' 3. Nguyin Quang Quyin (1997), Giai phiu hpe, Nxb
•*Vhpc,tr. 319-120.
4. Phan Hdng Viet (2001), "Nhan xet tinh trgng gian nd tTnh mgeh thuc quan va phinh vj dg day a bgnh nhan xa gan", Luan dn Thge sT Y hpc, Dgi hpe Y Ha Npi.
5. Nguyin Quang Vinh (2001), "Doi chieu hinh anh gian tTnh maeh thi/e quan qua ndij soi va kich thuac tTnh
mgeh cira qua sieu am a bgnh nhan xa gan", Luan van chuyen khoa cip 2, Dai hpc Y Ha Npi.
6. Arjmand S. A., Bagherzadeh Y. (2003),
"Measurement of main portal vein diameter, peak velocity and volume flow and Its associated factors In healthy adults, TaleghanI Hospital', Dordrecht: Kluver - Academic Pulisher, pp. 95-112.
KET QUA DIEU TRj 14 TRlTONG HOP Dl/gC PHAU THUAT CHUYEN GOC DONG MACH TAI BENH VIEN NHI TRUNG OONG
TOM T A T :
Tu' thang 10 nam 2006 den thing 4 nam 2009 Benh vien Nhi trung uang da tien hanh phiu thuat chuyen dgng mach cho 14 benh nhan chuyen goc dgng mach hoan toan. Tl le nam/nir la 10/4, tuoi trung binh khi phiu thuat la 35,9 ± 16,6 ngay, can nSng trung binh 3685 ± 550g. 12/14 benh nhan cd hinh thii that trai cho phep phau thuat chuyen dgng mach 1 thi. Thdi gian chay may trung binh la 337,9 ± 173,8 phut, thdi gian cap chu trung binh la 146,8 ± 30,5 phut. Ket qua song li 9/14(64,3%,) benh nhan. Ky thuat trong lai dgng mach vinh trong phiu thuat, thai gian ddng xuang uc vi thdi gian thd may keo dai la cic yeu to nguy ca chlnh.
Tie khoi: Benh vien Nhi trung ieang, chuyen goc ddng mach.
OATVAND^
Chuyen gdc ddng mach (TGA) hay cdn gpi chuyen gdc dpng mach hoan toan (Complete TGA) la benh ly tim bam sinh tim chiem khoang 5-7% cac benh ly tim bam sinh, tugng Crng vdi 20-30 tre trong 100.000 tre sinh ra. Benh nhan thudng cd bieu hien suy hd hap, tim tai ngay sau khi sinh. Tre sdng dugc Id nhd su trdn mdu do cdn Id bau due, cdn dng ddng mach, thdng lien nhT hoac thdng lien that. Neu khdng dugc dieu trj thi 30% tre mac benh tCr vong trong tuan dau sau khi sinh(5)
Tu" thdng 10 nam 2006 den thang 4 nam 2009 Benh vien Nhi trung uang da tien hanh phiu thuat ehuyin ddng maeh cho 14 benh nhan chuyen gdc dpng mach hoan todn. Muc dich nghien cCru cua chung tdi nham: Dinh gii hieu qua dieu trj trudc va sau phiu thuat
D 6 | TU'P'NG VA PHU'ONG P H A P NGHIEN CIJ'U 1. Ddi t u g n g :
14 benh nhdn chuyen gdc ddng mach da dugc phiu thudt tai Benh vien Nhi trung uang tu' thdng 10- 2006 d i n thang 4-2009
2. Phu'ang phap:
Nghien cCru hdi cCru theo mdt mdu nghien cCru cdc chi sd v l tinh trang chung khi nhap vien, cac dieu trj hd trg trudc phiu thuat (Prostaglandin, phd vdeh lien nhT...), chin dodn trudc va trong md, dilu trj hdi sCrc sau phiu thudt.
CAO VIET TUNG, NGUYEN THANH CONG, NGUYEN THANH LIEM, PHAM HLJfU HOA.
K^TQUA 1. Tudi va gid'i
- Tudi phiu thuat trung binh 35,9 ± 16,6 ngay -11/14 benh nhan md mudn sau 15 ngdy tudi - T i l e nam/nQ': 2,5/1
2. Dac d i l m lam sang va sieu am triPO'C p h l u thuat: Bang 1: Dgc diem lam sang vd sieu am
Oac diem lam sang Can nang (g) Sp02 khi nhap vien(%)
Loai TGA - Oon thuan - Th6ng lien that Pha vach lien nhT - SpOa sau pha vach lien nhT (%) - Dung PGE sau pha vach lien nhT Banding dong mach phoi va BT shunt
Di tat phoi hop
Oac diem sieu am hinh thai that trai:
- Typ 1 (favorable) -Typ II (acceptable) -Typ III (unfavorable)
3685 ± 550 59 ± 16
13 1 13 81 1 6
0 2 1 7 5 2 -. 13/14 bpnh nhan sau pha vach lien nhT cai thipn Sp02 khdng ein dung tilp Prostaglandin
- 2 bpnh nhan nhap vien luc 46 ngay va 56 ngay tudi dugc chi djnh lam Banding dpng mach phdi va shunt chu phdi bang Gortex 3.0
- 1 bpnh nhan dj tat phdi hgp sau de sinh ddi dinh phin byng, da dugc phiu thuat tach dinh song sinh 15 ngay sau de trude khi phau thuat chuyin dpng maeh luc 27 ngay tudi
- 2 benh nhan ed hinh thai thit trai khdng thuan lgi cin phai phiu thuat chuyin dpng mach 2 thi.
3. Dac diem trong va sau phau thuat Bang 2: Dac dilm trong va sau phau thuat
Oac diem trong phiu thuat Thdi gian chay may (phut) Thai gian cap dong mach chu (phut)
Bpnh nhan de md xuong uc Oac diem sau phiu thuat Thdi gian dong lai xuong uc (ngay)
Thdi gian thd may (median) Thdi gian nam khoa Hoi sue sau mo
(median)
Thdi gian diing thudc van mach va dan mach (median)
337,9 ±173,8 146,8 ±30,5
9/14 2.9 ±1.2 3.8(1 -22)
12(1 -22) 6(1 -22)
Y HOC THVC HANH (667) - SO 7/2009 B3
- Thdi gian chay may 337,9 + 173,8 phut; thdi gian cap chu 146,8 ±30,5 phut
- 9/14 benh nhan d l md xuang Crc va duge ddng lai sau 2.9 ± 1.2 ngay
- Benh nhan thudng duge tiep tgc duy tri thudc van mach khoang 2 ngay sau khi rut npi khi quan
4. Cac biln chu'ng sau phlu thu$t:
Bang 3: Cdc biln chCrng
Cac bien chung sau phiu thuat Co giat
Nhilm triing xuong uc Viem phoi Roi loan nhip tim
Suy tim Hep mach vanh
Liet CO hoanh Tran du'dng chap mang phoi
Tif vong
0 1 7 2 1 1 2 1 5/14 - 7 benh nhan sau md co tinh trang nhiem trung - Ngoai tam thu thit cd 2 bpnh nhan
- Lipt CO hoanh ed 2 bpnh nhan va duge phiu thupt ndi soi khau gip nlp eo hoanh
- Ti Ip tCr vong la 5/14 (35,7%).
5. So sanh mot s6 dac diem giij'a nhom sdng va nhdm tu" vong:
Bang 4: So sanh giua nhdm sdng va tCr vong
Tuoi phiu thuat (trung binh) Can nang (g) Sp02 trudc(%) Thdi gian chay may(phut)
Thdi gian cap chu (phut) Thdi gian dong xuong uc
Thdi gian thd may Thdi gian dieu tri tai khoa
hoi sue Viem phoi sau mo
Song 33 3644 57.7
245 145 2.3 5 14
4
Tu vong 43 3760
63.3 561 150 4.5 13 26 3
P 0.39 0.72 0.63 0.1 0.8 0.02 0.02 0.003
0.61 - TO" vong khdng lien quan den thdi diem phiu thuat vd thdi gian chay mdy
- Benh nhan ddng xugng Crc mupn va thd mdy keo ddi cd nguy ca tCr vong cao han
BAN LUAN
Phiu thuat thanh cdng chuyen dai dpng mach (ASO- Arterial Switch Operation) nhO'ng nam cua thap ky 80 da thay the cho phdu thuat chuyen tang nhT (Atrial Switch), md ra mpt tuang lai mdi trong phiu thuat chuyen gdc dpng mach nhd sau khi phiu thuat that trdi se dam nhiem cdng viec tudi mdu he thdng theo sinh ly cua ca the. Ngay 18 thdng 10 nam 2006, Benh vien Nhi trung uang da phdi hgp trien khai phiu thuat trudng hgp chuyen gdc dgng mach dau tien, eho d i n nay da cd 14 trudng hgp dugc phiu thuat.
Trong nghien cCru cua chung tdi ti le nam gap nhieu hgn nO' (2,5/1) phu hgp vdi cdc nghien cCru khde cung thiy trong chuyen gdc dong mach hodn toan nam hay gap hgn nCr vdi ti le dao dong tu' 1,5-
3,2/1 (8).Tat ca cdc benh nhan trong nghien cuu deu, dugc chin doan chuyen gdc ddng mach r^odn toan (complete TGA) vdi mdi tugng quan giO'a ddng mach chu va dpng mach phdi Id D-TGA, mdt benh nhan c6 kem theo thdng lien that phdi hgp (Bang 1).
Hau h i t benh nhan dugc phdu thuat mudn vdi tudi phiu thudt trung binh Id 35,9 ± 16,6 ngdy, chi c6 3 benh nhan dugc phiu thuat trudc 2 tuan. Mac dii mot sd tac gia nghien cu'u thay ASO cd the dat ket qua tdt cho cdc benh nhan trude 2 thdng nhung thdi diem phiu thudt tdt nhat Id trong 2 tuan dau (4,9).
Bang 1 cho thiy benh nhdn nhap vien vdi tinh trang suy hd hap ndng Id 85,7% (12/14) vdi SpOj trung binh Id 59±16%. De tang trgn mdu giu'a hai vdng tuan hodn sau khi dieu trj bang Prostagladin truyen tTnh mach, chung tdi da thuc hien pha vach lien nhT 13 benh nhan bdng bdng Rashkind. Sau phd vdeh li§n nhT cac benh nhan nghien CCFU cua chung tdi diu cai thien oxy vdi do bao hda oxy trung binh Id 81 ± 6% v^
khdng phdi dung Prostagladin (Bang 1). Mpt benh nhdn nhap vien luc 1 ngdy tudi la sinh ddi bj dinh phin bung nen phai duy tri Prostagladin bao dam trdn mdu cho ca the, den ngay thu' 15 benh nhan dugc md tach song sinh va ngay thCr 19 benh nhan dugc phd vdeh lien nhT vi tinh trang tudi mdu oxy to chCrc khdng tdt. TI le pha vach lien nhT cua chung toi cao han so vdi nghien cCru cua tdc gia Wojtalik co le vi benh nhan cua chung tdi dugc tien hdnh ASO mugn kem theo dieu ki$n khd khan trong trang thilt bj vd kinh nghiem dieu trj chua can thiep phiu thu§t dugc ngay khi tinh trang benh nhan chua dn djnh(IO)
Sieu am tim ddnh gid tinh trang that trdi thay da sd b§nh nhdn (12/14) cd hinh thai that trdi cho ph6p thuc hien phiu thuat chuyen dong mach. Tuy nhien cd 2 trudng hgp nhap vien mugn luc 46 ngay vd 56 ngay tudi cd hinh thdi that trai khdng thudn lgi, chii'c nang that trdi kem kha ndng that bai cao nlu phiu thudt sCra toan bg ngay. Chung tdi da tiln hdnh huan luyen that trdi bang phdu thudt Banding dgng mach phdi vd lam shunt chu phdi bang doan ndi Goretex 3.0 trudc khi phdu thudt chuyen dgng mach.
Thdi gian cap chu cua chung tdi trung binh Id 146 phut va thdi gian chay may trung binh Id 337 phut (Bang 2), ket qua nay cao hgn nhieu so vdi cdc tdc gia khde: Wojtalik thdi gian cap chu 91 phut, thdi gian chay may 198 phut; Losay thdi gian cap chu 77 phut, thdi gian chay mdy 153 phut (7,10). t h d i gian chay mdy vd cap chu trong nghien cCru cua chung tdi dSi han vi chung tdi mdi bat dau , kinh nghiem cdn han che trong phlu thudt chuyen dgng mach, day Id mpt phdu thudt phCrc tap ddi hdi thdi gian phiu thuat va chay mdy keo ddi. Han nO'a trong nghien cCru cua Chung tdi cd mgt trudng hgp cd hep dgng mach vdnh trdi phai chay mdy hd trg 12 gid sau md.
Viec de hd xugng u'c sau md Id can thiet, g lira tudi sg sinh tim va phdi cd xu hudng phu ne nhieu sau mdt thdi gian chay may tim phdi keo ddi. Viec de hd xuang u'c giup cho huyet ddng sau md cua b$nh nhdn dugc dn djnh (3,6). Nghien cu'u cua chung toi
84 Y HOC THVC HANH (667) - SO 009
cd 9 benh nhdn de hg xuang u'c (Bang 2), thdi gian ddng xuang u'c Id sau 3 ngay. K i t qua ndy phu hgp vdi nghien eCru cua Wojtalik (10)
Benh nhan ehung tdi sau md dugc an than sdu trong it nhit 24 tilng ddng hd kem theo su hd trg cua thudc van mach vd dan maeh: Dopamin, Adrenalin va Milrinone. Nghien cCru cua chung tdi thay trung binh sau 4 ngdy thd may tinh trang ehung cua benh nhdn dn djnh cho phep cai mdy va rut ndi khi qudn khi thude van mach vd dan mach da dugc giam xudng dung lilu tdi thieu (Bang 2). ChCing tdi thudng duy tri lieu hd trg tdi thilu thudc van mach hoac dan mach 2 ngdy sau khi rut ndi khi quan. K i t qua nghien cCru cua J. Foran cho thiy benh nhan thd may trung binh Id 5 ngdy, thude van maeh vd dan mach thudng dugc du'ng trudc hoac cung ngdy vdi thdi gian du'ng thd mdy(4). Ly do chung tdi duy tri thudc van mach vd dan mach lilu thap 2 ngdy sau thodt mdy thd vi benh nhan chung tdi dugc md mudn cd tinh trang suy tim va cgn tang dp phdi trudc md.
Thdi gian trung binh nam tai khoa Hdi sire sau md la 12 ngdy ddi han vdi cdc nghien cCru khde cua E.
Prifti vd J. Foran (trung binh 5-7 ngdy) (2,4). Nhdm benh nhdn chung tdi phai dieu trj tai khoa Hdi sCrc sau md lau han do ctiung tdi cd 7 benh nhdn viem phdi sau md va 1 benh nhan viem phdi kem nhilm trung xuang Crc.
Theo E.Prifti can ddnh gid tinh trang xuit huylt nao sau phiu thudt chuyin dgng mach neu benh nhan xuit hien tinh trang co giat. Trong nghien cCru cua chung tdi khdng cd benh nhdn cd bieu hien co giat, cac benh nhan tri giac binh thudng va khdng cd dau hieu than kinh khu tru. Cd 2 trudng hgp xuat hien ngoai tdm thu that ddp Crng tdt vdi dilu trj.
Trong nghien cu'u cua chung tdi cd 2 benh nhdn bj liet eg hoanh. Chin doan dua vdo XQ phdi thay vdm hoanh ben Net nang cao han ben lanh, tren sieu dm thiy di dgng nghjch thudng cua vdm hoanh ben liet.
Ddy Id bien chu'ng khdng phai hiem trong phlu thudt tim bam sinh dac biet trong phdu thudt chuyin ddng mach . Hien nay, de dieu trj liet ca hodnh chung tdi sii' dung phiu thudt ndi soi khdu gap nep ca hodnh.
Bang 3 cho thay ti le tir vong sdm Id 35,7% (5/14).
Xem xet cde trudng hgp tir vong, cd 2 v i n de Idn trong dilu tri chuyen gdc dgng mach bao gdm trdng lai 2 ddng mach vanh vd nhilm trung sau md:
Hai trudng hgp tCr vong true tilp do phdu tich va trdng lai ddng mach vdnh, dac biet benh nhan H ed hep dgng mach vdnh trdi bam sinh va chu'c nang thit trdi kem. Trudc phiu thudt chuyen dgng mach da dugc lam Banding ddng mach phdi vd shunt chu phdi. Trong phdu thuat chuyen dgng mach doan hep dgng mach vdnh trdi da dugc mg rdng bang mieng va mang tim tugi. Tuy vdy sau khi tim dap lai benh nhan phai chdy mdy tim phdi hd trg 12 gid, kiem tra lai tren sieu dm chCrc ndng thit trdi khdng hdi phuc.
Ba trudng hgp tCr vong do nhilm trung deu lien quan den viem phdi do thd mdy keo dai: 1 trudng hgp viem phdi, tran duang chip va cd cue mdu ddng
trong nhT phai; 1 trudng hgp sau md huyet ddng khdng dn djnh phai thd mdy keo dai va mic viem phdi; 1 trudng hgp liet ca hoanh da duge phiu thuat ndi soi khdu gap nep ca hoanh nhung khdng cai duge mdy vi tinh trang viem phdi nang.
Phdn tich giu'a hai nhdm sdng vd tCr vong ehung tdi thay khdng cd su khac biet v l thdi dilm phiu thuat va thdi gian chay mdy (bang 4). Tuy nhien, thdi gian tri hoan ddng xuang u'c vd thd mdy keo ddi Id cdc y l u td lam tang nguy ca tu' vong (p=0,02), khdng cd sy khac biet cd y nghTa thdng ke giO'a benh nhan sdng vd tir vong bj mac viem phdi sau phiu thudt.
Nhu vay phiu thudt chuyin gdc ddng mach benh nhdn dudi 2 thdng tudi trong dieu kien cua chung ta Id hodn todn cd the cho phep, chung ta can tiln hanh ddng xuang u'c va cai mdy thd sdm khi todn chung cho phep.
K^T LUAN
- Benh chuyen gdc dgng mach Id benh tim bam sinh tim can phdu thudt sdm trudc 2 thdng tudi. Ddnh gid hinh thdi that trdi rat quan trgng trong quyet djnh phiu thuat, can tien hanh huan luyen that trai bang Banding dgng mach phdi vd cau ndi chu phdi khi hinh thdi that trdi khdng thudn lgi
- Phd vdeh lien nhT Id phdu thudt can thiet chuan bj trudc cho phdu thudt chuyen gdc ddng mach
- Ky thudt trdng lai dgng mach vdnh trong phiu thudt, thai gian ddng xuang Crc va thdi gian thd may keo dai la ede y l u td quylt djnh y l u td nang cua benh.
TAI LIEU THAM KHAO
1. C. Planche, A. Serraf. Arterial Switch. Pediatr Cardiol 1998;19:297-307
2. E. Prifti, A. Crucean, M. Bonacchi et al. Eariy and long term outcome of the arterial switch operation for transposition of the great arteries: Predictors and .functional evaluation . Eur J Cardiothorac Surg 2002;22:
864-73
3. Iyer RS, Jacobs JP, Stark J. Outcome after delayed sternal closure in pediatric heart operation: a 10-year experience. Ann Thorac Surg 1997;63:489-91
4. Foran JP, Sullivan ID, Elliot MJ. Primary Arterial Switch Operation for Transposition of Great Arteries with intact ventricular septum in infants older than 21 days.
J/\CC 1998;31(4):883-89.
5. Kirklin JW, Barrett-Boyes BG. Complete transposition ofthe great arteries. Cardiac surgery 1993;
2nd ed, White Plains, New York: 1383-467
6. Korbmacher B, Rammos S. Two-stage sternal closure after repair of congenital heart disease in neonates. Cardiovase Surg 1993;1: 660-3
7. Losay J, Touchot A et al. Late outcome after arterial switch operation for transposition of the great arteries. Circulation 2001;104:1121-6.
8. Martins P, Castela E. Transpositon of the great arteries. Orphanet Journal of rare diseases 2008;1-10.
9. Johnson WH, James H. Pediatric Cardiology.
Blaekwell Publishing 2008, British Library,pp 174-184 10. Wojtalik M, Girish S. Arterial Switch Operation in Neonates with Complex Congenital Heart Defects. Asian Cardiovase Thorac Ann 2003;11:14-7
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