B GIO DC V O TO B QUC PHềNG VIN NGHIấN CU KHOA HC Y DC LM SNG 108 NGUYN XUN TUN NGHIÊN CứU HIệU QUả TRIệT ĐốT NGOạI TÂM THU THấT Và NHịP NHANH THấT BÊN PHảI BằNG NĂNG LƯợNG SóNG Có TầN Số RADIO DựA TRÊN LậP BảN Đồ NộI MạC CƠ TIM BA CHIềU Chuyờn ngnh : Tim mch Mó s : 62720141 CNG D TUYN NGHIấN CU SINH XUT NGI HNG DN: Tin s Phm Quc Khỏnh Tin s Phm Trng Sn H Ni 2016 CH VIấT TT RTP: ng thõt phai RTT: ng thõt trai MAPPING 2D: Lõp ban ụ nụi mac chiờu MAPPING 3D: Lõp ban ụ nụi mac c tim chiờu NNT: Nhip nhanh thõt NTTT: Ngoai tõm thu thõt RLN: Rụi loan nhip TP: Thõt phai MC LC T VN ấ .1 TễNG QUAN TAI LIấU 1.1 CU TO TIM, Hấ THNG PHT XUNG VA DN TRUYấN TRONG TIM 1.1.1 Cu to tim 1.1.2 H thng phỏt xung v dn truyn tim: 1.2 CU TO THT PHAI .6 1.2.1 Cu to v phõn chia ng tht phai (RTP) 1.2.2 Thõn cua tht phai: gụm buụng nhõn tht phai tiờp giỏp vi van ba lỏ, ni tiờp vi buụng nhõn l buụng tng mỏu Chi co 10% ri lon nhip tht bờn phai xut phỏt t õy, li l xut phỏt t ng tht phai 1.2.3 inh vi cỏc vi tri TP/RTP trờn XQ cỏc t thờ khỏc 1.3 NGOI TM THU THT (NTTT)/NHIP NHANH THT (NNT) 1.3.1 inh nghia 1.3.2 Dich tờ NTTT/NNT 1.3.3 Triu chng 1.3.4 Chõn oỏn ngoi tõm thu tht 10 1.3.5 C chờ ngoi tõm thu tht nhip nhanh tht .15 1.3.6 c iờm NTTT/NNT phỏt RTP 17 1.4 PHNG PHP LP BAN ễ NễI MC BA CHIấU 18 1.5 TRIấT T NGOI TM THU THT BNG NNG LNG SONG RADIO 21 1.5.1 Vi phng phỏp truyn thng: 21 1.5.2 Trit t vi tr giup cua lõp ban ụ nụi mc ba chiu .21 I TNG VA PHNG PHP NGHIấN CU 22 2.1 I TNG NGHIấN CU 22 2.1.1 La chon i tng nghiờn cu 22 2.1.2 Tiờu chuõn loi tr 22 2.1.3 Tiờu chuõn chuõn oỏn .22 2.2 PHNG PHP NGHIấN CU 23 2.2.1 Thiờt kờ nghiờn cu: Ct ngang mụ ta v theo doi doc 23 2.2.2 ia iờm v thi gian nghiờn cu: ia iờm ti phong can thip bnh vin tim H Nụi, thi gian nghiờn cu: 2016-2019 23 2.2.3 Cỏc bc tiờn hnh nghiờn cu 23 2.2.4 Cỏc tiờu chuõn dung nghiờn cu 24 2.2.5 Cỏc phng tin phuc vu nghiờn cu 26 2.2.6 Cỏc bc tiờn hnh trit t NTTT 27 2.2.7 S ụ nghiờn cu .31 31 2.3 THU THP VA S LY S LIấU 31 D KIấN KấT QUA NGHIấN CU 31 3.1 C IấM CHUNG CUA NHOM BấNH NHN 32 3.2 MễT S TRIấU CHNG LM SANG 32 3.3 MễT S C IấM CUA NTTT CUA NHOM BấNH NHN 33 3.3.1 Vi tri TP v RTP .33 3.3.2 Hinh dng NTTT v mụt s thụng s 33 3.4 CC LOI IấN CC DUNG CHO LP BAN ễ 33 3.5 TN SUT NTTT XUT HIấN KHI TIấN HANH LP BAN ễ 34 3.6 KấT QUA T NGOI TM THU THT 34 3.6.1 Ty l t Ngoi tõm thu tht thnh cụng 34 3.6.2 Vi tri trit t thnh cụng 34 3.6.3 Vi tri t RF khụng thnh cụng 35 3.6.4 c iờm in ụ cỏc ca thnh cụng 35 3.6.5 c iờm in ụ nhom t RF khụng thnh cụng 35 3.6.6 Cỏc ly t khụng thnh cụng 36 3.7 MễT CHI S LIấN QUAN ấN PHNG PHP 36 3.7.1 Mụt s khoang thi gian 36 3.7.2 S iờm trit t RF 36 3.7.3 Thay ụi men tim sau t RF .37 3.8 BIấN CHNG 37 BAN LUN 38 4.1 BAN LUN Vấ TY Lấ THANH CễNG .38 4.2 BAN LUN Vấ U NHC IấM CUA PHNG PHP 38 NHNG D ICH VA Kấ HOCH ấ T C MUC TIấU MONG MUN 39 TAI LIấU THAM KHAO 41 PH LC DANH MC HèNH Hinh 1.1: H thng dn truyn tim Hinh 1.2: Cu toa ng tht phai Hinh 1.3: Liờn quan giai phõu Hinh 1.4: Goc chờch trc phai, bờn trỏi bnh nhõn l thn trc, bờn phai bnh nhõn l thnh sau Hinh 1.5: Goc chờch trc trỏi: hng v cụt sng l thnh vỏch, hng i din l thnh t Hinh 1.6: Ngoi tõm thu tht: phc bụ QRS ờn sm, rụng; Song T theo sau phc bụ QRS ờn sm co hng ngc vi hng cua QRS; Thi gian nghi bu hon ton 10 Hinh 1.7: Nhip xoang tng i chõm (60 ln/ph), mụt NTTT ờn rt sm (PVC), xung ụng c dn truyn ngc lờn nhi kich thich nhi (P), nut xoang bi iu chinh li (reset) lm mt khoang nghi bu Xung ụng phỏt t nut xoang vi song P (theo sau P) cha kip dn truyn c xung tht, mụt nhip thoỏt tht (E) xut hin .11 Hinh 1.8: Nhip NTTT xen k (interpolated premature ventricular complex), theo sau bi mụt nhip xoang co khoang PR tng i di 11 Hinh 1.9: S ụ vong vo li Phõn nhỏnh hinh Y cua h thng Purkinje vo c tht c mụ ta cỏc hinh A, B, C Nhỏnh bờn phai (vung m) co thi gian tr di hn nhỏnh bờn trỏi 16 Hinh 1.10: Cỏc vi tri phỏt ngoi tõm thu tht v hinh anh song V1: 1-vung trc (dng QS block nhỏnh trỏi iờn hinh); 2,3: gia vung sau v trc xoang vnh phai (nhu song R); 4: xoang vnh trỏi co c iờm song R gian rụng 5: dng blc nhỏnh phai) 18 Hinh 1.11: Hinh anh giai phu in hoc chiu cua RTP vi cỏc mu khỏc thờ hin lan truyn in t ụ ri lon nhip: mu o gn ụ ri lon nhip nht 19 Hinh 1.12 H thng mapping 2D bờn trỏi v 3D bờn phai .20 Hinh 1.13: Hinh anh in hoc v giai phu u co thờ hiờn thi trờn mapping 3D 20 Hinh 1.14: in cc mapping co thờ nhiu in cc khỏc giup chung ta thu nhiu iờm cung luc xõy dng ban ụ nhanh hn .20 Hinh 2.1: Mỏy chiờu tia X cua hang Toshiba 26 Hinh 2.2: H thng hiờn thi v lu tr tin hin in tim mapping 2D (trỏi), h thng lõp ban ụ nụi mc c tim chiu (phai) 26 Hinh 2.3 Mỏy kich thich tim kờnh (trỏi) v mỏy to song RF(phai) .27 Hinh 2.4: Dõy in cc mapping (trỏi) v dõy in cc t (phai) 27 Hinh 2.5 Vi tri cỏc in cc inh vi dỏn trờn bnh nhõn .29 Hinh 2.6: Cỏc bin phỏp lõp ban ụ in hoc giai phu khỏc nhau: a-activation mapping: o l vung in thờ sm; b-Voltage mapping: o vung in thờ thp nht; c-propagation mapping: hng lan truyn in cua vong vo li 30 T VN Triờt ụt rụi loan nhip bng nng lng song co tõn sụ radio (RF) a tr mụt la chon hang õu iờu tri cho nhiờu loai rụi loan nhip khac Hiờn gõn nh moi rụi loan nhip tim ờu co thờ xem xet iờu tri bng RF S cai tiờn san xuõt iờn cc ụt (catheter ụt), may tao song RF, ky thuõt tiờp cõn va c biờt la ky thuõt lõp ban ụ iờn hoc qua tim chiờu (mapping 3D) a lam cho phụ rụi loan nhip c iờu tri cang rụng Triờt ụt rụi loan nhip da trờn lõp ban ụ truyờn thụng (mapping 2D) a at c cụng cao iờu tri rụi loan nhip liờn quan ờn ng phu, nhip nhanh vong vao lai nut nhi thõt, triờt ụt nut nhi thõt rung nhi nhanh va cuụng nhi iờn hinh, nhiờn nhng rụi loan nhip khac nh: Tim nhanh nhi, rung nhi, nhip nhanh thõt nhõt la liờn quan ờn thiờu mau võn la mụt thach thc cho bac sy thm iờn sinh ly trờn lõm sang Ngoai tõm thu thõt (NTTT), nhip nhanh thõt (NNT) la mụt rụi loan nhip gp kha phụ biờn trờn lõm sang, o ụ rụi loan nhip xuõt phat t bờn phai (thõt phai va ng thõt phai) chiờm ti 80%-85%, vi hai la chon iờu tri hiờn tai la dung thuục va triờt ụt ụ ngoai vi bng nng lng song co tõn sụ radio (RF), c biờt la la chon triờt ụt vi phng phap truyờn thụng (2D) cho kờt qua cụng t 85-90%, lai khoang 10%-15% bờnh nhõn ụt khụng cụng co liờn quan ờn nhiờu yờu tụ khac nhau: tõn sụ tha, vi tri kho, gõn His Ky thuõt lõp ban ụ truyờn thụng hiờn tai cung co nhiờu u iờm nh: chi cõn may chiờu tia X va ky thuõt lõp ban ụ: th t kh cc c tim ngoai tõm thu xuõt hiờn (activation mapping), phu hp phc bụ QRS tao nhip (pacing mapping) co thờ thc hiờn triờt ụt va cụng cao hõu hờt cac bờnh nhõn Tuy nhiờn nhng ca cụng co nhiờu ca phai trai qua thi gian lõp ban ụ keo dai i lai nhiờu lõn qua vung giai phõu cu ma khụng biờt, ụt lai vi tri cu nhiờu lõn, cung cụ sau ụt ngoai tõm thu thõt co thờ xa vi tri cụng thõm chi lp lai vi tri cu co thờ gõy tụn thng c tim nhiờu hn va dờ tai phat hn, nhng ca ụt khụng cụng lai liờn quan ờn vi tri phat kho tim, cụ inh iờn cc kho, hoc la qua tha kho lõp c ban ụ Ky thuõt lõp ban ụ giai phõu iờn hoc c tim ba chiờu (mapping: 3D) cho phep bac sy nhin giai phõu buụng tim chinh xac co liờn hờ vi iờn hoc tai vi tri o, cac ky thuõt lõp ban ụ iờn hoc khac co thờ thc hiờn trờn cung mụt bờnh nhõn nh: lõp ban ụ da vao vi tri kh cc sm nhõt (activation mapping) hinh anh giai phõu phu hp tao nhip tim (pacing mapping), ban ụ lan truyờn iờn hoc (propragation mapping), lõp ban ụ iờn thờ (Voltage mapping) va s kh cc c thõt vờ mt iờn hoc se c anh dõu bng cac mau khac trờn cõu truc giai phõu ba chiờu va c xõy dng giup bac sy inh vi chinh xac ụ rụi loan nhip, c chờ rụi loan nhip, sụ lng ụ rụi gõy rụi loan nhip t o co thờ tr giup cho cac bac sy nhiờu hn vờ vi tri triờt ụt, cac vi tri ụt cung cụ, tng ty lờ cụng cung nh t tin cua ngi lam vờ kờt qua at c Ky thuõt mapping 3D õu tiờn ng dung cụ lõp xung quanh tinh mach phụi iờu tri rung nhi, cuụng nhi khụng iờn hinh, tim nhanh nhi, rụi loan nhip trờn bờnh nhõn sau phõu thuõt tim bõm sinh, nhip nhanh thõt liờn quan thiờu mau c tim cuc bụ Tuy nhiờn tim nhanh nhi, cuụng nhi khụng iờn hinh sụ lng gp rõt it, cụng cua iờu tri rụi loan nhip thõt liờn quan thiờu mau c tim vi tr giup cua mapping 3D han chờ Hiờn ky thuõt c nhiờu nc vung va trờn thờ gii ap dung iờu tri cac rụi loan thụng thng vi cac muc ich khac nh: giam thi gian chiờu tia (cn nhip nhanh trờn thõt), hụi chng WPW tre em (han chờ ụt nhiờu tai vi tri cu va giam thi gian chiờu tia), Ngoai tõm thu thõt, nhip nhanh thõt vụ cn (giam thi gian chiờu tia, tng ty lờ cụng va giam tai phat ) Viờt Nam co mụt sụ tai nghiờn cu hiờu qua cua mapping 2D vi NTTT va NNT bờn phai, nhng cha co tac gia nao nghiờn cu ng dung cua ky thuõt mapping 3D trờn loai rụi loan nhip nay, chinh vi võy chung tụi tiờn hanh thc hiờn tai: "Nghiờn cu hiờu qua triờt t ngoi tõm thu thõt v nhip nhanh thõt bờn phai bng nng lng song co tõn s radio da trờn k thuõt lõp ban ụ ni mc c tim ba chiờu" vi cac muc tiờu sau: Nghiờn cu hiờu qua cua phng phap triờt ụt ngoai tõm thu thõt bờn phai bng nng lng song co tõn sụ radio da trờn ky thuõt lõp ban ụ giai phõu iờn hoc nụi mac ba chiờu (mapping 3D) Nghiờn cu u nhc iờm cua phng phap lõp ban ụ giai phõu iờn hoc nụi mac ba chiờu so vi ky thuõt mapping truyờn thụng triờt ụt ngoai tõm thu thõt bờn phai 34 3.5 TN SUT NTTT XUT HIN KHI TIấN HNH LP BAN ễ Mapping 2D Mapping 3D p Trờn Ngoai tõm thu/man hinh Ngoai tõm thu/man hinh Di 3.6 KấT QUA T NGOI TM THU THT 3.6.1 Ty lờ t Ngoi tõm thu thõt thnh cụng Nhom mapping 2D Nhom mapping 3D p ụt cụng ụt khụng cụng 3.6.2 Vi tri triờt t thnh cụng Thụng Vung vach Vung T Vung trc Vung sau Vung cao Vung thõp Tụng Nhom mapping 2D Nhom mapping 3D p 35 3.6.3 Vi tri t RF khụng thnh cụng Thụng Vung vach Vung T Vung trc Vung sau Vung cao Vung thõp Tụng Nhom mapping 2D Nhom mapping 3D p Nhom mapping 2D p 3.6.4 c im iờn ụ cỏc ca thnh cụng Nhom mapping 2D Sm t 20-30 ms Sm trờn 30 ms Tao nhip giụng 12/12 Tao nhip giụng 11//12 Ca sm va giụng 3.6.5 c im iờn ụ nhom t RF khụng thnh cụng Nhom mapping 2D Sm trờn 30 ms Tao nhip giụng 11/12-12/12 Ca Nhom mapping 2D p 36 3.6.6 Cỏc ly t khụng thnh cụng Nhom mapping 2D Nhom mapping 3D p Gõn His Ngoai mac Khụng tim c vi tri Bờnh nhõn au 3.7 MT CHI S LIấN QUAN ấN PHNG PHP 3.7.1 Mt s khoang thi gian Nhom mapping 2D Nhom mapping 3D p Thi gian t chuõn bi Thi gian Mapping Thi gian ụt Tụng thi gian lam TT 3.7.2 S im triờt t RF Nhom Mapping 2D Tụng sụ iờm ụt RF Sụ iờm cung cụ Thi gian ụt RF Nhom Mapping 3D p 37 3.7.3 Thay ụi men tim sau t RF Nhom mapping 2D Nhom mapping 3D p CK- MB sau gi CK-MB sau 12h Troponin T sau 6h Troponin T sau 12h 3.8 BIấN CHNG Nhom mapping 2D Hematome Thụng ụng tinh mach ui Chay mau phụi Tran mang phụi Nhom mapping 3D p 38 BN LUN 4.1 BN LUN V TY L THNH CễNG 4.2 BN LUN V U NHC IM CUA PHNG PHP 39 NHNG D ICH V Kấ HOCH T C MC TIấU MONG MUN Vờ sụ lng bờnh nhõn: NTTT/NNT bờn phai gp phụ biờn, hiờn tai mi nm Bờnh Viờn tim Ha Nụi ụt khoang 80-100 ca rụi loan nhip thõt, vi võy sụ lng bờnh nhõn u phuc vu cho nghiờn cu Trang thiờt bi: Hiờn tai BV tim Ha Nụi co hờ thụng may moc hiờn sanh ngang vi khu vc: may kich thich tim bụn cõn, may hiờn thi iờn tõm ụ tim nờn ờn 126 kờnh, may tao hinh anh chiờu thờ hờ hiờn nhõt cua S.Jude Medical: Ensite Velocity Ban thõn: c ao tao nhip hoc BV Bach Mai, Singapore, Bc King, a tng ụt NTTT hang vai trm ca trờn hờ thụng mapping truyờn thụng, khoang vai chuc ca trờn hờ thụng mapping 3D Kha nng chi tra: Hiờn tai ban iờn cc dan trờn ngi bờnh nhõn co gia khoang 2300 USD, thi gian dung c 18h, vi võy co thờ lam cho 8-10 ca NTTT/NNT ngay, cac iờn cc khac hoan toan giụng mapping 2D Võy bờnh nhõn chi phai chi tra thờm khoang triờu ụng-7 triờu ụng, rõt nhiờu bờnh nhõn co thờ chi tra c D kin thi gian Thi gian lõy sụ liờu: 08/2016- 08/2018 va tiờp tuc theo dừi bờnh nhõn ờn tai kờt thuc Thu thõp sụ liờu va tai liờu tham khao: song song vi thi gian lõy sụ liờu 1/2016- 10/2018 Hoan cac hoc phõn theo quy inh X ly sụ liờu: 11-12/2018 Cụng bụ it nhõt hai bai bao chuyờn nganh liờn quan luõn an Hoan luõn vn: 2019 40 D kiờn viờc lam va cac nghiờn cu tiờp theo sau 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