chat che a cac benh nhan thay van nhan tao co dimg thuoc chong dong. Tuy nhien, trong hoan canh thuc te a nuac ta, de lam dugc dieu nay con rat kho khan. Nhieu nai da sir dung may xet nghiem INR nhanh, thuan tien cho viec dieu chinh lieu chong dong. tuy nhien gia thanh con cao.
V. KET LUAN
Qua nghien cim 168 benh nhan thay van nhan tao (van ca hgc) tai benh vien Trung uang Quan dgi 108 trong 5 nam (2005-2009) chiing toi rut ra mgt so ket luan sau:
1. Phau thuat thay van tim nhan tao vai tuan hoan ngoai ca the la phuang phap dieu tri hieu qua vdi cac benh ly van hai la, benh ly van dgng mach chii hoac phoi hgp ca hai vdi ket qua tot, ty le tir vong va bien chirng thdp. Cac chi s6 lam sang nhu NYHA cung nhu cac chi so sieu am nhu EF, Paps cai thien sau m6 1 thang va ro ret sau 3 thang.
Ty le tir vong sau mo la 1,2%o. Cac bien chimg hay gap la: chay mau phai m6 lai (6%)), tran dich mang phoi phai chgc hiit dich (9,5%)), rung nhT mdi xuSt hien (3,6%)). Mgt s6 biln chung it gap nhung nang la: vd that (0,6%)), viem ngi tam mac nhiem tning (0,6%), tan huyit (0,6%o).
2. Biln chirng lien quan den thuoc ch6ng dong gap 20,2%o trong qua trinh theo doi sau m6. Trong do ty le bien chung xuat huyit la 19%o. Biln chiing huyit khoi gay ket xan nhan tao la l,2%o. Mgt s6 yeu to gop phSn lam tang ty le bien chung lien quan den thuoc chong dong la nai d ciia benh nhan (vimg nong thon) (75%o), khong uong thuoc
deu theo hudng dan (68,8%o), kh6ng kham lai thuong xuyen (62,5%o).
TAI UEU THAM KHAO
1. Do Kim Que. Danh gia ket qua som va trung han phau thuat thay van hai la voi van co hoc tai benh vien Thong Nhat.Y hoc Viet Nam (2008) 356: 42-48
2. Nguyen Van Phan: Tong quan dieu tri benh ly van tim. Y hoc Viet Nam (2008) 356: 49-55.
3. Lam Trieu Phat. Danh gia ket qua so'm phau thuat thay van hai la co' hoc trong benh ly hep van hai la. Luan van tot nghiep thac sy y khoa 2006.
4. Dang Hanh Son. Bien chung va that trai sau thay van hai la. Y hoc Viet Nam (2006) 328:
132-139.
5. Nguyin Lan Viet. Thuc hanh benh tim mach 2007. 374-392
6. Kirklin JW. Posoperative care. In Cardiac surgen.'2"". 1993. p 195-247
7. Gerard P Aurigemma. Complication of prosthetic heart valves. Uptodate 2008
8. Gerard P Aurigemma. Antithrombotic therapy in patients with prothetic heart valves. Uptodate.com 2007.
9. John E Hefner. Pleural efusions following cardiac surgery. Uptodate 2006.
10. Frank E Silvestry. Overview of the postoperative management of patients undergoing cardiac surgery. Uptodate.2007.
Birorc DAU DANH GIA KET QUA PHAU THUAT T I M TAI BENH VIEN OA KHOA KIEN GIANG
Danh Trung, Huynh Hai Dang^
Tran Van Thanh, Pham Van D6Tn(*)
TOM TAT
Muc tieu: Danh gia ket qua sdm phau thuat tim tai BVOK Kien giang.
Doi tu'dng va phu'dng phap nghien cu'u:
Nhii'ng benh nhan dUdc phau thuat tim tai Benh vien Da khoa dnh Kien giang td thang 5/2009 den thang 8/ 2010. Hdi cii'u mo ta.
Ket qua: Td thang 5/2009 den thang 8/2010 chung toi da phiu thuat dUdc 121 trUdng hgp, trong do: nam: 52, nii': 69. Tudi tir 1 - 81 tuoi, con dng dgng mach: 16, thong lien nhT: 16, thong lien that: 45, hep dgng mach phdi: 4, benh van 2 la: 24, benh van dgng mach chii va van 2 la: 10, benh dgng mach chii ngUc boc tach; 2, u nhay nhT phai: 1, benh mach vanh: 3. Ty le thanh
cdng: 99,2%. Bien chii'ng gap nhieu nhat la: loan nhjp tim.
Ke't luan: Chung toi da phau thuat dUdc cho 121 trUdng hdp vdi ty le thanh cong la 99,2%. Phan loai benh phau thuat nhieu nhat la thong lien that va benh ly van 2 la. Phau thuat tim la chuyen khoa sau nhUng c6 the trien khai dugc d cac benh vien tuyen tinh.
ABSTRACT
PRIMARY EVALUATION OF THE HEART SURGERY IN KIEN GIANG GENERAL HOSPITAL.
Objectives: To evaluate the results early heart surgery in Kien Giang general hospital.
* Benh vien da klioa tmh Kien Giang 116
