B GIO DC V O TO B Y T TRNG I HC Y H NI Lấ TRNG THễNG ĐáNH GIá KếT QUả PHẫU THUậT TạO HìNH VAN HAI Lá TạI BệNH VIệN hữu nghị VIệT ĐứC GIAI ĐOạN 2010 ĐếN NĂM 2016 Chuyờn ngnh : Ngoi khoa Mó s : 60720123 LUN VN THC S Y HC NGI HNG DN KHOA HC: PGS.TS Nguyn Hu c H NI - 2016 LI CM N Vi lũng kớnh trng v bit n sõu sc, tụi xin chõn thnh cm n: Bam giỏm hiu v Phũng o to sau i hc Trng i hc Y H Ni ng y Ban giỏm c Bnh vin Vit c ó to mi iu kin thun li giỳp tụi quỏ trỡnh hc v hon thnh lun ny Ban ch nhim b mụn Ngoi v cỏc thy cụ ó tham gia ging dy khúa cao hc 23 ti Trng i hc Y H Ni Tụi xin by t lũng kớnh trng, lũng bit n sõu sc ti nhng ngi thy ỏng kớnh hi ng ó úng gúp cho tụi nhng ý kin quý bỏu v xỏc ỏng hon thnh lun c bit tụi xin by t tỡnh cm, lũng kớnh trng v bit n sõu sc ti PGS.TS Nguyn Hu c , ngi thy ó tn tỡn dỡu dt, ch bo, trc tip giỳp tụi quỏ trỡnh hc tp, lm vic v thc hin ti ny Thy l tm gng sỏng v trớ tu, tri c cho tụi rốn luyn v noi theo Xin by t lũng bit n chõn thnh ti cỏc anh ch ng nghip ang cụng tỏc ti Khoa Phu thut Lng Ngc Tim Mch bnh vin Hu Ngh Vit c ó dnh cho tụi nhng s giỳp quý bỏu, s ng viờn chõn thnh quỏ trỡnh hc tp, tỡm h s, ti liu hon thnh lun Tụi xin by t lũng bit n ti Ban giỏm c, th khoa Ngoi tng hp Bnh vin Sn Nhi Ngh An ó to mi iu kin thun li cho tụi quỏ trỡnh hc Tụi xin chõn thnh bn bố, ng nghip ó luụn quan tõm, h tr tụi sut hai nm hc Cui cựng tụi xin by t lũng bit n ti gia ỡnh v nhng ngi thõn ó ht lũng ng viờn v ng h tụi quỏ trỡnh hc H Ni, thỏng 09 nm 2016 Lờ Trng Thụng LI CAM OAN Tụi l Lờ Trng Thụng, hc viờn cao hc khúa 23 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 Nguyn Hu c 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 thun ca c s ni nghiờn cu Tụi xin hon ton chu trỏch nhim trc phỏp lut v nhng cam kt ny H Ni, thỏng 09 nm 2016 Ngi vit cam oan Lờ Trng Thụng DANH MC VIT TT VBL Van ba lỏ BN Bnh nhõn KNT ng kớnh nh trỏi KTT ng kớnh tht trỏi MC ng mch ch MP ng mch phi T in tõm EF Phõn sut tng mỏu tht trỏi (Ejection Fraction) HoHL H van hai lỏ NT Nh trỏi NYHA Hi tim mch NewYork (New York Heart Association) SA Siờu õm TT Tht trỏi VHL Van hai lỏ XQ X-quang MICS Phu thut tim ớt xõm ln (Minimally Invasive Cardiac Surgery) MC LC DANH MC BNG DANH MC BIU DANH MC HèNH NH T VN Bnh van hai lỏ l mt nhng bnh tim rt thng gp Vit Nam [1] Trc õy, nguyờn nhõn gõy bnh ch yu thp tim vi thng tn chớnh l hp van, hp h van v h van n thun [1] Trong nhng nm gn õy, bnh thp tim cú gim i v cỏc nguyờn nhõn khỏc (thoỏi húa van, Osler, bm sinh) cú xu hng tng lờn, vi thng tn chớnh l h van hai lỏ n thun Bnh van hai lỏ hu ht u tin trin nng dn, dn n nhiu hu qu v bin chng nh: suy tim, lon nhp tim, tng ỏp lc ng mch phi, suy chc nng gan thn, bin chng tc mch cp tớnh , v nu khụng c iu tr kp thi s li nhiu di chng, thm t vong Bờn cnh lõm sng, siờu õm tim Doppler v siờu õm qua thc qun l thm dũ hỡnh nh quan trng nht chn oỏn bnh, th bnh, mc thng tn, t ú a cỏc ch nh iu tr phự hp i vi bnh van hai lỏ [2] Ch nh iu tr ngoi khoa thay van nhõn to hoc to hỡnh van [3], c t bnh mc nng (hp v/hoc h van nng) nh hng n chc nng sng ca bnh nhõn [4] Thay van hai lỏ (VHL) l phu thut khụng quỏ phc tp, d dng trin khai v ỏp dng cỏc trung tõm tim mch, kt qu sm sau m thng rt tt, nhiu loi van nhõn to khỏc tng thớch vi tng nhúm bnh nhõn [5] Tuy nhiờn cng cú mt s hn ch v: cht lng cuc sng (ung thuc chng ụng hng ngy, lch tỏi khỏm dy, hay phi nm vin chnh thuc, ch sinh hot cht ch), nguy c bin chng liờn quan n ụng mỏu (huyt trờn van nhõn to c hc, xut huyt - chy mỏu gim ụng), chi phớ phu thut ln, nguy c m li v t vong [6] Trong nhng nm gn õy, phu thut to hỡnh VHL cú xu hng phỏt trin ngy cng rng rói c v ngoi nc, phn no khc phc cỏc hn ch nờu trờn, nht l i vi nhúm bnh HoHL n thun v cu trỳc van khụng b hng quỏ nng [7], [8] V mt k thut to hỡnh VHL, hu ht cỏc nh ngoi khoa tim mch v ngoi nc u thng nht coi phng phỏp to hỡnh van theo trng phỏi Carpentier [9],[10] l nn tng c bn ca cỏc k thut to hỡnh van hin nay, bao gm rt nhiu can thip trờn tng loi thng tn ca b mỏy VHL (lỏ van, vũng van, mộp van, dõy chng, ct c) Tuy nhiờn, nh nhng hiu bit khụng ngng tng lờn v c ch bnh sinh, cu trỳc hot ng ca VHL, kinh nghim v kt qu lõu di sau to hỡnh van, s i ca nhiu vt liu mi (dõy chng nhõn to, vũng van) v cỏch tip cn van mi (phu thut tim h ớt xõm ln cú ni soi h tr); nờn ó cú mt s thay i quan trng cỏch thc thc hin phu thut to hỡnh VHL t vi nm tr li õy Vit Nam phu thut to hỡnh VHL c phỏt trin mnh t nhng u nm 90 ca th k trc, dn u l Vin Tim Thnh ph H Chớ Minh Cho n nay, phu thut ny ó khỏ ph bin nhiu trung tõm tim mch c nc, ú bnh vin Vit c l mt trung tõm i u khu vc phớa Bc vi vic ng dng thng qui phu thut to hỡnh VHL t nm 1996 Mc dự da trờn nguyờn tc c bn ca trng phỏi Carpentier, song tựy theo kinh nghim v iu kin c th ca mi trung tõm, m ch nh - k thut to hỡnh cng nh kt qu sau m cú th khụng ging [11], [12] ó cú nhiu nghiờn cu v phu thut to hỡnh VHL cỏc trung tõm khỏc vũng hn 20 nm qua Bnh vin Vit c cng cú cỏc bỏo cỏo ỏnh giỏ kt qu phu thut ny cho giai on trc nm 2009 [13 ], nhiờn ng trc nhiu thay i nhng nm qua v mụ hỡnh bnh tt, ch nh, cỏc k thut to hỡnh VHL ; thỡ vic thc hin mt nghiờn cu tip ni cho giai on t nm 2010 l cn thit, gúp mt phn vo vic nõng cao cht lng iu tr bnh VHL Vit Nam Xut phỏt t cỏch t nh vy, chỳng tụi thc hin ti: ỏnh giỏ kt qu phu thut to hỡnh van hai lỏ ti bnh vin Hu Ngh Vit c giai on 2010 n 2016, vi 02 mc tiờu: Mụ t c im tn thng v k thut to hỡnh van hai lỏ ti bnh vin Hu Ngh Vit c, giai on 2010 2016 ỏnh giỏ kt qu ca phu thut to hỡnh van hai lỏ 10 CHNG TNG QUAN TI LIU 1.1 c im gii phu ng dng ca van hai lỏ VHL cũn c gi l van m ni hay van nh tht trỏi nhng cỏc nghiờn cu thng gi l b mỏy van hai lỏ cu trỳc ca van rt phc tp, bao gm lỏ van, vũng van, cỏc dõy chng v ct nhỳ c Cỏc thnh phn ny c gn kt v sp xp vi rt tinh t lm cho hot ng ca van mang tớnh tun t cht ch, nh chic van mt chiu giỳp a mỏu t nh trỏi xung tht trỏi [2], [16][22] 1.1.1 Lỏ van 1.1.1.1 c im chung ca lỏ van VHL bao gm lỏ van trc v lỏ van sau (hỡnh 1.1), cỏc lỏ van bỏm vo vũng van v c tim sn nh trỏi trờn ng ranh gii gia nh tht trỏi Vựng ranh gii chuyn tip gia mụ lỏ van vi c tim d thy mt tht (mt di van) nhng li khụng rừ rng mt nh (mt nhỡn thy m) Din tớch ca lỏ van bao gi cng ln hn cỏc l van vỡ mi lỏ van u cú thờm mt din tớch phớa b t ỏp sỏt vo úng Do vy, bnh tim gõy gión vũng van hoc thp tim gõy co rỳt lỏ van thỡ din tớch lỏ van s khụng úng kớn l van, dn n h van Bỡnh thng din tớch van hai lỏ l cm2/ngi ln.[11], [12] Cỏc lỏ van rt mng v mm mi, dy khong -2 mm phn nn v thõn lỏ van, khong mm phớa b t Trong bnh tim thp, cỏc van b dy lờn, vụi húa v hn ch hot ng Bng cỏch o cỏc ch s ú trờn siờu õm s bit c cỏc mc tn thng ca VHL (theo bng im ca Willkins), giỳp cho la chn ch nh thay van hay to hỡnh van.[2], [12], [14], [15] 23 Maurizio Salati, Stefano Moriggia, Roberto Scofani (1997) Chordal transposition for anterio mitral prolapse: early and long term result European Juornal of Cardio Thoracic Surgery,11,268273 24 on Quc Hng (1994) ỏnh giỏ kt qu chn oỏn v iu tr phu thut tim kớn bnh hp van hai lỏ cú mỏu cc tiu nh trỏi Lun tt nghip cao hc, i hc Y khoa H Ni 25 Phm Th Hng Thi (2002) Hp van hai lỏ thp Thp tim v bnh tim thp, NXB Y hc,6484 26 Nguyn Hu c; on Quc Hng; Dng c Hựng (2001) Hp van hai lỏ thp: liờn quan gia mc thng tn trờn siờu õm v kt qu phu thut tỏch van tim kớn Ngoi khoa,chng3,512 27 Cremer JT, Andreas Bửning, Anssar MB et al Different approaches for minimally invasive closure of atrial septal defects Ann Thorac Surg 1999;67:1648-1652 28 Reichenspurner H, Boehm DH, Welz A, Schulze C, Zwissler B, Reichart B 3D-video- and robot-assisted minimally invasive ASD closure using the Port-Access techniques.Heart Surg Forum 1998; 1(2):104-6 28 Nguyn Lõn Vit (2006) Siờu õm Doppler bờnh h van hai lỏ Siờu õm Doppler thp tim v bnh tim tim thp,NXB Y hc,91101 29 Michele De Bonis (2006) Similar long-term 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Surgry,Vol131,Issue2,364370 MT S HèNH NH MINH HA Hỡnh 1: H VHL sa lỏ sau Hỡnh 2: t vũng van nhõn to VHL Hỡnh 3: ng m ngc phu thut tim ớt xõm ln cú ni soi h tr Hỡnh : Vt m phu thut tim ớt xõm ln cú ni soi h tr MU BNH N NGHIấN CU S TT Mó s h s Hnh chớnh: + + + + + H v tờn bnh nhõn: Tui: Gii: Nam N a ch: in thoi: Ngy m: Ngy vo vin: Ngy vin: Trc m: + + + + + Th bnh van hai lỏ: H Hp Hp H Tin s: Thp tim: Osler: Khụng rừ Lõm sng: NYHA: I II III IV Nhp u Lon nhp Tn s: l/p in tim: Nhp u Rung nh Tn s: l/p Siờu õm tim: h van: 1/4 2/4 3/4 4/4 Phõn loi h van theo Carpentier: Type I TypeII Type III Tn thng van trờn siờu õm: Din tớch van = cm2 p lc MP = mmHg Tn thng phi hp: H lỏ ( /4) HKNT Tht trỏi Nh Trỏi p lc MP Dd Trc m Sau m Ds EF Trong m: + + + ng tip cn : M dc gia xng c MICS Dng thng tn van hai lỏ: Thp Osler Thoỏi húa Thp + Osler Bm sinh Mộp van: Lỏ van: Dõy chng: Ct c: K thut m: ng m: Van hai lỏ: M mộp van Ct DC Gt mng lỏ van Chuyn DC Co ngn DC X DC ct c Ly vụi Ct mụ van M rng mụ van Hp vũng van sau t vũng van sau Dõy chng nhõn to Ch lỏ trc Van lỏ: Sa van Ly HKNT To hỡnh NT Thi gian chy mỏy: phỳt Thi gian cp ch:phỳt Hu phu: + + + Trong 24 gi u: in tim: Xoang Lon nhp Chy mỏu: >500ml >1000ml M li Sau 24 gi: Ra vin sau:.ngy in tim: Xoang Lon nhp Nhng khỏc: Thi gian th mỏy: Gi Thi gian nm hi sc ngy Siờu õm tim kim tra: Ngy th Sau m DT.VHL + + HoHL HHL KTTTTr PSTM KNT TDMT Cht Sau m: gi - Ngy Nguyờn nhõn cht: Lu lng tim thp Chốn ộp tim cp Chy mỏu: Do ri lon ụng mỏu Do phu thut Tc mch vnh Tc mch nóo Suy thn Do nguyờn nhõn khỏc: Cỏc nhn xột khỏc: + Nhim trựng Phự phi PHIU KIM TRA SAU M TO HèNH VAN HAI L S TT: Loi KT: thỏng - > thỏng > nm Hnh chớnh: + + + + + + H v tờn bnh nhõn: Tui: Gii: Nam N a ch: in thoi: Ngy m: Ngy vin: Ngy kim tra: Kt qu thm khỏm: + Lõm sng: + NYHA: I Nhp u II Lon nhp III Tn s: IV l/p Siờu õm tim: DT.VHL HoHL Mc HoHL KTTTTr PSTM KNT TDMT Nhn xột khỏc: DANH SCH BNH NHN TT H v Tờn Hong Th H Tui 07 Gii a ch N H Nam Ngy vv 31/05/2010 Ngy vin Mó b.a 25/06/2010 14055 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 Trung Phm Nguyn Phng A Hũa Th Th Phm Cụng H Lờ Hng L Nguyn Hu Q Bựi Vn T ng c M ng ỡnh D Hong Lõm Chớ K V Th L Bựi Vn Q Lờ Th H Trnh Vn Th Hong Vn B Trn Th M Phm Xuõn S Phan c V Trnh Vn V Bựi Th V V Bỏ T Th Th Phm Vn D Phựng Vn L Bựi Vn H Phm Th Ngh Nụng Th D Lõm Vn L Dng Vn Ph Trnh Th L Bựi Vn Ch Nguyn Th Minh H Nguyn Vn T Mua th Ch Lng Th T Dng Thnh Trn Vn M Bựi V Q Lờ Th Th Nguyn Vn L Nguyn Th H Lờ Th Võn A Phựng Th Thanh Th Khng Tin Th Trn Vn T 28 03 29 41 29 60 45 48 58 03 53 48 43 24 49 44 30 57 50 52 23 54 28 58 12 21 54 21 68 50 65 14 63 59 09 62 13 39 64 06 39 44 30 Nam N N Nam N Nam Nam Nam Nam Nam N Nam N Nam Nam N Nam Nam Nam N Nam N Nam Nam Nam N N N Nam N N N Nam N N Nam Nam Nam N Nam N N N Nam Nam Hung Yờn Ninh Bỡnh Thỏi Bỡnh Hi Phũng H Ni H Ni Hi Phũng H Ni Nam nh Sn La Hi Phũng H Ni c Lc Thanh Húa Ngh An Nam nh Hi Phũng Ngh An Thanh Húa Hi Phũng Thỏi Bỡnh Hi Phũng Hi Dng Sn La H Ni Hi Dng Cao Bng Lng Sn Ngh An Thanh Húa Hung Yờn H Ni Ninh Bỡnh Sn La Tuyờn Quang H Tnh Thanh Húa H Tnh H Tnh Hi Phũng H Tnh H Ni H Ni Thỏi Bỡnh H Ni 28/07/2010 06/09/2010 06/09/2010 07/09/2010 18/10/2010 25/10/2010 29/10/2010 06/01/2011 07/03/2011 04/04/2011 16/05/2011 25/05/2011 23/05/2011 06/06/2011 20/06/2011 20/06/2011 16/06/2011 19/07/2011 09/08/2011 13/09/2011 26/09/2011 08/11/2011 23/11/2011 14/12/2011 30/07/2012 16/11/2012 14/11/2012 25/09/2012 23/07/2012 26/02/2013 19/03/2013 22/03/2013 05/03/2013 23/01/2013 18/03/2013 28/03/2013 08/04/2013 15/04/2013 18/04/2013 06/05/2013 20/05/2013 17/06/2013 18/06/2013 16/07/2013 29/07/2013 03/09/2010 24/09/2010 04/10/2010 24/09/2010 12/10/2010 05/11/2010 15/11/2010 25/01/2011 21/03/2011 16/05/2011 06/06/2011 20/06/2011 13/06/2011 11/07/2011 07/07/2011 11/07/2011 24/07/2011 15/07/2011 30/08/2011 07/10/2011 18/10/2011 15/12/2011 09/12/2011 03/01/2012 20/08/2012 14/12/2012 18/12/2012 07/11/2012 24/08/2012 19/03/2013 08/04/2013 04/04/2013 08/04/2013 05/02/2013 16/04/2013 16/04/2013 03/05/2013 04/05/2013 17/05/2013 29/05/2013 04/06/2013 08/7/2013 05/07/2013 20/08/2013 08/08/2013 20465 25500 25504 25543 29806 30549 31015 521 5409 8799 12779 13672 13592 15154 16761 16766 14110 20277 22741 26903 28381 33402 35203 37635 22455 36015 35183 29449 22143 5231 7623 8183 6182 2402 7612 8859 10253 11091 11494 13486 15211 18907 18959 22810 24545 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 T ỡnh H Dng Khỏnh Q Nguyn Th Thanh Th Hong Q Lờ Th Th V Mnh T Nguyn Hong L Phan Th B Nguyn Th Th Phm Quang Kh Lờ Th Q Nguyn Vn T Nguyn S H Trnh Th Kim C Nguyn Quang V Nguyn ỡnh B Vn S Hi V ng ỡnh H Bựi Hng Th Phm Bớch Ng Bựi Th M Phm Vn Nh Phm Quc T V ỡnh T Nguyn Võn A Nguyn Hoi H Hong Vn Nguyn Hu T Phm c N Hong Vn Ph Nguyn Th G Trung Nụng Thnh on Th H Ph Nguyn Th Ng Nguyn Vn V Nguyn Th M Bựi Th V ng Th Thu H ng ỡnh Th 34 57 52 19th 08 37 06 71 26 62 24 47 74 54 8th 34 31 03 49 34 46 57 52 09 25 09 29 59 49 41 56 40 12 15 57 54 56 70 23 41 Nam Nam N Nam N Nam N N N Nam N Nam Nam N Nam Nam Nam N Nam N N N Nam Nam Nam N Nam Nam Nam Nam Nam N Nam N N Nam N N N Nam Ngh An Thỏi Nguyờn Hi Phũng Thỏi Bỡnh Thanh Húa Thỏi Bỡnh Thanh Húa H Ni Bc Giang Hi Dng Ninh Bỡnh Hi Dng H Ni Qung Ninh Bc Ninh Ninh Bỡnh Hi Phũng H Ni H Ni Hũa Bỡnh H Ni H Ni Bc Giang Nam nh Hi Dng Bc Ninh H Ni Thanh Húa H Ni Hi Dng Tuyờn Quang Tuyờn Quang Cao Bng Hi Phũng Phỳ Th Nam nh Tuyờn Quang Hi Dng Hung Yờn Hi Dng 12/08/2013 26/08/2013 14/10/2013 24/03/2014 2/6/2014 15/07/2014 05/08/2014 11/09/2014 13/10/2014 17/11/2014 06/01/2015 20/01/2015 05/03/2015 02/03/2015 06/03/2015 05/03/2015 15/03/2015 30/3/2015 30/03/2015 30/03/2015 05/05/2015 11/05/2015 22/05/2015 06/07/2015 28/07/2015 25/08/2015 22/07/2015 07/09/2015 16/09/2015 14/09/2015 8/9/2015 1/10/2015 28/09/2015 9/10/2015 22/10/2015 20/10/2015 24/02/2016 26/02/2016 19/04/2016 15/4/2016 04/09/2013 02/10/2013 29/10/2013 28/04/2014 24/06/2014 06/08/2014 19/08/2014 30/09/2014 03/11/2014 12/12/2014 10/02/2015 14/02/2015 27/03/2015 13/03/2015 06/04/2015 25/04/2015 08/04/2015 16/04/2015 22/04/2015 27/04/2015 29/05/2015 08/06/2015 12/06/2015 03/08/2015 14/08/2015 23/09/2015 25/08/2015 22/09/2015 01/10/2015 30/09/2015 12/10/2015 14/11/2015 19/10/2015 30/11/2015 13/11/2015 6/11/2015 15/3/2016 14/03/2016 10/05/2016 18/5/2016 26404 28258 33123 8380 20124 23270 259028 29358 33670 39592 528 2221 6615 6215 6251 6624 7843 10004 9896 9888 14712 15405 17133 23652 25121 31927 24203 33611 33873 50981 30781 33481 97153 34034 40830 40626 6595 8249 13169 10640 H Ni, ngy thỏng nm 2016 Xỏc nhn ca thy hng dn Xỏc nhn ca phũng KHTH Bnh vin Hu Ngh Vit c PGS.TS Nguyn Hu c ... thương kỹ thuật tạo hình van hai bệnh viện Hữu Nghị Việt Đức, giai đoạn 2010 – 2016 Đánh giá kết phẫu thuật tạo hình van hai 10 CHƯƠNG TỔNG QUAN TÀI LIỆU 1.1 Đặc điểm giải phẫu ứng dụng van hai VHL... chất lượng điều trị bệnh VHL Việt Nam Xuất phát từ cách đặt vấn đề vậy, thực đề tài: Đánh giá kết phẫu thuật tạo hình van hai bệnh viện Hữu Nghị Việt Đức giai đoạn 2010 đến 2016 ’, với 02 mục... kỹ thuật tạo kết sau mổ không giống [11], [12] Đã có nhiều nghiên cứu phẫu thuật tạo hình VHL trung tâm khác vòng 20 năm qua Bệnh viện Việt Đức có báo cáo đánh giá kết phẫu thuật cho giai đoạn