1 B GIO DC V O TO B Y T TRNG I HC Y H NI PHM THNH T ĐáNH GIá KếT QUả SớM PHẫU THUậT THAY VAN HAI Lá íT XÂM LấN Có NộI SOI Hỗ TRợ TạI TRUNG TÂM TIM MạCH BệNH VIệN E Chuyờn ngnh : Ngoi khoa Mó s : NT 62720750 LUN VN TT NGHIP BC S NI TR Ngi hng dn khoa hc: PGS.TS Lờ Ngc Thnh H NI 2015 LI CM N Tụi xin by t lũng bit n sõu sc ti: PGS.TS Lờ Ngc Thnh Giỏm c Bnh vin E, Giỏm c Trung Tõm Tim Mch - Bnh vin E, ngi thy ó tn tõm truyn t kin thc, trc tip hng dn tụi sut quỏ trỡnh lm nghiờn cu Tụi xin trõn trng cm n cỏc thy cụ hi ng ó úng gúp nhng ý kin khoa hc tụi hon thin lun Tụi vụ cựng bit n cỏc thy B mụn Ngoi Trng i hc Y H Ni ó truyn t nhng kin thc quý bỏu cho tụi sut quỏ trỡnh nghiờn cu cng nh thi gian hc ni trỳ Tụi xin chõn thnh cm n ng u, Ban Giỏm c, Phũng K hoch tng hp, th Khoa Phu thut tim mch v lng ngc, Phũng M Trung Tõm Tim Mch Bnh vin E, ó to mi iu kin thun li giỳp tụi hc v thc hin lun ny Tụi xin chõn thnh cm n: Ban Giỏm hiu, Phũng o to sau i hc Trng i hc Y H Ni Ban Giỏm c, Phũng K hoch tng hp, cỏc khoa phũng, phũng m Bnh vin Vit c ó giỳp , to iu kin cho tụi sut thi gian hc tp, thc hnh Bỏc s ni trỳ bnh vin Cui cựng tụi xin cm n sõu sc ti nhng ngi thõn gia ỡnh, bn bố, ng nghip ó giỳp , chia s, ng viờn tụi sut quỏ trỡnh hc v hon thnh lun H Ni, ngy 16 thỏng 09 nm 2015 Phm Thnh t LI CAM OAN Tụi l Phm Thnh t, Ni trỳ khúa XXXVII, Trng i hc Y H Ni, chuyờn ngnh: Ngoi khoa, xin cam oan õy l Lun bn thõn tụi trc tip thc hin di s hng dn ca PGS.TS Lờ Ngc Thnh Cụng trỡnh ny khụng trựng lp vi bt k nghiờn cu no khỏc ó c cụng b ti Vit Nam Cỏc s liu v thụng tin nghiờn cu l hon ton chớnh xỏc, trung thc v khỏch quan, ó c xỏc nhn v chp nhn ca c s ni nghiờn cu Tụi xin hon ton chu trỏch nhim trc phỏp lut v nhng cam kt ny H Ni, ngy 16 thỏng 09 nm 2015 Ngi vit cam oan Phm Thnh t MC LC T VN CHNG 1: TNG QUAN TI LIU 15 1.1 c im gii phu van hai lỏ v ng dng phu thut thay van 15 1.1.1 Lỏ van .15 1.1.2 Vũng van 18 1.1.3 Dõy chng 19 1.1.4 Ct c nhỳ 21 1.1.5 Liờn quan gii phu van hai lỏ v ng dng phu thut 21 1.2 Nguyờn nhõn, nhng thay i cu trỳc, chc nng bnh van hai lỏ .24 1.2.1 Hp van hai lỏ 24 1.2.2 H van hai lỏ n thun 29 1.3 c im chn oỏn bnh VHL 33 1.3.1 Hp VHL 33 1.3.2 H van hai lỏ 37 1.4 Ch nh phu thut bnh van hai lỏ .39 1.4.1 Hp van hai lỏ 40 1.4.2 H van hai lỏ 41 1.5 Phu thut thay van hai lỏ ớt xõm ln cú ni soi h tr 45 1.5.1 Lch s phỏt trin phu thut van hai lỏ ớt xõm ln trờn th gii 45 1.5.2 Phu thut van hai lỏ ớt xõm ln Vit Nam 47 CHNG 2: I TNG V PHNG PHP NGHIấN CU 48 2.1 i tng nghiờn cu .48 2.1.1 Tiờu chun la chn bnh nhõn 48 2.1.2 Tiờu chun loi tr 48 2.2 Phng phỏp nghiờn cu 48 2.2.1 Thit k nghiờn cu 48 2.2.2 Phng tin v dng c 48 2.2.3 Quy trỡnh phu thut 50 2.2.4 Cỏc ch tiờu nghiờn cu 56 2.2.5 Phõn tớch v x lý s liu 59 CHNG 3: KT QU NGHIấN CU 60 3.1 c im chung 60 3.1.1 c im tui 60 3.1.2 c im gii 60 3.2 c im lõm sng 61 3.2.1 Thi gian phỏt hin bnh tim n lỳc m 61 3.2.2 Tin s bnh lý van hai lỏ 61 3.2.3 c im lõm sng 61 3.3 c im cn lõm sng 62 3.3.1 XQ ngc thng 62 3.3.2 in tim 63 3.3.3 Siờu õm tim qua thnh ngc trc m .63 3.4 c im m 64 3.4.1 Tun hon ngoi c th 64 3.4.2 Tn thng m 65 3.4.3 K thut m 65 3.5 Kt qu sau m .67 3.5.1 Thi gian iu tr sau m 67 3.5.2 Bin chng sau m 67 3.5.3 S lng mỏu truyn sau m 68 3.5.4 Tỡnh trng bnh nhõn sau m 68 CHNG 4: BN LUN 70 4.1 c im chung ca nhúm bnh nhõn nghiờn cu 70 4.1.1 Tui v gii 70 4.1.2 Tin s 71 4.1.3 c im lõm sng 71 4.1.4 X quang ngc thng 73 4.1.5 Siờu õm Doppler tim 73 4.2 Quy trỡnh phu thut thay van hai lỏ ớt xõm ln cú ni soi h tr 76 4.2.1 La chn ng tip cn phu thut van hai lỏ ớt xõm ln .76 4.2.2 Cỏch thit lp tun hon ngoi c th 81 4.2.3 Thit lp h thng ni soi 83 4.2.4 Bo v c tim phu thut van hai lỏ ớt xõm ln .83 4.3 Kt qu phu thut thay van hai lỏ ớt xõm ln qua ng m ngc phi cú ni soi h tr .85 4.3.1 Tn thng m 85 4.3.2 X lý tn thng 86 4.3.3 Thi gian phu thut 89 4.3.4 T l t vong .92 4.3.5 Bin chng thn kinh .93 4.3.6 Bin chng liờn quan n chy mỏu v s lng mỏu truyn sau m .95 4.3.7 Nhim trựng sau m 97 4.3.8 Bin chng phi, hụ hp 98 4.3.9 Bin chng liờn quan n quỏ trỡnh thit lp tun hon ngoi c th 99 4.3.10 Tht bi k thut .99 4.3.11 Bin chng h cnh van nhõn to 100 4.3.12 au v thi gian hi phc sau m 101 4.3.13 Mt s thay i trờn siờu õm tim sau phu thut 103 KT LUN 105 TI LIU THAM KHO PH LC DANH MC CH VIT TT ACC/AHA American College of Cardiology/American Heart Association ALMPTT p lc ng mch phi tõm thu Dd (Diamốtre diastolique) ng kớnh tht trỏi cui tõm trng Ds (Diamốtre systolique) ng kớnh tht trỏi cui tõm thu KTP ng kớnh tht phi MC ng mch ch EF (Ejection fraction) Phõn sut tng mỏu tht trỏi HK Huyt HKNT Huyt nh trỏi NT Nh trỏi S Siờu õm THNCT Tun hon ngoi c th TNT Tiu nh trỏi VHL Van hai lỏ DANH MC BNG Bng 1.1 Thang im Wilkins trờn siờu õm ỏnh giỏ van hai lỏ 36 Bng 1.2 Mc hp van hai lỏ ỏnh giỏ trờn siờu õm 37 Bng 1.3 Phõn h van hai lỏ trờn siờu õm tim 38 Bng 1.4 Mc suy tim theo NYHA 40 Bng 1.5 Cỏc giai on ca hp van hai lỏ 40 Bng 1.6 Cỏc mc ca h VHL mn tớnh nguyờn phỏt 42 Bng 1.7 Cỏc mc ca h VHL mn tớnh th phỏt 44 Bng 3.1 Thi gian phỏt hin n lỳc m 61 Bng 3.2 Tin s bnh lý van hai lỏ 61 Bng 3.3 Phõn b cỏc du hiu trờn lõm sng 62 Bng 3.4 Ch s tim ngc trc m 62 Bng 3.5 Cỏc du hiu ca X quang ngc thng 62 Bng 3.6 Cỏc ch s S tim trc m 63 Bng 3.7 Huyt nh trỏi phỏt hin trờn siờu õm 64 Bng 3.8 Bnh VHL phõn b theo th bnh 64 Bng 3.9 Tn thng van ba lỏ kốm theo 64 Bng 3.10 Thi gian kp MC v thi gian chy mỏy THNCT 64 Bng 3.11 Tn thng m 65 Bng 3.12 ng m tip cn van hai lỏ 65 Bng 3.13 K thut ly HKNT v can thip trờn nh trỏi 65 Bng 3.14 K Thut thay van hai lỏ 66 Bng 3.15 Can thip van ba lỏ 66 Bng 3.16 Thi gian iu tr sau m 67 Bng 3.17 Cỏc tai bin bin chng v sau m 67 Bng 3.18 Bnh nhõn cn truyn mỏu v s lng mỏu truyn sau m 68 Bng 3.19 Mc suy tim sau m 68 Bng 3.20 Cỏc ch s trờn S tim qua thnh ngc lỳc vin 69 Bng 3.21 Thay i trờn S lỳc vin so vi trc m 69 Bng 4.1 So sỏnh t l rung nh cỏc nghiờn cu phu thut thay VHL 72 Bng 4.2 So sỏnh cỏc th bnh cỏc nghiờn cu phu thut thay van hai lỏ74 Bng 4.3 So sỏnh kớch thc nh trỏi cỏc nghiờn cu 75 Bng 4.4 Thi gian cp ng mch ch, chy mỏy tun hon ngoi c th, thi gian m ca mt s nghiờn cu Phu thut van hai lỏ ớt xõm ln qua ng ngc phi cú ni soi h tr 89 Bng 4.5 So sỏnh thi gian m ca phu thut ớt xõm ln vi phu thut truyn thng 91 Bng 4.6 Kt qu phõn tớch meta nghiờn cu Paul Modi v cng s 92 Bng 4.7 T l t vong mt s nghiờn cu phu thut van hai lỏ ớt xõm ln 92 Bng 4.8 T l tai bin mch nóo cỏc nghiờn cu 94 Bng 4.9 T l chy mỏu m li cỏc nghiờn cu 96 Bng 4.10 T l nhim trựng sau m cỏc nghiờn cu 97 Bng 4.11 Thi gian iu tr sau m ca cỏc nghiờn cu trờn th gii v nc 101 10 DANH MC BIU Biu 3.1 Phõn b bnh nhõn theo tui 60 Biu 3.2 Phõn b bnh nhõn theo gii 60 Biu 3.3 Phõn b bnh nhõn theo mc suy tim NYHA 61 Biu 3.4 c im in tõm 63 Biu 3.5 So sỏnh NYHA trc v sau m 68 48 Robert L Treasure, W Gerald Rainer, Tracy E Strevey and Theodore R Sadler (1973), Intraoperative left ventricular rupture associated with mitral valve replacement, Chest, Vol 66(5), 11-4 49 Seiya Matsuyama M.D, Tsuneya Watabe M.D, et al (1983), Plain 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Heart Valve Dis 12(4):469-74 80 Mihaljevic T, Cohn LH, Unic D, Aranki SF, Couper GS, Byrne JG (2004) One thousand minimally invasive valve operations: early and late results Ann Surg, 240(3): 529 -34 81 G A Crooke, C F Schwartz, G H Ribakove et al (2010), Retrograde arterial perfusion, not incision location, significantly increases the risk of stroke inreoperative mitral valve procedures, Annals of Thoracic Surgery,89(3), 723730 82 E A Grossi, D F Loulmet, C F Schwartz et al (2011) Minimally invasive valve surgery with antegrade perfusion strategy is not associated with increased neurologic complications, The Annals of Thoracic Surgery, 92 (4), 13461350 83 Robert M.Bojar (2011) Manual of Perioperative Care in Adult Cardiac Surgery 5th ed, Wiley Blackwell Publishing, 242 251 84 Chitwood Jr WR, Wixon CL, Elbeery JR, Moran JF, Chapman WH, Lust RM (1997) Video-assisted minimally invasive mitral valve surgery J Thorac Cardiovasc Surg, 114 (5):773 -80 discussion 80-2 85 O Santana, J Reyna, R Grana, M Buendia, G A Lamas, and J Lamelas (2011), Outcomes of minimally invasive valve surgery versus standard sternotomy in obese patients undergoing isolated valve surgery Annals of Thoracic Surgery 91(2) 406410 MT S BNH N V HèNH NH MINH HA Phm Vn L 37 tui Nam a ch: Bc Giang MSBA 5.6749 Ngy PT 17.11.14 Chn oỏn: Hp khớt van hai lỏ Lon nhp hon ton, HKNT Phng phỏp phu thut: phu thut ớt xõm ln cú ni soi h tr thay van hai lỏ c hc s 29, khõu chõn tiu nh trỏi qua ng m nh ngc phi Hỡnh 1: t ng ng mch, tnh Hỡnh 2: t ng tnh mch ch trờn qua mch ựi ng tnh mch cnh P qua da Hỡnh 3: ng m ngc v thit lp THNCT Hỡnh 4: t cỏc mi ch vũng van Hỡnh 5: Khõu chõn tiu nh trỏi Hỡnh 6: Thay van hai lỏ V Th T 52 tui N a ch: Thỏi Bỡnh MSBA 4.4926 Ngy PT 20.03.14 Chn oỏn: Hp h van hai lỏ Rung nh, Lon nhp hon ton Phng phỏp phu thut: Phu thut ớt xõm ln cú ni soi h tr thay van hai lỏ c hc s 25, khõu chõn tiu nh trỏi SA Tim trc m: van hai lỏ hp khớt, h va, chờnh ỏp ti a qua van 14mmHg SA Tim sau m: van hai lỏ nhõn to c hc hot ng tt, chờnh ỏp ti a qua van 6mmHg Hỡnh 1: Siờu õm tim trc m Hỡnh 2: Siờu õm tim sau m Hỡnh 3: Thit lp ni soi v cp ng mch Hỡnh 4: Phu trng phu thut thay van hai ch qua thnh ngc lỏ ớt xõm ln Hỡnh 5: Khõu cỏc mi ch vũng van nhõn to Hỡnh 6: H van, kim tra hot ng van hai lỏ nhõn to Lờ Th H 29 tui N a ch: Phỳ Th MSBA 4.5291 Ngy PT 29.04.14 Lý vo vin: khú th gng sc Lõm sng: NYHA III, tim lon nhp, TTT 3/6 mm tim in tim: trc m rung nh, sau m: rung nh X quang trc m: ch s tim ngc 58%, b trỏi cú hỡnh cung, cung di phi hai b Sau m: ch s tim ngc 55 %, B trỏi mt hỡnh cung S tim trc m: H VHL 4/4 van dy, co rỳt NT 70, Dd 76, ALMP 51 S tim vin: NT 52, Dd 64, ALMP 40 Hỡnh 1: in tim trc m Hỡnh 3: X quang trc m Hỡnh 2: in tim sau m Hỡnh 4: X quang sau m Hỡnh 5: Siờu õm tim trc m Hỡnh 6: Siờu õm tim sau m Hỡnh 7: Ct van, t cỏc mi ch vũng van Hỡnh 8: Thay van hai lỏ sinh hc MU BNH N NGHIấN CU I Hnh chớnh H v tờn: Tui: Gii: a ch: in thoi: Ngh nghip: Ngy vo vin: Mó bnh ỏn: Ngy m: Lý vo vin: Chn oỏn vo vin: Chn oỏn sau m: Cỏch thc phu thut: II Tin s: - Bnh tim mch: - Bnh khỏc: - Tin s phu thut : III Triu chng lõm sng Triu chng c nng - Mt mi - Ho - Khú th - Khú th gng sc - Hi hp ỏnh trng ngc - Tim p nhanh - au ngc - Triu chng khỏc Khỏm ton thõn v thc th - NYHA - Phự - Gan to - Lon nhp Ngy vin: - Thi tõm thu - Rung tõm trng - T1 anh, T2 tỏch ụi - Phi cú rales IV Cn lõm sng in tim - Rung nh - LNHT XQ ngc thng - Cung ng mch phi phng - Tim hỡnh cung - Ch s tim ngc Siờu õm tim - NT Dd - ALMP: - HoHL - Gión vũng van - Hp hai lỏ: din tớch l van - HoBL - HKNT: I I II Ds III EF TP IV t dõy chng II III cm2 Wilkins: IV V Cỏc thụng s m: - - THNCT: t ng ng mch ựi tnh mch ựi phi tnh mch ch trờn V trớ khỏc: Lý do: Thi gian m (gi): Thi gian chy mỏy tim phi(phỳt): Thi gian cp ng mch ch(phỳt): Cỏch x trớ thng tn: Ct van cú bo tn dõy chng lỏ sau: cú hay khụng C van hai lỏ (mm) Thay van c hc hay sinh hc K thut khõu van: Khõu ch U hay khõu vt VI: Cỏc thụng s sau m: Thi gian th mỏy(gi): Thi gian nm hi sc (ngy): Thi gian nm vin(ngy): S lng mỏu truyn(ml): hng cu, tiu cu, plasma VII Tai bin m Thng ng mch ựi Thng tnh mch ựi Phi m rng ng m ngc Chuyn m xng c Nguyờn nhõn Nguyờn nhõn Tai bin khỏc VIII Bin chng sau m Chy mỏu m li: Nguyờn nhõnCỏch thc x trớ Trn dch mng phi phi dn lu: ngy thsau m Bờn phi Bờn trỏi bờn Trn khớ mng phi phi dn lu: ngy thsau m Bờn phi Bờn trỏi bờn Mỏu cc mng phi: ngy thsau m Bờn phi Bờn trỏi bờn Xp phi: ngy thsau m Bờn phi Bờn trỏi bờn Trn dch mng tim phi dn lu: ngy thsau m X lý vt m: - Nhim trựng vt m ngc, ngy th Cỏch thc x lý: - Nhim trựng vt m ựi, ngy th Cỏch thc x lý: Lon thn: xy ngy th Kộo di: TBMN: xy ngy th Nguyờn nhõn 10 Viờm phi: xy ngy th 11 Nhim trựng huyt: xy ngy th 12 Suy thn: xy ngy th 13 t thm phõn phỳc mc ngy th kộo di (ngy) 14 Huyt ng mch ựi: 15 Huyt tnh mch ựi: phỏt hin ngy th phỏt hin ngy th Cỏch thc x trớ Cỏch thc x trớ 16 T vong sau m ngy th IX Tỡnh trng vin Nguyờn nhõn Lõm sng: - NYHA - au ngc - ỏnh trng ngc Gan to - Thi tõm thu Lon nhp - Nhp tim: l/phỳt Phự Vt m(ựi, ngc): in tim: - Nhp u - Rung nh: lin so tt chy dch l/phỳt - LNHT Siờu õm tim: - NT EF - ALMP: tõm thu - HoHL I II III IV HoBL I II III IV Chờnh ỏp qua van nhõn to: Hot ng cỏnh van - H cnh van nhõn to Huyt bung nh Dd TP trung bỡnh: mmHg ... xâm lấn có nội soi hỗ trợ Đánh giá kết sớm phẫu thuật thay van hai xâm lấn có nội soi hỗ trợ Trung tâm tim mạch Bệnh viện E 15 CHƯƠNG TỔNG QUAN TÀI LIỆU 1.1 Đặc điểm giải phẫu van hai ứng dụng phẫu. .. Đánh giá kết sớm phẫu thuật thay van hai xâm lấn có nội soi hỗ trợ Trung tâm tim mạch Bệnh viện E với hai mục tiêu sau: Nhận xét đặc điểm chẩn đoán, định quy trình phẫu thuật thay van hai xâm. .. 1.3.2 Hở van hai 37 1.4 Chỉ định phẫu thuật bệnh van hai .39 1.4.1 Hẹp van hai 40 1.4.2 Hở van hai 41 1.5 Phẫu thuật thay van hai xâm lấn có nội soi hỗ trợ