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Trong tay cc bn l mt cun sch rt b ch v thc hnh trong chn on v iu tr cc bnh tim mch thng gp. Tnh n gin, thc tin cao nhng cng kh cp nht v y thng tin cc bn c th vn dng c tt nht trong thc t cng vic cng nh hc tp l mong mi ca nhng tc gi tham gia bin son quyn sch ny...

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Nguyn ln vit (Ch bin)

Thc hnh

Bnh tim mch


r ese sr n t gh .v l ri .com l . A oo oev yah inl @ . F 2020 8 00 y 2 tocit ht Po rig ved

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Nh xut bn Y hc 2003
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Nguyn ln vit (Ch bin)

Thc hnh

Bnh tim mch


r ese sr n t gh .v l ri .com l . A oo oev yah inl @ . F 2020 8 00 y 2 tocit ht Po rig ved

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py

Nh xut bn Y hc 2003

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Li gii thiu
S kt hp cht ch trong cng tc iu tr, ging dy, nghin cu khoa hc gia cc thnh vin ca B mn Tim mch Trng i hc Y H ni v Vin Tim mch Vit nam to iu kin cho s ra i ca cun sch: Thc hnh Bnh Tim mch vi s tham gia trc tip ca cc tc gi m Ph Gio s Tin s Nguyn Ln Vit l ch bin. Chng ta cn nh tp Bnh hc Ni khoa vi nhng bi vit rt c bn, thc t, xc tch m c Gio s ng Vn Chung truyn t t nhng nm 50 ca th k va qua. Ngy nay, nhng tin b to ln ca y hc hin i trong chuyn ngnh Tim mch c phn nh mt phn qua 32 bi vit ca tp ved th tc gi. y cng l phn nh s pht trin ti Vin Tim ser re mch Vit nam trong nhng nm gn y, mt thnh n ts qu t s gh m.vnhm p n lc ca mi c nhn, ca tp th cc thyrithuc, ll .co ng nhu cu nng cao sc kho trong bi .cnhohi nhp quc t v A ah o loe y m nc ta l mt thnh vin. Fin020@ . 0 Qua cc bi vit ny, m 8 ity2 cc tc gi cng t nhn 20 ochnh c xt l cn b hn ch v ithi gian chun b cho in n, cc th h ht Pot rg k tip t r kh opy gp phn y mnh v lm phong ph nng C thm cho nhng thnh tu ca ngi i trc, gip chng ta cp nht v hi nhp vi y hc hin i ti khu vc. Chng ti xin gii thiu cun Thc hnh Bnh Tim mch mt ti liu phc v ging dy, thc hnh, mt ti liu tham kho c gi tr, mang tnh h thng v cp nht. Xin cm n cc tc gi v chc bn c rt ra nhng iu b ch ca mt chuyn ngnh ang pht trin mnh m ny. Gio s Tin s Phm Gia Khi Vin trng Vin Tim mch Vit nam Ch nhim B mn Tim mch - Trng i hc Y H ni

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Li ni u
Bc sang thin nin k mi, chng ta vui mng chng kin v tip thu nhng thnh tu pht trin ca khoa hc k thut nhm khng ngng ci thin v nng cao i sng ca con ngi. Tuy vy, chng ta cng khng khi lo u bi m hnh bnh tt c nhng s thay i theo chiu hng ca cc nc pht trin. Trong cc loi bnh l , bnh tim mch l mt trong nhng bnh ang c xu hng tng nhanh mt cch r rt nc ved ta. ser re Trong thi gian gn y, cc bc s caights .vn tip chng ta r m thu v ng dng nhiu phng php, k All oo.co tin trong . thut tin h vt ci thin c chn on v iu tr cc bnh tim mch, @ya loe Fin0sng ca bnh nhn. . hn tin lng bnh v cht lng8cuc 20 0 ty2 20 ocithc v nhng hiu bit mi Tuy nhin, khi lng kin t gh Pot trong lnh vc tim mch ith ngy cng gia tng, nhng iu kin yr p Co trang thit b thc t ti nhiu tuyn ca chng ta cn cha p ng c mt cch y . V vy, cc thy thuc nhiu khi s kh lng tng trong thc hnh chn on v iu tr cho cc bnh nhn tim mch. Xut pht t thc tin cng tc iu tr v ging dy trong nhiu nm, tp th cc cn b ging dy ca B mn Tim mch, Trng i hc Y H ni v mt s cng s c gng tham gia bin son quyn sch ny. Vi phng chm l bm st thc t, d dng ng dng nhng cng khng km phn cp nht, chng ti c lm ht sc mnh trong vic bin son ph hp vi nhng yu cu ni trn. Trong qu trnh bin son, chng ti c gng cp nht nhng thng tin mi nht c th c trn nn tng nhng kin thc kinh in bit trong lnh vc tnh mch.

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Chng ti hy vng cun sch Thc hnh Bnh Tim mch ny khng ch dnh cho cc bc s chuyn khoa tim mch m c th cn gip ch cho cc bc s thc hnh ni chung cng nh cc sinh vin y khoa tham kho thm trong hc tp. Y hc l mt ngnh khoa hc c lng thng tin c b sung v i mi hng ngy. Mt khc, s hiu bit ca chng ti cn c hn v thi gian bin son kh st sao nn quyn sch ny chc chn cn nhng thiu st nht nh. Chng ti rt hoan nghnh v sn sng tip thu nhng kin ng gp qu bu ca cc bn c ln ti bn sau c hon thin hn.
Cc tc gi

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CH bin
Ph gio s, Tin s Nguyn Ln Vit

Tham gia bin son:


ved ser e Thc s Phm Mnh Hng hts r n g m.v l ri o Tin s Don Li v. Al hoo.c loe ya Fin0 Quang Bc s Nguyn Ngc 20@ . 08 2 20 ocity Thc s Phm Thi Sn ht Pot rig py Ph gio s, Tin s Nguyn Ln Vit Co
Thc s Nguyn Ln Hiu

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Mc lc

1. au tht ngc khng n nh ......................................................... 1 2. au tht ngc n nh..................................................................... 17 3. Nhi mu c tim cp ....................................................................... 35 4. Bin chng ca nhi mu c tim cp.......................................... 53 5. Sc tim................................................................................................. 75 6. Ri lon lipid mu ........................................................................... 85 7. Tng huyt p .................................................................................... 95 8. Tai bin mch mu no ................................................................121 ved ser 9. Tch thnh ng mch ch .........................................................139 re ts gh m.vn 10. iu tr mt s ri lon nhp tim thng gpi.........................167 ll r co . A ahoo. 11. Thp tim ............................................................................................219 oev inl 20@y F 12. Hp van hai l .................................................................................231 8. 0 00 ity2 2 13. H van hai l ...................................................................................253 t oc gh Pot ri 14. H van ng mchych .................................................................267 p Co 15. Hp van ng mch ch ...............................................................287 16. Vim ni tm mc nhim khun................................................305 17. Van tim nhn to ............................................................................321 18. Suy tim ..............................................................................................341 19. Bnh c tim gin.............................................................................379 20. Bnh c tim ph i ........................................................................387 21. Bnh c tim hn ch ......................................................................395 22. Vim mng ngoi tim cp............................................................399 23. Trn dch mng ngoi tim............................................................411 24. Vim mng ngoi tim co tht .....................................................423 25. Tm ph mn ...................................................................................431 26. Nhi mu phi ................................................................................453

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27. Thng lin nh .................................................................................475 28. Thng lin tht ................................................................................485 29. Cn ng ng mch.......................................................................495 30. Bnh van ng mch phi ...........................................................503 31. T chng Fallot...............................................................................509 32. Hp eo ng mch ch .................................................................519

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au tht ngc khng n nh

au tht ngc khng n nh (unstable angina, TNK) l mt trong nhng vn kh thi s hin nay do tnh cht thng gp ca n cng nh nhiu tin b mi trong chn on v iu tr. Hng nm M c tnh c ti > 700 000 bnh nhn nhp vin v TNK. Tin lng ca TNK cng nng n khng km nu so vi NMCT. Thut ng Hi chng mch vnh cp bao gm: NMCT cp c ST chnh ln (hoc c Q); NMCT cp khng Q; v TNK. Trong , ngi ta thng xp NMCT khng Q v TNK vo cng mt bnh cnh gi l Bnh mchdvnh e erv khng n nh v c cch x tr nh nhau. res hts n Trong bi ny cp ch yu n TNK trong bi rig com.v ll cnh ca bnh mch vnh khng n nh A hoo. cng l p v. nhng a le dng cho iu tr NMCT khng c sngo Q. y Fin020@ . 08 2 I. Sinh l bnh 20 ocity ht Pot A. Cho n nay ngi ta hiu r c ch ca TNK l rig py Cnh ca mng x va v mng ny b v ra. s khng n o S v ra ca mng x va cng gp trong NMCT cp, tuy nhin mc v din bin c khc nhau i cht. Nu s nt v l ln v hnh thnh mu ng t lp ton b lng mch s dn n NMCT. Nu s nt v nh hn v cc mu ng ny cha dn n tc hon ton MV th l TNK. Tuy nhin, TNK c th din bin nng v bin thnh NMCT thc s. B. S hnh thnh cc mu ng: Nh trnh by trn, khi mng x va b v, lp di ni mc c l ra v tip xc vi tiu cu, dn n hot ho cc th th IIb/IIIa trn b mt tiu cu v hot ho qu trnh ngng kt ca tiu cu. Thm vo tiu cu ngng kt ny s gii

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phng ra mt lot cc cht trung gian lm co mch v hnh thnh nhanh hn cc mu ng. C. Hu qu l lm gim nghim trng dng mu ti vng c tim do MV nui dng, v biu hin trn lm sng l cn au ngc khng n nh. Trong thc t mt s yu t sau c th lm nng bnh hn: st, tng huyt p nhiu, ri lon nhp tim, cng gip...

ved ser re ts gh m.vn Hnh 1-1. S nt ra ca mng x va trong TNK. i ll r co . A ahoo. II. Chn on oev inl 20@y A. Triu chng lm sng 8. F 20 00 ty so vi bnh nhn NMCT, bnh 1. c im chung:2 otoci t igh P nhn TNK thng c tui gi hn, c t l tiu yr p Co ng cao hn, t l tng huyt p (THA) v ri lon lipid mu cng gp nhiu hn. Thm vo , s bnh nhn TNK sau NMCT hoc cc th thut can thip MV cng nhiu. 2. Triu chng c nng: Triu chng au ngc cng ging nh trong au ngc n nh m t, ch c s khc nhau v tnh cht, trong TNK tnh cht d di hn, ko di hn, c th xy ra c trong khi ngh, c th khng hoc t p ng vi Nitrates.
3. Khm lm sng: a. Khm lm sng t c gi tr chn on TNK, nhng khm lm sng l cc k quan trng gip chn on phn bit cng nh nh gi cc yu t nguy c, bin chng... 2 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

b. Chn on phn bit vi cc bnh nh vim mng ngoi tim, vim ph qun, vim khp c sn, cc bnh tim thc tn km theo... c. Pht hin cc triu chng ca suy tim, ting T3, h van tim... 4. Phn loi TNK theo Braunwald: gip phn loi bnh nhn v d on tin lng bnh cng nh c thi x tr thch hp. Bng 1-1. Phn loi TNK theo Braunwald. c im au ngc khi gng sc: I Mi xy ra, nng, tin trin nhanh au ngc mi trong vng 2 thng au ngc vi tn s dy hn ved ser au ngc gia tng khi gng sc nh s re ht . n Khng c au ngc khi ngh tronggvngv2 thng l ri .com II au ngc khi ngh, bn cp: v. Al hoo au ngc khi ngh xy loe @ya vng 1 thng in ra0 trong nhng khng phi08. F xy ra trong vng 48 gi mi 202 y 0 2 tocit III au ngc khi ngh, cp: ht ra trong vng 48 gi o au ngcrig xy P pylm sng Cc hon cnh Co au ngc th pht: xy ra do cc yu t khng A phi bnh tim mch nh thiu mu, nhim trng, cng gip trng, thiu xy... au ngc t pht B au ngc khng n nh sau NMCT: trong vng C 2 tun sau NMCT B. Cc xt nghim chn on 1. in tm : a. Trong cn au c th thy s bin i ca on ST: ST chnh xung, T o chiu, ST chnh ln thong qua. Nu ST chnh ln bn vng hoc mi c xut hin bloc nhnh tri th ta cn phi ngh n NMCT. 3 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

b. C 20 % bnh nhn khng c thay i trn T. c. Vic phn bit TNK vi NMCT cp khng c sng Q ch yu l xem c s thay i ca men tim hay khng. Bng 1-2. Phn tng nguy c ca bnh nhn TNK Nguy c cao Nguy c va Nguy c thp C mt trong cc Khng c cc du Khng c cc biu hin sau: hiu nguy c cao biu hin ca nhng c 1 trong nguy c cao hoc va cc du hiu sau: au ngc khi au ngc khi C s gia tng ngh > 20 pht, ngh >20 pht v tn s v ca bnh mch nhng t mc au vnh au ngc khi ngc d C ph phi cp ngh >20 pht au serve ngc re do bnh mch nhng p ng khi pht do ts gh m.vn nh vnh tt vi iu tr o l ri gng sc au ngc khi au ngc v. Al oo.c v h au ngc mi loe ya xut ngh c km m hin Fin020@ . 2 theo on ST au 08ngc c trong vng 2 thay i > 1mm km otheo thay tun- 2 thng 20 ity t ot c hiPST au ngc km rig Khng thay theo xut hinpy au ngc mi i ST Co ran phi, ting xy ra trong tim th 3 hoc vng 2 tun, HoHL mi tnh cht nng. au ngc km C sng Q bnh theo tt huyt l hoc xut p hin ST chnh xung nhiu chuyn o. Tui > 65 2. Men tim: a. V tnh cht kh phn bit vi NMCT (khng sng Q) v c th tin trin n NMCT ca TNK nn mi bnh nhn cn c lm xt nghim men tim v theo di cc men ny.

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b. Cc men thng c dng theo di l CK v CK-MB; Troponin T v I. c. V nguyn tc trong TNK khng c s thay i cc men tim, tuy nhin trong mt s trng hp c th thy tng i cht men Troponin I v iu ny bo hiu tin lng xu hn. 3. Siu m tim: Siu m tim thng gip ch cho ta chn on ri lon vn ng vng (nu c), nh gi chc nng tht tri (c bit sau NMCT) v cc bnh l thc tn van tim km theo hoc gip cho vic chn on phn bit. 4. Cc nghim php gng sc: a. Cn ch l khi chn on chc chn ed TNK th khng c ch nh lm cc vnghim ser e php gng sc do tnh cht bt n ca rbnh. ts gh m.vn ri khi b. Cc nghim php ny ch tllra o.co bnh nhn . A aho nhm nguy c thp, lmevsng khng in hnh, lo y Fin020@ v iu tr n khng c thay i . trn T 8 00 y2 nh ti bnh vin otrong vi ngy. 2 t cit ht Po 5. Chp ng rig y mch vnh: op a. Ch C nh chp ng mch vnh trong TNK c cc tc gi thng nht l nhm bnh nhn c nguy c cao, v mc ch ca chp MV l can thip MV nu c th. Cc ch nh khc l khi bnh nhn khng p ng hoc ti pht au ngc sau khi dng thuc iu tr ti u, khi bnh nhn c suy tim, ri lon nhp, gim chc nng tht tri... (bng 1-3). Hin nay mt s trung tm trn th gii ch trng chp MV v can thip cho mi bnh nhn TNK ngay th u. Tuy nhin, cch ny cha t ra li ch vt tri so vi cch iu tr bo tn trc, n ch vt tri nhm c nguy c cao.

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Bng 1-3. Cc ch nh ca chp MV trong TNK. Nhm nguy c cao. Tin s c can thip MV hoc m cu ni. Suy tim. Gim chc nng tht tri (EF < 50%). Ri lon nhp tht c tnh. Cn tn ti hoc ti pht au ngc sau dng thuc . C vng gim ti mu c tim rng trn cc xt nghim chn on khng chy mu (x c tim, siu m tim stress). C bnh van tim r rt km theo (HoHL, HoC).

III. iu tr Tu tng trng hp c th m ta bt u bng cc phng ed php iu tr thch hp. iu tr ni khoa l nn tngeservbt u v r ts cho mi trng hp. Cc bin php iu tr ti hto.vn g m mch (can i thip nong hoc t Stent MV, phu thut rlmo cu ni chll c . A ahoo. vnh) rt quan trng v l iu tr mangv tnh trit , cn c loe y Fin020@ cn nhc trong tng tnh hung c .th. 08 2 20 niy A. Mc tiu ca iu trotocit khoa t igh P yr dng thuc chng ngng kt tiu cu. 1. Nhanh chng p Co 2. Lm gim au ngc bng cc thuc chng thiu mu cc b c tim. 3. Cc bnh nhn khng p ng vi iu tr ni khoa cn c ch nh can thip cp cu. Vi nhng bnh nhn p ng tt vi iu tr ni khoa cng cn c sng lc v xem xt chp ng mch vnh quyt nh tip hng iu tr ti to mch cho bnh nhn (nong MV v/hoc t Stent, m cu ni...). B. Cc u tin trong iu tr 1. Aspirin. 2. Gim au ngc bng Nitrate v/hoc chn bta giao cm. 6 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

3. Chng ng mu bng Heparin hoc Heparin trng lng phn t thp (LMWH). 4. Cc thuc c ch th th GP IIb/IIIa tiu cu. C. Thuc chng ngng kt tiu cu ng ung 1. Aspirin: a. C ch chng ngng kt tiu cu ca Aspirin l thng qua chn con ng Thromboxan A2 lm bt hot tiu cu. b. Tuy tc dng ca Aspirin c coi l yu trong chng ngng kt tiu cu nhng nhiu nghin cu chng minh c l n c th lm gim ti 50% t vong hoc NMCT bnh nhn TNK. ved ser c ch c. Thuc c th pht huy tc dng re ts vn gh mnn cn cho Thromboxan A2 trong vng 15 rpht, . i o ll ngay khi bnh nhn nhp vvin.hoo.c cho loi hp . A a Nn e thu nhanh (BabyAspirinloviny81 mg nhai 4 vin). Fin020@ . hoc gi bt Aspegicy2 100 mg) ung 3 gi. 08 (gi 20 ocit d. Tuy cn bnt ciot liu duy tr nhng liu lng h P v rig nn dng khong 300 mg c th ngay opy u lc C t c kh nng tc dng ti a chng ngng kt tiu cu trong ngy u, nhng ngy sau c th dng liu t 81 - 325 mg/ngy. 2. Tilcopidine (Ticlid) v Clopidogrel (Plavix): a. Cc thuc ny chng ngng kt tiu cu thng qua con ng c ch ADP c lin quan hot ho tiu cu, do kh nng chng ngng kt tiu cu mnh hn Aspirin. b. Ticlopidine cn khong 2-3 ngy t c hiu qu tc dng ti a. Vi Clopidogrel th thi gian ny ngn hn i cht. c. Tc dng ph: Ticlid c th gy h bch cu mu (0,2 -5 % cc trng hp), c th gy h tiu cu 7 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

mu km theo. Tc dng ph ny t gp hn i vi Clopidogrel. d. Liu lng: Ticlid cho ngay 500 mg sau cho 250mg x 2 ln/ngy trong nhng ngy sau. Plavix cho liu ban u 300 mg sau 75 mg/ngy. e. Ch nh: V l do gi thnh cn tng i cao v v tc dng ph nng c th xy ra nn cc thuc ny ch nn ch nh trong trng hp bnh nhn km dung np vi Aspirin. Trong trng hp c can thip t Stent MV th nn cho thm thuc ny phi hp vi Aspirin. Sau khi t Stent cc thuc ny c dng tip trong 2-4 tun ri ngng v ch tip tc cho Aspirin D. Cc thuc chng ng ved ser re 1. Heparin: ts gh m.vn i o l c a. V c ch hnh thnh cc l rmu ng trong . A ahoo. TNK, nn vic chooev y chng ng l bt thuc inl @ . F 2020 buc. 8 00 y toc b. Nhiu nghin 2cu it ch ra rng vic dng t igh Po Heparin rphi hp vi Aspirin trong TNK y p lm Co gim nguy c t vong v NMCT ti 33 % so vi ch dng Aspirin n c. c. Thi gian dng Heparin nn ko di khong 3-7 ngy, nu dng di qu c th lm tng nguy c gy h tiu cu mu ca Heparin. d. Hiu ng bng li (rebound) thiu mu c tim cc b khi ngng Heparin c th gp l do hnh thnh huyt khi lin quan n kch thch hot ho tiu cu. Do vic duy tr lin tc Aspirin l bin php tt phng trnh hiu ng ny. e. Nn dng Heparin theo ng truyn TM. f. Liu dng: Liu khuyn co hin nay l liu tng i thp, tim ngay TM 60 UI/kg sau truyn TM lin tc liu 15 UI/kg/gi. Cn kim 8 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

tra thi gian aPTT mi 6 gi sao cho thi gian ny t khong 50-70 giy. 2. Heparin c trng lng phn t thp (LMWH): a. Li th so vi Heparin thng l: c thi gian tc dng ko di, liu c nh do dng tim di da m t cn theo di bng cc xt nghim lin tc, c ch c yu t Xa v IIa ca tiu cu, t gy gim tiu cu mu. b. Mt s nghin cu cho thy LMWH lm gim 17 % t l NMCT hoc t vong bnh nhn TNK so vi dng Heparin thng. c. Liu lng: C nhiu loi LMWH trong c nhng loi hay c dng: tim di da: d Enoxaparin (Lovenox): 1mg/kg miservegi, 12 e Dalteparin: 120 U/kg mi 12 gi, r n ts v . gh ml/10kg cn ri Nadroparin (Fraxiparin): ll 0,1.com A h .2 lnoo nng, tim di da chia a trong ngy. ev nlo y itip0@thrombin (Hirudin, 3. Thuc c ch trc F 02 8. 2 Hirulog): Cc thuc 0ocity c ch trc tip thrombin 20 ny ht Pot nn c tc dng chng ng kh mnh. Tuy nhin, rig y cho n op chng cha c chp nhn dng C nay thng quy trong TNK thay th cho Heparin. Chng ch nn c dng nhng bnh nhn c tin s b gim tiu cu do dng Heparin. E. Cc thuc c ch th th Glycoprotein IIb/IIIa ca tiu cu 1. C ch: Trn b mt ca tiu cu c cc v tr (th th) m khi c hot ho s gn kt vi mng fibrin gy nn s ngng kt tiu cu, cc v tr ny gi l cc th th Glycoprotein IIb/IIa. Vic c ch th th ny c ch tn gc qu trnh ngng kt tiu cu nn cc thuc nhm ny s c tc dng chng ngng kt tiu cu rt mnh. 2. Cc loi thuc v liu: 9 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

a. Abciximab (Reopro): l thuc c pht hin v dng u tin. Liu dng tn cng 0,25 mg/kg tim thng TM sau truyn TM 10 mcg/pht trong 12 gi tip theo. b. Eptifibatid (Intergrilin): Liu dng tn cng 180 mcg/kg tim thng TM sau truyn TM 1,3 2,0 mcg/pht trong 12 gi tip theo. c. Tirofiban (Aggrastat): liu tn cng 0,6 mcg/kg/ pht truyn TM trong 30 pht sau truyn TM 0,15 mcg/kg/pht trong 12 -24 gi tip theo. d. Lamifiban: 0,1 mcg/kg/pht truyn TM/ 24 gi. 3. Cch dng: cc thuc ny c th c dng nh sau: a. Dng trong lc can thip MV lm gim nguy c ed t vong hoc NMCT (th nghim sEPIC vi erv re Reopro lm gim ti 90 % nguy c stvvong hoc t gh m. n NMCT sau 30 ngy lin quan ln .can thip). l ri co . A ahoo b. Dng trc lc can thip y oev MV (th nghim @ inllm gim ti 20 % nguy CAPTURE vi Reopro 020 .F 08 ty2 0 c t vong, NMCTci 2 hoc phi can thip li sau 30 htquanto can thip). ngy c lin Po n rig py C c. Dngoc lp cho TNK: lm gim 10-17 % nguy c t vong hoc NMCT trong TNK (th nghim PURSUIT vi Eptifibatid, th nghim PRISM vi Tirofiban). F. Cc Nitrates 1. Cha c nghin cu no chng minh c Nitrate lm gim nguy c t vong hoc NMCT bnh nhn TNK, nhng Nitrate l iu tr quan trng gim au ngc cho bnh nhn v ci thin triu chng. 2. Liu dng: nn bt u ngay bng xt di li (hoc ngm) cho bnh nhn, sau thit lp ng truyn TM truyn Nitroglycerin vi liu 10-20 mcg/pht. C th tng liu sau mi 5-10 pht tu p ng ca 10 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

G. Cc thuc chn bta giao cm 1. Cc thuc chn bta giao cm gip lm gim nhu cu xy ca c tim do gim co bp c tim v gim nhp tim. Hn na, thuc c th lm gim p lc y tm trng nn lm tng mu v MV trong k tm thu. Dng chn bta giao cm bnh nhn TNK khng nhng lm gim au ngc tt m cn c chng minh l lm gim t l bin thnh NMCT v gim din hoi t c tim nu b NMCT. Cc thuc chn giao cm c coi l thuc hng u trong iu tr TNK. ved ser re ts 2. Nn dng cc thuc chn chn lc 1: Metoprolol, gh m.vn i Atenolol... ll r co . A ahoo. ov 3. Chng ch nh: Nhp chme (bloc nh tht cao); inl 20@y F 0 Bnh phi mn tnh tc. nghn; Suy tim nng mt b; 8 00 ity2 2 Huyt p thp; Sc tim. Bnh mch ngoi vi; toc t gh Po ri 4. Mc tiuoiu tr l gim c triu chng au ngc py Cnhp tim. Nn bt u bng liu thp v theo v gim di st. Thng dng Metoprolol tim TM 5 mg sau tng dn liu theo p ng sau 5-10 pht. C th dng gi bng vin Metoprolol liu thp 25-50 mg mi 12 gi. H. Cc thuc chn knh canxi 1. Cc thuc ny lm gin mch, chm nhp tim, gim sc co bp c tim. Nu dng n c trong TNK c th lm tng nguy c NMCT hoc t vong. 2. Ch nn dng thuc chn knh calci trong trng hp c THA nhiu v/hoc khi chc nng tht tri bnh nhn cn tt, nhp khng chm v c yu t co tht 11 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

m t p ng vi Nitrates hoc khng th dng c thuc chn bta giao cm. I. Cc thuc c ch men chuyn 1. Khng phi thuc thng quy trong iu tr TNK. 2. Nn dng khi c km theo gim chc nng tht tri m huyt p cn tt.

J. Vn dng cc thuc tiu huyt khi 1. Cho n nay thng nht l KHNG dng thuc tiu huyt khi cho bnh nhn TNK v khng nhng khng ci thin c tin lng m cn gia tng t l NMCT v t vong (nghin cu TIMI-IIIb). d 2. C ch c th l v trong TNK cha erve hon s tc e ton MV nn thuc tiu huyt khi hts r vn ny khng lm g m. ri c ci thin thm dng chy m n l li .co th lm tan Al . vahoo mng x va, cc mu ng bao ly ch y ca oev inl 2mc ny gy hot ho lm l ra li lp di Fni 0@ 8. 0 ngng kt tiu cu 200 li. 2 tr city ht Poto K. iu tr can thip MV (nong hoc t Stent) rig py Co cho chp MV: can thip MV 1. Ch nh c bn n phn ch nh chp MV ni trn. a. Cc tn thng MV ph hp cho can thip l: tn thng ngn, khng vi ho, tn thng t mch, khng phi thn chung, chc nng tht tri cn tt... b. Mt s trung tm c iu kin trang thit b v kinh nghim tt ca bc s can thip th c th xt can thip ngay (cp cu) cho mi bnh nhn TNK khi n vin, tuy nhin kt qu cha vt tri so vi bt u bng iu tr ni khoa.

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Hnh 1-2. Hnh nh T ca mt trng hp TNK, ved ST chnh xung v T m t V1-V6 ser re 2. Khi can thip MV, vic dng phiights cc thuc l hp .vn ll r com rt quan trng: . A ahoo. oev a. Cc thuc chng ngng lkt@y cu ng ung : in 20 tiu F 0 Aspirin phi hp 08. Ticlopidin hoc Clopidogrel. 0 vity2 2 oci t b. Thuc c ch thtth Glycoprotein IIb/IIIa. gh Po i yr c. Thucpchng ng (Heparin, LMWH). Co

Hnh 1-3. Hnh nh chp ng mch vnh ca bnh nhn TNK trc (hnh tri) v sau (hnh phi) t Stent (mi tn ch v tr thng tn). 13 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

L. M lm cu ni ch-vnh 1. Cc ch nh cho phu thut: a. Tn thng nhiu thn MV m on xa cn tt. b. Tn thng thn chung MV. c. Cc tn thng qu phc tp (vi ho, xon vn, gp gc, ch chia nhnh...) m khng th can thip nong hoc t stent c. d. Tht bi khi can thip. 2. Cc yu t d on nguy c cao cho phu thut l: tui cao, c nhiu bnh nng km theo, chc nng tht tri gim nhiu, tiu ng, kinh nghim ca phu thut vin... Tuy nhin, mt s nghin cu (BARI, CASS) cho thy nhng bnh nhn tiu ved ng hoc suy gim chc nng tht reser c tn tri, thng nhiu thn MV th phu thut ts .vn ni t gh lm cu l ri .com l ra u th hn so vi can thip MV.oo .A oev yah Ti liu tham kho inl @ . F 2020 8 00 y 1. Antman EM, Tanasuevic MJ, Thompson B, et al. Cardiac-specific 2 tocit of mortality in patients with acute t troponin I levels to predict the risk igh Po coronary syndromes. N Engl J Med 1996;335:1342-1349. yr p Co
2. Bittl JA, Strony J, Brinker JA, et al. Treatment with bivalirudin (Hirulog) as compared with heparin during coronary angioplasty for unstable or ostinfarction angina. N Engl J Med 1995;333:764-769.

3.

Boden WE, O'Rourke RA, Crawford MR, et al. Outcomes in patients with acute non-Q-wave myocardial infarction randomly assigned to an invasive as compared with a conservative management strategy. N Engl J Med 1998;338:1785-1792. Braunwald EG, Mark DB, Jones RH et. al. Unstable angina: diagnosis and management. Clinical Practice Guideline Number 10. AHCPR Publication No.94-0602. Rockville, MD: Agency for Health Care Policy Research and the National Heart, Lung, and Blood Institute, Public Health Service, U.S. Department of Health and Human Services, 1994. Cohen M, Demers C, Garfinkel EP, et al. Low-molecular-weight heparins in non-ST segment elevation ischemia: the ESSENCE trial. Am J Cardiol 1998;82:196-246.

4.

5.

14 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

6.

EPILOG Investigators. Platelet glycoprotein Ilb/lIla receptor blockade and low-dose heparin during percutaneous coronary revascularization. N Engl J Med 1997; 336:1689-1696. Fuster V, Badimon L, Badimon JJ, et. al. The pathogenesis of coronary artery disease and the acute coronary syndromes. N EngI J Med 1992;326:242-250. Gersh BJ, Braunwald EG, Rutherford JD. Chronic coronary artery disease: unstable angina. In: Braunwald EG, ed. Heart disease: a textbook of cardiovascular medicine, 5th ed. Philadelphia: WB Saunders, 1997:1331-1339. Granger CB, Califf RM. Stabilizing the unstable artery. In: Califf RM, Mark DB, Wagner GS, eds. Acute coronary care, 2nd ed. St. Louis: Mosby, 1995:525-541.

7.

8.

9.

10. Hamm CW, Goldmann BU, Heeschen C,et al. Emergency room triage of patients with acute chest pain by means of rapid testing for cardiac troponin T or I. N Engl J Med 1997;337:1648-1653. ed rv

11. Lincoff AM, Califf RM, Moliterno DM, et al.ts n h Complementary v clinical benefits of coronary-artery stenting andig om. of platelet r blockade ll o.c glycoprotein lIb/Illa receptors. N Engl J v. A 1999;341:319-327. Med ho

res

in @ 12. Moliterno DJ, Granger CB. Differences between unstable angina and . F 20 acute myocardial infarction:08 ypathophysiological and clinical the 20 0 2 cit spectrum. In: Topol EJ, ted. Acute coronary syndromes, 1st ed. New h Poto York: Marcel Dekker, 1998:67-104. rig C 13. Ohman EM, Armstrong PW, Christenson RH, et al. Cardiac troponin T levels for risk stratification in acute myocardial ischemia. N Engl J Med 1996;335:1333-1341.
14. Oler A, Whooley MA, Oler J, et al. Adding heparin to aspirin reduces the incidence of myocardial infarction and death in patients with unstable angina: a meta-analysis. JAMA 1996;276:811-515. 15. Roe MT. Unstable angina and non-ST-segment elevation MI. In: Marso SP, Griffin BP, Topol EJ, eds. Manual of Cardiovascular Medicine. Philadelphia: LippincottRaven, 2000. 16. Stone PH, Thompson B, Anderson HV, et al. Influence of race, sex, and age on management of unstable angina and non-Q-wave myocardial infarction: the TIMI III registry. JAMA 1996;275:11041112. 17. Theroux P, Ouimet H, IvicCans J, et. al. Aspirin, heparin, or both to treat acute UA. N Engl J Med 1988;319:1105-1111.

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18. TIMI IIIB Investigators. Effects of tissue plasminogen activator and a comparison of early invasive and conservative strategies in unstable angina and non-Q-wave myocardial infarction. Circulation 1994;89: 1545-1556. 19. Van Miltenburg AJ, Simoons ML, Veerhoek RJ, et al. Incidence and follow-up of Braunwald subgroups in unstable angina. J Am Coll Cardiol 1995;25:1256A292. 20. White RD. Unstable angina: ischemic syndromes. In: Topol EJ, ed. Textbook of cardiovascular medicine. 1st ed. Philadelphia: Lippincott-Raven, 1998:365-393. 21. Williams DO, Braunwald E, Thompson B, et al. Results of percutaneous transluminal coronary angioplasty in unstable angina and non-Q-wave myocardial infarction: observations from the TIMI IIIB trial. Circulation 1996;94:2749-2755.

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au tht ngc n nh (Bnh tim thiu mu cc b mn tnh)

William Heberden l ngi u tin m t thut ng au tht ngc t hn 220 nm nay. Cho n by gi, y l loi bnh kh thng gp cc nc pht trin v c xu hng gia tng rt mnh cc nc ang pht trin. Theo c tnh hin M c khong gn 7 triu ngi b au tht ngc v hng nm c thm khong 350 000 ngi b au tht ngc mi. au tht ngc n nh cn c gi l Bnh c tim thiu mu cc b mn tnh hoc Suy vnh. Cn au thtrved l ngc e re triu chng thng c trong hai tnh trng ca bnhs tim thiu ts n mu cc b, l: au tht ngc n nh v aughomngc khng ri tht .v ll .c n nh. v. A ahoo loe y A. au tht ngc n nh l tnhin 20@khng c nhng din F trng . 0 08 bin nng ln bt n ca cn2au tht ngc trong vng 20 ocity vi tun gn y.ight au tht ngc n nh th tnh trng Vi Pot r py lm sng thng n nh, cn au tht ngc ngn, xy ra Co khi gng sc, khi ngh v p ng tt vi Nitrates. au tht ngc n nh thng lin quan n s n nh ca mng x va. B. au tht ngc khng n nh l tnh trng bt n v lm sng, cn au tht ngc xut hin nhiu v di hn, xy ra c khi bnh nhn ngh ngi v cn au t p ng vi cc Nitrates. Cn au ny thng lin quan n tnh trng bt n ca mng x va ng mch vnh. I. Triu chng lm sng Ch khai thc k bnh s, nh gi cc yu t nguy c. A. Triu chng c nng 1. Cn au tht ngc in hnh: 17 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

a. V tr: Thng sau xng c v l mt vng (ch khng phi mt im), au c th lan ln c, vai, tay, hm, thng v, sau lng. Hay gp hn c l hng lan ln vai tri ri lan xung mt trong tay tri, c khi xung tn cc ngn tay 4, 5. b. Hon cnh xut hin: Thng xut hin khi gng sc, xc cm mnh, gp lnh, sau ba n nhiu hoc ht thuc l. Mt s trng hp cn au tht ngc c th xut hin v m, khi thay i t th, hoc khi km cn nhp nhanh. c. Mc au v cc triu chng km theo: Hu ht cc bnh nhn m t cn au tht ngc nh tht li, nght, rt, b nng trc ngc v i khi cm gic but gi. Mt s bnh nhnved kh c ser th, mt l, au u, bun nn, v mrhi... e ts vn . gh mvi pht, c d. Thi gian cn au: Thng khong l ri co th di hn nhng khng qu l30opht. Nhng cn . A ah o. oev au xy ra do xc cm thng ko di hn l au inl 20@y F 8. 0 do gng sc. Nhng cn au m ch ko di di 00 ity2 2 1 pht th nntmtoc nguyn nhn khc ngoi tim. t gh Po i yr tht ngc n nh: Cho n nay cch 2. Phn loipau Co phn loi mc au tht ngc theo Hip hi Tim mch Canada (Canadian Cardiovascular Society CCS) l c ng dng rng ri nht v rt thc t. B. Khm lm sng: Khm thc th t c hiu nhng rt quan trng, c th pht hin cc yu t nguy c hoc nhng nh hng n tim. 1. Cc yu t nguy c cao ca bnh ng mch vnh c th pht hin thy l: Tng huyt p, mng Xantheplasma, bin i y mt, cc bng chng ca bnh ng mch ngoi vi. 2. Trong cn au tht ngc c th nghe thy ting T3, T4; ting ran phi... Ngoi ra t c triu chng thc th no l c hiu. 18 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

3. Khm lm sng gip chn on phn bit cc nguyn nhn khc gy au tht ngc nh: Hp ng mch ch, bnh c tim ph i, bnh mng ngoi tim, vim khp c sn... Bng 2-1. Phn au tht ngc theo CCS. c dim Ch thch Nhng hot ng th au tht ngc ch xut I lc bnh thng khng hin khi hot ng th lc rt mnh. gy au tht ngc. Hn ch nh hot ng au tht ngc xut hin II th lc bnh thng. khi leo cao >1 tng gc thng thng bng cu thang hoc i b di hn 2 dy nh. ed khi i III Hn ch ng k hot au tht ngc reserv b dy n ng th lc thng di t 1-2 ghts nh hoc ri c m.v leo cao 1l tngogc. thng. Al o. IV Cc hot ng th lc au v.ththongc khi lm oe ya inl 2 nh, khi gng sc bnh thng u gy. Fvic 0@ 20 08 nh. au tht ngc. 20 ocity ht Pot II. Cc xt nghim chn on rig py Co

Hnh 2-1. Cc xt nghim chn on au tht ngc. 19 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

A. in tm lc ngh: l mt thm d sng lc trong bnh mch vnh. 1. C ti > 60% s bnh nhn au tht ngc n nh c in tm (T) bnh thng. Mt s bnh nhn c sng Q (chng t c NMCT c), mt s khc c ST chnh xung, cng, thng un. T cn gip pht hin cc tn thng khc nh ph i tht tri, bloc nhnh, hi chng tin kch thch... 2. T trong cn au c th thy s thay i sng T v on ST (ST chnh xung, sng T m). Tuy nhin nu T bnh thng cng khng th loi tr c chn on c bnh tim thiu mu cc b. B. Nghim php gng sc (NPGS): Rt quan dtrng e trong au tht ngc n nh, gip cho chnserv xc on re nh, tin lng cng nh iu tr. hts n rig com.v l . 1. NPGS s gy ra tnh trng thiu lmu c tim cc b v. A ahoo oe hoc lm gin MV v c theo di lin tc bng inl 0@y Fnh2T gng sc hay siu mt phng tin no0 20 8. 20 ocity v c hiu ca tng m tim gng sc. nhy t ot gh sc phng phprigng P l c s khc nhau. y op 2. PhngCphp gy thiu mu c tim cc b: a. Gng sc th lc: C ch: Lm tng nhu cu xy c tim, lm c tim tng co bp, tng tin gnh v hu gnh. Vic tng nhu cu xy c tim s dn n tng nhp tim v nh hng n huyt p. Da vo s tng nhp tim ny xc nh kh nng gng sc ca bnh nhn. Mt khc, khi nhp tim tng ln s lm cho nhu cu tiu th xy c tim tng ln v lc s xut hin nhng bin i trn T hoc cc hnh nh khc m khi ngh c th s khng thy.

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Gng sc th lc gip d on kh nng hot ng th lc ca bnh nhn v giai on gy ra thiu mu c tim. Tuy nhin gng sc th lc khng th thc hin c nhng bnh nhn c chng i cch hi, bnh phi nng, bnh khp, hoc nhng d tt, nhng bnh c nh hng n kh nng thc hin gng sc ca bnh nhn. b. Dng mt s thuc lm gin MV: nh Adenosin v Dipyridamole. C ch: Adenosin lm gin cc vi mch ca h thng mch vnh, do nu c hp mt nhnh MV th cc nhnh cn li gin ra ly ht mu nhnh gy ra hin tngd thiu e erv mu c tim tng ng vi nhnh MV b hp res hts n (hin tng n cp mu). rig com.v ll . Dipyridamole cng c Ac ooch ging nh v. atc dng chm hn Adenosin nhng xut ehin h lo y Fin020@ v ko di hn. . 2 08 20 thng dng cho phng php Cc thuc nyocity t t igh Po chn ron ti mu c tim bng phng x. y p C c. Dngo cc thuc lm tng co bp c tim v tng nhp tim (Dobutamine v Arbutamine) C ch: L cc thuc kch thch 1 giao cm, lm tng co bp c tim, lm tng nhu cu xy ca c tim. Cc thuc ny thng dng khi lm siu m gng sc. 3. Cc phng php gng sc: a. in tm gng sc: nh gi c nhng bnh nhn c nguy c cao v bnh mch vnh. Nhng d liu trong bng sau s gip chng ta c th d on c nhng bnh nhn c nguy c cao b bnh MV khi lm T gng sc. 21 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

D on mc hot ng th lc an ton cho bnh nhn (nht l sau NMCT). Tuy nhin, T gng sc t c gi tr nhng bnh nhn m T c bn c nhng bt thng nh dy tht tri, ang c t my to nhp, bloc nhnh tri, ri lon dn truyn... T gng sc cng khng d on c mc hp MV v khng nh v chnh xc c vng c tim thiu mu. Bng 2-2. Nhng d kin gip d on nguy c cao b bnh mch vnh trn in tm gng sc. Khng kh nng chy 6 pht theo phc Bruce. Nghim php dng tnh sm ( 3 pht). Kt qu gng sc dng tnh mnh (ST chnh xung ved 2 pht). ser sc. re ST chnh xung 3 pht sau khi ngngsgng t gh m.vn ST chnh xung kiu dc xung (down-sloping). ri co Thiu mu c tim xut hin mc All ootim cn tng . nhp . v ah i thp ( 120 ck/pht). loe ini.0@y F Huyt p khng tng hoc. tt 02 8 00 it 2 Xut hin nhp nhanh tht y mc nhp tim 120 chu 2 t oc k/pht. gh Pot ri b. SiuCm tim gng sc: L thm d c gi tr, n opy gin v c th cho php d on vng c tim thiu mu v v tr MV tng ng b tn thng. Siu m gng sc c th lm vi gng sc th lc (xe p nm) hoc thuc (Dobutamine). Tuy nhin, kt qu ca thm d ny cn ph thuc nhiu vo kinh nghim ca ngi lm siu m v i khi kh khn nu hnh nh m (Bnh nhn bo, bnh phi...) c. Phng php phng x o ti mu c tim: Thng dng Thalium201 hoc Technectium99m. C nhy, c hiu cao, o c tng vng ti mu c tim song nhy, c hiu b gim nhng bnh nhn bo ph, bnh hp c 3 nhnh MV, bloc nhnh tri, n gii...

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C. Siu m tim thng quy 1. Tm nhng ri lon vn ng vng (nu c). 2. Gip nh gi chc nng tim, bnh km theo (van tim, mng tim, c tim...). D. Holter in tim: C th pht hin nhng thi im xut hin bnh tim thiu mu cc b trong ngy, rt c ngha nhng bnh nhn b co tht MV (Hi chng Prinzmetal) hoc bnh tim thiu mu cc b thm lng (khng c au tht ngc). Trong cn co tht mch vnh c th thy hnh nh on ST chnh ln. Ngoi ra c th thy c mt s cc ri lon nhp tim khc. Bng 2-3. Ch nh chp MV theo AHA/ACC. Nhm I: C ch nh thng nht ved sr Khng khng ch c triu chng vi iue tr ni re ts khoa ti u. gh m.vn ri Bnh nhn c nguy c cao khi lm All oo.c(bng 2-2). NPGS o . ah C bng chng ca ri lon loev y nng tht tri t chc Fin020@ mc va. . 08 2 Chun b cho phu thut mch mu ln. 20 ocity h P Ngh nghip hoct liotsng c nhng nguy c bt rig thng. Copy Nhm II: (Thng c ch nh, nhng cn cn nhc) Bnh nhn tr tui c bng chng ca bnh c tim thiu mu cc b trn NPGS hoc c tin s NMCT. Bng chng ca thiu mu c tim nng trn NPGS. Nhm III: (Thng khng c ch nh) Bnh nhn au tht ngc mc nh (CCS I, II) v triu chng, khng c ri lon chc nng tht tri v khng c nguy c cao trn NPGS. E. Chp ng mch vnh: l phng php quan trng gip chn on xc nh c hp MV hay khng v mc cng nh v tr hp ca tng nhnh MV. 1. Ch nh chp MV: Nhn chung ch nh chp MV bnh nhn suy vnh l nhm mc ch can thip nu c th. V y l mt thm d chy mu v 23 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

kh tn km nn vic ch nh cn cn nhc n li ch thc s cho bnh nhn. Hi Tim mch Hoa k v Trng mn Tim mch Hoa k (AHA/ACC) c nhng khuyn co v ch nh chp MV bnh nhn suy vnh nh trong bng 2-3. III. iu tr A. Mc ch: Ngn nga nguy c t vong v bin chng, ci thin cht lng cuc sng.

ved ser re ts gh m.vn i ll r co . A ahoo. oev inl 20@y Hnh 2-2. Tin trin ca 08. F 2x va MV. mng 0 20 ocity B. La chn phng php t t igh Po yr php iu tr: Thuc, can thip MV, p 1. C 3 phng Co m lm cu ni ch vnh. Thm vo , cn phi iu chnh cc yu t nguy c cho ngi bnh. 2. Vic ch nh ph thuc vo tnh trng bnh v nn bt u cng nh duy tr bng iu tr ni khoa. Trong trng hp iu tr ni khoa tht bi hoc bnh nhn c nguy c cao trn cc thm d th cn c ch nh chp MV v can thip kp thi.
C. iu tr ni khoa 1. Cc thuc chng ngng kt tiu cu: a. Aspirin: Lm gim t l t vong v nhi mu c tim ti 33% (SAPAT). Liu dng t 75 - 325 mg/ngy. b. Nu d ng hoc dung np km vi Aspirin: 24 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Ticlopidine (Ticlid): vin 250mg, dng 2 vin/ngy. Tc dng ph c th gp l h bch cu mu (3-5%), h tiu cu. Cn phi theo di cng thc mu khi dng. Clopidogrel (Plavix): Vin 75mg, hiu qu cao v t tc dng ph hn Ticlid, liu 75mg/ngy. c. Trong trng hp c ch nh chp MV m c can thip t stent th cn dng phi hp gia mt trong hai loi thuc ny vi Aspirin v dng cho bnh nhn t nht trc 2 ngy can thip. Sau can thip MV thuc ny cng Aspirin phi c dng thm t nht 1 thng, sau c th ch cn dng Aspirin. Tuy nhin, nhng nghin cu gn ed y cho thy rng dng thm Plavix koerv thm s di re 9 thng cng cho li ch r rt hn. ts .vn gh m l ri o d. Thuc c ch th th GP. IIb/IIIa: Ch c dng Al hoo.c v tim c chng minh loe ci a in l 0@y thin tt t l sng v t bin chng08. F 202 nhn c nong ng bnh 20 ocity mch vnh hoc t Stent. ht Pot rig py Co

Hnh 2-3. C ch tc dng ca cc thuc chng ngng tp tiu cu. 25 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

2. iu chnh ri lon Lipid mu: c chng minh l c kh nng phng nga c tin pht ln th pht bnh MV. a. Ch nh: Bnh nhn c ri lon lipid mu m c tin s au tht ngc hoc NMCT. Bnh nhn sau lm cu ni MV. b. Cc nhm thuc: c ch men HMG-CoA: Simvastatin (Zocor), Atorvastatin (Lipitor), Fluvastatin (Lescol)... l nhng thuc c chng minh l rt tt trong ngn nga bnh ng mch vnh. Th nghim 4S vi Simvastatin cho thy gim r rt nguy c bnh MV bnh nhnd c e erv dng thuc so vi nhm chng. s res t gh .vn Dn xut Fibrat: nh Gemfibrozil (Lopid), l ri .com l Fenofibrat (Lipanthyl),Benzafibrat (Banzalip). . A oo oev yah Nicotinic acid (Niacin).@ inl 2 . Fgn 0 8 Cc loi Resins y20 acid mt: Colestipol, 00 2 tocit Cholestyramine. t igh Po yr Nitrates: 3. Cc dn op xut C a. C ch: Lm gim nhu cu xy c tim do gy gin mch lm gim tin gnh v mt phn hu gnh ca tht tri. C th lm tng dng mu ca MV do lm gim p lc cui tm trng ca tht tri v lm gin MV. Ngoi ra cn c mt phn tc dng c ch ngng kt tiu cu. b. La chn thuc: (Bng 2-4). c. Tc dng ph: au u: Do gin mch no, c th gim bt liu khi c triu chng ny. C th gp bng mt, chng mt, h HA. 26 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Cn thn khi ung vi cc thuc gin mch khc. Chng ch nh dng cng vi Sildenafil (Viagra). Ch l thng c s quen thuc khi dng Nitrates lin tc ko di, do cn dng ngt qung (khng nn dng lin tc). Bng 2-4. Cc loi Nitrates. Tn thuc ng Liu S ln/ngy dng Theo nhu cu Nitroglycerin Vin ngm 0,15-0,6 mg di li (Glycerin Theo nhu cu 0,4 mg Dng xt trinitrate Mi 6-12 gi Vin gii 2,5 - 9,0 mg Nitrobid, phng chm Nitrostat, ved ser gi Mie 4-8 1,25 5 cm M bi Nitrodur, sr Mi n 2,5 - 15 mg right m.v24 gi Ming dn Natispray, ll Truyn lin Dng tim 5-400g/pht oo.co Nitromit...) v. A ah loe @y tc truyn TM in . F-2020 8 Mi 2 - 3 gi Vin ngm 002,5y 10 mg Isosorbide t di li t 2 otoci dinitrate igh Mi 2 - 3 gi Vin nhai P 5 - 10 mg (Isosorbid, yr p Co Mi 6 gi Vin ung 10 - 40 mg Lenitral, Mi 8 - 12 gi 40 80 mg Vin chm Sorbitrate) Mi 12 gi Isosorbid - 5- Vin ngm 10 - 40 mg mononitrate di li Mi 24 gi 60 mg (Imdur, Ismo) Vin chm Erythrityl tetranitrate (Cardilate) Vin ngm Vin ung 5 - 10 mg 10 mg Theo nhu cu Mi 8 gi

4. Cc thuc chn giao cm: a. C ch: Chn 1 giao cm do lm gim nhp tim, gim sc co c tim v lm gim nhu cu xy c tim. N cng lm gim sc cng ln thnh 27 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

tht tri nn lm dng mu t thng tm mc ti n ni tm mc nhiu hn. Ring cc thuc c chn 2 giao cm c th gy co mch vnh, nn khng dng bnh nhn c co tht MV. Thuc chn giao cm c s dng nh thuc hng u trong iu tr suy vnh (nu khng c chng ch nh). N c chng minh l lm gim t l t vong v nhi mu c tim bnh nhn au tht ngc n nh. b. Chng ch nh: Bnh phi mn tnh tc nghn. Nhp chm, cc bloc nh-tht. Suy tim nng. ved Bnh mch mu ngoi vi. ser re ts i tho ng, ri lon m hmu nl nhng g m.v ri chng ch nh tng i. ll oo.co . A ah oev c. Cc loi thuc: inl 20@y F Chn lc 1. 08. 20 0 ity 2 (a) Metoprolol c t to (Betaloc): 50 - 200 mg/ ngy. gh Po(Tenormin): 25 - 200 mg/ngy. (b)pyri Atenolol Co (c) Acebutolol (Sectral): 200 - 600 mg (d) Betaxolol: 20 - 40 mg/ngy Khng chn lc (chn c 1 v 2) (a) Propranolol (Inderal): 40 - 320 mg/ ngy (b) Nadolol, Timolol, Pindolol Chn c v : Labetalol, Carvedilol 5. Cc thuc chn dng canxi: a. C ch: Chn dng canxi vo cc t bo c trn mch mu, v vo t bo c tim nn lm gin mch, v c th gim sc co bp c tim. b. Cc nhm thuc: Dihydropyridines: (Nifedipin, Amlordipine, Felodipine, Isradipine); t tc dng ln MV. Nifedipin v Amlordipine c th dng trong 28 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

mt s trng hp, c bit khi c THA v c yu t co tht km theo. Benzothiazepines: Diltiazem (Tildiem) 30-90 mg x 3 ln/ngy. Khng dng bnh nhn c gim chc nng co bp tht tri, nhp chm. Phenylalkylamine: Verapamil (Isoptine): 120 - 240 mg x 2 ln/ngy. C th lm gim chc nng co bp tht tri v lm chm nhp tim. Khng dng thuc ny bnh nhn suy tim. c. Tc dng ph: H huyt p, bng mt, chng mt, au u... Gy gim sc co bp c tim, nhp chm, nn thuc c coi l chng ch nh bnh nhn c suy tim hoc nhp chm. ved ser bnh 6. c ch men chuyn: Ch nn dng re nhng ts nhn au tht ngc n nh sau NMCT .c ri lon gh m vn i ll r chc nng tht tri hoc bnhAnhnco THA km . ahoo. c ev theo. Nn khi u bng iliu thp trnh tt huyt nlo 0@y F 8. 02 p v suy thn. 00 ity2 2 oc t 7. iu tr Hormon thay th: gh Pot i yr a. ph pn mn kinh c s gim Estrogen do c Co th ri lon Lipid mu lm tng nguy c bnh mch vnh v THA. C nhiu nghin cu chng minh vai tr ca iu tr thay th hormon nhng bnh nhn n mn kinh lm gim nguy c mc bnh THA hoc MV. b. Hin nay thng dng l Estrogen, liu 0,625 mg /ngy, ung trong 25 ngy lin tc, ngh 5 ngy. 8. Cc thuc chng gc xy t do: Vitamin E 400 800 n v/ngy c th lm gim mt s bin c bnh tim mch. Tuy nhin cc nghin cu cn cha thng nht v li ch thc s ca n trong bnh MV. D. iu tr can thip ng mch vnh (Nong MV bng bng, t Stent hoc dng cc thit b khc). 29 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

1. So snh vi dng thuc iu tr: lm gim triu chng v gim t l t vong ng k (cc th nghim ACME, MASS, RITA - 2). So snh vi phu thut lm cu ni: Nu nhng bnh nhn c bnh tn thng 1 ng mch vnh, li ch vt tri ca can thip MV khng cn phi bn ci. Tuy nhin nhng bnh nhn b tn thng nhiu ng mch vnh, trc y thng ch nh cho phu thut, nhng nay mt s nghin cu cho thy kt qu cng tng t nh m lm cu ni (Th nghim BARI). Ring nhng bnh nhn c km theo tiu ng th m lm cu ni MV t ra u th hn. 2. Ch nh: (Xem cc ch nh chp ng mch vnh). Ngoi ra, khi chp MV thy tn thng khu tr, ved ser c 3 khng phi thn chung, khng phi rebnh s n MV, chc nng tht tri cn tt...ght mnn u tin ri th .v ll .co cho can thip MV. v. A ahoo oe 3. Cc phng php trong l iuy tr can thip ng Fin020@ . 2 0 mch vnh bao gm:8 nong ng mch vnh bng 20 ocity t o bng, t Stenthtrongt MV, bo gt mng x va c P rig nh hng (Directional Coronary Angioplasty), py Co khoan mng x va (Rotablator)... S la chn cc phng php ny tu thuc vo tn thng khi chp MV, trnh , kinh nghim thy thuc cng nh kh nng trang thit b. Hin nay, vi s pht trin mnh m ca khoa hc k thut cho ra i nhng dng c tin tin v vic dng cc thuc mi (v d thuc c ch th th IIb/IIIa) phi hp vi can thip MV cho t l thnh cng ca can thip rt cao vi rt t bin chng. 4. Mt vn cc k quan trng l khi can thip MV phi dng phi hp cc thuc iu tr ni khoa tt, trong vai tr ca cc thuc chng ngng kt tiu cu l rt quan trng ngn nga bin chng tc mch vnh cp. Nu c t Stent th nn dng phi 30 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

hp Aspirin vi Ticlopidin (hoc Clopidogrel) trc t nht 2 ngy, sau ko di thm Clopidogrel (Plavix) hoc Ticlopidine (Ticlid) khong 2 4 tun th dng, ch cn Aspirin l ko di mi. Tuy nhin, nhng nghin cu gn y cho thy rng dng phi hp Plavix v Aspirin ko di thm 9 thng cng cho li ch r rt hn. Trong lc can thip th cn dng Heparin, nu kt qu can thip tt, khng cn dng tip Heparin. Cc thuc mi c ch th th GP IIb/IIIa nu c dng phi hp s cho kt qu cao hn v t bin chng. Tuy nhin gi cc loi thuc ny kh t. 5. Vn ti hp (restenosis) sau khi can thip cng rt nan gii. Mc d Stent lm gim ng ved t l k ser ti hp nu so vi ch nong ng mch vnh n re ts thun, nhng t l ti hp sau 6 thngm.vn kh cao gh vn i ll r co (10-20%). Ngi ta ang th nghimonhiu bin php . A aho . ov mi ngn nga ti hp choe kt qu kh quan nh inl 20@y F 8. 0 dng phng x ti ch (Brachial Therapy) hoc k 00 ity2 thut gen. Gn ht 2 cc th nghim vi cc loi stent y otoc P rig c ph thuc khng phn bo c nhiu kt qu kh py Co quan trong vic chng ti hp. Cho ti nay, hu nh cha c loi thuc ung no c th ngn ti hp tt. E. M lm cu ni ch - vnh 1. Ch nh: Bnh nhiu ng mch vnh b hp (vd. Tn thng 3 MV), tn thng thn chung, tn thng phc tp khng ph hp cho can thip m on xa cn tt... 2. So snh vi iu tr ni khoa: Lm gim triu chng v ci thin t l t vong ng k (Nghin cu CASS, ECSS, VACS). So vi can thip MV: Cho kt qu tng t vi bnh tn thng khng nhiu MV, vi bnh nhiu MV th c v c li ch hn, nhng trong bnh MV km theo tiu ng th phu thut lm cu ni ch-vnh t ra c li hn. 31 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

3. K thut m lm cu ni ng mch vnh hin nay c nhiu tin b nh vic dng cc on ng mch quay, ng mch v trong lm gim nguy c tc cu ni sau m so vi dng tnh mch hin theo cch truyn thng. Hn th na, nhng k thut t xm ln nh m vi tim vn p (khng phi dng tim phi my) ang ha hn nhng kt qu tt p. F. iu chnh li sng 1. Tp th dc, vn ng th lc u n. 2. iu chnh ch n cho hp l. 3. B thuc l, phi tht cng quyt. 4. Cc yu t tm l: Trnh cng thng thn kinh... ved G. Mt s phng php mi ser re hts .v 1. Ti to mch xuyn c tim igbng n LASER r m (Directional Myocardial Laser . All oo.co Revascularization): v ah e a. Dng tia Laser khoaninlo 0@y nh trc tip vo nhiu l F 02 cc vng c tim 008trong lp ni tm mc cho n t . y2 t 2 omc. C ch l to ra cc vi di thngt tmt ci gh Po mch pyri mu t bung tim c th nui trc nh o tip C c c tim v sau mt thi gian s xut hin h thng vi tun hon mi ti mu cho c tim. b. C th thc hin k thut ny khi m tim hoc qua ng ng thng tim. c. K thut ny c ch nh khi vic la chon cc phng php iu tr khc gp b tc (v d bnh nhiu MV m tn thng phc tp khng can thip c v on xa khng ph hp cho lm cu ni). 2. Gene liu php: vn cn trong giai on nghin cu vi hy vng dng gene bin i ci to h tun hon vnh bng cc h tun hon bng h tn to.

32 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Ti liu tham kho


1. 2. 3. 4. 5. 6. 7. Alderman EL, Bourassa MG, Cohen LS, et al. Ten-year follow-up of survival and myocardial infarction in the randomized coronary artery surgery study. Circulation 1990;52:1629-1646. Armstrong PW. Stable ischemic syndromes. In: Topol EJ, ed. Textbook of cardiovascular medicine. Philadelphia: LippincottRaven, 1998:333-365. CAPRIE Steering Committee. A randomized, blinded trial of clopidogrel versus aspirin in patients at risk of ischemic events (CAPRIE). Lancet 1996;345:1329-1339. Diaz MN, Frei B, Vita JA, Keaney JF Jr. Mechanism of disease: antioxidants and atherosclerotic heart disease. N Engl J Med 1997;337:408-4166. Ferrari R. Major differences among the three classes of calcium antagonists. Eur Heart J 1997;18:A56-A7O. Furberg CD, Psaty BM, Meyer JV. Nifedipine: dose related increase in mortality in patients with coronary heart disease. Circulation 1995;92: 1326-1331. Gersh BJ, Braunwaid E, Rutheiford JD. Chronic coronaryd artery e disease. In: Braunwald E, ed. Heart disease: sa rvtextbook e re o[cardiovascular medicine, 5th ed. Philadelphia: s WB Saunders, t 1997:1289-1366. gh .vn l ri angina pectoris: Guidelines and management of stable .com Al oo recommendations of the Task Force ev. the hEuropean Society of o of ya Cardiology. Eur Heart J 1997;18:394-413. inl @ . F 2020 Juul-Moller S, Edvardsson N, Jahnmatz B, et al. Double blind trial of 08 aspirin in primary prevention city 20 oof pectoris.myocardial infarction in patients t with stable chronic angina ot Lancet 1992;114:1421-1425. igh Kapadia SR. Stablerangina.PIn: Marso SP, Griffin BP, Topol EJ, eds. y p Manual of Cardiovascular Medicine. Philadelphia: Lippincott-Co Raven, 2000. Mark DB, Nelson CL, Califf RM, et al. Continuing evolution of therapy for coronary artery disease. Circulation 1994;59:2015-2125. Mark DB, Shaw L, Harrell FE, et al. Prognostic value of a treadmill exercise score in outpatients with suspected coronary artery disease. N Engl J Med 1991;325:S4-S53. Parker JD, Parker JO. Drug therapy: nitrate therapy for stable angina pectoris. N Engl J Med 1995;335:520-531. Solomon AJ, Gersh BJ. Management of chronic stable angina: medical therapy, percutaneous transluminal coronary angioplasty, and coronary artery bypass graft surgery, lessons from randomized trials. Ann Intern Med 1998;125:216223. The Bypass Angioplasty Revascularization (BARI) Investigators. Comparison of coronary bypass surgery with angioplasty in patients with multivessel disease. N Engl J Med 1996;335:217-225. The Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: The Scandinavian Simvastatin Survival Study (4S). Lancet 1994;344:1383-1389.

8. 9. 10. 11. 12. 13. 14.

15. 16.

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Nhi mu c tim cp
Nhi mu c tim (NMCT) cp l mt trong nhng nguyn nhn hng u gy t vong M v cc nc chu u. c tnh M c khong 1 triu bnh nhn nhp vin mi nm v NMCT cp v khong 200.000 n 300.000 bnh nhn t vong hng nm v NMCT cp. Vit nam s bnh nhn NMCT ngy cng c xu hng gia tng nhanh chng. Nu nh nhng nm 50, NMCT l bnh rt him gp th hin nay hu nh ngy no cng gp nhng bnh nhn NMCT cp nhp vin (ti Vin Tim mch). Nhng tin b trong chn on v iu tr NMCT cp lm gim ng k t l t vong do NMCT cp. S ra i ca n v cp cu mch vnh (CCU) u nhng nm 60, tip n l cc d thuc tiu huyt khi nhng nm 80 v hin nay lserve thip can e ng mch vnh cp cu v nhng tin b v cchts r vnphi hp thuc g m. i lm cho t l t vong do NMCT cp trn rth ogii hin nay ll c . A ahoo. l > 30 %. gim xung ch cn khong < 7% so vietrc y ov inl 20@y F 8. 0 00 ity2 2 I. Sinh l bnh t oc gh Pot ri py C tim c nui dng bi 2 ng mch vnh (MV) Co l MV tri v MV phi. MV tri xut pht t l vnh tri ca MC v MV phi xut pht t l vnh phi. Thc t, MV tri li chia ra 2 nhnh ln l nhnh lin tht trc (LAD) v nhnh m (LCx). Do vy ngi ta thng gi l 3 thn MV nui c tim. NMCT c hiu l do s tc nghn hon ton mt hoc nhiu nhnh MV gy thiu mu c tim t ngt v hoi t vng c tim c ti mu bi nhnh MV . Th phm y chnh l mng x va ng mch. Nhng vn t ra l trong thc t nu mng x va c pht trin m thm gy hp nhiu thm ch tc hon ton MV theo thi gian cng khng gy ra triu chng ca NMCT cp v c s thch nghi v pht trin ca tun hon bng h. C ch ch yu ca NMCT cp l do s khng n nh v nt ra ca mng x va hnh thnh 35 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

huyt khi gy lp ton b lng mch. Nu vic nt ra ny khng ln v hnh thnh cc mu ng cha gy lp kn ton b lng mch, th l cn au tht ngc khng n nh trn lm sng. II. Triu chng lm sng A. Triu chng c nng 1. Cn au tht ngc in hnh: a. au nh bp nght pha sau xng c hoc hi lch sang tri, lan ln vai tri v mt trong tay tri cho n tn ngn eo nhn v ngn t. Nhn chung cn au c tnh cht ging cn au tht ngc nhng ko di hn 20 pht v khng khi dng Nitroglycerin. ved ser cm, b. Mt s trng hp au c th lan sln c, re ht .vn vai, sau lng, tay phi, hoc vnggthng v. l ri om Al ho c c. Mt s trng hp NMCT .c tho.xy ra m bnh ev a nhn khng hoc t Finlo 0@y au (NMCT thm cm gic 2 . lng), hay gp 08 ty20 0 bnh nhn sau m, ngi gi, 2 i bnh nhngc tiutoc ht Po ng hoc tng huyt p. i yr d. Trong ptrng hp au lan nhiu ra pha sau lng Co phi phn bit vi tch thnh ng mch ch. 2. Cc triu chng khc i km theo c th gp l: v m hi, kh th, hi hp nh trng ngc, nn hoc bun nn, l ln... Cc triu chng ca ri lon tiu ho thng gp trong trng hp NMCT sau di. 3. t t cng l mt trong nhng th hay gp ca NMCT cp. B. Triu chng thc th 1. Khm thc th trong NMCT cp ni chung t c gi tr chn on xc nh nhng cc k quan trng gip chn on phn bit vi cc bnh khc, gip pht hin cc bin chng, tin lng bnh cng nh l c s theo di bnh nhn. 36 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

2. Nhng triu chng hay gp l: nhp tim nhanh, ting tim m, ting nga phi, huyt p c th tng hoc tt, xut hin ting thi mi tim, cc ri lon nhp, ran m phi, cc du hiu ca suy tim, ph phi cp.... Sau vi ngy c th thy ting c mng tim (hi chng Dressler). C. Cc yu t lm sng c gi tr tin lng bnh Vic nh gi tin lng bnh nhn NMCT cp ng vai tr rt quan trng gip thy thuc c thi x tr, theo di bnh, cng nh gii thch cho bnh nhn v gia nh tt hn. Nhng nghin cu ln trn th gii ch ra nhng yu t sau (xp theo mc t cao n thp) c tin lng xu i vi NMCT cp: (bng 3-1 v 3-2) ved 1. Tui: cng cao tin lng cng xu. ser re 2. Huyt p tm thu tt (< 90 mmHg). ights .vn l r com 3. Killip cng cao t l t vongAl hoo.tng. . cng oev a inl 20@y 4. Nhp tim nhanh > 100 chu k /pht. F 8. 0 00 ity2 5. V tr ca NMCT. 2 oc t t igh Po Bng 3-1. Lin quan gia Killip v t l t vong yr p Co trong vng 30 ngy. c im lm sng % T l t vong Killip trong 30 ngy (%) I Khng c triu chng 85 5,1 ca suy tim tri 13,6 II C ran m < 1/2 phi, 13 tnh mch c ni, c th c ting T3 nga phi III Ph phi cp 1 32,2 IV Sc tim 1 57,8 III. Cn lm sng A. in tm (T): L mt trong nhng thm d rt c gi tr chn on NMCT cp v nh khu NMCT. 37 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

T cn c lm ngay khi bnh nhn nhp vin v lm nhc li nhiu ln sau gip chn on cng nh theo di. Nhng thay i trn T bin thin theo thi gian mi c nhiu gi tr. Cc tiu chun ca chn on NMCT cp trn T l: 1. Xut hin sng Q mi (rng t nht 30 ms v su 0,20 mV) t nht 2 trong s cc min chuyn o sau: D2, D3 v aVF; V1 n V6; D1 v aVL, hoc 2. Xut hin on ST chnh ln hoc chnh xung (> 0,10 mV) t nht 2 trong s cc min chuyn o ni trn, hoc 3. S xut hin mi bloc nhnh tri hon ton trong bnh cnh lm sng ni trn. ed Bng 3-2. Lin quan gia v tr NMCT cp v t elerv vong. s t r t Tsl t gh m.vn vong i V tr NMCT Thay i trn All r o.co (%) o . aTrong T loev y h Trong Fin020@ 30 ngy 1 nm . 08 19,6 25,6 on gn ca ST chnh ln 2 V120 ocity ht PotaVL hoc MLTT (LAD) 6,g DI, ri (NMCT trc rng) opykm theo bloc C nhnh tri on gia ca LAD ST chnh ln V1-6, 9,2 12,5 DI v aVL 6,8 10,2 on xa ca LAD ST chnh ln V14, hoc D1, aVL v V5-6 NMCT sau di rng ST chnh ln D2, 6,4 8,4 (on gn ca MV D3, aVF v km phi hoc ng mch theo mt trong cc m) chuyn o sau NMCT sau di nh V1, V3R, V4R 4,5 6,7 (on xa ca MV V5-6 phi hoc M m) R>S V1, V2 hoc ST chnh ln ch D2, D3 v aVF 38 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Lu l: sng Q thng xut hin trung bnh sau 8-12 gi, tuy nhin trong mt s trng hp khng c sng Q m ch c bin i ca on ST (NMCT khng Q - hay NMCT di ni tm mc). Trng hp NMCT tht phi th cn lm thm cc chuyn o V3R n V6R tm cc bin i ny. Trong trng hp km theo bloc nhnh phi hon ton, vic chn on trn T tr nn kh khn hn. Nu bnh nhn c NMCT trc bn c th thy hnh nh sng T chnh ng hng vi phc b QRS V1-V4.

ved ser re ts gh m.vn i ll r co . A ahoo. oev inl 20@y F 8. 0 00 ity2 2 t oc gh Pot ri py Hnh 3-1. NMCT sau di cp. Co B. Cc men sinh hc trong huyt thanh bnh nhn 1. Creatine Kinase (CK): 3 iso-enzyme ca men ny l CK-MB, CK-MM, CK-BB i din cho c tim, c vn v no theo th t trn. Bnh thng CK-MB chim khong <5% lng CK ton phn (bnh thng CK ton phn trong huyt thanh t 24-190 U/l 37oC v CK-MB < 24 U/l). a. Men ny bt u tng 3-12 gi sau nhi mu, nh cao khong 24 gi v tr v bnh thng sau 48-72 gi. b. Lu l men ny c th tng trong mt s trng hp khc nh vim c tim, vim mng ngoi tim, sau m tim, sau sc in. N cng tng trong mt
39 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

s bnh khc nh: chn thng s no, chn thng c (k c tim truyn), tiu c vn, bnh vim c, suy thn mn, tp th lc qu mnh... 2. Troponin: bao gm Troponin I v T, l hai loi men c gi tr chn on cao v kh c hiu cho c tim, hn na n cn c gi tr tin lng bnh. Cc men ny bt u tng kh sm sau NMCT (3-12 gi) t nh 24-48 gi v tng tng i di (5-14 ngy). 3. Lactate DeHydrogenase (LDH): bao gm 5 isoenzymes v gp mi m trong c th. LDH tng t 8-12 gi sau nhi mu, t nh 24-48 gi v ko di 10-14 ngy. T l LDH1/LDH2 > 1 c ngha trong NMCT. ved ser re ts gh m.vn i ll r co . A ahoo. oev inl 20@y F 8. 0 00 ity2 2 t oc gh Pot ri py Co

Gi

Hnh 3-2. Thay i cc men sau NMCT cp (theo gi). 4. Cc Transaminase SGOT v SGPT: t c hiu cho c tim. Tuy nhin iu kin ca chng ta th xt nghim cc men ny cng vn c gi tr nht nh. Trong NMCT th SGOT tng nhiu hn SGPT. C. Siu m tim: cng rt c gi tr, c bit trong nhng th NMCT khng Q hoc c bloc nhnh. Thng thy hnh nh ri lon vn ng vng lin quan n v tr nhi 40 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

mu. Mc ri lon t gim vn ng, khng vn ng, vn ng nghch thng v phnh thnh tim. Siu m tim cn gip nh gi chc nng tht tri, cc bin chng c hc ca NMCT (thng vch tim gy thng lin tht, h van tim do t dy chng), trn dch mng tim, huyt khi trong bung tim... D. Thm d phng x ti mu c tim: thng khng cn dng trong giai on cp ca NMCT. Cc thm d ny c ch giai on sau nh gi mc ti mu cho tng vng c tim v s sng cn ca c tim nhm gip ch cho ch nh can thip mch vnh. IV. Chn on phn bit A. Vim mng ngoi tim: au thng lin tc v cm ved gic rt, au thay i theo t th v nhp th,reser thng au hts n tng khi nm nga. Trong vim mng ngoi tim cng c rig com.v th c ST chnh ln nhng l chnhl ln. ng hng Al o ev. ya o okhngh c hnh nh soi cc chuyn o trc tim vl @ Fin gng. Siu m c th gip. ch 020 chn on. 08 ty2 cho 0 2 toci B. Vim c tim cp:t lPmt chn on phn bit kh kh h o ig yr khn v cc otriu chng lm sng cng nh T kh p C ging NMCT. Bnh s v khm lm sng cho thy bnh cnh nhim trng (c bit l virus) v siu m tim c gim vn ng ng u gip thm chn on phn bit. C. Tch thnh ng mch ch: in hnh l au d di lan pha sau lng. Nhiu khi tch thnh MC cng gy ra NMCT khi n nh hng n MC ln v gc MC. Siu m tim c th thy hnh nh tch thnh MC nu MC ln. Siu m qua thc qun rt c gi tr chn on. Chp ct lp vi tnh (CT scan) hoc chp cng hng t l nhng thm d tt gip chn on xc nh. D. Nhi mu phi: thng t ngt kh th, au ngc, ho ra mu m khng c ph phi. T l hnh nh tm ph cp vi S1 Q3 (S su D1 v Q su D3). Chp Xquang 41 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

c th thy hnh nh mt m m phi v siu m tim khng thy c ri lon vn ng vng. E. Cc bnh cp cu bng nh thng d dy, cn au d dy cp, vim tu cp, vim ti mt, giun chui ng mt... cng cn c phn bit nht l vi NMCT cp th sau di. V. iu tr NMCT cp A. iu tr ban u 1. Khn trng nh gi tnh trng bnh nhn v nn chuyn ngay n nhng c s c th iu tr ti ti mu. Kp thi nh gi cc bin chng nguy him khng ch (lon nhp, suy tim...). Bnh nhn phi c vn chuyn bng xe cu thng v c nhn vin ed erv sphp iu y t i cng. ng thi thc hin cc bin re ts gh m.vn tr ban u. i ll r o.co o . A ami bnh nhn l: 2. Cc bin php chung, ban uvcho h oe y inl ng a. Bnh nhn phi cFbt 20@ ti ging. . 08 20 20 ity b. Th xy: vi liuoc2-4 lt/pht qua ng mi v t t igh Po trong NMCT cp thng km theo thiu xy. Mt yr p s trng hp suy h hp nng cn phi t ni Co kh qun v cho th my ph hp. c. Gim au y : lm gim s tng tit cathecholamin trong mu v gp phn lm gim nhu cu xy c tim. Morphin sulphat l thuc c la chn hng u, liu dng t 2-4 mg tim tnh mch sau nhc li sau 5-10 pht nu bnh nhn vn au. Ch nhp th ca bnh nhn v nhp tim. Nu gy nhp chm c th cho Atropin 0,5 mg tim TM. d. Nitroglycerin (0,4 mg) ngm di li, c th nhc li sau mi 5 pht. cn ch huyt p ca bnh nhn. Nu huyt p ti a cn > 90 mmHg l tt. Tip sau cn thit lp ngay ng 42 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

truyn tnh mch v truyn Nitroglycerin vi tc 10 mcg/pht, c th chnh liu theo con s huyt p ca bnh nhn. Nu bnh nhn huyt p tt th khng th dng Nitroglycerin, khi cn p dng ngay cc bin php vn mch tt. Lu l Nitroglycerin c th gy nhp chm v khng dng khi c NMCT tht phi. e. Cho ngay thuc chng ngng kt tiu cu: Aspirin cn cho ngay bng ng ung dng khng bc vi liu 160 - 325 mg hoc c th cho bng ng tim tnh mch 500 mg. C th cho bng dng gi bt Aspegic. Nu bnh nhn c tin s lot d dy t trng ang tin trin th c th thay bng Ticlopidine (Ticlid) 250 mg x 2 ed erv vin/ngy hoc Clopidogrel (Plavix)escho ngay r hts .vn 300 mg sau 75 mg/ngy. Ccgnghin cu gn ri m y cho thy phi hp gia. All oo.co v Ticlopidin Aspirin oev ng hoc Clopidogrel lm gim @yah k t l t vong. inl 20 F 8. 0 f. Thuc chng ng: Heparin tim thng TM liu 00 ity2 2 65-70 v/kg tsauotoc duy tr liu 15-18 v/kg/gi. gh P Heparin ri n khng lm gim t l t vong do py t Co NMCT nhng rt quan trng nu bnh nhn c cho thuc tiu huyt khi hoc can thip ng mch vnh cp. Dng Heparin vi thuc tiu huyt khi cn cho ngay 5000 v tim TM sau truyn tnh mch liu khong 1000 v/gi (tr trng hp cho Streptokinase th khng dng Heparin phi hp). Khi dng Heparin cn iu chnh liu theo thi gian APTT sao cho thi gian ny gp 1,5 thi gian chng (50-75 giy). g. Thuc chn bta giao cm: lm gim t l t vong v gim din c tim b nhi mu hoi t. Thuc hay dng l Metoprolol tim TM 5 mg sau nhc li mi 5 pht cho n tng liu l 15 mg, trong khi bt u cho ung 25-50 mg. Cc thuc khc c th dng l Atenolol, Esmolol. 43 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Khng dng cc thuc ny khi bnh nhn c du hiu suy tim nng, nhp tim chm < 60, huyt p tm thu < 90 mmHg, bloc nh tht cao, bnh phi tc nghn, bnh mch ngoi vi nng. B. iu tr ti ti mu Mc tiu quan trng nht trong iu tr NMCT cp l lm ti ti mu (ti lu thng MV b tc) cng sm cng tt. Ba bin php iu tr ti ti mu hin nay l: dng thuc tiu huyt khi, can thip (nong, t stent) ng mch vnh cp, m bc cu ni ch-vnh cp. Vic iu tr sm ti ti mu lm gim mc hoi t c tim, gim t l t vong v bo tn chc nng tht tri. 1. La chn phng php iu tr ti ti mu: Vic ved la chn phng php iu tr ti ti mu engay cho sr re bnh nhn NMCT cp ph thuc votsnhiu yu t gh m.vn c th, ri o nh thi gian n vin, tnh trngl bnh nhn Al hoo c .aca. c s y t. iu kin trang thit b v trnh oev inl 20@y F 2. Thi im iu tr ti .ti0mu: Cc nghin cu 8 00lity2 cng ln nu tin hnh chng minh c 2 oci ch t l gh Pot sm. Nu thi gian c ti c ti ti i mu cng r py ti mu otrong vng 1 gi u (k t khi au) th li C ch l ln nht. Hin nay, khi can thip MV th u c p dng nhiu trung tm, th thi gian c c hiu qu tt nht l trc 120 pht. Ni chung l trong vng 12 gi u th vn cn ch nh iu tr ti ti mu. Nu sau 12 gi, m vn cn tn ti cc triu chng th vn c th c li ch khi iu tr ti ti mu (khng phi l thuc tiu huyt khi). 3. iu tr ti ti mu mch vnh bng cc thuc tiu huyt khi: a. L phng php n gin v nn c la chn hng u. Cc th nghim ln chng minh cc thuc ny lm gim ng k t l t vong do NMCT cp, gii quyt c 60 - 90 % cc trng 44 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

b. Ch nh thuc tiu huyt khi cng sm cng tt v tt nht trong vng 6 gi u, nu bnh nhn n mun hn v trong vng 12 gi m vn cn tn ti du hiu ca hoi t c tim lan rng th vn c th dng thuc tiu huyt khi . c. Cc thuc ny c mt s chng ch nh tng i v tuyt i (Bng 3-3). Bng 3-3. Chng ch nh ca thuc tiu huyt khi. Chng ch nh tuyt i ang c bnh hoc th thut gy chy mu nng. Thiu ht cc yu t ng mu (ri lon). Mi b cc chn thng nng. ved ser re Mi phu thut (<10 ngy). ts gh m.vn Cc th thut xm ln (< 10 ngy). ll ri o .c Phu thut thn kinh trong vngev. thng. 2 A oo o yah Chy mu ng tiu ho trong210 ngy. inl @ . F 20 0 08 TBMN trong vng 1 nm. ity 20 oc mch no. t Tin s u no, phnh Pot igh yr tim cp. Vim mngongoi p C Nghi ng tch thnh ng mch ch. Lot ng tiu ho ang tin trin. Bnh mng phi cp tnh. ang c thai. Chng ch nh tng i: Huyt p ti a > 180 mmHg. Huyt p ti thiu > 110 mmHg. Vim ni tm mc nhim khun. Xut huyt vng mc do bnh l i tho ng. TBMN > 12 thng. C hi sinh tim phi trong vng 10 pht. ang dng chng ng khng Vitamin K lu di. Suy thn hoc gan nng. Rong kinh rong huyt nng. 45 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Cc loi thuc tiu huyt khi: a. Vic la chn cc thuc tiu huyt khi phi cn nhc da vo hon cnh thc t v gi thnh. Trong cc thuc trn, rt-PA c cc tc gi nc ngoi a dng nhng gi thnh kh cao. Streptokinase l thuc cng c dng rng ri, gi thnh r hn v tng i t tai bin. Bng 3-4. Cc loi thuc tiu huyt khi v liu dng. Cc thuc c hiu vi fibrin Alteplase (rt-PA): Tim thng TM 15 mg sau truyn TM 0,75 mg/kg (cho ti 50 mg) trong vng 30 pht, tip theo 0,5 mg/kg (cho ti 35 mg) truyn TM trong 60 pht tip. Liu ti a 100 mg trong 90 pht. Reteplase (r-PA): tim thng TM 10 n v trong 2 ved ser r pht, sau 30 pht li tim nh vy (10 ne v). ts gh m.vn Cc thuc khng c hiu vi fibrin l ri o l c . A oo Streptokinase (SK): Truyn TMe1,5 triu. n v trong o v yah vng 60 pht. inl @ . F 2020 Anistreplase (APSAC):08 ty thng TM 30 n v 20 tim i trong vng 2 pht. t Potoc h g ri Urokinase (UK): truyn TM 3 triu n v trong vng py Co 60 pht. b. Khi dng cc thuc tiu huyt khi bt buc phi phi hp vi Heparin v cc nghin cu chng minh l lm gim nguy c b tc li mch sau dng thuc tiu huyt khi. Heparin c dng trc v sau khi dng thuc tiu huyt khi 4 gi th truyn tip Heparin vi liu 1000 v/gi trong vng 48 - 72 gi tip. Ring i vi Streptokinase th khng cn dng Heparin phi hp v thuc ny tc ng khng c hiu vi h fibrin nn c th gy chy mu nhiu nu phi hp Heparin. c. Bin chng ca cc thuc tiu huyt khi: quan trng nht l chy mu. Chy mu ni s l bin chng nguy him nht (gp khong 0,5% i 46 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

4.

vi Streptokinase v 0,7% i vi tPA) , ngoi ra c th gy chy mu nhiu bt k ni no. Cn theo di thi gian aPTT. Nu b mt mu nhiu phi truyn mu, huyt tng ti. 5. Can thip ng mch vnh trong giai on cp cu (nong, t Stent): Mc d thuc tiu huyt khi l tin b ng k, nhng do nhiu chng ch nh v s bnh nhn n vin kh mun nn t l bnh nhn c dng thuc tiu huyt khi khng cao. Hin nay c nhiu nghin cu chng minh tnh u vit ca phng php can thip ng mch vnh trong giai on cp. Tuy nhin, n tu thuc nhiu vo trang thit b v kinh nghim ca thy thuc can thip. d a. Ch nh: Can thip MV cp ch nn chenh erv sca thuc nhng bnh nhn c chng ch nhe r ts vn gh mhuyt ng tiu huyt khi hoc c tnh ri trng . ll c ori lon nhp khng n nh (sc tim) vhoc oo.c . A ah loe @s trung tm c kinh tim. Hin nay, i vinmt y i . F 20 nghim v c trang thit b tt, ngi ta thng 08 ty20 20 i c xu hng canocthip MV th u (primary ht Pot rig intervention) (tc l can thip ngay lp tc khi py Co bnh nhn n vin v cha dng thuc tiu si huyt). Cc khuyn co gn y c xu hng ng h cho vic can thip ny. b. Can thip khi dng thuc tiu huyt khi tht bi: tc l sau khi dng thuc tiu huyt khi m bnh nhn vn cn au ngc, lm sng khng n, ST vn chnh ln trn T th c ch nh can thip MV. c. Khi can thip ng mch vnh cp cn dng phi hp vi cc thuc: Aspirin 325 mg/ngy ko di mi, phi hp Ticlopidin (Ticlid) 250 mg x 2 ln ngy trong na thng hoc Clopidogrel (Plavix) 75 mg/ngy. Vai tr ca Clopidogrel ngy cng 47 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

c nhn mnh v tnh hiu qu v kh an ton ca n. Nhng nghin cu gn y cho thy li ch ca Plavix cng c khng nh khi dng ko di n 9 thng. Cc thuc c ch th th GP IIb/IIIa (ReoPro, Aggrastat...) l nhng thuc chng ngng kt tiu cu trit . Khi dng cng vi can thip MV cp lm gim ng k t l tai bin do can thip v t l tc mch sau can thip. Tuy nhin cc thuc ny kh t tin. Heparin l cn thit trong khi can thip. Nu can thip kt qu thnh cng c th xt dng Heparin sau can thip. 6. M lm cu ni ch - vnh cp cu: ved serngc ti Ch c ch nh khi bnh nhnsau re t gh m.vn pht sau dng tiu huyt khi hoc ing mch vnh lr o khng thch hp cho can thip l (tnc thng nhiu . A ahoo. oev thn, tn thng thn chung, 0@y thng phc tp...), inl 2 tn F hoc can thip tht008. yhoc bnh nhn c nhng bi, 20 t 2 bin chng c hc.v.v...i t oc gh Pot ri py Co

Trc khi nong Sau nong v t Stent Hnh 3-3. Nong v t Stent ng mch lin tht trc. C. iu tr tip theo 1. Cc bin php chung: a. Ch vn ng: Vi nhng bnh nhn trong giai on cp hoc cha n nh cn bt ng ti 48 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

ging. Tuy nhin nu nhng bnh nhn c iu tr ti ti mu tt m khng cn au ngc th sau 12 gi c th cho c ng nh ti ging v ngi dy nh nhng ti ging. Sau 24 gi c th cho vn ng nh nhng v sau 48 gi c th cho i b nh ti phng ri tng dn mc vn ng tr v bnh thng. b. Ch dinh dng: Trong giai on cp (au nhiu) th khng nn cho n m nn dinh dng bng ng truyn tnh mch. Khi bnh nhn cn ch ch n nng lng (1200 - 1800 calorie/ngy) t cholesterol v mui. Bnh nhn NMCT cn trnh to bn v nn cho thm cc nhun trng. ed erv sngi nh c. An thn: nn trnh thm hi nhiu ca e sr trong giai on cp. Nu bnh right mlonlng qu nhn .v c th cho thm mt cht anAll oo.co thn. v. h loe @ya 2. Cc thuc: in . F 2020 08ngng kt tiu cu (Aspirin, a. Cc thuc chng ity 0 2 c ht Poto Ticlopidin, Clopidogrel): c bit quan trng. rig py Liu Aspirin t 75-325 mg/ngy nhng nn Co dng > 160 mg/ngy. b. Cc thuc chng ng: Heparin cn thit khi c dng thuc tiu huyt khi v khi can thip MV. Heparin khng nn dng ko di > 5 ngy. Cc thuc khng vitamin K ng ung ch dng khi c km theo rung nh hoc c phnh vch tht gy cc mu ng. c. Cc Nitrates: mc d khng lm gim t l t vong nhng chng ci thin tnh trng thiu mu cc b, ci thin triu chng v suy tim nu c. d. Cc thuc chn beta giao cm: nn tip tc ko di (nu khng c cc chng ch nh). e. Cc thuc c ch men chuyn (CMC): Nn cho sm v bt u liu nh (trong vng 24 gi 49 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

u). Ch huyt p ca bnh nhn. Thuc CMC lm gim t l t vong, bo tn chc nng tht tri. Nn dng bt u bng thuc c tc dng ngn nh Captopril 6,25 mg trong 24 gi u sau nh gi tnh trng v iu chnh liu hoc thay cc thuc CMC khc c thi gian tc dng ko di hn. f. iu tr tch cc cc yu t nguy c trong ch iu tr tt i tho ng, ri lon m mu (nu c) km theo. D. Phc hi chc nng sau NMCT 1. Giai on ti bnh vin: i vi nhng bnh nhn n nh cn sm ed erv phc hi chc nng bng cch cho bnhesnhn sm r vn ng nh. Ngy th ba c th chots .vn nhn i bnh gh m l ri ra li nh nhng trong phng. Trc lkhio.co vin cn gio . A aho dc bnh nhn v ch loev luyn, loi b yu t tp y Fin020@v ch thuc men nguy c, iu chnh ch n . 08 2 2 ocity hng ngy cho bnh0nhn. ht ot 2. Giai on yrnh: P ig p Co Bnh nhn cn i b sm ti thiu mi ngy 23 ln, mi ln 20-30 pht v duy tr nhp tim khng tng qu 20 nhp so vi nhp tim lc ngh. khng nh bnh nhn c th tr v cuc sng sinh hot bnh thng, bnh nhn cn c lm nghim php gng sc nh gi. Vic gio dc bnh nhn vn c bit quan trng trong giai on ny v ch sinh hot v thuc men. Ti liu tham kho
1. 2. Falk E, Shah PK, Fuster V. Coronary plaque disruption. Circulation 1995;92:657-671. Flather M, Pipilis A, Collins R, et al. Randomized controlled trial of oral captopril, of oral isosorbide mononitrate and of intravenous magnesium sulphate started early in acute myocardial infarction: safety and haemodynamic effects. ISIS-4

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3. 4. 5. 6. 7.

8.

9.

10. 11.

12.

13. 14. 15. 16.

(Fourth International Study of Infarct Survival) Pilot Study Investigators. Eur Heart J 1994;15:605-619. GUSTO Investigators. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med 1993;329: 673682. Lauer MA, Lincoff AM. Acute myocardial infarction. In: Marso SP, Griffin BP, Topol EJ, eds. Manual of Cardiovascular Medicine. Philadelphia: LippincottRaven, 2000. Lee K, WoodliefL, Topol E, et al. Predictors of 30-day mortality in the era of reperfusion for acute myocardial infarction. Circulation 1995;91:1659-1668. Lincoff A, Topol E, CaliffR, et al. Significance of a coronary artery with thrombolysis in myocardial infarction grade 2 flow "patency". Am J Cardiol 1995;75: 871-876. Lincoff AM, Califf RM, Moliterno DM, et al. Complementary clinical benefits of coronary-artery stenting and blockade of platelet glycoprotein ub/Iha receptors. N Engl J Med 1999;341:319-327. Mark D, Hlatky M, CaliffR, et al. Cost effectiveness of thrombolytic therapy with tissue plasminogen activator as ved compared with streptokinase for acute myocardial einfarction. N ser r Engl J Med 1995;332:1415-1424. htsal. get m.vnACC/AHA Ryan TJ, Anderson JL, Antman EM, i r o guidelines for the management . of ll patients with acute A hoo.c myocardial infarction: a report loev thea American College of of y Cardiology/American Heart Association Task Force on Practice Fin020@ Guidelines (Committee on .Management of Acute Myocardial 08 2 Infarction). J Am CoIl 20 ocity Cardiol 1996;25:1328-1428. Sgarbossa EB, ight PoG. Electrocardiography. In: Topol EJ, Wagner t ed. Textbook r of cardiovascular medicine. New York: y p Co Lippincott-Raven, 1998. The EPILOG Investigators. Platelet glycoprotein IIb/IIIa receptor blockade and low-dose heparin during coronary revascularization during percutaneous coronary revascularization. N Engl J Med 1997;336:1689-1696. The GUSTO IIb Angioplasty Sub study Investigators. A clinical trial comparing primary coronary angioplasty with tissue plasminogen activator for acute myocardial infarction. N Engl J Med 1997;336: 1621-1628. The GUSTO III Investigators. A comparison of reteplase with alteplase for acute myocardial infarction. N Engl J Med 1997;337:1115-1123. Topol EJ, Van de Werf FJ. Acute myocardial infarction: early diagnosis and management. In: Topol EJ, ed. Textbook of Cardiovascular Medicine. New York: LippincottRaven, 1998. White RD, Van de Werf FJ. Thrombolysis for acute myocardial infarction. Circulation 1998;97:1632-1646. Woods K', Fletcher S. Long-term outcome after intravenous magnesium sulphate in suspected acute myocardial infarction: the second Leicester Intravenous Magnesium Intervention Trial (LIMIT-2). Lancet 1994;343:516-S19.

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Bin chng Nhi mu c tim

Bnh nhn NMCT thng cht ch yu l do cc bin chng cp v nu qua khi giai on cp cng thng li mt s bin chng i khi rt nng nu khng c iu tr mt cch tho ng. Cc bin chng ca NMCT rt phong ph v c th chia lm cc nhm: bin chng c hc, bin chng ri lon nhp, bin chng thiu mu c tim, tc mch I. Bin chng c hc Cc bin chng c hc c th e do tnh mng bnh nhn l: thng lin tht, h van hai l cp do t dy chng, v thnh tim t do, phnh thnh tim... ved ser e sr A. Thng lin tht (TLT) do thng vch tlinntht gh m.v i ll r co 1. Triu chng lm sng: . A ahoo. v a. TLT xy ra khongnloe @y 2% s bnh nhn i 0,5 0 F NMCT cp. T l08. 202 nhau gia cc nhm gp ngang 0 ity NMCT pha t 2 otov sau di. TLT thng xy ra trc c igh P rbnh nhn b NMCT din rng, tc mt nhng py Co mch m tun hon bng h km. TLT c th xy ra sm ngay sau 24 gi ca NMCT nhng thng xy ra sau khong 3-7 ngy. b. Bnh nhn c bin chng TLT thng c du hiu lm sng nng n hn. Cc bnh cnh lm sng nh au ngc tng, ph phi cp, tt huyt p, sc tim c th xy ra t ngt trong qua trnh ang din bin bnh thng ca bnh. c. Khi nghe tim thy mt ting thi tm thu mi xut hin vng trc tim, ting thi r nht pha thp bn tri xng c. Khi bnh nhn c l thng ln vch lin tht v tnh trng suy tim nng th c th khng nghe thy ting thi na. d. Cn phn bit vi h van hai l hoc h van ba l. 53 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

2. Gii phu bnh: L TLT l hu qu ca l thng vng c tim b hoi t do NMCT v xy ra ch ranh gii gia vng khng hoi t v vng b nhi mu. L ny thng vng gn mm tim i vi nhng bnh nhn NMCT vng trc v vng vch sau vi NMCT pha sau. 3. Cc xt nghim chn on: a. in tm : c th thy bt thng v dn truyn nt nh tht hoc ng dn truyn t nh xung tht. b. Siu m tim: l thm d c gi tr trong chn on bnh c bit l siu m mu. i vi thng vng gn mm, mt ct 4 bung t mm l mt d ct tt nht quan st. i vi thng serve vch vng e sr sau, mt ct trc dc c li gc i tchtnhoc mt gh m.v i ct trc dc di mi c cho rphp nh gi r ll co . A ahoo. phi dng n nht. Trong mt s trngvhp cn loe y Fin0 qun siu m qua ung .thc 20@ nh gi r hn 8 00 v bn cht thng ity2 Siu m tim c th gip 2 toc tn. t nh giric Po gh kch thc l thng, mc ln y Siu m tim cng c th gip nh gi ca Cop shunt. chc nng tht tri v tht phi, t gp phn tin lng bnh. c. Thng tim phi: khi c ch nh chp MV thng nn thng tim phi nh gi c lung thng v lu lng shunt cng nh p lc ng mch phi, cung lng tim... gip c thi iu tr v tin lng bnh tt hn. 4. iu tr: a. Thi : T l t vong khi c bin chng TLT c iu tr ni khoa l khong 24% sau 24 gi, 46% sau 1 tun v 67-82% sau 2 thng. Do vy, cn nhanh chng xc nh v c k hoch m sm ng l thng ngay khi tnh trng bnh nhn khng c n nh. 54 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

b. iu tr ni khoa: iu tr ni khoa l bin php c bn v l cu ni cho iu tr ngoi khoa. Cc thuc gin mch lm gim lu lng shunt v lm tng cung lng h thng do lm gim sc cn h thng; tuy nhin, nu lm gim sc cn ng mch phi qu li dn n lm tng lu lng shunt. Thuc thng dng l Nitroprusside truyn TM, bt u bng liu 0,5-3 mcg/kg/ph v theo di huyt p trung bnh mc 70-80mmHg. c. t bng bm ngc dng trong ng mch ch (IABP): l bin php nn c thc hin cng sm cng tt trc khi gi i m. IABP lm gim sc cn h thng, gim lu lng shunt, tng ti mu MV v duy tr uc huyt p ved ng mch. ser re ts d. Phu thut: L bin php la rchnm.vn d tnh gh mc l i trng huyt ng khng c lnoo.co Phu thut . A ah nh. ev bnh nhn c bin ichng y nlo 0@ TLT lm gim ng F k t l t vong so8. 202 tr bo tn. Tuy nhin, vi iu 00 ity 2 t l t vong vntocn cao c bit nhm bnh t o c gh tim, suy a ph tng, NMCT vng i nhn c rsc P py Co gy l thng vng vch sau do k thut sau di kh khn hn nhiu so vi vng mm... B. H van hai l (HoHL) cp HoHL cp do t dy chng ct c l mt bin chng nng n v bo hiu tin lng rt xu trong NMCT. t dy chng ct c thng xy ra trong vng 2-7 ngy sau NMCT cp v chim t l khong 1% trong s NMCT cp. 1. Triu chng lm sng: a. HoHL cp do t dy chng ct c thng xy ra bnh nhn b NMCT cp thnh sau. b. Nu tnh trng t hon ton mt ct c gy HoHL cp s dn n tnh trng sc tim nhanh chng hoc t t. Nhng trng hp nh hn c 55 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

c. Nghe tim: c th thy xut hin mt ting thi tm thu mi vng mm lan ln nch hoc ln vng y tim. Trong trng hp NMCT vng thnh sau gy t dy chng sau c th nghe thy ting thi tm thu pha cnh xng c d nhm ln vi thng lin tht hoc hp van ng mch ch. Cng ting thi khng c ngha d on mc nng nh ca HoHL. i khi ting thi rt nh hoc khng thy do bnh nhn b suy tim qu mc hoc gim cung lng tim qu. d. Ch : t dy chng thng xy ra NMCT vng di. NMCT vng ny (tc nhnh lin tht d rve sev gy sa sau PDA) gy hoi t ct c pha sau re ts van hai l v HoHL. gh m.vn i ll r co 2. Cc xt nghim chn on: ev. A hoo. lo ya a. in tm : cho thy hnh nh ca NMCT cp Fin020@ . 08 2 thng l pha sau di. 20 ocity t t b. Xquang rtim phi c th cho thy hnh nh ca igh Po ph Copy tu mc . Mt s bnh nhn c hnh phi nh ph phi nhiu thu trn phi v dng HoHL pht trc tip nhiu v pha tnh mch phi phi pha trn. c. Siu m Doppler tim: l phng php rt c gi tr trong chn on cng nh tin lng bnh. Hnh nh sa l van hai l. Hnh nh dng mu ca HoHL v cho php nh gi mc HoHL. Cho php chn on phn bit vi ting thi do bin chng thng lin tht hoc cc bin chng khc. Gip nh gi chc nng tim v p lc ng mch phi. 56 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

d. Thm d huyt ng: Thng thng i vi nhng bnh nhn ny cn theo di huyt ng cht ch bng mt ng thng Swan-Ganz theo di p lc ng mch phi, cung lng tim v p lc mao mch phi bt (PCW). Trn ng cong p lc ca PCW c th thy hnh nh sng V cao mt cch bt ng. 3. iu tr: a. Cc u tin trong iu tr: Cn thit phi pht hin c nhanh chng bin chng HoHL cp kp thi i ph. Bnh nhn cn c iu tr ni khoa mt cch ht sc tch cc v cn nhc iu tr ngoi khoa sm nu c th. b. iu tr ni khoa: ved ser e Cc thuc gin mch ng vai trrquan trng. ts vn . gh Nitroprusside, Thuc c u tin dng ril com ll . thuc ny lm gim ev. A acn h thng mt sc hoo lo cch c ngha, Fin 20@y phn s h van hai lm gim . 0 l v c th 008 ity2 cung lng tim. Thuc 2 lm tng t otoc ny c dng bng ng truyn tnh mch gh ritc P liny vi liu khi u l 0,5-3 p Co mcg/kg/pht v iu chnh theo huyt p trung bnh trong khong 70-80 mmHg. Thuc gin mch khng nn dng cho bnh nhn b tt huyt p. Trong trng hp ny, gii php tt nht l nn t bng bm ngc dng trong ng mch ch (IABP). IABP lm gim hu gnh ca tht tri v tng lu lng n mch vnh. Sau khi t IABP c th cn nhc cho tip thuc gin mch. c. Bin php can thip ng mch vnh cp cu: Nong MV hoc t Stent cp cu lm ci thin c tnh trng huyt ng v mc HoHL nhng bnh nhn HoHL mi do thiu mu cc b. Tuy nhin, khi b t hn ct c th can 57 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

thip MV n thun cng khng ci thin c tnh trng bnh. d. iu tr ngoi khoa: L bin php cn c tin hnh sm khi c t hon ton ct c. T l t vong khi m kh cao (20-25% cc nc pht trin) tuy nhin vn l bin php hiu qu nht v cn c ch nh sm. Nn tin hnh can thip MV trc khi tin hnh phu thut can thip van hai l. C th tin hnh sa van hai l nhng bnh nhn HoHL mc va m khng cn phi thay van hai l. C. V thnh t do ca tim ved 1. Triu chng lm sng: ser re ts a. V thnh t do tim c th gp hkhong 3% s g m.vn bnh nhn NMCT cp v All rmto trong nhng l i o c . at . ngt. V thnh ev nguyn nhn dn n tovong ho inl 20@y F 0 tim cng ch xy ra . nhng bnh nhn c NMCT 8 00 ity2 t nguy c d xy ra v xuyn thnh. 2 oc yu Nhng t thnh timigh tuit gi, n gii, tng huyt p qu l: Po yr nhiu, p NMCT ln u v h thng mch vnh Co khng phong ph. b. Triu chng ca th cp: c th thy biu hin ca phn ly in c trn T v t t. Mt s bnh nhn ku au ngc d di hn, ho v nc. c. Th bn cp: gp s t bnh nhn m bnh cnh d nhm vi vim mng ngoi tim cp, nn, tt huyt p. d. Khm thy cc du hiu ca p tim cp t ngt: gin tnh mch cnh, mch o, ting tim m.. 2. Cc xt nghim chn on: a. in tm : c hnh nh nhp b ni hoc t tht, in th ngoi vi thp, sng T cao nhn

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cc chuyn o trc tim. Mt s bnh nhn biu hin nhp chm trc khi v thnh t do. b. Siu m tim: cho php nhn thy hnh nh p tim cp v c th cho php nhn thy ch v. 3. iu tr: a. Bin php iu tr ti ti mu lm gim bt t l b v thnh tim. b. Mc ch l phi nhanh chng nhn bit c tnh trng v tim v tin hnh m cp cu. c. iu tr ni khoa ch ng vai tr tm thi khi hi sc v trong lc a n phng m. Dng thuc vn mch v truyn dch duy tr huyt p. d. Nhanh chng chc dch mng tim nu xc nh l ed c p tim cp trong lc thu xp cuc m.erv s re ts e. Phu thut ti cp cu l bin php duy nht c gh m.vn l ri c th cu sng c bnh nhn ltrongotrng hp b . A ahoo. v thnh t do tim. nloev @y Fi 20 D. Gi phnh thnh tim 008. y20 2 it t oc 1. Triu chng ilm sng: gh Pot yr a. Gi Cop phnh thnh tht thng c tin trin thm lng v thng c pht hin tnh c khi lm cc thm d chn on. Tuy nhin, mt s bnh nhn c biu hin ca cc cn tim nhanh ti pht v suy tim. b. Thm khm c th thy ting thi tm thu hoc tm trng hoc ting thi theo t th do dng mu xoy qua l thng vo ch phnh. c. Bn cht bnh l ca gi phnh thnh tht l do v mt ch nh ca thnh t do tht v c mng ngoi tim cng huyt khi thnh bao bc li. Gia ti phnh v tht vn cn lin h vi nhau nh l thng. 2. Cc xt nghim chn on: 59 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

a. Xquang tim phi: thng c th thy hnh nh bng tim bt thng vi mt ch li tng ng vi ti phnh. b. in tm : c th cho thy hnh nh ST chnh vm c nh ging trng hp b phnh tht. c. Siu m tim: c th gip chn on xc nh bnh. Chp cng hng t (MRI) cng l mt bin php kh chnh xc chn on bnh. 3. iu tr: Phu thut l ch nh bt buc bt k kch c hoc triu chng ca ti gi phnh ny nh th no ngn nga vic v th pht ca ti gi phnh ny. E. Phnh vch tht 1. Triu chng lm sng: ved ser ra th a. Th cp: Khi mt vng c tim rngsbe gin r t v nhanh chng dn n suy timghhoc nsc tim. ri m. llv o.coc nh hng Nhng bnh nhn b NMCTA ho tr ev. n vng mm thngnlo c nguy c cao nht. l 0@ya i .F 2 b. Th mn tnh: L8nhng th phnh vch tht tin 0 ty20 20 i trin t t ght hno6 tun. Chng xy ra 10-30% sau Pot c ri cc trng hp NMCT. Nhng bnh nhn ny py Co c cc triu chng ca suy tim, ri lon thng nhp tht, tc mch i tun hon.. c. Khm tim: i khi c th pht hin c vng b phnh ca tht thng qua s mm tim hoc g tim. Cn phn ln cc trng hp l c th thy ting nga phi nhng bnh nhn suy gim nhiu chc nng tht tri. 2. Sinh l bnh: Phnh vch tht l mt vng c tht b gin ra do vng b hoi t do ng mch vnh nui dng tng ng b tc. Nu MV b tc c gii phng cng sm th nguy c b phnh vch tht cng thp. Qu trnh phnh vch tht l phi hp nhiu c ch 60 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

trong qu trnh ti cu trc (remodeling) c tim l rt quan trng. 3. Cc thm d cn lm sng: a. in tm : Nu phnh vch tht xy ra cp tnh th sng ST chnh ln c nh mc d MV c c ti ti mu. Nu phnh vch tht xy ra t t th ST chnh ln tn ti khong hn 6 tun. b. Xquang tim phi: thy hnh nh mt vng bng tim phnh ra tng ng vi vng c tht b phnh. c. Siu m tim: l mt thm d c gi tr gip chn on xc nh bnh, nh khu, nh ga cc bin ved chng, chc nng tht, huyt khi. cerbit siu s m gip chn on vi ga phnh re n (trong hts .tht v rig cocn gi phnh phnh vch tht tht th c vo lrng m l o. th c vo hp). v. A ho loe @ya Fincng d. Chp cng hng .t: 020 gip xc nh phnh 08 ty2 0 vch tht. 2 ci ht Poto 4. iu tr: yrig p C tr a. iu o ni khoa: Phnh cp: Nn nhanh chng iu tr tnh trng suy tim bng cc thuc gin mch truyn tnh mch v t bng bm ngc dng trong MC. Cho thuc c ch men chuyn sm l mt bin php quan trng ngn nga c qu trnh ti cu trc v lan rng ca vng nhi mu. V qu trnh lan rng ca nhi mu xy ra rt sm nn cn cho thuc c ch men chuyn sm trong vng 24 gi ca NMCT cp (nu huyt p khng qu thp). Phnh mn tnh: Cc thuc dng iu tr suy tim do phnh mn tnh vch tht l: c ch men chuyn, li tiu hoc c th cho Digoxin. 61 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Chng ng: Cc thuc khng vitamin K ng ung c ch nh nhng bnh nhn c phnh vch tht m c huyt khi bm thnh. Trc tin nn cho Heparin trong vng vi ngy v cng bt u lun bng cc thuc chng ng dng ung loi khng vitamin K. Khi iu tr, nn chnh liu sao cho INR t khong 2-3 trong vng 3-6 thng. i vi nhng phnh vch tht d ln m khng thy hnh nh huyt khi bm thnh th ngi ta cng cha r li ch v ch nh ca khng vitamin K. i vi nhng bnh nhn c phnh vch tht m chc nng tht tri rt km th nn cho thuc chng ng ng ungdtrong e erv t nht 3 thng sau NMCT cp. res b. iu tr can thip: hts n rig com.v l Nhng bnh nhn b nhil mu th can thip . A ahoo. oev ygip ngn chn qu MV cng sm cng tt l Fin 20@ trnh gin thnh. tht0v ti cu trc. Can thip 08 2 20 oci vn mun sau 12 tgity c th c ch nhng sau ht o 24 yrig th P th khng ci thin c tnh gi c p Co phnh vch tht. hnh i vi nhng bnh nhn c phnh vch tht m c ri lon nhp tht nguy him th c th cn nhc vic cy my ph rung t ng trong bung tim (ICD). c. Ngoi khoa: i vi nhng bnh nhn phnh vch tht c suy tim dai dng hoc ri lon nhp tim nng n th c th cn nhc iu tr ngoi khoa. iu tr ngoi khoa c th ct ng on phnh hoc lm mt ming v duy tr c th tch tht tri. Cng nn cn nhc vic iu tr ti ti mu ng mch vnh trc .

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II. Cc ri lon nhp Trong NMCT, bin chng ri lon nhp tim l rt thng gp cc mc khc nhau (90% cc trng hp). C th gp tt c cc loi ri lon nhp khc nhau (xin tham kho chi tit phn cc ri lon nhp tim). A. Ri lon nhp tht 1. Ngoi tm thu tht: hay gp, cn theo di tt, iu chnh cc ri lon in gii. Thuc chn bta giao cm c th c tc dng tt. Mt s tc gi a dng Amiodarone. 2. Nhp t tht gia tc: hay gp bnh nhn c hi chng ti ti mu, phng cn nhanh tht hoc rung tht. ved ser cp cu 3. Nhp nhanh tht v rung tht: l tnhts re trng n gh m.vtun hon. v cn x tr theo ng nh phc ri o l ngng Al o.c B. Ri lon nhp trn tht: c thv.gp ho ri lon nh: oe ya cc inl @ 1. Nhp nhanh xoang. 08. F 2020 20 ity 2. Cn nhp nhanh kchcpht trn tht. ht Poto rig p 3. Rung nh. y Co 4. Nhp b ni. C. Cc ri lon nhp chm 1. Nhp chm xoang: hay gp bnh nhn NMCT sau di, cn iu tr khi c nh hng n huyt ng. 2. Bloc nh tht t cp I n cp III: Nu bloc cao nh hng n huyt ng th cn cp cu theo phc v ch t my to nhp tm thi sm. Ch nh t my to nhp tm thi: a. V tm thu; b. Bloc nh tht cp III; c. Nhp chm xoang hoc bloc nh tht thp nhng c nh hng n huyt ng. 63 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

III. Suy chc nng tht tri v sc tim Ri lon chc nng tht tri l din bin kh trnh khi sau NMCT, ch tu theo mc nh hay nng. Mc suy chc nng tht tri lin quan n vng tn thng nhiu hay t. Bnh nhn NMCT vi vng tn thng nh c th gy ri lon vn ng mt vng c tim nhng khng gy gim chc nng ng k ton b tht tri. Tuy nhin, khi nhi mu din rng, c bit l vng trc hoc n gii, ngi cao tui, tiu ng l nhng yu t d bo nguy c cao ca suy tim tri nng v sc tim. A. Phn loi Hin nay phn loi ca Killip v Kimban (bng 4-1) l phn loi c s dng rng ri nht trn lm sng phn loi mc nng nh v c gi tr tin lng bnh ved Bng 4-1. Mi lin quan gia Killip v t evong trong ser r ts 30 ngy. gh m.vn i o ll r T c . A ahoo. l t vong v Killip c im lm sng loe% y trong 30 ngy in @ (%) . F 20 08 ty20 85 I Khng c triu 0chng 5,1 2 i ca suy tim ht Potoc tri ig II C ranpyr < 1/2 phi, 13 m 13,6 o tnh C mch c ni, c th c ting T3 nga phi III Ph phi cp 1 32,2 IV Sc tim 1 57,8 Mt phn loi khc ca Forrester da trn cc thng s huyt ng cng c gi tr tin lng bnh rt tt (bng 4-2). Bng 4-2. Phn loi ca Forrester trong NMCT cp. I II III IV 64 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn p lc mao mch phi bt (mmHg) < 18 > 18 < 18 > 18 Ch s tim l/pht/m2 > 2,2 > 2,2 < 2,2 < 2,2 T l t vong trong 30 ngy (%) 3 9 23 51

B. Triu chng lm sng 1. Triu chng c nng: a. Bnh nhn c th c cc du hiu ca suy h hp, kh th, cm gic lnh... bn cnh cc du hiu kinh in ca NMCT. b. Bnh nhn sc tim c cc du hiu trm trng hn nh kh th nhiu, tiu t, rt run, ri lon tm thn 2. Triu chng thc th: a. H huyt p do gim cung lng tim, gim th tch tun hon. b. tr tun hon phi, vi ran phi. c. Gim ti mu ngoi vi: da lnh, u chi ved v lnh, ser m hi. re ts gh m.vn phi.. d. Nghe tim: thy nhp tim nhanh, ri o nga ting ll o c . A atim. bnh nhn 3. Nguyn nhn d dn n ev sc ho lo @y in NMCT cp: . F 20 08 ty20 0 a. NMCT din rng. ci 2 to ht phi din rng. Po b. Nhi muig yr tht p Co c. V thnh tht. d. H van hai l cp. e. p tim cp c km hoc khng km v thnh tim. C. Cc xt nghim thm d 1. Xt nghim mu: Tng acid lactic trong mu, tng creatinin v thiu xy mu ng mch. 2. Xquang tim phi: thy hnh nh huyt phi cc mc . 3. in tm (T): thng ch ra du hiu ca NMCT lan rng. C th thy hnh nh ST chnh xung (do thiu mu c tim) lan rng nhiu chuyn o. Nu T khng bin ng c hiu khi sc tim th phi ngh ti nguyn nhn khc gy sc tim nh 65 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

tch thnh MC hoc cc bin chng c hc trm trng ca NMCT cp. 4. Siu m tim: gip nh gi mc lan rng ca vng nhi mu, chc nng tht v tm hiu thm cc bin chng c th gy ra sc tim. 5. Cc thm d chy mu: gip theo di v huyt ng chnh xc. Thng th nn t mt ng thng Swan Ganz theo di p lc ng mch phi v p lc mao mch phi bt cng nh cung lng tim (xem thm phn sc tim). D. iu tr 1. Cc u tin trong iu tr: Nu bnh nhn c sc tim nn t bng ngc dng trong MC (IABP) ved ser trc nu c th, sau tm cch gii quyt nguyn e sr nhn v cc bin php iu tr ni khoa tthch hp. gh m.vn i ll r co 2. Cc thuc: . A ahoo. oev inl 20@y tr cc k quan a. Cc thuc gin mch ng vai F 8. 0 trng trong iu 0tr ty2 nhn suy tim tri sau 0 i bnh 2 c NMCT. Cnt theo odi huyt p cht ch khi cho gh Pot ri py cc thuc gin mch. Co b. Nitroglycerin dng truyn tnh mch l thuc nn c la chn hng u. Liu dng bt u t 10 20 mcg/pht v c th tng mi 10 mcg/pht sau vi pht tu theo p ng v huyt p. Nn iu chnh sao cho huyt p trung bnh ng mch khong 70 mmHg. c. Nitropruside c th thm vo c tc dng lm gim hu gnh v nu dng Nitroglycerin mt mnh ch yu lm gim tin gnh do gin h tnh mch. Nitroprusside c dng bt u bng liu 0,3-5 mcg/kg/pht v chnh liu theo huyt p ng mch. d. Thuc c ch men chuyn (CMC) ci thin c chc nng tht tri bnh nhn sau NMCT. 66 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

CMC nn c cho sm trong NMCT nu huyt p khng thp qu. Ch tc dng gy tt p liu u ca CMC, do vy nn cho bnh nhn dng truyn TM vi liu bt u thp v khng dng khi c sc tim. e. Thuc li tiu c tc dng tt nhng bnh nhn c ph phi sau NMCT. Furosemide l thuc nn c la chn. f. Digitalis tr tim khng nn cho rng ri trong NMCT, nhng c tc dng tt bnh nhn suy tim tri nhiu km rung nh hoc cung nh hoc cc thuc khc iu tr suy tim km hiu qu. g. Cc thuc ging giao cm (Dopamine v Dobutamine) c ch nh cho nhng bnh nhn ved ser suy tim nng c tt p hoc sc tim. s re t gh .vn h. Thuc vn mch khc (Norepinephrine) c th l ri .com Al oo phi dng khi cn thit .duyhtr huyt p trong oev ya sc tim (xem bi scFtim).0@ inl . 202 8 3. iu tr can thip200 city ng mch vnh: o t t a. t ngay igh Pbm ngc dng ng mch ch bng o yr nu Copth bnh nhn sc tim. Bin php ny rt c hu ch gip lm gim hu gnh, tng cung lng tim, gim nhu cu tiu th xy c tim. b. Can thip ng mch vnh tc th gip ci thin c tin lng nhng bnh nhn c sc tim c bit ngi khng qu gi. 4. Phu thut: a. Phu thut lm cu ni ch-vnh trong sc tim bnh nhn NMCT c ch nh nhng bnh nhn b bnh nhiu MV, hoc tn thng thn chung MV tri m khng thch hp cho can thip MV. b. C khi phu thut c ch nh cy ghp nhng thit b h tr tht trong khi ch ghp tim. 67 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

IV. Nhi mu c tim tht phi Ri lon chc nng tht phi nh thng gp nhng bnh nhn b NMCT vng sau di, tuy nhin c khong 10% s bnh nhn ny c suy tht phi cp v iu tr cn ch mt s c im khc bit. A. Gii phu bnh Thnh tht phi bnh thng mng hn v t nhu cu tiu th xy hn bung tht tri, do vy thng thng th tht phi c th chu ng v hi phc sau khi c iu tr kp thi. Vic suy chc nng tht phi nng xy ra ph thuc vo mc tc nhnh ng mch vnh nui dng tht phi v mc tun hon bng h t bn tri sang khi nhnh nui tht phi b tc (nhnh ny thng thng bt ngun t ng ved mch vnh bn phi). ser re ts B. Triu chng lm sng gh m.vn i ll r co 1. Bnh nhn NMCT tht phievthngo. c triu chng . A aho n nhng ca tr tun hon ngoi ivilo 0@y khng kh th. .F 2 2 08 phi0nng c th c biu hin 2. Bnh nhn c suy 20 city tht t ot hlng otim nng nh rt run, chn tay ca gim cung P rig py lnh, riClon tm thn, huyt p tt v thiu niu. o 3. Thm khm thc th bnh nhn NMCT tht phi thng thy tnh mch c ni, gan to, huyt p thp nhng phi khng c ran. Du hiu Kussmaul (tnh mch c ni to hn trong thi k ht vo) l kh c hiu v bo hiu c suy tht phi nng. C. Cc xt nghim chn on 1. in tm : thng cho thy hnh nh NMCT vng sau di km theo ST chnh ln V1 v c bit l V3R v V4R. 2. Xquang tim phi: khng c du hiu ca tr tun hon phi. 3. Siu m tim: l mt thm d c gi tr trong NMCT tht phi. Trn siu m tim thng cho thy hnh nh 68 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

tht phi gin, suy chc nng tht phi, ri lon vn ng vng sau di, v c bit gip loi tr trn dch mng tim gy p tht phi (d nhm vi NMCT tht phi). 4. Cc thng s v huyt ng trn thm d chy mu cho thy tng p lc ca nh phi nhng khng tng p lc mao mch phi bt (PCWP). NMCT tht phi cng lm gim cung lng tim do gim lng mu v tht tri. Khi p lc nh phi trn 10 mmHg v t l p lc nh phi/PCWP trn 0,8 l mt du hiu huyt ng quan trng gi NMCT tht phi. D. iu tr 1. iu tr ni khoa: ved a. Truyn dch l mt bin php quan etrng hng ser sr u v trong NMCT tht phi chts .vn g m gim cung ri lng tim do gim th tch. All yotht tri. Mt oo.c ev truyn ti 1 lt dch s bnh nhn nng cnlocho yah in 20@ F 0 trong gi u. Khi .truyn dch cn phi theo di 8 00 ity2huyt ng v nu truyn 2 oc cht ch cct thng s gh Pot khi li dn n suy gim chc qu nhiui dch i r py Co tri (hin tng ny l do vch lin tht nng tht b p qu v pha tht tri gy gim cung lng tim). Mc tiu iu tr l a p lc tnh mch trung tm n khong 15 mmHg. b. Thuc tng co bp c tim: Khi truyn dch vn khng lm tng cung lng tim th c ch nh dng cc thuc tng co bp cm tim. Dobutamine l thuc c la chn hng u lm tng cung lng tim v phn s tng mu ca tht phi. c. Mt lu rt quan trng l khng c dng cc thuc gin mch (Nitrates, c ch men chuyn...) v li tiu khi c suy tht phi v cc thuc ny cng lm gim cung lng tim. 2. iu tr can thip: 69 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

a. Nong hoc t Stent ng mch vnh sm s gip ci thin r rt t l t vong bnh nhn NMCT tht phi. Vic ti ti mu MV tht phi gip ci thin chc nng tht phi. b. Mt s trng hp NMCT tht phi thng km theo nhp chm hoc bloc nh tht cp III cn c t my to nhp tm thi sm v i a s phc hi tt sau khi can thip tt MV. c. Mt s trng hp huyt p thp qu c th cn phi t bng bm ngc dng ng mch ch. 3. Phu thut: a. Mt s trng hp m tnh trng sc tim ko di khng p ng cc bin php iu tr thng ved thng c th c ch nh m ct mng ngoi tim. ser e s r tnh b. Phu thut cy thit b h tr tim tkhivn trng gh m. i sc tim qu nng. ll r co . A ahoo. c. M lm cu ni ch-vnh y oev cp khi tn thng inl 20@ khng th can thipFc hoc khi can thip c . 08 20 2 oc y bin chng hoc0khiitc cc bin chng c hc. ht Pot rig V. au ngc ti pht sau NMCT py Co Bin chng thiu mu c tim (au ngc) xy ra sau NMCT cp c th do vng tn thng lan rng, thiu mu c tim ti pht, ti NMCT... A. Vng tn thng lan rng: Bnh nhn vn au ngc lin tc hoc ti pht, trn in tm c thay i mi (chnh hn v lan rng), men tim vn tng ko di. Thm d siu m tim hoc phng x gip xc nh c vng c tim tn thng. B. Thiu mu c tim ti pht: Bnh nhn au ngc sau giai on cp t vi gi n 30 ngy vi s thay i trn in tim chng t c thiu mu c tim. Thiu mu c tim ti pht thng hay xy ra hn bnh nhn NMCT khng c sng Q. au ngc ti pht sau NMCT thng c tin lng xu v c ch bnh sinh c coi nh l 70 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

au tht ngc khng n nh. Vic iu tr do c coi nh l iu tr au tht ngc khng n nh. C. Nhi mu c tim ti pht: Bnh nhn au ngc li vi thay i mi in tim v men tim. Nu bnh nhn nhi mu li sau khi dng thuc tiu huyt khi cn tin hnh can thip ng mch vnh ngay. Vn iu tr: Cn ch nh chp v can thip MV sm cc bnh nhn ny. Cc thuc Heparin, Aspirin, Nitrates, chn Beta giao cm cn c cho mt cch tch cc hn. VI. Cc bin chng tc mch Cc bin chng tc mch bnh nhn NMCT cp xy ra trong khong 20% s bnh nhn. Nhng bnh nhn b NMCT trc rng l c nguy c cao d b bin chng ny. ved ser re A. Triu chng lm sng ts gh m.vn Cc biu hin lm sng hay gp ll ri .cl ca tai bin nht o o v. A achi, tc mch thn, mch no, mt s bnh nhn b tcloe y ho mch Fin tai bin tc mch thng tc mch mc treo Hu ht8.cc 020@ 0 ty2 xy ra trong 10 ngy u 0ca NMCT cp. i vi nhng 2 i t oc bnh nhn nm bt ng lu, c th c cc bin chng huyt gh Pot ri opy khi tnh mchCsu chi di v tc mch phi. Tu theo th bnh m c cc triu chng tng ng trn lm sng. B. iu tr 1. Truyn Heparin tnh mch lin tc trong 3-4 ngy sao cho thi gian aPTT khong 50-65 giy. 2. Vi nhng bnh nhn b NMCT thnh trc m c du hiu huyt khi bm thnh cn cho thuc chng ng ng ung (khng vitamin K) t nht trong 3 thng, gi u vi Heparin. 3. Heparin trng lng phn t thp c tc dng phng nga tt huyt khi tnh mch chi di v nhi mu phi i vi nhng bnh nhn nm lu.

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VII. Bin chng vim mng ngoi tim A. Vim mng ngoi tim cp 1. Triu chng lm sng: a. Bin chng vim mng ngoi tim cp xy ra khong 10% s bnh nhn NMCT cp v l mt trong nhng nguyn nhn gy au ngc. Bin chng ny thng xy ra trong vng 24-96 gi sau NMCT cp. b. Vim mng ngoi tim cp thng xy ra bnh nhn c NMCT xuyn thnh. Mt s khng c triu chng lm sng m ch nghe thy ting c mng tim. c. a s cc bnh nhn thng c du hiu au ed erv ngc ko di v cm gic rt bng.esau ngc r ts tng ln khi bnh nhn ngi v ici ravpha trc gh m. n r c hoc ht th su, ho hay nut.llau othng khng . A ahoo. v lan v quanh qun trcloe @y in ngc. F 0 0 8 d. Nghe tim cho thy. du 2 00 ity2 hiu quan trng nht l c ting c mng 2ngoi tim. Mt s trng hp c ht oto rigthyPting c ny. Ting c mng tim th khng py Co thng nghe r nht cnh c tri vng thp. Ting c mng tim tin trin theo thi gian, gim hoc mt i khi lng dch mng tim nhiu. e. C ch ca vim mng ngoi tim cp l do phn ng vim vng mng tim tng ng vi vng b nhi mu. S tin trin ca phn ng vim c th lin quan n mc v din rng ca NMCT. 2. Cc xt nghim chn on: a. in tm : l mt thm d c gi tr trong chn on vim mng tim cp. Tuy nhin khi bnh nhn b vim mng ngoi tim cp sau NMCT cp th cc du hiu vim mng ngoi tim c th b che lp mt. Nhn chung, du hiu c hiu ca vim mng ngoi tim trn T l on 72 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

ST chnh ln ng hng cc chuyn o v kiu chnh ln hnh yn nga. Cc du hiu thay i on ST cng thay i theo thi gian, u tin l ST v T chnh ln, sau T dt ri ST v ng ng in v sng T th m ri cng dng tr li. b. Xquang tim phi: t c gi tr chn on vim mng ngoi tim cp. c. Siu m tim: c th cho thy dch mng ngoi tim, nhng cng khng th hon ton loi tr chn on c. 3. iu tr: a. Aspirin l thuc c la chn vi liu khong ved 2,5g n 4g trong mt ngy chia lm 4-6erln. s re b. Cc thuc gim vim chng au khng n ts steroid v gh m.v i steroid khng nn dng iu tr trong trng ll r co . A ahoo. trnh lin so hp ny v n c th nhoev y qu l hng Fin rng ca c tim v lm .lan 020@ vng nhi mu mt 8 y cch m thm. 200 cis 2 Mt t bnh nhn m c au ngc o ht Pot ti pht rig nhiu khng p ng vi Aspirin th c py th cho Colchicine. Co B. Hi chng Dressler Hi chng Dressler (vim mng ngoi tim mun) xy ra khong 1-3% s bnh nhn NMCT. Hi chng ny thng xy ra sau t 1-8 tun sau NMCT cp. Hin c ch bnh sinh ca bnh cha c r hon ton, nhng ngi ta thy c nhiu bng chng lin quan n c ch t min dch ca c th. Bnh nhn thng c biu hin au ngc kiu vim mng ngoi tim, c th st, au khp, au c, tng bch cu mu, tc lng mu tng. Nghe tim c ting c mng ngoi tim. Siu m tim cho thy c dch mng ngoi tim. V iu tr th ging nh trong iu tr vim mng tim cp sau NMCT. Tuy nhin, nu sau qu 4 tun ca NMCT 73 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

th c th cho bnh nhn c cc thuc khng vim khng phi steroid thm ch c th cho c steroid. Ti liu tham kho 1. Chatterjee K. Complications of acute myocardial infarction. Curr
Probi Cardiol 1993;18:1-79.

2. Mukherjee D. Complications of myocardial infarction. In: Marso SP,


Griffin BP, Topol EJ, eds. Manual of Cardiovascular Medicine. Philadelphia: LippincottRaven, 2000. 3. O'Donnell L. Complications of MI beyond the acute stage. Am J Nurs 1996;96:25-31. 4. Reeder GS. Identification and treatment of complications of myocardial infarction. Mayo Clin Proc 1995;70:SS0-884. 5. Subramaniam PN. Complications of acute myocardial infarction. Postgrad Med 1994;95:143-145.

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Sc tim

Sc l tnh trng mt cn bng gia dng tun hon v nhu cu xy ca cc m: tnh trng ny dn ti thiu xy m, ri lon chuyn ho m v gim chc nng ca cc c quan. V triu chng lm sng: sc biu hin bng mch nhanh, huyt p tt v kt, thiu niu hoc v niu, v m hi, da xanh ti, ri lon tm thn c th gp. Sc tim (cardiogenic shock) ch l mt trong nhiu loi sc khc nhau. Cc c im v huyt ng ca sc tim cng nh mt s loi sc khc c tm tt trong bng 5-1 di y. Ngy nay mc d c nhiu tin b trong vic iu tr NMCTed nhng erv bit nu NMCT m c sc tim th t l t vong vn cn c res cao (60-80%). hts .vn ig ll r o.com . A ho oev im lc@ya v huyt ng. Bng 5-1. Phn loi sc v cc 0 Fin 2 8. 0PVy20 Loi sc C SV 0 it Sv R R PA PA 2 c I ghtR PotoR O2 AP VP P W ri P py Co Sc tim (NMCT, p tim cp) Sc gim th tch (mt mu) Sc phn b (nhim khun, phn v) Sc tc nghn (nhi - mu phi rng) Trong : CI: ch s cung lng tim; SVR: sc cn i tun hon; PVR: sc cn tiu tun hon; SvO2: bo ho xy mch trn; RAP: p lc nh phi; RVP: p lc tht phi; PAP: p lc ng mch phi; PAWP: p lc ng mch phi bt. : Khng thay i; : gim; : tng. 75 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

I. nh ngha v sinh l bnh ca sc tim A. nh ngha Sc tim l tnh trng gim cung lng tim khng p ng c nhu cu xy ca cc m c th. Chn on sc tim gm: 1. Huyt p tm thu < 80 mmHg khi khng c mt cc thuc vn mch hoc < 90 mmHg khi c mt cc thuc vn mch v t nht ko di > 30 pht. 2. Gim cung lng tim (Ch s tim < 2,0 lt/pht/m2) m khng lin quan n gim th tch tun hon (PAWP > 12 mmHg). 3. Gim ti mu m: thiu niu (nc tiu < 30 ml/gi), co mch ngoi vi, ri lon tm thn. B. Nguyn nhn 1. Nhi mu c tim cp: l nguyn nhn hngrved ca u se sc tim c bit l nhi mu trc rnge v c mt sr n t gh .v vng c tim ln b hoi t. l ri .com l . A oo 2. Cc nguyn nhn khc: loev yah in @ . a. H hai l cp do t F 2020 08 tdy chng trong NMCT hoc vim ni tm mc onhim khun. 20 ci y t hlin ot cp trong NMCT. b. Thng vch P tht rig py tim cp do cc nguyn nhn. c. Vimoc C d. Giai on cui ca bnh c tim gin. e. Cc bnh van tim nng (h van hai l, h van ng mch ch ...). f. p tim cp. g. Ri lon nhp nng. h. Mt s trng hp sau m tim phi nhn to. C. T l gp sc tim trong NMCT cp T nhng nm 50 cho ti nhng nm 90 ca th k va qua, t l sc tim c thay i cht t khong 19% 6%, nhng vn gi mt t l cao trong NMCT cp. c tnh trong khong 1 triu bnh nhn b NMCT cp M mi nm th c ti 70.000 n 150.000 bnh nhn b sc tim. T l t vong bnh nhn c sc tim vn c bit cao t 60 - 90 %. 76 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

D. Sinh l bnh ca sc tim do NMCT cp 1. u tin l vic nhi mu gy mt mt vng c tim ln hoc nhi mu nh bnh nhn c gim chc nng tht tri t trc dn n gim th tch nht bp tim v gim cung lng tim, vic ny cng dn n gim dng mu n mch vnh b tn thng to nn mt vng xon bnh l. 2. Vic gim cung lng tim li cng lm huyt p tt v thiu mu cc m dn n mt lot cc p ng cc m theo vng xon bnh l lm bnh thm nng. II. Biu hin lm sng A. Tnh trng sc: Nh trnh by trong phn nh ngha, sc tim c biu hin bi: ved ser 1. Huyt p tm thu < 80 mmHg khi khngrec mt cc hts n thuc vn mch hoc < 90 mmHgigkhi .v mt cc r comc ll . . A > 30 thuc vn mch v t nht ko vdi ahoo pht. loe y Fin02 tim 2. Gim cung lng tim (Ch s 0@ < 2,0 l/pht/m2) m 8. 2 khng lin quan n 0ocity th tch tun hon (PAWP 20 gim t > 12 mmHg).igh Pot r py Co 3. Gim ti mu m: thiu niu (nc tiu < 30 ml/gi), co mch ngoi vi, ri lon tm thn. B. Khm lm sng: c th thy Bnh nhn xanh ti, kh th, th ngoi cnh hoc ri lon tm thn, mch nhanh, huyt p tt, v m hi... 1. Khai thc bnh s v khm lm sng pht hin cc nguyn nhn: a. NMCT cp: C th au ngc in hnh ca NMCT cp. Trong NMCT cp, sc tim thng xy ra gi th 8-10 sau au ngc. in tm thay i: xut hin sng Q v on ST chnh. Cc men tim tng. 77 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

b.

c.

d.

e.

Siu m cho thy c ri lon vn ng vng ca c tim, c th thy cc bin chng c hc km theo nh h van hai l, thng lin tht... p tim cp: Kh th d di. Tnh mch c ni. Mch o (chm hoc mt khi ht vo). Huyt p tt, kt. Nghe tim ting m, gan to. Din c tim to, bng tim to trn Xquang. Siu m gip xc nh khi lng dch nhiu hay t. Cc bnh van tim: Nghe tim c th pht hin c cc tn ved thng van tim. ser re Siu m Doppler tim c ch trong n ts vic nh gh m.v tim. gi chnh xc tn thng cai cc van ll r co . A ahoo. Vim c tim cp: oev y inl 20@cp. Rt d nhm vi F NMCT 8. 0 Tin s c 2th ity2 00 c cc du hiu nhim trng c hra. mi xy t Poto rig y Cpth km theo cc ri lon nhp nng n. Co Cc bnh khc: Giai on cui ca bnh c tim gin, bnh c tim ph i. Ri lon nhp nng: in tm gip xc nh chn on. Nhi mu phi gy suy chc nng tht phi cp: bnh nhn au ngc, ho mu, kh th nhiu, chp phim c th thy m m.

III. iu tr A. Cc bin php chung 1. Nhanh chng xc nh tnh trng sc tim ca bnh nhn, loi tr cc nguyn nhn khc gy ra huyt p thp. 78 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

2. Bnh nhn cn c nm khoa iu tr tch cc. 3. xy: cn c cung cp y , nu bnh nhn t th tt c th cho th qua ng mi, nu bnh nhn c ri lon nhp th hoc suy h hp nng th cn t ni kh qun v cho th my ng ch . 4. Thit lp mt ng truyn tnh mch. 5. t catherter tnh mch trung tm theo di, tt nht l c Swan-Ganz theo di cung lng tim v p lc ng mch phi bt. 6. Theo di bo ho xy ng mch. 7. Theo di lng nc tiu (t thng i). 8. m bo tt th tch tun hon sao cho p lc nh phi t 10-14 mmHg v PAWP t 18-20 mmHg. ved 9. Kim sot tt cc ri lon nhp tim km theo nu c ser re t (nhanh tht: sc in, nhp chm qu:s t my to gh m.vn i nhp). ll r co . A ahoo. ov 10. Kim sot cc ri lon thng ebng kim toan v nc inl 20@y F in gii. 8. 0 00 ity2 11. Dng cc thuc t 2 mch (xem phn sau). vn c h Poto rig php h tr c hc tun hon (phn 12. Dng cc pbin oy sau). C B. Theo di huyt ng Trong iu tr sc tim, theo di huyt ng l yu t quyt nh iu chnh v can thip kp thi. C. Cc thuc 1. Dobutamine: L mt catecholamin tng hp, c tc dng tri trn bta 1 giao cm lm tng sc co bp c tim v tng nhp tim phn no, t nh hng n co mch, lon nhp v dng mu n thn. L thuc la chn hng u trong iu tr sc tim, ch nh ti u khi huyt p cn > 80 mmHg. Liu dng: 2 - 5 g/kg/pht. 79 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Bng 5-2. Cc thuc dng trong sc tim. Thuc Liu thng thng Tc dng ph Dobutamine 5-15 g/kg/pht truyn Quen thuc, phi TM. tng liu dn. Dopamine Noradrenalin Nitroglycerin 2-20 g/kg/pht, truyn TM. 2-16 g/kg/pht, truyn TM. 10 g/pht, tng dn liu mi 10 mcg trong 10 pht nu khng p ng. 10 g/pht, c th tng 5 g mi 10 pht. Lm tng nhu cu xy c tim. Co mch ngoi vi v mch tng. au u, tt huyt p.

Nitroprussiat

au u, tt huyt p, ng c ved ser cyanid. e r ts n gh Amrinone 0,75 mg/kg tim TM Gimm.vtiu cu l ri o trong 2 pht sau v. Al mu. hoo.c a oe truyn TM inl5-10y F 020@ g/kg/pht. 008. y2 2 ocit t Milrinone Tim TM 50mcg trong Ri lon nhp gh Pot i 10oppht sau truyn tht. yr C TM 0,375 - 0,750 g/kg/pht. Furosemide 20 - 160 mg tim TM. H kali mu, magi mu. Bumetanide 1-3 mg tim TM. Nn, chut rt. 2. Dopamine: a. L 1 catecholamin t nhin, c tc dng trn cc th th giao cm tu theo liu. Vi liu thp (2-5 g/kg/ph) ch yu tc dng trn th th dopamine lm gin mch thn, tng dng mu n thn v lm tng th tch nht bp ca tim. Vi liu trung bnh (5-15 g/kg/pht) ch yu kch thch 1 giao cm lm tng sc co bp c tim v tng nhp tim. Vi liu cao 15 - 20 g/kg/pht s c tc 80 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

3.

4.

5.

6.

dng kch thch giao cm gy co mch ngoi vi mnh. b. Ch nh tt khi huyt p tm thu < 80 mmHg, liu dng t 2-20 g/kg/pht, ty theo p ng. Noradrenalin: a. Cng l mt catecholamin t nhin vi tc dng mnh trn giao cm gy co mch nhiu. b. Nn c ch nh khi HA tm thu < 70 mmHg v liu dng t 2-16 g/kg/pht. Cc thuc gin mch: a. Cc thuc ny ch dng khi duy tr c con s HA mc n nh. b. Cc thuc ny gy gin mch nn lm gim tin d rve seli khi b gnh v hu gnh cho tim, do rt c e sr NMCT cp hoc cc suy tim cpight mtheo. km .vn lr o c. Cc thuc thng dng v. AlNitroglycerin dng l: hoo.c a loe truyn hoc Nitroprussiad0@y liu bt u t 10 Fin02 vi . g/pht. 08 2 20 ocity Cc thuc tr ht Pot tim: rig a. Khngpy Co nn dng Digitalis trong NMCT cp c sc tim d c suy tht tri nng v thuc ny lm tng nguy c b lon nhp v tng t l t vong. b. Trong cc trng hp khc khi c suy tim do bnh van tim hoc bnh c tim m c km rung nh nhanh th Digitalis rt nn dng. c. Cc thuc lm tng sc co bp c tim do c ch phosphodiesterase (Milrinone, Amrinone) c th dng trong trng hp c suy tim nng. Cc thuc li tiu: a. Cc thuc li tiu lm gim p lc y tht tri v nn dng khi c suy tim m c tng khi lng tun hon v khng ch c huyt p.

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b. Thng dng l Furosemide, Bumetanid tim tnh mch. D. H tr tun hon bng c hc Khi cc thuc dng t ra t p ng hoc tht bi, cn cn nhc sm vic dng cc bin php h tr c hc c bit khi cn phi can thip MV hoc m cu ni. 1. Bm bng ngc dng trong ng mch ch (Intra - Aortic Balloon Counterpulsation Pump - IABP): a. Dng mt qu bng to v di t trong MC t on trn ca MC xung cho n tn MC bng trc ch chia ra ng mch chu. Vic bm bng v lm xp nh kh heli do mt my bm ngoi ni vi bng v lm vic theo chu ed chuyn ca tim. Bng s c bm eserv phng ln r t trong thi k tm trng v lm xps i n gh m.v trong thi i k tm thu, do vy s lmAtng .co ll r dng mu n . ahoo MV trong thi k tm ev y v ch yu lm lo trng @ Fintrong k tm thu nn lm gim p lc hu gnh 020 . 08 ty2 2 cho gim gnh nng 0 oci tim. t t gh Pokhi c h ch nng, tch thnh b. Chng yri nh ch p Co ng mch ch, bnh l mch ngoi vi. c. Cc nghin cu cho thy, t khi ra i loi bng bm ny lm gim ng k t l t vong do sc tim. 2. My tim phi nhn to chy ngoi (Hemopump): ang c th nghim v cho kt qu kh tt. Ngy nay, mt s trung tm cn c loi my xch tay rt tin li. E. iu tr nguyn nhn 1. NMCT cp: Khi sc tim xy ra th cc bin php ti ti mu MV cng t ra cp thit: a. Thuc tiu huyt khi: cha chng minh c lm gim t l t vong trong NMCT cp c sc tim (nghin cu GISSI-1, GUSTO-1), tuy nhin 82 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

nu khng c chng ch nh nn cho thuc tiu huyt khi v lm ci thin c dng chy ca MV ng k nu bnh nhn sng st. Nn dng rt-PA hn l dng Streptokinase. b. Can thip MV: Nhiu nghin cu chng minh can thip MV khi c sc tim lm gim t l t vong v phc hi sc tim nhanh. Tuy nhin can thip ch t kt qu ti u khi c cc bin php khc h tr tt v i hi th thut can thip phi c tin hnh mt cch nhanh chng bi nhm ngi lm c kinh nghim (nghin cu SHOCK, SMASH). Can thip MV trong sc tim s c th t tc dng nu qu mun (>36 gi) hoc bnh nhn cao tui (>75 tui) (theo khuyn ved co rt ra t nghin cu SHOCK). ser re hts vn c. M lm cu ni ch-vnh: cigbit .c ngha l r om khi c cc bin chng c .hc km theo nh h Al hoo.c oev a hai l cp do t dy chng, thng lin tht... inl 20@y .F 2. Cc nguyn nhn 008 ty20 c iu tr tch cc khc: cn 2 i t theo nguyn nhn: Potoc gh ri py a. Bnh onhn c p tim cp phi xc nh v chc C dch ngay. b. Bnh nhn c bnh van tim cn c phu thut sa hoc thay van tim. c. Vim c tim cp hoc bnh c tim vn cn l vn nan gii, vic iu tr cn nhiu kh khn, ch yu vn l iu tr triu chng. Ti liu tham kho
1. 2. 3. Antman E. Braunwald E. Acute Myocardial Infarction. In Braunwald E ed, Heart Disease, a textbook of cardiovascular medicine, 5th edition WB Saunders Philadephia, 1997. Barron HW, Pirzada SR, Lomnitz Dj et al. Use of IABP in patients with AMI complicated by cardiogenic shock. J Am Coll Cardiol 1998;31. Eagle and Guyton et al.ACC/AHA Guidelines for Coronary Artery Bypass Graft Surgery surgery JACC Vol. 34, No. 4, October

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1999:1262-347 Recommendations of the ACC/AHA Task Force in order to decrease morbidity and mortality in patients undergoing CABG. Circulation 1999;100:1464-1480. 4. Goldstein JA, Barzilai B, Rosamond TL, Eisenberg PR, Jaffe AS. Determinants of hemodynamic compromise with severe right ventricular infarction. Circulation 1990;82:359-368. 5. Hasdai D, Holmes DR Jr, Califf RM, et al. Cardiogenic shock complicating AMI: Predictors of death. Am Heart J 1999;138:2131. 6. Hochman JS, Buller C, Sleeper L et al. for the SHOCK Investigators. Cardiogenic shock complicating AMI-Etiologies, management and outcome: A report from the SHOCK trial registry. J Am Coll Cardiol 2000; 36:1063-70. 7. Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock. N Eng J Med 1999; d 341: 625-634. rve 8. Kinch JW, Ryan TJ. Right ventricular infarction. Nese Engl J Med r ts 1994;330:1211-1217. gh m.vn 9. Kosuge M, Kimura K. Ishikawa T et al. Implications of the absence l ri o Al hoo c . patients. who have inferior of ST-segment elevation in lead V4R ev a in wall AMI with right ventricular iinvolvement Clin Cardiol 2001; nlo 0@y F 24:225-230. 8. 02 00 etty2 AMI complicated by systemic 10. Menon V, Slater J, White H,oci al. 2 hypoperfusion withoutt hypotension. A report from the SCHOCK gh Pot ri trial registry. Amy Med 2000; 108:374-80 op J

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ri lon Lipid mu

I. nh ngha Ngi ta gi l ri lon lipid mu khi c mt hoc nhiu cc ri lon sau: 1. Tng Cholesterol huyt tng: a. Bnh thng: Cholesterol trong mu < 5,2 mmol/l (< 200 mg/dl) b. Tng gii hn: Cholesterol trong mu t 5,2 n 6,2 mmol/l (200 239 mg/dl) c. Tng cholesterol mu khi >6,2 mmol/l d (>240 e erv mg/dl) res hts .vn 2. Tng TG (Triglycerid) trong mu: ig l r om Al hoo (<200 mg/dl). a. Bnh thng: TG mu <2,26v.mmol/l.c a oe b. Tng gii hn: TG t inl 20@y mmol/l (200-400 F 2,26-4,5 . 08 20 mg/dl). 20 ocity c. Tng TG:ght TGot t 4,511,3mmol/l (400P ri py 1000mg/dl). Co d. Rt tng: TG mu > 11,3 mmol/l (> 1000 mg/dl). 3. Gim HDL-C (High Density Lipoprotein Cholesterol): HDL-C l 1 Lipoprotein c tnh bo v thnh mch. Khc vi LDL-C, nu gim HDL-C l c nguy c cao vi x va ng mch: a. Bnh thng HDL-C trong mu > 0,9 mmol/l. b. Khi HDL-C mu < 0,9 mmol/l (<35mg/dl) l gim. 4. Tng LDLC (Low Density Lipoprotein Cholesterol) a. Bnh thng: LDL-C trong mu <3,4 mmol/l (<130 mg/dl) b. Tng gii hn: 3,4 4,1 mmol/l (130-159 mg/dl) c. Tng nhiu khi: > 4,1 mmol/l (>160 mg/dl) 85 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

5. Ri lon lipid mu kiu hn hp: Khi Cholesterol > 6,2 mmol/l v TG trong khong 2,26 4,5 mmol/l. II. Nguyn nhn gy ri lon lipid mu A. Nguyn nhn gy tng cholesterol mu 1. Ch n: a. n qu nhiu m ng vt. b. n qu nhiu thc n c cha nhiu Cholesterol (ph tng ng vt, m ngvt, trng, b, sa ton phn...). c. Ch n d tha nng lng (bo ph). 2. Di truyn: a. Tng Cholesterol gia nh (thiu ht th th vi LDL). ved ser cht gia b. Ri lon lipid mu kiu hn hp c tnh re ts nh. gh m.vn ri co c. Tng Cholesterol mu do riAll oohn hp gen. . lon . oev ah 3. Th pht: inl 20@y F 8. a. Hi chng thn h. ity20 00 2 c b. Suy gip. ight Poto r c. i Copy ng. tho d. Bnh l gan tc nghn. e. Mt s bnh gy ri lon protein mu (a u tu xng, macroglobulinemia). B. Nguyn nhn gy tng Triglycerid mu 1. Thiu ht gen lipase tiu hu lipoprotein hoc apolipoprotein C-II. 2. Tng TG c tnh cht gia nh. 3. Bo ph. 4. Ung qu nhiu ru. 5. i tho ng. 6. Dng thuc chn bta giao cm ko di.

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C. Nguyn nhn gy gim HDL-C: 1. Ht thuc l. 2. Bo ph. 3. Li vn ng th lc. 4. i tho ng khng ph thuc insulin. 5. Tng TG mu. 6. Dng thuc chn b ta giao cm ko di. 7. Ri lon gen chuyn ho HDL.

r ese sr n t gh .v l ri .com l . A oo oev yah inl @ . F 2020 8 00 y 2 tocit t igh Po yr ca lipoprotein. Hnh 6-1. Cu trc p Co III. Nguyn tc iu tr ri lon lipid mu

ved

A. Vic iu tr tu thuc vo tng c th bnh nhn trn c s nh gi tnh trng ri lon Lipid mu v cc yu t nguy c ca bnh mch vnh (bng 6-1). Bng 6-1. Cc yu t nguy c ca bnh mch vnh.

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Yu t nguy c dng tnh: Nam 45 tui N 55 tui C tin s gia nh b bnh MV Ht thuc l nhiu Tng huyt p HDL-C < 0,9 mmol/l i tho ng Yu t nguy c m tnh: tnh tr i 1 yu t nguy c nu c HDL-C 60 mg/dl B. iu tr cp mt v iu tr cp hai. Gi l iu tr cp mt khi bnh nhn c ri lon Lipid mu nhng cha c tin s b bnh mch vnh, iu tr cp hai khi ved bnh nhn c tin s bnh mch vnh: ser re 1. iu tr cp mt: nhm t c LDL-C mu < 4,1 ts vn . gh 2 yu t nguy i mmol/l vi nhng bnh nhn c tl hn om l r o.c A o c hoc LDL-C < 3,4 mmol/lv.nu hbnh nhn c 2 loe @ya yu t nguy c. iu tr Fin02bt u bng iu chnh phi 0 8. 00 ty2 ch n v luyn2tp. iDng thuc khi iu chnh oc ht gian ch n mtgthi Pot m tht bi hoc phi bt u ri ngay khi:opy C a. C qu nhiu yu t nguy c bnh mch vnh v lng LDL-C trong mu cao (> 4,1 mmol/l), hoc b. Khi lng LDL-C trong mu qu cao (> 5 mmol/l). 2. iu tr cp hai: Khi bnh nhn c biu hin bnh mch vnh. Mc ch iu tr ch yu l phi lm gim c LDL-C < 2,6 mmol/l (<100 mg/dl). Cn iu chnh ch n tht nghim ngt cho mi bnh nhn, ng thi cho thuc phi hp ngay khi LDL-C > 3,4 mmol/l.

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IV. iu tr c th A. Ch n v sinh hot 1. Dng ch n gim Cholesterol v calo (nu bnh nhn bo ph). Gm 2 bc: a. Bc 1: thnh phn cht dinh dng n hng ngy c lng acid bo bo ho < 10 %, tng s cc cht bo khng qu 30 % v lng Cholesterol phi < 300 mg/ ngy. Nh vy l cn trnh hoc gim cc cht m ng vt, trng, sa nguyn, ph tng ng vt, cc loi pho-mat, kem... Tng cng n hoa qu ti, rau, v cc loi ng cc vi lng tinh bt chim khong 55 60 % khu phn. ed erv b. Bc 2: c p dng khi thc hin sbc trn re sau 6-12 tun khng kt qu. Trongts .vn ny lm bc gh m i ll c gim tip lng acid bo bo rhoo xung < 7% . A ahoo. khu phn v lng Cholesterol < 200 mg/ ngy. oev inl 20@y . c. Thi gian iu chnhF 20 n v mt s lu : 08 ch 20 ocity Nu chhcn iu chnh ch n theo nh ch t ot ig r niPtrn th thi gian cn t nht l 6 nh py Co thng. C 6-8 tun nn kim tra li lng Cholesterol mu. Ch n phi c duy tr lu di cho d c dng thuc hay khng dng. Cn lu hn khi dng ch n ny ngi gi v ph n c thai. bnh nhn b tng TG, cn hn ch m ng vt, ng v ru. Gim cn nng cho nhng bnh nhn bo ph. Nn bt u gim dn dn lng calo hng ngy, thng hn ch mc 500 calo/ngy. Tp th lc l rt quan trng, n c th lm gim c LDL-C v tng HDL-C. Tp th lc cn lm gim cn nng, gim huyt p, v gim nguy c bnh mch vnh. 89 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

B. iu tr bng thuc 1. Cc nhm thuc: a. Cc loi resins gn acid mt: nh Cholestyramine (Questran), Colestipol (Colestid): Cc thuc ny khng hp thu qua rut, n gn vi acid mt lm gim hp thu ca chng. Do vy n s lm tng chuyn ho t Cholesterol sang acid mt trong gan, lm gim lng Cholesterol d tr trong gan v lm tng hot tnh ca th th vi LDL ca gan. N lm gim LDL-C ti 30%, lm tng HDL-C khong 5 % nhng lm tng nh TG. Do vy thng dng kt hp vi thuc khc v khng dng khi TG tng cao. ved ser g/ngy Liu thng dng: Questran 8 te 16 sr gh m.vn 10 i chia 2 ln dng trong ba ln, Colestid: l r co . A ahoo. khi u bng 30 g/ngy chia lm 2eln. Nn ov liu thp sau tng 20@y inl dn. .F 0 Tc dng ph 8 tyth gp bao gm: to bn, 00 c 2 2 oci t au bng, bun nn, nn, nng rut... Ch gh Pot i khi yr p dng chung cc thuc khc c th lm Co gim hp thu cc thuc . b. Nicotinic acid (Niacin): y l mt loi Vitamin tan trong nc, c ch gan sn xut ra cc Lipoprotein. Cc thuc ny: Lm gim VDLD-C ti 50%, lm gim LDLC ti 25% v tng HDL-C 15-35%. Liu bt u nn thp khong 100 mg x 3 ln/ ngy, sau c th tng liu ti khong 2-4 g/ngy. Tc dng ph: Cm gic bng da rt hay gp (hu nh gp tt c cc bnh nhn). C th trnh bng cch ung thuc trong ba n hoc ung Aspirin 100 mg trc mi ln dng thuc 30 pht. Cc tc dng ph khc bao 90 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Chng ch nh ca Niacin: bnh nhn b Goutte, lot d dy t trng, bnh vim i trng mn. Chng ch nh tng i bnh nhn i tho ng. c. Thuc c ch men HMG-CoA Reductase (nhm Statin): Gm Simvastatin (Zocor); Lovastatin; Pravastatin; Fluvastatin; Atorvastatin (Lipitor)... Cc thuc ny c ch hot ho men HGMCoA-reductase lm gim tng ed hp v Cholesterol trong t bo gan v tnger res hot ho th th LDL do lm gim ts .vn trong gh LDL-C l ri .com c th lm l mu. Simvastatin v Artovastatin . A oo oev vah gim LDL-C ti 60% @y lm gim TG ti l Fin020 37%. nhiu .nghin cu chng minh c 08 y2 l cc Statin0c ith lm gim t l t vong 2 toc t t o gh bnhrinhn Pc bnh mch vnh, gim t l y p Co bnh mch vnh bnh nhn b tng Lipid mu, v lm gim t l phi can thip li bnh nhn sau can thip ng mch vnh hoc m cu ni ch-vnh. Liu dng: Simvastatin (Zocor) t 5-40 mg/ngy; Atorvastatin (Lipitor) 10-80 mg/ ngy; Lovastatin 10-20 mg/ngy; Pravastatin 10-40 mg/ngy. Cc thuc nhm ny khng nn dng gn ba n v c th dng 1 ln trong ngy trc khi i ng. Cc statin khc nhau c hiu lc i vi LDL-C khc nhau (bng 6-2). Bng 6-2. Tc dng ca cc statin khc nhau i vi s thay i ca LDL-C v HDL-C. Thuc Liu u Ti a Gim Tng 91 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

(LB) Lovastatin (Mevacor) Pravastatin (Pravachol) Simvastatin (Zocor) Fluvastatin (Lescol) Atorvastatin (Lipitor) 20mg 10-20 mg 20 mg 20-40 mg 10 mg 80 mg 40 mg 80 mg 80 mg 80 mg

LDL-C vi LT 40% 34% 47% 36% 60%

HDL-C vi LT 9,5% 12% 8% 5,6% 5%

Tc dng ph: Bao gm kh tiu, a chy, to ved sr bn, bun nn, au bng, au u, emt ng. re ts Tng men gan c th gp i h1-2% s bnh g m.vn r co nhn dng thuc. Khng ll oo.dng statin cho . A nn oev ah bnh nhn b bnh lgan@ang tin trin, au in 20 y F c c, vim a c, .tiu 0 vn... Khng nn dng 8 00 ity2 2 Statin cng vi Cyclosporin, cc dn xut t oc gh Pot Fibrat, Erythromycin, Niacin... v cc thuc ri py Co c th lm tng c tnh khi dng cng ny nhau. Ch : hin nay thuc Lipobay (Cerivastatin) phi rt khi th trng do tc dng ph nguy him gy tiu c vn khi dng cng vi cc Fibrat. d. Cc dn xut fibrat (acid fibric) bao gm : Gemfibrozil (Lopid); Fenofibrat (Lipanthyl, Tricor); Bezafibrat (Benzalip). Cc thuc ny lm gim VLDL v do lm gim TG khong 20-50%, lm tng HDL-C khong 10-15%. Gemfibrozil lm gim LDLC khong 10-15%. Do vy cc thuc ny ch nh tt trong cc trng hp tng TG mu v c th kt hp tt vi thuc gn mui mt. 92 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Liu thng dng l: Gemfibrozil 600 mg x 2 ln/ngy trc khi n; Fenofibrat 300 mg/ngy. Tc dng ph c th gp l: sng ph mt, au bng, bun nn, au u, mn nga... Men gan c th tng, cn theo di men gan khi dng cc thuc ny. Nhm thuc ny cn lm tng nguy c si mt. e. iu tr thay th bng hormon sinh dc n (Estrogen): c th c ch ph n sau tui mn kinh c ri lon lipid mu. Estrogen ung lm gim LDL-C khong 15% v lm tng HDL-C cng khong 15%. y l thuc nn chn la u tin cho iu tr ph n sau tui mn kinh d ri e c erv lm lon lipid mu. Tuy nhin, thuc nyrec th s tng TG i cht. hts .vn ig ll r o2com thuc 2 2. Vn kt hp thuc: c th. dng . loi v A ho l e @y mu khc nhau nu nhm thuc iu tr ri lonolipid a Fin 20 thy cn thit. Vic kt. hp02 loi thuc vi liu thp 08 ty2 0 2 ci s thay th cho tvic tdng 1 loi vi liu cao v kh h Po o ig dung np. pTrong mt s trng hp khi tng qu cao yr Co Cholesterol mu nn kt hp 2 loi thuc. S kt hp tt nht l gia Statin v Niacin. 3. Theo di khi dng thuc: cn kim tra Cholesterol v TG mu mi 3-4 tun iu tr. Nu khng p ng sau 2 thng iu tr, mc d dng liu ti u, th nn thay bng thuc khc hoc kt hp thuc th 2. Lu l vic iu chnh ch n v luyn tp phi lun lun c bo m. 4. Mt s tnh hung c th: a. iu tr bnh nhn tng Triglycerid mu: Vi bnh nhn tng gii hn TG th ch cn iu chnh ch n v sinh hot, c bit l gim trng lng, ch n t tinh bt, m v khng ung ru. Trong trng hp phi dng thuc th 93 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

nn la chn Niacin hoc dn xut fibrat. Khi TG rt cao trong mu th cn phi phng nguy c vim tu cp. b. iu tr bnh nhn tng lipid mu hn hp (tng c Cholesterol v TG). Mc ch th nht l phi a LDL-C v gii hn bnh thng, sau c gng a TG v mc bnh thng hoc gn bnh thng nu c th. Vic iu chnh ch n v gim cn nng vn l quan trng hng u. Khi dng thuc nn kt hp Niacin hoc mt Fibrat vi mt Statin. c. iu tr bnh nhn b gim HDL-C: Ch trc tin l loi b cc cn nguyn gy gim HDL nh ht thuc l, bo ph, li tp th dc, i tho ved ser mu, ng khng c khng ch, tnge TG sr dng chn bta giao cm ko rdi.t m.vnth dng gh C i ll Niacin, Statin hoc Gemfibrozil. oo.co . A ah oev Ti liu tham kho inl 20@y F 8. 0 1. Abramowicz M, editor. Choice ty2 00 i of lipid-lowering drugs. Med Lett 2 1998;40:117-22. t oc gh Pot Management of dyslipidemia in r 2. American Diabetes i Association. py adults with diabetes. Diabetes Care 1999;22:Suppl 1:S56-S59. Co
3. Bachmaier K, Neu N, de la Maza LM, Pal S, Hessel A, Penninger JM. Chlamydia infections and heart disease linked through antigenic mimicry. Science 1999;283:1335-9. Denke MA. Cholesterol-lowering diets: a review of the evidence. Arch Intern Med 1995;155:17-26. Diaz MN, Frei B, Vita JA, Keaney JF Jr. Antioxidants and atherosclerotic heart disease. N Engl J Med 1997;337:408-16. Fielding CJ, Fielding PE. Molecular physiology of reverse cholesterol transport. J Lipid Res 1995;36:211-28. Ginsberg HN. Is hypertriglyceridemia a risk factor for atherosclerotic cardiovascular disease? A simple question with a complicated answer. Ann Intern Med 1997;126:912-4. Ginsburg HN, Goldberg IJ. Disorders of lipoprotein metabolism. In: Fauci AS, Braunwald E, Isselbacher KJ, et al., eds. Harrisons principles of internal medicine. 14th ed. Vol. 2. New York: McGraw-Hill, 1998:2138-

4. 5. 6. 7. 8.

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9. 10. 11. 12.

13. 14.

Havel RJ, Rapaport E. Management of primary hyperlipidemia. N Engl J Med 1995;332:1491-8. [Erratum, N Engl J Med 1995;333:467]. Illingworth DR, Tobert JA. A review of clinical trials comparing HMG-CoA reductase inhibitors. Clin Ther 1994;16:366-85. Levine GN, Keaney JF Jr, Vita JA. Cholesterol reduction in cardiovascular disease: clinical benefits and possible mechanisms. N Engl J Med 1995;332:512-21. Lipid Metabolism Branch, Division of Heart and Vascular Diseases, National Heart, Lung, and Blood Institute. The Lipid Research Clinics population studies data book. Vol. 1. The Prevalence Study: aggregate distribution of lipids, lipoproteins and selected variables in North American populations. Bethesda, Md.: National Institutes of Health, 1980:1-136. Staels B, Dallongeville J, Auwerx J, Schoonjans K, Leitersdorf E, Fruchart J-C. Mechanism of action of fibrates on lipid and lipoprotein metabolism. Circulation 1998;98:2088-93. e Stone NJ. Secondary causes of hyperlipidemia. Med Clind North erv Am1994;78:117-41. res

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tng huyt p

Tng huyt p (THA) l mt bnh rt thng gp v hin tr thnh mt vn x hi. cc nc pht trin, t l THA ngi ln (>18 tui) theo nh ngha ca JNC VI l khong gn 30 % dn s v c trn mt na dn s > 50 tui c THA. Theo thng k Vit nam nhng nm cui thp k 80 t l THA ngi ln l khong 11% th thng k gn y t l THA H ni cho ngi ln khong 20 %. THA nguy him bi cc bin chng ca n khng ch c th gy cht ngi m cn li nhng di chng nng n (vd. tai bin mch no) nh hng n cht lng cuc sng ca bnh nhn v l gnh nng cho gia nh x hi. Ngy nay c kh nhiu thay i trong quan nim v THA, phng thc iu tr cng nh vic gio dc bnh nhn tc ng n tin lng ca THA. I. nh ngha tng huyt p (THA) Cho n nay, T chc Y t th gii v hi THA quc t (World Health Organization - WHO v International Society of Hypertension - ISH) thng nht gi l THA khi huyt p tm thu 140 mmHg v/hoc huyt p tm trng 90 mmHg. Con s ny c c l do da trn nhng nghin cu ln v dch t cho thy: C s gia tng c bit nguy c tai bin mch no ngi ln c con s huyt p 140/90 mmHg. T l TBMN ngi c s huyt p < 140/90 mmHg gim r rt. II. Giai on tng huyt p Hu ht hin nay ngi ta s dng cch phn loi ca JNC VI (U ban phng chng huyt p Hoa k) do tnh cht thc tin v kh thi ca n. Thm vo WHO-ISH cng cho cch phn
1

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loi tng t ch khc nhau v thut ng (bng 7-1). Nhng im ch trong cch phn loi ny: cp n khi nim HA bnh thng cao, v nhng nghin cu cho thy trong mt s trng hp vi nhng nguy c cao (v d tiu ng) th cn iu tr. Khng cn giai on IV nh trc y (HA > 210/120 mmHg) v trong thc t trng hp ny gp khng nhiu v phng n iu tr th ging nh giai on III. Bng 7-1. Phn loi THA theo JNC VI (1997). Khi nim HA tm thu HA tm trng (mmHg) (mmHg) HA ti u < 120 v < 80 HA bnh thng < 130 v < 85 Bnh thng cao 130 - 139 v 85-89 Tng huyt p Giai on I 140 - 159 v/hoc 90 - 99 Giai on II 160 - 179 v/hoc 100 - 109 Giai on III 180 v/hoc 110 III. Xc nh v nh gi mt bnh nhn THA A. Chn on xc nh THA: rt n gin l o HA. 1. Nhng lu khi xc nh huyt p: a. Bnh nhn phi trong trng thi ngh ngi (t nht 5 pht trc o), khng dng cc cht kch thch c nh hng n huyt p (c ph, ht thuc l). b. Bnh nhn nn t th ngi gh ta, tay trn bn sao cho np khuu ngang vi mc tim. Trong mt s trng hp c bit cn o HA c t th nm v ngi hoc ng. c. B rng bao o huyt p nn bng 80 % chu vi cnh tay, do mt s bnh nhn tay to cn dng loi bao rng hn. d. Nn dng loi my o huyt p thu ngn.

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e. Con s huyt p tm thu tng ng vi pha I ca Korotkoff (xut hin ting p u tin) v huyt p tm trng l pha V (mt ting p). Cn ch l c th gp khong trng HA. f. Nn o HA c hai tay v ly tr s bn c s o cao hn. g. Cn thit phi o t nht 2 ln cch nhau t nht 2 pht v con s cui cng l trung bnh cng nu c s khc bit > 5 mmHg. 2. Xc nh l THA: Nu khi o ngay ln u HA > 160/100 mmHg th c th xc nh l b THA, nu khng th nn khm li khng nh (bng 7-2). Bng 7-2. Thi i vi bnh nhn THA khi o ln u (theo JNC VI). HA ti a HA ti thiu Thi < 130 < 85 Kim tra li trong 2 nm 130-139 85-89 Kim tra li trong 1 nm 140-159 90-99 Khng nh li trong vng 2 thng 160-179 100-109 nh gi v iu tr trong vng 1 thng 180 110 Lp tc nh gi v iu tr ngay hoc trong vng 1 tun tu tnh hnh lm sng 3. Mt s phng php o huyt p khc: a. Gio dc bnh nhn t o huyt p theo di, vic ny c nhng li ch l: trnh cho bnh nhn phi n c s y t lin tc, gim chi ph, gip theo di iu tr tt; trnh hin tng THA o chong trng; lm bnh nhn tch cc vi iu tr THA. b. o huyt p lin tc (Holter huyt p). Bin php ny khng dng p dng thng quy, n c ch trong mt s trng hp nh nghi ng bnh nhn c THA o chong trng, THA cn, THA khng li iu tr, tt HA do dng thuc h HA.

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B. nh gi mt bnh nhn THA Vic thm khm mt bnh nhn THA nhm vo 3 mc ch sau: Tm hiu nguyn nhn (nu c). nh gi cc bin chng (tn thng c quan ch). nh gi cc yu t nguy c v tim mch hoc cc ri lon khc c thi iu tr ng mc v tin lng bnh. 1. Khai thc bnh s bao gm: a. Khai thc tin s THA, thi gian, mc THA. b. Tin s cc bnh tim mch, cc triu chng bnh tim mch, suy tim, TBMN, bnh mch ngoi vi, bnh thn, tiu ng, ri lon m mu... c. Cc thi quen, li sng (bo ph, ht thuc l, ung ru, ch n nhiu mui...), trnh gio dc, iu kin sng... d. Tin s gia nh v THA v cc bnh tim mch... e. Cc thuc h p dng v mc p ng... 2. Thm khm thc th: a. o HA (nu trn). Trong mt s trng hp nghi ng cn o huyt p cc t th v o HA t chi. b. Khm ton trng, ch chiu cao, cn nng. c. Thm khm y mt. d. Thm khm h tim mch, ch cc ting thi tim, nhp tim, cc du hiu suy tim, ting thi cc mch mu ln... e. Thm khm bng ch ting thi ng mch ch hay ng mch thn, thn to hay khng, cc khi bt thng bng... 3. Cc thm d cn lm sng: a. Cc thm d thng quy trong THA l: Phn tch nc tiu. Cng thc mu. Sinh ho mu (in gii , glucose khi i, Cholesterol ton phn v HDL- cholesterol). in tm 12 chuyn o.

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b. Cc thm d h tr: nu cn th thm d thm: Creatinin mu, protein niu 24 gi, acid uric, LDL-C, Triglycerid trong mu. Nng renin, catecholamin... mu trong mt s trng hp hn hu. Siu m tim nh gi khi lng c tht tri v chc nng tht tri hoc c km theo bnh hay cc bin chng tim mch khc. IV. Nguyn nhn tng huyt p Bng 7-3. Mt s nguyn nhn THA th pht. Cc bnh v thn: Vim cu thn cp Vim cu thn mn Si thn Vim thn k Hp ng mch thn... Cc bnh ni tit: U tu thng thn (Pheocromocytom) Cushing Cng aldosteron Cng gip Cng tuyn yn... Cc bnh h tim mch: H van MC (gy THA tm thu n c) Hp eo MC (gy THA chi trn) Bnh v mch (Takayashu) Hp, x va MC bng, nh hng n ng mch thn Do dng mt s thuc: Cam tho Cc thuc cng alpha giao cm (vd. cc thuc nh mi cha ngt...) Thuc trnh thai... Nguyn nhn khc: Ng c thai nghn Ri lon thn kinh

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A. i a s THA ngi ln l khng c cn nguyn (hay THA nguyn pht) chim ti > 95%. Mt s yu t c coi l yu t nguy c ca THA s c trnh by sau. B. THA th pht hay THA c cn nguyn cn c ch nht trong cc trng hp sau: (Bng 7-3) 1. Pht hin ra THA tui tr < 30 hoc gi > 60. 2. THA rt kh khng ch bng thuc. 3. THA tin trin nhanh hoc THA c tnh. 4. C biu hin bnh l c quan khc m c th l nguyn nhn ca THA. V. Phn tng mi nguy c cho bnh nhn THA Vic phn tng cc mi nguy c cho bnh nhn THA rt quan trng gip hoch nh chin lc iu tr THA cho bnh nhn hp l. Vic phn tng THA da trn cc yu t nguy c v cc tn thng c quan ch. A. Cc yu t nguy c ca bnh tim mch bnh nhn THA 1. Ht thuc l. 2. Ri lon lipid mu. 3. i tho ng. 4. Tui > 60. 5. Nam gii hoc n gii mn kinh. 6. Tin s gia nh c ngi thn b bnh MV: n < 65 tui hoc nam < 55 tui. B. Tn thng c quan ch c th gp trong THA 1. Tim: a. Cp: Ph phi cp, NMCT cp. b. Mn: dy tht tri, suy vnh mn, suy tim... 2. No: a. Cp: Xut huyt no, tc mch no, TBMN thong qua, bnh no do THA... b. Mn: TBMN, TBMN thong qua.

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3. Thn: i mu, i ra protein, suy thn... 4. Mt: Soi y mt c th thy: cc mch mu co nh, du hiu bt cho ng mch/tnh mch (du hiu Salus Gnn), xut huyt, xut tit vng mc, ph gai th 5. Bnh ng mch ngoi vi. C. Phn tng mi nguy c i vi bnh nhn THA C 3 nhm nguy c (theo JNC VI): 1. Nhm A: L nhng bnh nhn THA nh hoc THA m khng c tn thng c quan ch, khng c cc nguy c bnh mch vnh, khng c biu hin bnh tim mch. 2. Nhm B: L nhng bnh nhn THA cha c tn thng c quan ch v khng c bnh tim mch km theo m c t nht mt yu t nguy c bnh tim mch ni trn nhng khng phi l tiu ng. 3. Nhm C: l nhm c bnh tim mch km theo hoc c tn thng c quan ch hoc tiu ng v c hoc khng km theo yu t nguy c bnh tim mch. Bng 7-4. Phn tng mi nguy c v thi iu tr THA. Nhm nguy c Giai on THA A B C Bnh thng iu chnh iu chnh Dng cao li sng li sng thuc** Giai on I iu chnh iu chnh Dng li sng (ti li sng (ti thuc 6 thng)* 12 thng) Giai on II Dng thuc Dng thuc Dng v III thuc Ghi ch: (*) Cho nhng bnh nhn c nhiu yu t nguy c, cn nhc cho ngay thuc phi hp vi iu chnh li sng. (**) Cho nhng bnh nhn c suy tim, suy thn, tiu ng.

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VII. iu tr tng huyt p A. Mc ch v nguyn tc iu tr 1. Ngn nga lu di cc bin chng. 2. a HA v tr s bnh thng (< 140/90 mmHg, nu c tiu ng th s HA phi <135/85 mmHg). 3. iu tr cn ht sc tch cc bnh nhn c tn thng c quan ch. 4. Phi cn nhc tng c th bnh nhn, cc bnh km theo, cc yu t nguy c, cc tc dng ph v nh hng c th ca thuc m c ch dng thuc thch hp. 5. Nu khng c nhng tnh hung THA cp cu th HA nn c h t t trnh nhng bin chng thiu mu c quan ch (no). 6. Vic gio dc bnh nhn cn phi nhn mnh: a. iu tr THA l mt iu tr sut i; b. Triu chng c nng ca THA khng phi lc no cng gp v khng tng xng vi mc nng nh ca THA; c. Ch c tun th ch iu tr thch hp mi gim c ng k cc tai bin do THA. B. Ch iu tr khng dng thuc (thay i li sng): L phng php iu tr bt buc d c km theo dng thuc hay khng. 1. Gim cn nng nu tha cn: a. Ch gim cn cn c bit c nhn mnh nhng bnh nhn nam gii bo ph th trung tm (bo bng). b. Vic gim bo ph c chng minh lm gim c cholesterol v gim ph i tht tri. c. Khng p dng ch ny cho ph n c thai b THA.

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2. Hn ch ru: a. Nu dng qu nhiu ru lm tng nguy c tai bin mch no bnh nhn THA, lm tng tr khng vi thuc iu tr THA. b. Mt s iu tra cho thy nu dng lng ru thch hp th c th lm gim nguy c bnh mch vnh (hiu ng ngc). c. Do lng ru nu c dng cn hn ch t hn 30 ml ethanol/ngy (t hn 720 ml bia, 300 ml ru vang v 60 ml ru Whisky). d. Tuy nhin, vi mt s dn tc m s cn nng khng nhiu (nh ngi dn nc ta) th lng ru nu c dng ch nn bng mt na lng ru ni trn. 3. Tng cng luyn tp th lc: a. Nu tnh hung lm sng cho php nn khuyn khch bnh nhn tp th dc u. b. Ch luyn tp cn u n t nht 30 - 45 pht/ngy v hu ht cc ngy trong tun. c. Vi nhng bnh nhn c triu chng hoc nguy c bnh mch vnh cn phi cho bnh nhn lm cc nghim php gng sc th lc trc khi quyt nh cho bnh nhn ch tp th lc. 4. Ch n: a. Gim mui (Natri), c chng minh lm gim s huyt p v nguy c bin chng bnh nhn THA. Ch n gim mui nn thc hin vi lng mui < 6 g NaCl/ngy hoc < 2,4 g Natri/ngy. b. Duy tr y lng Kali khong 90 mmol/ngy, c bit bnh nhn c dng thuc li tiu iu tr THA. c. Bo m y calcium v magnesium. d. Ch n hn ch cc m ng vt bo ho, hn ch cc thc n giu Cholesterol. 5. B thuc l: Cn ht sc nhn mnh bnh nhn cng quyt t b ht thuc l trong mi trng hp, v y l mt trong nhng nguy c mnh nht ca cc bin chng tim mch.

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C. Cc thuc iu tr tng huyt p 1. Thuc chn bta giao cm (bng 7-5): a. L mt trong cc th thuc c la chn hng u trong iu tr THA, c chng minh lm gim t l TBMN v c bit l gim NMCT. b. C ch: Lm h huyt p do chn th th bta giao cm vi catecholamin do lm gim nhp tim v cung lng tim. N cng lm gim nng renin trong mu, lm tng gii phng cc prostaglandins gy gin mch. Bng 7-5. Cc loi thuc chn bta giao cm hay dng. Cc loi thuc Atenolol Betaxolol Bisoprolol Metoprolol Metoprolol XL Acebutolol Propranolol Propranolol LA Timolol Pindolol Carteolol Penbutolol Labetalol Carvedilol ISA Liu u 50 mg 10 mg 5 mg Liu duy tr 25- 100 mg 5 - 40 mg 2,5 - 20 mg 50 - 450 mg 50 - 400 mg 200 - 1200 40 - 240 mg 60 - 120 mg 20 60 10 - 60 mg 2,5 - 10 mg 20 - 80 mg 200 - 1200 mg 12,5- 1200 mg Loi chn chn lc 1

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Cc thuc khng chn lc

Thuc chn c bta v alpha giao cm 100 mg x 2 6,25 mg x 2

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50 mg x 2 50-100 mg 200 mg x 2 40 mg x 2 40 - 80 mg 10 mg x 2 5 mg x 2 2,5 mg 20 mg

10

c. Phn loi: Da trn mc chn lc trn tim m c th chia ra nhm c chn lc vi th th 1 v khng chn lc (chn c 1 v 2). Tuy nhin vi liu cao th cc thuc chn lc 1 s khng cn chn lc na. Cc thuc chn bta giao cm ny cn c phn bit bi c hot tnh giao cm ni ti (ISA) hoc khng c. Thuc c hot tnh ging giao cm ni ti t gy h nhp tim hn. d. Chng ch nh v tc dng ph: cc thuc chn bta giao cm c kh nhiu chng ch nh: Nhp chm, c bit l bloc nh tht cao. Suy tim nng. Cc bnh phi co tht (hen ph qun). Bnh ng mch ngoi vi. Thn trng bnh nhn c tiu ng, ri lon m mu. Thuc dng lu c th gy hi chng Raynaud, lit dng, mt ng, trm cm... C hiu ng cn THA bng pht nu ngng thuc t ngt. 2. Cc thuc chn alpha giao cm (bng 7-6): a. C ch tc dng: Cc thuc ny c ch th th 1 giao cm lm bloc th th alpha giao cm hu hch, dn n gin ng mch v tnh mch. Bng 7-6. Cc thuc chn alpha giao cm thng dng.

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Cc loi thuc Doxazosin mesylate

Bit dc Minipress

Khi u

Duy tr 1-16 mg 1-20 mg

Cardura

1 mg 1 mg x 2

Prazosin hydrochloride

Terazosin hydrochloride Hytrin 1 mg 1-20 mg b. c im: cc thuc chn alpha giao cm thng c hi chng liu u tin tc l tc dng rt mnh khi dng liu u tin, c th dn n tt huyt p, do khi dng liu u tin cn bt u rt thp v theo di cht ch. Cc thuc ny c
11

th gy tt huyt p t th, au u, chng mt... Thuc chn lc 1 giao cm dng lu di c th ci thin tnh trng ri lon m mu. Thuc cn c tc dng tt cha triu chng nhng bnh nhn c ph i tin lit tuyn lnh tnh. 3. Thuc chn c alpha v bta giao cm: (bng 7-5) a. Do chn c th th bta tim v alpha mch ngoi vi nn c c c hai c ch gy h HA ca hai nhm ni trn. b. Carvedilol l loi thuc hin c xut khng nhng iu tr THA, suy vnh m cn tc dng tt trong suy tim vi liu kim sot cht ch. c. Tc dng ph ging nh cc thuc chn bta giao cm, ngoi ra c th gy hu hoi t bo gan, h HA t th, hi chng ging lupus ban , run chn tay v bng pht THA khi ngng thuc t ngt. 4. Cc thuc tc ng ln h giao cm trung ng: a. C ch: cc thuc nhm ny kch thch th th 2 giao cm tin hch trong h thn kinh trung ng, lm gim trng lc giao cm ngoi vi v lm gim tr khng mch h thng, t h huyt p. b. c im: Cc thuc ny khng phi l thuc la chn u tin cho iu tr THA do c nhiu tc dng ph nh: nhp chm, chng mt, kh ming, h huyt p t th, trm cm, ri lon hot ng tnh dc. Mt s thuc c th gy tng men gan, gim chc nng tht tri v c bit l hi chng ngng thuc t ngt- THA bng pht khi ngng thuc t ngt. 5. Cc thuc khc tc ng ln h giao cm: a. C ch tc dng: Cc thuc ny ngn chn gii phng ngun Norepinephrin (Noradrenalin) tn cng thn kinh ngoi vi. Ring Reserpine cn c

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b. c im: hin nay cc thuc ny khng cn c coi l thuc la chn u tin trong iu tr THA, nhng vn cn c ch trong mt s trng hp nht nh. c. Tc dng ph ca cc thuc ny kh nhiu: Reserpin gy trm cm 2 % s bnh nhn. Ngoi ra cc thuc nhm ny c th gy bun ng, kh ming, nght mi, h HA t th, cc ri lon tnh dc hoc ri lon tiu ho. Bng 7-7. Cc thuc tc ng ln h giao cm trung ng v ngoi vi Tn thuc Bit dc Liu u Duy tr Thuc tc ng ln h giao cm trung ng Clonidine Catapres 0,1 mg x 2 0,1 - 1,2 mg Methyldopa Aldomet, 250 mg x 2-3 250-2000 mg Dopegyt Thuc tc ng ln h giao cm ngoi vi Guanfacine Tenex 1 mg 1 - 3 mg Guanabenz Wytensin 4 mg x 2 4 - 64 mg Thuc c tc dng hn hp Reserpine 0,5 mg 0,01- 0,25 mg 6. Cc thuc li tiu: a. Li tiu c coi l thuc nn la chn hng u trong iu tr THA. b. C ch tc dng: Li tiu lm gim khi lng tun hon trong lng mch, do lm h HA. Ngoi ra, li tiu c th lm gim nh cung lng tim v tng tr khng mch ngoi vi nhng tc dng ny khng tri v ht nu dng lu di.

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Mt s loi c tc dng gy gin mch nh (Indapamide) do c ch dng Natri vo t bo c trn thnh mch. c. Cc nhm thuc li tiu (bng 7-8). Bng 7-8. Cc loi thuc li tiu thng dng. Loi thuc Liu u Duy tr Nhm Thiazide Benzthiazide 25 mg x 2 50-100 mg Chlorothiazide 500 mg 125-1000 mg Chlorothalidone 25 mg 12,5-50 mg Hydrochlorothiazide 25 mg 12,5 - 50 mg Hydroflumethiazide 50 mg 50- 100 mg Indapamide 1,25 mg 2,5 - 5,0 mg Methylchlothyiazide 2,5 mg 2,5 - 5 mg Metolazone 2,5 mg 1,25-5 mg Quinethazone 50 mg 25-100 mg Li tiu tc ng ln quai Henle Bumetanide 0,5 mg ung 0,5-5,0 mg hoc tim TM Ethacrynic acid 50 mg ung 25-100 mg hoc tim TM Furosemide 20 mg ung 20-320 mg hoc tim TM Torsemide 5 mg ung 5-10 mg hoc tim TM Li tiu gi kali Amiloride 5 mg 5-10 mg Spironolactone 50 mg 25-100 mg Triamterene 50 mg x 2 50 - 200 mg d. Tc dng ph: Khc nhau tu tng nhm. Nhm Thiazide gy h kali mu, h magne mu v gy ri lon m mu nu dng ko di. C th gy yu c, chut rt, lit dng...

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Thiazide c th lm xu chc nng thn bnh nhn suy thn. Li tiu tc dng trn quai l li tiu mnh, lm mt kali v in gii khc nhiu v c th gy ng c vi tai. N ci thin c chc nng thn v khng nh hng n m mu. Li tiu gi kali l li tiu yu v t khi dng n c. Khi phi hp vi mt loi li tiu thi kali lm tng tc dng li tiu v ngn nga c tc dng ph gy ri lon in gii mu. Ch khi dng bnh nhn suy thn. 7. Cc thuc chn knh canxi: a. Cc thuc nhm ny c tc dng h HA rt r v tng i t tc dng ph. Tc dng ca cc thuc thuc nhm ny trn h thng tim mch rt khc nhau tu tng loi. Bng 7-9. Cc thuc chn knh canxi thng dng. Tn thuc Bit dc Liu ban u Duy tr Nhm Dihydropyridine (DHP) Nifedipine Adalate 10 mg 10-30 mg NifedipineXL,LL Adalate LA 30 mg 30-90 mg Amlordipine Amlor 5 mg 2,5-10 mg Isradipine 2,5 mg x 2 2,5-10 mg Nicardipine 20 mg x 4 60-120 mg Felodipine Plendil 5 mg 2,5-10 mg Nhm Benzothiazepine Diltiazem SR 60-120mgx2 120-360 mg Diltiazem CD 180 mg 180-360 mg Diltiazem XR 180 mg 180-480 mg Nhm Diphenylalkylamine Verapamil 80 mg 80-480 mg VerapamilCOER 180 mg 180-480 mg Verapamil SR Isoptine 120 mg 120-480 mg

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b. C ch tc dng: Cc thuc chn knh calci lm gin h tiu ng mch bng cch ngn chn dng canxi chm vo trong t bo c trn thnh mch. Cc tc ng trn nhp tim v sc co bp c tim tu thuc vo tng phn nhm thuc. c. c im: Cc thuc nhm DHP th h sau (Amlordipine, Felodipine, Isradipine...) tc dng tng i chn lc trn mch v c tc dng h HA tt, t nh hng n chc nng co bp c tim v nhp tim, c tc dng ko di nn c th dng liu duy nht trong ngy. Nifedipin lm nhp tim nhanh phn ng. N c nh hng n sc co bp c tim nhng khng nhiu bng Verapamil v Diltiazem. Verapamil v Diltiazem c nh hng nhiu n ng dn truyn gy nhp chm v c nh hng nhiu n sc co c tim. d. Tc dng ph: Verapamil c th gy to bn, nn, au u, h huyt p t th. Diltiazem c th gy nn, au u, mn nga... Cc DHP c th gy ph cc u chi, bng mt, au u, mn nga. Cc thuc chn knh canxi thng khng gy nh hng n ng mu, lipid mu khi dng ko di. Nhn chung cc thuc chn knh canxi khng c ch nh bnh nhn NMCT cp m c ri lon chc nng tht tri. 8. Thuc c ch men chuyn (CMC): a. L nhng thuc iu tr THA tt, t gy nhng tc dng ph trm trng, khng nh hng nhp tim

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b. C ch tc dng: thuc c tc dng c ch men chuyn, l loi men gip chuyn t angiotensin I thnh angiotensin II, do lm gin mch, gim tit aldosterone gy h HA. N cn c ch con ng thoi ging ca bradykinin, lm cht ny ng li v cng gy ra gin mch, h huyt p. Copyright 2008. Finloev. All rights reserved Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn Potocity2020@yahoo.com.vn Angiotensinogen Renin CMC Angiotensin I Karikinin

Angiotensin II Aldosterone

Co mch trc tip

THA Hnh 7-1. C ch tc dng ca thuc c ch men chuyn. c. c im: Khng gy ri lon lipid mu, ng mu, acid uric khi dng ko di. Tc dng ph kh chu hay gp ca CMC l gy ho khan, nhiu khi phi cho ngng thuc v tc dng ph ny. CMC gin u tin tiu ng mch i cu thn nn c th gy suy thn t ngt do gim dng mu ti thn nhng bnh nhn b hp ng mch thn 2 bn. Chng ch nh tuyt

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Cc peptid bt hot

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i ca CMC l bnh nhn c hp ng mch thn 2 bn. CMC cng khng dng ph n c thai. V lm tng kali mu nn thn trng bnh nhn suy thn, ang dng thuc li tiu gi kali, hoc ch bi ph kali. Bng 7-10. Cc thuc tc ng ln h Renin-Angiotensin. Thuc Bit dc Liu u Liu duy tr Cc thuc c ch men chuyn Captopril Capoten, Lopril 25 mg 50 - 450 mg Enalapril Renitec 5 mg 2,5 - 40 mg Benazepril Lotensin 10 mg 10 - 40 mg Fosinopril Monopril 10 mg 10 - 40 mg Lisinopril Zestril 5-10 mg 5 - 40 mg Moexipril Univasc 7,5 mg 7,5 - 30 mg Quinapril Accupril 5-10 mg 5 - 40 mg Ramipril Altace 2,5 mg 1,25 - 20 mg Trandolapril Mavik 1-2 mg 1 - 4 mg Perindopril Coversyl 2-4 mg 4 mg Cc thuc c ch th th AT1 Losartan Cozaar 25 - 100 mg Valsartan Diovan 80 - 320 mg Irbesartan Avapro 150 - 300 mg Telmisartan Micardis 20 - 160 mg 9. Cc thuc i khng vi th th AT1 ca Angiotensin II: y l cc thuc kh mi trong iu tr THA v suy tim. a. C ch: c ch th th AT1, ni tip nhn tc dng ca angiotensin II (l mt cht gy co mch mnh), t lm gin mch, h huyt p. b. V c ch ny nn thng khng gy ra ho nh khi dng CMC. C th c tc dng ph nh vim ph mch ngoi vi, d ng, nga... Tc ng ln thn v kali mu t hn khi dng CMC. 10. Cc thuc gin mch trc tip:

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a. C ch tc dng: Cc thuc ny lm gin trc tip c trn ng mch gy h huyt p. N c th phn ng tng ti hp thu nc v natri v lm tng hot ng h giao cm phn ng gy nhp tim nhanh. b. L thuc h huyt p mnh, nhng khng phi l la chn hng u. Rt c ch khi bnh nhn c biu hin khng li cc thuc h huyt p khc, hoc c th ch nh cho ph n c thai. C th phi hp thm loi thuc ny vi nitrate iu tr suy tim. c. Tc dng ph c th gp l: au u, nn, nhp nhanh, h HA t th. C th gy hi chng ging Lupus ban (10 % bnh nhn dng ko di, liu cao), do khi c hi chng ny phi ngng ngay thuc. Minoxidil c th gy tng cn, ri lon nh v bt thng in tim, tng mc lng tc, trn dch mng tim. Bng 7-11. Cc thuc gin mch trc tip. Thuc Bit dc Liu u Liu duy tr Hydralazine Apresolin 10 mg 50 - 300 mg Minoxidil Loniten 5 mg 2,5 - 100 mg 11. Cc thuc h huyt p dng theo ng truyn tnh mch: cc thuc ny (bng 7-12) c th c xp loi trong cc nhm thuc ni trn hoc khng. a. Cc thuc nhm ny c th c ch nh trong mt s tnh hung THA lm sng nht nh: Tng huyt p c tnh. Chy mu ni s do THA. Tch thnh ng mch ch. Suy thn tin trin nhanh. Sn git. THA km NMCT cp hoc suy tim tri cp.

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b. Ch nn s dng cc thuc ny ti mt s n v hi sc tch cc (c trang thit b k thut v iu kin theo di tt bnh nhn). 12. Cc thuc h HA dng theo ng di li: a. Trong mt s trng hp cp cu dng thuc theo con ng ny cho kt qu tt. Hai loi thuc hay dng l Nifedipine v Clonidine. b. Nifedipine cho ngm di li bt u c tc dng trong vng 30 pht. Loi vin nang 10 mg, cho cn, nhai v nut th tc dng cn nhanh hn. Tc dng c th ko di n 4-5 gi theo ng dng ny. Ch thuc c th gy tt HA qu nhiu v nhanh. Khng nn dng trong trng hp bnh nhn b NMCT cp hoc suy tim cp. Bng 7-12. Cc thuc iu tr THA theo ng tnh mch. Thuc Liu dng Ch Truyn TM: 0,5 - L thuc la chn u Sodium 10 g/kg/pht tin, c th gy tt p, Nitroprusside nn, nguy c ng c - Tc dng: cyanide bnh nhn suy tc thi gan, hen. Phi bc k - Ko di: trnh nh sng 2-3 pht Tim: 50-100 mg, Nhp nhanh, tt HA, Diazoxide nhc li 5-10 pht, nn, tng ng mu. C - Tc dng: tng liu 600 mg. th lm tng thiu mu 1-5 pht - Ko di: Truyn TM: 10-30 c tim bnh nhn NMCT, lm nng thm 6-12 gi mg/pht suy tim, tch thnh MC Tim: 20-80 mg, C th gy tt p, bloc Labetalol nhc li 5-10 pht, nh tht, suy tim, co tht - Tc dng: ph qun, nn, THA tng liu 300mg. 5-10 pht Truyn TM: 0,5-2 bng li khi ngng. C - Ko di: th t tc dng bnh mg/pht 3-6 gi nhn dng chn bta

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Nitroglycerin - TD: 1-2 pht - KD: 3-5 pht Esmolol - Tc dng: 1-5 pht - Ko di: 10 pht Phentolamine - TD: 1-2 pht -KD:3-10 pht Hydralazine - Tc dng: 10-20 pht - Ko di: 3-6 gi Nicardipine - Tc dng: 1-5 pht - Ko di: 3-6 gi Enalaprilat - TD:5-15 pht - KD: 1-6 gi

Truyn TM: 5-100 au u, nn. C th g/pht gim tc dng nu dng lu di. Tim TM: 500 Tt HA, bloc nh tht, g/kg/ph trong suy tim, co tht ph qun pht u Truyn TM: 50300 g/kg/ph Tim TM: 5-10 Tt HA, tim nhanh, au mg mi 5-15 pht u, au ngc, p ng THA nghch thng. Tim TM: 10-20 u tin dng trong sn mg sau 20 pht git. C th gy tt p, nhc li (nu suy thai, nhp nhanh, au khng c p ng) u, nn, vim tc TM ti ch. Truyn 5 mg/gi , Tt p, au u, nhp c th tng 1,0-2,5 nhanh, nn. mg/gi mi 15 pht, ti a 15 mg/gi Tim TM 0,625- Tt huyt p. 2,5 mg mi 6 h

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VI. Mt s tnh hung lm sng

A. THA ngi tr 1. Nn ch tm nguyn nhn. 2. c im THA ngi tr tui l c s tng trng lc h giao cm v tng nng renin huyt tng. 3. Cc thuc nhn chung d la chn cho ngi tr. B. THA ngi c tui 1. Thng km theo tng tr khng h mch mu, gim nng renin mu, tng khi lng c tht tri.

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D.

E.

F.

G.

2. Hay c km cc bnh khc, nn khi cho thuc h HA phi cn nhc cc chng ch nh v tc dng ph. 3. Li tiu hoc chn knh calci nn c la chn nu khng c cc chng ch nh. 4. Nn trnh dng cc thuc c th gy h HA t th hoc cc thuc tc ng ln h thn kinh trung ng v tng nguy c gy trm cm. THA ngi bo ph 1. Thng hay c tng tr khng mch, tng cung lng tim, v tng khi lng tun hon. 2. Gim cn nng l mc tiu quan trng nht. 3. Thuc u tin nn la chn l li tiu. THA ngi tiu ng 1. Thng c km theo bnh l thn do tiu ng. 2. Mc tiu l h HA v di mc bnh thng cao. 3. Thuc CMC nn c la chn hng u v tc dng tt v lm gim protein niu. THA c suy thn mn tnh 1. Ph thuc nhiu vo khi lng tun hon. 2. Li tiu l thuc u tin, trong li tiu quai c bit c tc dng khi m creatinin mu > 2,5 mg/dl, n gip ci thin c chc nng thn. THA c ph i tht tri 1. Ph i tht tri lm tng nguy c t t, NMCT. 2. Ch n gim mui; gim cn nng v cc thuc h HA (tr thuc gin mch trc tip) c th lm gim ph i tht tri. Thuc CMC l loi lm gim ph i tht tri mnh nht. THA c km theo bnh mch vnh 1. Chn bta giao cm nn c la chn hng u nu khng c cc chng ch nh. 2. Chn bta giao cm lm gim t l t vong do NMCT, lm gim nguy c dn n NMCT bnh nhn au ngc khng n nh. N cn lm gim

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nguy c ti NMCT bnh nhn sau NMCT v lm tng t l sng st sau NMCT. 3. CMC c ch nht l khi bnh nhn c gim chc nng tht tri km theo. 4. Chn knh calci c th dng khi THA nhiu, nhng cn ht sc thn trng v ch nn dng khi khng c suy gim chc nng tht tri. H. THA c suy tim 1. CMC v li tiu l thuc la chn hng u. 2. C th dng phi hp gia Nitrate vi Hydralazine trong trng hp THA kh tr. Cn ht sc thn trng vi Hydralazine v n lm tng nhp tim phn x, do c th lm xu i tnh trng thiu mu cc b bnh nhn c suy vnh km theo. I. THA v thai nghn 1. Phn loi THA ph n c thai: (theo Trng mn Sn Ph khoa Hoa k 1996) THA ph n c thai c th gp cc tnh hung sau: a. Tin sn git hoc sn git: l tnh trng THA khi c thai km theo protein niu, ph v c th c ri lon chc nng gan, thn. b. THA mn tnh do bt k nguyn nhn no: l tnh trng THA xut hin trc tun th 20 thai k. c. THA mn tnh do hu qu ca tin sn git hoc sn git. d. THA thong qua hoc mun: L THA khng lin quan n protein niu v khng c nh hng n h thn kinh trung ng. THA tr li bnh thng vi ngy sau . 2. iu tr: a. Nn iu tr khi HA ti thiu > 100 mmHg. b. Khng p dng ch gim cn nng v tp luyn qu sc. c. Methyldopa l thuc nn c la chn hng u; Hydralazine c th c dng thay th.

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Bt u hoc tip tc thay i li sng 23

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THA

Khng t c ch iu tr THA (< 140/90 mmHg) H HA thp hn vi bnh nhn i tho ng hay bnh thn
La chn thuc iu tr ban u (tr phi c chng ch nh)

Tng huyt p khng c bin chng:


Thuc li tiu Thuc chn th th giao cm i ng tp I c protein niu: Thuc c ch men chuyn Suy tim: Thuc c ch men chuyn, li tiu THA tm thu n c (ngi gi): u tin thuc li tiu, chn knh canxi loi dihydropyridine tc dng ko di. NMCT: Thuc chn giao cm (khng c ISA), thuc c ch men chuyn (khi ri lon chc nng tm thu) Thuc c ch men chuyn Thuc c ch th th angiotensin II Thuc chn th th giao cm Thuc chn th th giao cm Thuc chn th th - giao cm Thuc chn knh canxi Thuc li tiu

Ch nh bt buc:

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Cc ch nh c bit cho cc loi thuc sau:

Bt u loi thuc tc dng ko di, liu duy nht trong ngy, liu thp. iu chnh liu. C th kt hp liu thp cc thuc khc

Khng t c ch iu tr THA Khng p ng C cc tc dng ph Thay bng thuc nhm khc

Cha t ti ch iu tr THA

Tip tc thm loi thuc th ba khc nhm nh gi li nguyn nhn, ch iu tr

Hnh 7- 2. Phc iu tr THA (theo JNC VI).

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Dung np tt nhng p ng khng Thm thuc nhm khc (li tiu nu cha dng)

24

Tai bin mch mu no

Theo T chc Y t th gii (1993) tai bin mch mu no (TBMN) hay t qu l mt trong 10 nguyn nhn gy t vong hng u, ch ng sau bnh tim mch v ung th. Hng nm, ti M c khong 730000 ca t qu, t l t vong chim ti 27%. Ti Vin Tim mch Vit nam (19962000) tnh trung bnh c 2 ngy c mt bnh nhn vo vin v TBMN. T vong do TBMN chim 1/4 t l t vong chung ti Vin Tim mch. Ngay ti cc nc pht trin, TBMN vn l mt bin chng nng, d t vong, nh hng ln ti sc kho, tm thn v i sng ngi bnh, cc di chng tn ph ved tr thnh gnh nng cho gia nh, x hi. ser re TBMN gp nam nhiu hn n gii, hayts .vn la tui gh gp i trung nin (> 40 tui). Tui ca nhng All r o.nhn TBMN c bnh com . aho ev lin quan n tng huyt p, nhilomu c tim hay x va in 20@y F ng mch thng ln hn bnh2nhn TBMN c lin quan 8. 0 00 ity tm mc nhim khun. 2 n bnh van tim hay vimc ni t oto ghgiPno trong ngy v bt c ma no TBMN xy ra bt ri y k trong nm, songopthng xy ra 1-10 gi sng v vo cc C thng nng nht (thng 7, 8) hay lnh nht (thng 12,1 - theo thng k ca Vin Tim mch Vit nam). I. Phn loi tai bin mch mu no (TBMN) A. TBMN (hay t qu) l mt ri lon khu tr chc nng ca no c tin trin nhanh trn lm sng, nguyn nhn thng do mt mch mu no b v hoc tc. TBMN c cc loi tn thng chnh l chy mu no, chy mu mng no v nhn no hoc phi hp cc loi. 1. Chy mu no do v mch mu no, lin quan vi huyt p cao hoc d dng mch mu no. 2. Nhn no xy ra khi mt nhnh ng mch no b tc thng do 3 nguyn nhn chnh l mng x va, cc tc bn t xa ti v nhn no do gim ti mu 121 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

no. Cc nguyn nhn him gp khc bao gm: tch thnh ng mch no, vim mch no v huyt khi tnh mch no. a. Nhn no do mng x va ch yu xy ra cc mch mu ln (ng mch cnh trong, ng mch sng, ng mch nn) song cng xy ra cc ng mch no nh v va bt k vng no. Thng tn lc u ch l mng x va gy hp dn lng mch, t to thnh huyt khi, sau cng gy tc mch. Huyt khi c khi hnh thnh mi d khng c x va t trc, hay gp bnh nhn c tnh trng tng ng. Khuyt no (lacunar stroke) thng v tc cc tiu ng mch nm su trong no do mng x va nh hoc do ved qu trnh lipohya-linolysis (hay gp eser nhn bnh r ts tng huyt p). gh m.vn ri o a. TBMN do cc tc bn t .xallthng gy tc cc A hoo.c v ng mch no ng loe @ya in knh trung bnh, nht l 0 F ng mch no gia v 2 nhnh chnh ca h 8. 20 cc y 00 sng nn. Ngun gc ca cc thng ng t 2 tocit mch cc tcyrighch oyu t tim, mt s t hnh thnh ny P p ngay oti vng x va ca phn u cc ng C mch no. Gn mt na nguyn nhn cc tc t tim l huyt khi hnh thnh do rung nh, phn cn li l huyt khi hnh thnh do ri lon chc nng tht tri nng, do cc bnh van tim (hp van hai l), tc mch nghch thng hoc nhi mu c tim mi, thm ch do mng x va bn t quai MC, cc si do vim ni tm mc nhim khun. b. TBMN do gim ti mu no xy ra nhng mch no hp nhiu cha n mc tc hn, gy thiu mu nhng vng xa ni gip ranh ti mu ca cc ng mch no. Kinh in l vng gip ranh gia ng mch no trc v ng mch no gia, l vng chi phi vn ng cc chi. Hp ng mch cnh trong mc nng c th 122 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

gy thiu mu vng ny, nht l sau khi c tt huyt p. c. Tch thnh ng mch no hay gp ng mch cnh trong hoc ng mch sng, do chn thng hoc t pht (50%). Tch thnh ng mch cng c th gp cc ng mch c hin tng lon sn x c. d. t qu cn xy ra nhng bnh nhn vim mch mu no do cc bnh t min, nhim trng, nghin ma tu hoc v cn. Mt s t trng hp t qu do huyt khi trong tnh mch hoc xoang tnh mch ni s: nhng trng hp ny hay c km theo chy mu no, ng kinh v cc du hiu tng p lc ni s. ved 3. TBMN thong qua (cn thiu mu no thong qua, ser re TIA: transient ischemic attack): ngi bnhn nhin ts t gh m.v na mt, b lit na ngi hoc mt nhm ll rinh lit c co . . A c, tay bung ri ni nghu, t nhin khng oev ahoo nhai inl @y vt ang cm; nhngFcc2du hiu ny thoi trin . 20 0 08 gi. ht ngay trong vng024ity Nguyn nhn do tc mt 2 toc t o ng mch nohnhng cc mu ng li t tiu c. P ig yr v tr tn thng ng mch no. Bng 8-1. Dpbo Co Khi pht ng mch Nguyn nhn tn thng thng gp Tht ngn + Lit 1/2 ng mch Cc tc t xa hoc ngi no gia do mng x va Yu na ngi n thun Khuyt no Mng x va nh v/hoc mt cm gic na ngi n thun Yu chn nhiu hn tay, ng mch Cc tc t xa hoc do mng x va i dm, thay i tnh no trc tnh Mt th trng n thun ng mch Cc tc t xa hoc no sau do mng x va Yu t chi, lit thn kinh ng mch Mng x va s, tht iu nn 123 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

B. Hi bnh v khm lm sng thn kinh t m cho php xc nh s b vng mch no b tn thng v nguyn nhn gy ra TBMN. Chng hn: bnh nhn c tht vn ngn v lit na ngi phi s c thng tn ca ng mch no gia bn tri, thng do cc tc t ng mch cnh hoc ngun gc ng mch. Ngc li, yu mt, tay v chn m khng c cc du hiu khc thng gi tn thng khuyt no do tc cc mch nh nm su trong no. 1. Khng th phn bit chnh xc nhn no v xut huyt no trn lm sng d c nhiu im gi nh: din bin ca xut huyt no thng t ngt hn, km du hiu mng no v chc dch tu sng c mu khng ng khi chy mu no-mng no...dtrong e erv khi nhn no thng c tin triu i trc,shay gp re hs bnh nhn tng huyt p (2/3 TBMNt m.vn rig co bnh nhn l THA l nhn no, ch 1/3 l xutl huyt no), c cc . A oo. oev yah tin s i tho du hiu hp, tc ng mch cnh, c inl @ . F 2020 ng, hay km st...08 20 ity 2. Nhng yu tght Potocquan trng ca TBMN l tng nguy c i huyt p,opyr tho ng, bnh tim (bnh van hai l, i C rung nh, vim ni tm mc nhim khun, bnh c tim gin, nhi mu c tim...), thiu mu no thong qua, bo ph, nghin ru, ht thuc l, ri lon lipid mu, tng axt uric mu. II. Chn on v nh gi tai bin mch no A. Triu chng lm sng 1. TBMN c th c cc du hiu bo trc nhng khng c trng v rt d b b qua nh: au u, chng mt, tai... c bit l nhc u: au nhc 2 bn thi dng, hoc c khi au d di mt na u hay sau gy, km theo cng ct sng. Phi ngh n TBMN khi ngi bnh c lit na ngi, ri lon tri gic hoc hn m. Khi bnh nhn nghi ng t qu 124 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

n vin th cn hi k bnh s v tin s, khm lm sng v thn kinh t m. Vi bnh nhn tht ngn, nn hi k ngi nh. Cn khm tim mch v thn kinh mt cch ton din k c vic nghe mch cnh hai bn v o huyt p c hai tay. Khm thn kinh bao gm nh gi tri gic, vn ngn, cc dy thn kinh s, vn ng, tiu no, tht iu, cm gic v phn x gn xng. 2. TBMN bao gi cng c xem l mt tnh trng cp cu ni khoa, khi pht hin cn s cu ti ch v chuyn bnh nhn n n v chuyn bit: n v Chm sc v iu tr TBMN (Stroke Unit). B. Cc xt nghim chn on ved 1. Khi nghi ng bnh nhn c TBMN nnerlm cc s re xt nghim: ts gh m.vn i Cng thc mu. ll r co . A ahoo. ng mu. oev @ inl 2c y F in gii mu .gm 0 magi v canxi (ri 08 ty20 2 i lon hai ion0magi v canxi c th gy triu t toc gh Ponh TBMN). chngi ging r py Creatinin mu. Co Thi gian Quick, t l PT v thi gian aPTT. in tm . Xquang ngc: nh gi chung v bnh tim mch v tnh trng vim phi do sc. Tng phn tch nc tiu (nu thy hng cu niu, nn i tm cc nguyn nhn gy tc c mch thn). Chp ct lp vi tnh (CT) hoc cng hng t (MRI) s no. Holter in tim, siu m mch cnh, siu m tim (qua thnh ngc hoc thc qun), chp mch no, chc dch tu sng - l nhm xt nghim c ch nh trong mt s bnh cnh lm sng nht nh. 125 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

2. Hi Tim mch M (AHA) khuyn co rng tt c nhng bnh nhn nghi ng t qu nn chp ct lp vi tnh theo t trng (CT) hoc chp cng hng t (MRI) phn bit gia nhn no v xut huyt no, nh khu v tr tn thng v loi tr nhng bnh l c biu hin ging t qu. Cc nguyn nhn gy biu hin ging TBMN gm: Thoi ho myelin (x cng ri rc). U no. p xe no, vim no, cc nhim trng thn kinh khc. Cc ri lon chuyn ho (tng ng mu hoc h ng mu, tng hoc h canxi mu, tng hoc h natri mu). ved Triu chng thn kinh sau ng kinh.r se re ts Chn thng (t mu di imng.vcng, dp gh m n ll r co no...). . A ahoo. Triu chng thn kinhv @y quan vi au na loe lin Fin020 u Migraine.08. 2 20 c ty Hi chng phn ily (Hysteri), bnh tm cn. ht Poto ri 3. Chp ctplpgtheo t trng (CT) s no rt gi tr oy Chin cc vng chy mu ln, u no hoc pht nhng thng tn cu trc trong s khc gy ra cc biu hin ging nh t qu cp tnh. Tuy nhin CT c th b st kh nhiu (ln ti 50%) nu chp ngay trong vng 12 gi k t khi khi pht. Hn na chp CT khng phi l bin php l tng pht hin cc vng nhn no nh, nhn no vng h sau hoc cc thng tn gy mt myelin (nh trong bnh x cng ri rc gy biu hin ging t qu). Chp CT xon c cho nhng hnh nh chi tit v cc ng mch trong v ngoi s, vi phn gii tt hn hn so vi chp MRI c thuc cn quang. 4. Hnh nh chp MRI s no nhy hn so vi chp CT, c bit trong nhng trng hp t qu cp, 126 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

nhi mu no nh (khuyt no) hoc vng tn thng lin quan n khu vc thn no. Mt khc chp MRI c thuc cn quang s cho php sng lc v kho st c bnh l cc ng mch ln trong hoc ngoi s. Nhng k thut MRI tin tin (MRI diffusion perfusion, spectroscopy) cn cho bit tnh trng chuyn ho v cp mu vng no b thiu mu. Tuy nhin Vit nam, chp MRI t hn nhiu so vi CT v c mt s chng ch nh. Do , nn dng cc triu chng lm sng d on v tr thng tn v nguyn nhn, t la chn phng tin chn on hnh nh thch hp. Chng hn trong trng hp nghi ng khuyt no, MRI l la chn tt nht v CT s khng th pht hin c cc thng tn ny nu ed din bin cp tnh hoc vng thn no.eserv Ngc li, r nu TBMN do tn thng cc mchgno .ln, nht l hts vn i xy ra vi ngy, khng cn All ch.cnh can thip c r om . ahoo thm th nn la chn chp loev s no. CT y Fin020@ 5. Siu m mch cnh 8. 2 thm d v nh gi 0 dng y 20 nhnh cc ng mch cnh, h thng tn ch chiaocit ht Pot rig thng ng mch sng nn. Siu m Doppler qua s py o dng Ckho st dng chy (hng, vn tc) ca cc ng mch ln trong s. 6. Ch nh Holter in tim 24-48 gi ( pht hin cn rung nh kch pht hoc cc loi ri lon nhp khc) hoc siu m Doppler tim nu nghi ng nguyn nhn TBMN do cc tc nghn t tim. Siu m Doppler tim qua thnh ngc c th pht hin rt nhiu nguyn nhn tim mch gy t qu nh huyt khi nh tri hoc tht tri, ri lon chc nng tht tri nng, bnh van tim hoc cn l bu dc. Nu nghi ng cn nguyn t tim m siu m tim qua thnh ngc khng pht hin bt thng g, th cn lm siu m tim qua thc qun. Tuy nhin i khi khng th lm c siu m qua thc qun mt s 127 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

bnh nhn nng. Siu m tim qua thc qun c nhy rt cao pht hin huyt khi nh tri, l bu dc, mt vi bnh l van tim (nh hp h van hai l) cng nh pht hin cc mng x va quai ng mch ch c kh nng bn i gy tc mch. 7. Chp ng mch no vn l tiu chun vng chn on bnh l cc mch no ln v cc mch nh trong s. Ch nh ch yu cho nhng bnh nhn t qu tr tui; trong trng hp nghi ng tch thnh mch no hoc vim mch mu no hoc ch nh trc khi phu thut bc ni mc ng mch cnh. Siu m Doppler mch cnh, chp CT, k c chp MRI mch no c cn quang vn c nhy thp (15%) pht hin nhng trng hp ved m cn ser bc ni mc ng mch cnh, v th nht thit phi e sr chp mch no trc loi phu thutight m.vn ny. ll r co . A ahoo. oev inl 20@y F 8. 0 00 ity2 2 t oc gh Pot ri py Co

A B C Hnh 8-1. Hnh nh xut huyt no (A), nhn no (B), v phnh d dng mch no (C) gy TBMN. 8. Chc dch no tu v lm in no khng cn phi lm thng quy i vi tt c nhng bnh nhn nghi ng t qu. D sao th chc dch no tu vn c gi tr trong nhng trng hp nghi ng xut huyt nh di mng nhn. Nhng bnh nhn nghi c vim mch, cng c bt thng trong dch no tu: s lng t bo tng cao (a s l bch cu lymph) v

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tng protein. Nhng bnh nhn c lit kiu Todd (sau ng kinh) s c bt thng trn in no . 9. Nn thm d tnh trng tng ng bnh nhn t qu tui di 45, c tin s tc ng mch hoc tnh mch t trc, tin s sy thai t nhin, tin s gia nh c thuyn tc mch tui tr, t qu khng r nguyn nhn xy ra trn bnh nhn c bnh t min... III. iu tr iu tr TBMN nhm mc ch phng cc bin chng, khi phc tn thng cp tnh ca nhu m no v phng t qu ti pht. A. Phng bin chng 1. Chng ph no: ved ser re a. Bng cc dung dch u trng: ts gh m.vn pht, i Mannitol truyn 0,5-1 g/kg rtrong 20-30 ll o co o . A g/kg. c 6h/ln. Nu sau truyn li 0,25-0,5 ah oev y inl 2gim dn liu mannitol truyn qu 48 h,Fnn 0@ 8. 0 trnh gy 0ph 2 20 ocity no hi li do thuc. Ni chungight Pot khng nn truyn qu 3 ngy, mannitol r p nuymun truyn nhiu hn, nn c khong Co ngh thi thuc, trnh tc dng gy tng p lc ni s th pht. Glycerol (1mg/kg trong vng 120 pht). Cho n nay, mannitol vn l bin php hng u chng ph no. Khi mannitol bt u gim tc dng m vn cn gim p, nn cn nhc truyn dch mui u trng hoc gim p bng phu thut. b. Tng thng kh c kim sot trong thi gian ngn (mc ch h PaCO2 xung cn 25-30 mmHg), gy kim ho mu, co mch no v gim th tch mu no, do lm gim ng k p lc ni s, tc dng ny xut hin ngay sau 20 pht nhng cng nhanh chng mt i sau 1-2 gi do h thng 129 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

m trong c th s trung ho tc dng ny, v th ch nn coi tng thng kh nh mt bin php cp cu tm thi trong khi ch i hoc phi hp vi cc bin php khc nh truyn dch u trng, m hp s... C th truyn dung dch THAM 60 mmol pha vi 100 ml Glucose 5% truyn tnh mch trong 45 pht sau duy tr qua tnh mch trung tm 3 mmol/h lm kim ho mu. c. Barbiturate: lm gim th tch dng mu no do co mch. Liu dng 250-500 mg thiopental (tim bolus) sau truyn tip tc 5 mg/kg/h hoc tim bolus tng lc. Bin chng c th xy ra l gim huyt p nng gy h p lc ti mu no. 2. Kim sot huyt p ng mch: ved ser huyt a. Mc d rt nhiu bnh nhn TBMNts re tng c n h p song a s trng hp huyt p .s gim t rig com v l . l . A huyt nhin. Nu tnh trng tng ahoo p vn cn, oev y nl xung t ngt v iu khng nn h huytFip 20@ . 20 ny lm ri lon08 ty 20 c ch t iu ho mch no, i lm trm ght Pothm tnh trng thiu mu no trng toc i ranh opyr vi tn thng, lm triu chng lm gii C sng nng thm. Gim mc tng huyt p bt buc phi lm trong mt s trng hp nh c triu chng bnh tim nng, tng huyt p c tnh, phnh tch ng mch ch v bnh nhn iu tr t-PA. Mt s tc gi yu cu phi h huyt p bnh nhn dng Heparin tnh mch gim nguy c chuyn nhn no thnh xut huyt no. b. Duy tr huyt p tm thu < 185 mmHg v huyt p tm trng < 110 mmHg. Nhng bnh nhn c huyt p qu cao (HA tm thu 220 mmHg, HA tm trng 120 mmHg) phi h p ngay, tuy nhin nn gim t t HA tm thu xung 170-180 mmHg v HA tm trng xung 95-100 mmHg. Sau nu vn tn ti triu chng lin quan n 130 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

tng huyt p, c th h tip HA tm thu cn 150160 mmHg v HA tm trng cn 90-95 mmHg. c. Khng nn dng Nifedipine di li h HA cp khi TBMN v kh nng h HA qu nhanh cng nh tc dng bt li ln c ch iu ho mu no s lm t qu nng hn. Nn trnh dng cc thuc h p c th gy tng p lc ni s nh cc thuc gin mch trc tip (Sodium Nitroprusside, Nitroglycerin, Hydralazin) v cc thuc chn knh canxi, nht l nhng bnh nhn nhi mu din rng gy ph n v do tt no. Cc nhm thuc h p khc nh c ch men chuyn, chn bta giao cm c tc dng h p tt m khng gy tc dng ph i vi huytd ng e erv ca mch mu no, c th ung (Captopril) hoc res hts n tim tnh mch (Enalapril, Labetalol, Esmolol)... rig com.v ll 3. Phng huyt khi tnh mchvsu hoo.tc ng mch . A av e phi: bng Heparin timinlo 0@y (5000 UI 12h/ln) di da F 02 hoc Heparin trng 008. y2 lng phn t thp liu d phng, t hoc i ng kht 2 op icng chn nu c chng ch toc gh P i nh dngpHeparin. yr Co 4. Phng vim phi do sc hoc tro ngc: a. Gn mt na s bnh nhn TBMN c nut kh, t c th gy sc v vim phi (15%). Nguy c ny cao nht bnh nhn tn thng gc cc ng mch no ln (80-90%), nguy c va bnh nhn nhn na bn cu (40-60%) v thp nht (10-15%) bnh nhn nhi mu no nh. b. Bnh nhn kh nut nn cho n qua ng thng mm trong tun u tin. Nu tnh trng kh nut cn ko di, nn m thng d dy hoc hng trng cho n v lm gim nguy c bin chng tro ngc.

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c. Phi hp thm vi cc thuc khng cholinergic nhAatropine hoc Glyco-pyrrolate gim tit dch v v gim nguy c vim phi do tro ngc. 5. Kim sot ng mu: rt nhiu bnh nhn TBMN c i tho ng thc s hoc tnh trng tng ng huyt thong qua, c hai u lm nng thm tn thng no. Do , khuynh hng hin nay l kim sot tch cc tnh trng tng ng mu bnh nhn t qu, duy tr ng mu < 170 mg/dl (< 9,5 mmol/l), dng Insulin tim/truyn tnh mch nu cn. 6. Kim sot thn nhit: bng thuc h st hoc p chn/khn lnh. Gim thn nhit t mc nhva s hn ch lan rng tn thng no th pht, gim p lc ni s v gim t l t vong. Tc dng rph hay ved se r gp l gim s lng tiu cu v tng tslevim phi. t vn gh mtrong 6 gi Khuynh hng h thn nhit sm rngay . i ll co u k t khi khi pht ang c nghin cu. . A ahoo. oev inl 20@y 7. Theo di v chm sc:. F 0 08 2 20 o n v TBMN, theo di st a. Nn bnh nhncity t t tnh trnggh Pokinh, cc du hiu sinh tn v i thn yr chmop ton din (1 y t cho 2-4 bnh nhn) C sc ch khng cn phi chuyn sang n v hi sc tch cc. b. Trong giai on cp cn p dng cc k thut cp cu ni khoa nhm m bo ng th thng thong (k c vic phi thng kh nhn to), duy tr cn bng nc - in gii, kim toan, dinh dng tt qua ng ming, qua ng thng d dy hoc nui dng hon ton qua ng tnh mch. c. Thc hin tt v sinh cho ngi bnh nh v sinh rng ming, thay qun o, v sinh ngoi da, v sinh ng tiu, cho nm m nc v xoay tr bnh nhn chng lot mc da cc im t , 132 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

d. Phc hi chc nng sm v tch cc ngay sau khi TBMN hi phc, luyn tp phng co cng cc c, khp, huyt khi... Ban u vic luyn tp phi do nhn vin y t thc hin v sau hun luyn cho ngi nh khi v nh c th tip tc tp cho bnh nhn. 8. Phu thut m hp s hoc dn lu no tht lm gim p lc ni s, trnh tt no, gip cu sng bnh nhn v ngn nga cc tn thng khng hi phc. Tuy nhin ch nh v thi gian ti u m hp s cn cn nghin cu thm. ed 9. Song song vi nhng vic ny, phi tip tc viu tr ser re nguyn nhn gy t qu v cc yu ts nguy c ca t gh m.vnbnh van TBMN nh tng huyt p, i tho ing, l r co Al h mu, .lipid oo. bo ph, ht tim, ri lon nhp tim, ri lonv a loe thuc l, nghin ru... . Fin 20@y 08 20 B. Khi phc cc tn thng nhu m no cp tnh 20 ocity t ot i h Trong giai ongsmPca TBMN, vng thng tn cha yr p Co ng nhng vng no b hu hoi vnh vin gia v nhng vng thiu mu no c kh nng hi phc xung quanh. Kch thc v kh nng sng ca vng thiu mu no ranh gii ny ph thuc rt nhiu vo v tr, nng, thi gian tai bin, tun hon bng h... Cc nghin cu cho thy kh nng sng ca vng ny ch duy tr c trong vng 417 gi. Ti ti mu bng thuc tiu si huyt hoc can thip mch no trong trng hp tc mch no v bo v no bng cc thuc bo v thn kinh l hai bin php chnh khi phc vng nhu m cn thoi thp ny. 1. Thuc tiu si huyt: a. Trong s nhng thuc tiu si huyt, ch c rtPA (c FDA cng nhn ch nh dng thuc t 1996) vi liu 0,9mg/kg dng ngay trong vng 133 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

3 gi k t khi khi pht (tim bolus tnh mch 10%, sau truyn phn cn li trong vng 1 gi, liu ti a 90 mg) l liu c hiu qu c chng minh (nghin cu NINDS), cho d c mt t l nht nh chuyn dng nhn no thnh xut huyt no (3% xut huyt nng). Nu tng liu rt-PA cao hn, thi gian ca s dng thuc di hn (trong 6 gi k t khi khi pht) th khng h c li m cn tng nguy c xut huyt no nng (ln n 20%, nghin cu ECASS). b. Yu t lm tng nguy c xut huyt no th pht l hnh nh nhn no sm trn phim CT v mc nng ca t qu (> 20 im theo thang im NIHS). Tuy nhin cn tun th cc ch d nh, rve chng ch nh v phi nh gi y ecc nguy res hts n c khi dng rt-PA. rig com.v ll . c. Ch nh dng rt-PA: v. A ahoo e t qu kiu thiunlo 0@y mu no. Fi 02 8 C th xc nh .r 2 gian khi pht. 00 ty thi C th ht 2 otoci rt-PA trong vng 3 gi k dng ngay P g t pyrikhi pht. khi Co Chp CT khng c hnh nh xut huyt no hoc cc bnh nng khc ca no. Tui 18. d. Tiu chun loi tr: t qu hoc chn thng nng s no mi trong vng 3 thng. Tin s xut huyt no (XH mng no hoc trong no) hoc c nghi ng XH mng no. CT s c hnh nh chy mu no, d dng ng-tnh mch, u no hoc cc phnh mch no. Huyt p tm thu > 185 mmHg hoc huyt p tm trng > 110 mmHg (o 3 ln, mi ln cch nhau 10 pht). 134 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Tin s c hoc trong cn t qu c ng kinh. Chy mu trong ang tin trin. Ri lon ng mu (aPTT hoc PT di, tiu cu < 100000/ml). Triu chng lm sng ci thin nhanh hoc mc nh. Hn m hoc ng g. M i phu hoc can thip mi trong vng 2 tun. Xut huyt tiu ho hoc sinh dc tit niu mi trong vng 3 tun. Mi chc ng mch (vng p c) hoc mi sinh thit trong vng 1 tun. ed ng mu < 50 mg/dl hoc > 400eserv mg/dl. r ts Vim ni tm mc, vim mng .vn gh m ngoi tim, i huyt khi nhim trng,Avim.crut ang tin ll r o . ahoo e trin hoc ang c thaivv cho con b. nlo 0@y Fima2tu nng. Nghin ru hoc 0 . 08 2 20 ocity 2. Heparin: ht Pot rig tnh mch khng lm gim mc a. Heparin tim py Co nng ca t qu khi xy ra, m cn lm tng nguy c chuyn vng nhi mu no thnh xut huyt no do tng lng mu n vng nhn no ch khng phi do t Heparin gy chuyn thnh xut huyt. Nhng bnh nhn c nhi mu no din rng (> 2/3 bn cu) nu dng Heparin c nguy c t vong cao hn hn bnh nhn nhi mu din nh hoc trung bnh (do ph no tin trin khi nhn no din rng chuyn thnh xut huyt no), do khng c dng Heparin. Cng chng ch nh dng heparin trong vng 24 gi nu bnh nhn c dng rt-PA.

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b. Tuy nhin, c mt s trng hp Heparin c ch nh phng nhi mu no tin trin hoc ti pht bao gm: Nhn no ang tin trin. Huyt khi gy TBMN t tim (nu vng nhn no nh hoc va). Huyt khi ng mch sng nn. Phnh tch ng mch no. Cc tc nghn di chuyn t ng mch n ng mch no. Tai bin mch no thong qua tin trin hn. Huyt khi tnh mch no. Mt vi tnh trng tng ng. c. Bnh nhn c thi gian aPTT > 2 ln chng cng ved c nguy c cao chuyn dng thnh xuter s huyt, v re ts vy gim nguy c ny nu hdngn Heparin, g m.v ri o khng nn tim bolus tnh All oo.cm ch truyn . mch Heparin 15-18 UI/kg/gi,v @yah thi khng ch loe ng Fin020 aPTT gp 1,5 ln 08. vi chng. so 2 20 ocitykhng c ch li g (nghin d. Heparin tim di da t t igh Po cu International Stroke Trial Project). yr op 3. AspirinC (160-300 mg/ngy) dng ngay trong giai on cp cho thy hiu qu r rt trong vic phng nga c ti pht t qu v gim t l t vong. 4. Thuc bo v thn kinh: nhiu thuc khc nhau (nh Lubeluzole...) nhm vo vng t bo thn kinh ang thiu mu c th nghim lm gim hoc khc phc cc hu qu ca t qu vi cc c ch nh: c ch th th p ng vi cc acid amine vng sau xinp, c ch men glutamate release, hn ch cc tc ng ca ion canxi v cc gc t do, c ch hnh thnh nitric oxide. Tuy nhin vn cn qu sm ni v hiu qu ca cc thuc ny.

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C. Phng ti pht TBMN 1. Phng ti pht t qu chnh l kim sot v iu tr tt cc yu t nguy c ca TBMN nh tng huyt p, bnh tim thc tn, i tho ng, ht thuc... 2. Cn iu tr trit cc bnh van tim (hp van hai l kht, sa van hai l) hay vim ni tm mc nhim khun bng mt s th thut nh nong van hai l, phu thut sa van tim hoc thay van tim nhn to. i vi bnh nhn rung nh, sau khi iu tr nguyn nhn, cn sc in hoc dng thuc chng lon nhp chuyn nhp v nhp xoang. Nu chuyn nhp tht bi, bnh nhn phi ung thm thuc chng ng duy tr ngng c tc dng (INR t 2-3) e phng TBMN do huyt khi. Cng cn ung dthuc erv resgin nng chng ng nu bnh nhn c bnh c ttim hs n (bung tht tri gin, chc nng lcogbp .km: EF < ri com v l .A o 30%), ri lon nng chc nng thto.tri, NMCT c oev yah huyt khi bm thnh, tiinl 20@tht tri... phnh .F 08 ty20 cn phi ung thuc h 3. i vi bnh tng 0 ci p 2huyt t o p thng xuyn votheo di huyt p nh k ti c gh P t ri s y t. Copy xc nh dng thuc h p sut i km Phi vi ch n gim mn kt hp vi cc thuc chng ngng tp tiu cu (nh Aspirin 325 mg/ngy, Ticlodipine 500mg/ngy hoc Clopidogrel 75 mg/ngy). Cc thuc chng ngng tp tiu cu chng t c vai tr d phng khng nhng TBMN m cn cc bin c tim mch khc (Aspirin lm gim ti 25% cc bin c), v th nn dng c h thng cho cc bnh nhn TBMN tr phi c chng ch nh. 4. i vi bnh i tho ng cn phi thc hin nghim ngt ch n king ca bnh nhn tiu ng ng thi ung thuc hoc tim insulin gi ng mu mc bnh thng v theo di ng mu nh k ti c s chuyn khoa ni tit. 137 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

5. i vi ngi c nhiu yu t nguy c ca TBMN th phi ch ti nhng triu chng bo trc nh: nhc u ko di, hoa mt, chng mt, tai, cn thiu mu no thong qua c bin php phng bnh kp thi. 6. Nhng bnh nhn c hp nhiu (>70%) ng mch cnh trong hoc ng mch cnh gc th nn ch nh phu thut bc ni mc ng mch cnh hoc can thip t gi qua ch hp d phng TBMN (gim t l t vong do TBMN t 26% xung 9% sau 2 nm). Ti liu tham kho
1. Broderick J, Brott T, Kothari R, et al. The greater Cincinnati/Northern Kentucky stroke study: preliminary rved first-ever, e and total incidence rates of stroke among blacks. Stroke, res 1998;29:415 421. hts n rig com.v Ameri A, Bousser MG. Cerebral venous thrombosis. Neurol Clin, ll . 1992;10:87111. v. A ahoo loe Barnett HJM, Stein BM, MohrinJP, 0@y F 02 Yatsu FM, eds. Stroke: Pathophysiology, Diagnosis, 08. Management. 2nd ed. New York: 0 and y2 Churchill Livingstone, 1992. ocit 2 t t Alberts MJ, Chaturvedi S,Po Graham G, et al. Acute stroke teams: igh yr p results of national survey. Stroke, 1998;29:2318 2320. Co McNamara RL, Lima JA, Whelton PK, Powe NR. Echocardiographic identification of cardiovascular sources of emboli to guide clinical management of stroke: a cost-effectiveness analysis. Ann Intern Med, 1997;127:775787. Pulsinelli W. The ischemic penumbra: from benchtop to bedside. Neurology, 1994;134:1 6. Wardlaw J, Warlow C, Counsell C. Systemic review of evidence on thrombolytic therapy for acute ischemic stroke. Lancet, 1997;350: 607614. Adams HP, Brott TG, Furlan AJ, et al. Guidelines for thrombolytic therapy for acute stroke: a supplement to the guidelines for the management of patients with acute ischemic stroke. Stroke, 1996; 27:17111718. Adams HP, Adams RJ, Brott T, et al. Guidelines for the Early Management of Patients With Ischemic Stroke: A Scientific Statement From the Stroke Council of the American Stroke Association. Stroke, 2003;34:1056 1083.

2. 3. 4. 5.

6. 7. 8.

9.

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10. Latchaw RE, Yonas H, Hunter GJ, et al. Guidelines and Recommendations for Perfusion Imaging Cerebral Ischemia: A Scientific Statement for Healthcare Professionals by the Writing Group on Perfusion Imaging, From the Council on Cardiovascular Radiology the American Heart Association. Stroke, 2003;34:10841104.

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tch THNH ng mch ch

Tch thnh ng mch ch (MC) l bnh t gp (t l hin mc khong 5-30 ca/triu ngi/nm), tn sut thay i ph thuc vo tng qun th vi cc yu t nguy c khc nhau. Triu chng bnh thng a dng, d nhm vi nhiu bnh cnh cp cu khc, cn ch nghi ng mi c th chn on v x tr kp thi, trnh nhng bin chng gy t vong. T l nam/n l 2/1, tui hay gp nht l t 60 n 70 tui. T l t vong khong 1%/mi gi trong 48 gi u. V tr tch thnh MC hay gp l MC ln (ch li, vng cao trn cc xoang vnh phi v xoang khng vnh khong 1-2 ved cm, chim khong 60-65%), MC xung - ch xut epht (ngay ser r di ch xut pht ca ng mch di n ghts .20%), quai tri, vn l ri c m MC (10%), cn li MC bng do nhng lvng ony phi cng . A ahoo. gin nhiu nht di p lc cao trongloev tm thu hoc l im k y @ Fin02v di ng ca MC. ni (xung yu) gia nhng vng c. nh 0 08 ty2 0 2 i I. Phn loi: Tch thnhtMC cc th theo nhiu kiu: h Poto rig py A. Phn loiCokinh in: theo hai kiu DeBakey v Stanford. Tch thnh MC hay gp nht on MC ln sau l vng ln cn vi dy chng ng mch. 1. Phn loi theo DeBakey c 3 tp: a. Tp I: thng tn c MC ln v MC xung. b. Tp II: thng tn ch MC ln. c. Tp III: thng tn ch on MC xung. 2. Phn loi theo Stanford gm 2 kiu: a. Tp A: tn thng on MC ln cho d khi pht bt k on MC no. b. Tp B: thng tn MC on xa k t ch xut pht ca nhnh ng mch di n tri. Tuy nhin c khi khng th phn nh r tp chng hn nu tch thnh MC ch quai MC cnh vng 139 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

xut pht ng mch di n tri gn vi gc MC m khng c km on MC ln. V th, c th chia theo v tr tch thnh hai loi: tch thnh MC on gn (tnh t gc MC ln n ch xut pht ca ng mch di n tri) v on xa (t tr i).

ved ser re t Hnh 9-1. Phn loi tch thnhs .vn gh mMC theo i ll r co DeBakey v Stanford. . A ahoo. oev 3. Phn loi theo v tr gii lphu, ty vo on tn in 20@y F 8. 0 thng. 00 ity2 2 t toc 4. Phn loi theohthiogian b bnh: P g ri a. Cp Copy thi gian k t khi khi pht 2 tun. tnh: b. Mn tnh: thi gian > 2 tun, khong mt phn ba s bnh nhn thuc nhm mn tnh. T l t vong tng dn ln trong vng 2 tun l u tin, t cc i vo khong 75-80%, to ra mt ngng t nhin v din bin bnh. 5. Phn loi ca Svensson: mi xut gn y, nh k thut chn on hnh nh mi, l: a. Tch thnh MC kinh in do ni mc b tch ra chia MC thnh hai lng gi v tht, c hoc khng thng vi nhau qua cc vt rch ni mc, chnh lch p lc gia hai vng ch t 15-25 mmHg nn lng gi c khuynh hng phng ln

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theo thi gian, to ra phnh mch, lc rng, thm ch v ra.

ed Hnh 9-2. Phn loi tch thnh MC theosSvensson. erv re t b. Huyt khi hoc chy mu trong sthnh MC gh m.vn i ll r co thng do t cc mch nui oMC gy xut . A aho . ev huyt/huyt khi tronglothnh MC, lm thnh in 20@y loi 1, v ra hoc F 0 MC dy ln, tin .trin thnh 08 0tpity2 bit theo cn nguyn: 2 khi hn vi 2 oc khc t P thnh nang Erdheim-Gsell hoc ghgiaot hoi t lp ri py x va - vi loi ny khng th chn to mng Co on c khi chp mch m phi dng cc phng php chn on khc. c. Tch thnh MC khu tr gy phng thnh MC: khng th chn on trn lm sng, song pht hin c di hnh nh khi phng khi chp mch hoc chp ct lp mch mu. d. Lot v nt mng x va MC: thng gp MC bng tuy cng thy MC ngc, cc mng x va lot c th tin trin thnh tch thnh MC kinh in hoc v bung mng x va, gy bnh cnh tc mch do cholesterol.

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e. Tch thnh MC do chn thng hoc do th thut, can thip trong lng mch, c th tin trin thnh loi 1 hoc 2, thm ch v ra. 6. ng knh vng van MC ngi trng thnh bnh thng l 2,6 0,3 cm nam, 2,3 0,2 cm n; i vi MC ln tng ng hai gii l 2,9 0,3 v 2,6 0,3 cm. ng knh MC ln bnh thng ti a l 2,1 cm/m2 da, ln hn l gin v nu > 4 cm c coi l ti phnh. i vi MC xung, gi tr bnh thng l 1,6 cm/m2, nu > 3 cm c coi l phnh dng ti. dy thnh MC bnh thng l < 4mm. ng knh lng MC s tng dn theo tui khong 1-2 mm/10 nm, mc tng cng ln khi ng knh lng mch cng tng. ved ser re II. Nguyn nhn v c ch bnh sinh ts gh m.vn Gin MC hoc tng huyt p All rirn nt ni mc gy .co v.quahoo nt. Di tc lng mch, sau mu s thm vo ya vt loe F n020 dng ca p lc tun hon theoi nhp@p, dng mu thm 8. 2 vo s tch ri cc lp ca 00ocityMC. Mt s t cc trng 2 thnh ht Po hp cn li c lin quan vi tcc yu t lm yu thnh mch, rig y d gy nn tch op Cthnh MC: nh hi chng Marfan (bin d nhim sc th lm thay i tng hp polypeptide). Cc yu t nguy c hay gp ca tch thnh MC bao gm: 1. Tng p lc ln thnh MC: a. Tng huyt p. b. Gin MC. c. Van MC mt hoc hai l. d. Hp eo MC. e. Thiu sn quai MC. f. Do th thut, phu thut vi MC: dng c thng tim, bng MC, v tr phu thut tim (t canuyn, kp ng mch ch, ni mnh ghp...). 2. Gim sc chu ti ca MC: 142 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

a. Tui gi. b. Thoi ho lp gia: hi chng Marfan, hi chng Ehlers-Danlos. c. Hi chng Noonan, hi chng Turner, vim ng mch t bo khng l. d. Thai nghn. Trong s cc yu t ni trn th tui v tng huyt p khng kim sot tt l hai yu t nguy c thng gp nht. Thai nghn lm tng nguy c ca phnh tch MC: 50% bin c xy ra tui < 40, trong ba thng cui hoc giai on sau . Nguy c cng cao ph n c hi chng Marfan v gin gc MC t trc. III. Triu chng lm sng ved ser A. Triu chng c nng re ts v ghnht n 1. au ngc l triu chng thngllgp com. (95%), v ri . A ahoo. tr thng gia ngc pha vtrc (61%) hoc sau oe inl 20@y (36%), ph thuc vo vFtr MC b phnh tch (tch . 08 20 thnh MC ln thng igy au ngc pha trc, tch 20 oc ty thnh MC ixung othng gy au ngc pha sau, ht P t rg au lng,oau bng. Cm gic au c th au chi, d py C di, nh dao m (51%), nhng ni bt l s xut hin au t ngt nhanh chng t mc ti a (85%). Cm gic au khi tch MC t khi lan ln c, vai, xung hai cnh tay nh au tht ngc in hnh ca hi chng mch vnh cp. Hng lan ca cn au xung lng, bng, bn v i l ch im cho qu trnh tch thnh MC lan i xa. Khng t bnh nhn hon ton khng au. Mt s khc c khong thi gian hon ton khng au ri au tr li. y l du hiu bo ng cho nguy c v ca phnh tch MC. 2. Mt s biu hin him gp khc bao gm suy tim huyt (do HoC nng khi phnh tch on MC ln), ngt (4-5% trng hp do v vo khoang mng tim, 143 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

p tim), tai bin mch no, lit hai chi di, ngng tim... B. Triu chng thc th 1. Huyt p cao: a s l nguyn nhn, phn cn li l hu qu ca tch thnh MC on xa do phnh tch lan n ng mch thn gy thiu mu thn. 25% trng hp tt HA tm thu ng mch < 100 mmHg. Nguyn nhn tt p v sc tim trong tch thnh MC do h van MC nng cp tnh, v khi phng, p tim, hoc ri lon chc nng tm thu tht tri. Khi phnh v hoc nt vo khoang mng tim c th nhanh chng dn n trn mu v gy p tim cp, ri t vong. Cn ch n du hiu gi tt huyt p do ng mch di n b chn p. ved ser re ts tch 2. H van MC: 18-50% cc trng hp .vn MC gh m i on gn c h van MC t nh rno nng, c th ll c . A ahoo. h van MC nghe thy ting thi tm trng ca oev inl 2Hy MC nng, cp trong s 25% s bnh8nhn. 0@ van . F 20 00 ityt vong ng hng th hai tnh l nguyn nhn gy 2 t otoc P g (sau v phnh hMC), thng biu hin lm sng ri py trong tnh trng tru tim mch cp tnh v sc tim. C Co ch gy h van MC bao gm gin vng van, gin gc MC, rch vng van hoc l van, ng khng kn l van MC (do lng gi trong MC khng cn, mt nng ca l van hoc chnh mnh nt ni mc cn tr s ng kn van MC. Ri lon vn ng thnh tim gp trong 10-15% ch yu do gim ti mu mch vnh v: lng gi pht trin vo mch vnh, tch thnh MC tin trin vo MV, tt huyt p. MV bn phi thng b nh hng nhiu hn so vi bn tri, d him khi xy ra ng thi tch thnh MC v nhi mu c tim (1-2%). C tim thiu mu dn ti ri lon chc nng tm thu tht tri l yu t gp phn gy tt huyt p v sc tim bnh nhn tch thnh MC. 144 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

3. C chnh lch v ny ca mch hoc huyt p ng mch gia hai tay hoc mt mch t ngt. Mch hai tay khc nhau l du hiu thc th c hiu nht ca tch thnh MC, gp trong 38% cc trng hp. Chnh lch mch v huyt p gia hai tay l do mt hay c hai ng mch di n b chn p mt phn, hoc c mnh nt di ng trong lng mch nn c th nghe thy ting thi dc theo cc ng mch ln nh ng mch cnh, di n hoc ng mch i. Biu hin thiu mu ngoi vi, nht l chi di c th gp trong 15 n 20% s bnh nhn phnh tch MC. Biu hin mch p (him gp) do chnh lch v tc dng chy gia lng gi v tht trong trng hp lng gi tin trin vo gia lng tht. ved Khm vng c c th thy cc biu hin enh gin sr re mch c mt bn do p ca lng ghtsquanh MC, gi .vn i hoc gin tnh mch c hai bn dol tnhcom ch trn l r mch . A ahoo. b chn p hoc trn dch mng tim, p tim. oev inl 20@y F 4. Triu chng thn kinh 20 trong s 18-30% cc 8. gp 00 ity trng hp: ht 2 otoc P rig a. Nhnono/t qu l triu chng thng gp nht py C tch thnh MC, chim 5-10% s bnh nhn. a s bnh nhn tch thnh MC biu hin t qu c tin s au ngc. Ngoi t qu, thay i ti mu no c th gy thiu mu no thong qua vi cc biu hin a dng t ri lon thc n ngt (12% s bnh nhn). b. Thiu mu tu sng v bnh thn kinh ngoi vi do thiu mu hay gp nht nu tch thnh MC on xa (ti 10%) do hu qu p vo cc ng mch gian sn, nhnh ng mch Adamkiewicz, hoc cc ng mch nui r tu sng. Vng ti mu cho tu sng gip ranh gia nhnh ng mch Adamkiewicz v cc nhnh nui r tu sng rt d b tn thng do thiu mu khi tch 145 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

thnh MC. Thiu mu tu biu hin rt a dng nh hi chng vim tu ct ngang, bnh l tu sng tin trin, nhi mu tu sng, hi chng sng trc tu sng, lit hai chi hoc lit t chi. Bnh thn kinh ngoi vi trong tch thnh MC (do thiu mu ca n-ron hoc lng gi p trc tip vo dy thn kinh) him gp song biu hin rt a dng, khng c nh nh: lit hai chi di, khn ting, bnh l m ri tht lng cng v hi chng Horner. Phn ln triu chng thn kinh lin quan bnh nhn tch thnh MC l au. Tuy nhin triu chng t qu, ngt hoc khn ting cng c th l nhng triu chng u tin. 5. Cc biu hin khc: ved ser phnh a. Trn dch khoang mng phi tri dorekhi hts n v vo khoang mng phi. rig com.v ll . b. Ph phi mt bn hoc ho. ra amu do tch thnh v A hoo loe y MC lan vo ng mch2phi. Fin0 0@ 8. c. Xut huyt tiu00 ity2 tnh do lot thc qun 2 ho cp c ht hoc t trng. Poto rig d. auCopy cp do phng mch lan vo ng mch bng mc treo trng. e. Kh nut do khi phng MC vo thc qun. 6. Tiu chun chn on lm sng c th xc nh ti 96% trng hp tch thnh MC (theo von Kodolistch) da trn cc triu chng: a. au ngc khi pht t ngt, hoc cm gic au ngc chi d di hoc c hai. b. Chnh lch mch, huyt p hoc c hai. c. Trung tht hoc MC gin rng hoc c hai. Nu ch c triu chng s 2 n thun hoc t nht 2 trong 3 triu chng th t l ng l 83%. Nu ch c triu chng 1 hoc 3 n thun th t l ng

146 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

ln lt l 31 v 39%. Chn on loi tr 93% cc trng hp nu khng c triu chng no. IV. Cc xt nghim chn on 1. Xquang ngc mc d c c hiu thp, song vn c gi tr chn on ban u nu phi hp vi triu chng c nng v thc th. Du hiu kinh in gi tch thnh MC l bng trung tht gin rng (50% cc trng hp). Bng trung tht to v bn tri l chnh nu tch thnh MC ngc, to v bn phi nu tch thnh MC ln. Cc du hiu khc l nhng thay i v hnh dng ca MC nh: bu kh tr quai MC, gin rng cung MC on xa ngay sau ch xut pht ca ng mch di n tri, dy thnh e MC (tng dy ca bng MC pha ngoid im erv res vi ho ni mc), di lch im vi hots cung MC gh vn (hn 1cm), hnh nh MC hai lng, ikhc .bit v kch l r .com l . v oo thc gia cc phn MC ln A ahxung, thng c oev y l @ trn dch mng phi tri, in 20tim huyt... Tuy vy, . F suy 0 08 y2 nhng du hiu ny0chitc tnh cht gi ch khng 2 toc t c gi tr chngon o nh. i h P xc yr 2. in tmp: khng c hiu, hay gp nht l dy Co tht tri, cc du hiu khc bao gm ST chnh xung, thay i sng T hoc ST chnh ln. Du hiu thiu mu c tim c th gp nu km tn thng ng mch vnh, do vy cn ngh n kh nng ny nu hi chng vnh cp c kiu au d di bt thng. Cc du hiu ca vim mng tim v bloc dn truyn nh tht cng c th gp trn in tim . 3. Tch thnh MC c th nhanh chng dn ti t vong nu b st chn on v khng iu tr. Do la chn phng tin chn on no ph thuc ch yu vo kh nng thit b tng c s: thng thng l chp ct lp vi tnh (CT), chp cng hng t ht nhn (MRI), siu m qua thc qun (STQ) v chp mch bng thuc cn quang. Cc phng php ny 147 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

u chng t chnh xc, nhy v c hiu cao trong chn on. Barbant v cng s thy nhng nhm bnh nhn nguy c cao (t l hin mc > 50%), gi tr d bo dng tnh (kh nng pht hin bnh) > 85% cho c 4 phng tin chn on hnh nh (CT, MRI, STQ, chp mch). Tuy nhin i vi nhm c nguy c trung bnh (t l hin mc khong 10%), gi tr d bo dng tnh ca CT, MRI v STQ > 90% so vi chp mch bng thuc cn quang ch cn 65%. Nu t l hin mc ch cn 1% (nhm nguy c thp) th gi tr d bo dng tnh u < 50% vi CT, STQ, hoc chp mch, ch tr MRI vn t gn 100%. Ngc li d th no, gi tr d bo m tnh v chnh xc (kh nng loi tr bnh) vn t trn ved 85% trong c 4 bin php chn on hnh nh. ser e sr 4. Chp ct lp vi tnh (CT) l binight m.vn php c dng ll r co nhiu do t xm ln v cho php chn on nhanh . A ahoo. v chng khi cp cu, pht inloe c huyt khi trong hin @y 0 F lng gi v xc nh 08. dch mng tim. nhy t trn 02 0 ity2 2 c 83-94%, ct hiu ol 87-100% i vi chn on o gh trt nhng trng hp MC ln, tch thnh yri MC, P p Co nhy gim cn < 80%. Nhc im chnh ca chp CT, ngoi vic phi dng thuc cn quang, l kh xc nh c nguyn u ca vt rch ni mc, kh kho st cc nhnh bn ca MC b tn thng v khng th nh gi mc h van MC. Cc k thut mi nh chp CT xon c hoc chp siu nhanh lm tng nhy ca phng php ny. So vi chp CT c in, chp CT xon c c u th hn do chp kiu xon c cho php ghi c nhiu hnh nh hn lc mc cn quang t cc i, pht hin v nh gi tt hn cc bin i theo nhp th ca bnh nhn trn trc di. Hn na, hnh nh dng li 2D v 3D cho php nhn r ng i ca mng nt so vi xut pht im ca ng mch di n, mt im c bit quan trng i vi tch thnh MC on xa 148 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

loi tr tch thnh MC ngc dng vo quai MC (chim 27% cc trng hp tch thnh MC xung, vn c t l t vong cao ti 43%). Chp CT xon c cng nhanh hn, d thao tc hn v cht lng hnh nh t ph thuc vo ngi lm, ng thi, do mt ct c xc nh chnh xc nn vic so snh gia cc kt qu vi nhau chnh xc hn (d theo di). 5. Chp cng hng t (MRI) c nhy v c hiu rt cao t 95-100%. MRI c th xc nh chc chn tch thnh MC, mc lan rng, xc nh chnh xc v tr nt u tin, xc nh cc nhnh ng mch bn c lin quan, ng thi c th nh gi nhng tn thng c lin quan ca ng mch thn. Cho d c mt s hn ch, song MRI tr dthnh rve phng php chun chn on tch thnhe MC. res ts n a. Ch chp spin echo theo inighom cho php r tm .v ll c xc nh dng chy chmvtrongolng gi. Ch . A ah o. e chp cine v gradientinlo 0@y F recall echo cng cung cp 2 . nhng d kin 0v ty20 chy trong lng ng 08 dng 2 oci mch gi ght tht, mc h van MC. Ch v Pot ri hnh nh cho php chn on r hn tng cng py Co qu ca cc ch chp trn khng th khi kt kt lun v huyt khi hoc dng chy c hay khng. Nhng k thut chp mi nh fastgradient echo, K-space acquistion cho php gim thi gian xt nghim hn na m khng gim chnh xc. So snh MRI, CT v STQ cho thy nhy v c hiu ca MRI cao hn nhm c bnh van MC. Hn na, MRI cho php dng li hnh nh 3 chiu bt k gc no. b. Hn ch ca MRI ch: khng phi c sn mi bnh vin, thi gian thao tc lu hn, c chng ch nh mt s nhm bnh nhn, kh theo di cc du hiu sinh tn nht l nhng trng hp huyt ng khng n nh, Hn na MRI khng 149 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

an ton cho nhng bnh nhn t my to nhp tim, kp mch mu hoc cc thit b cy ca nhn khoa, ca mi hng... 6. Siu m tim: a. Siu m tim qua thnh ngc ch c nhy 3580% v c hiu 39-96%, ph thuc vo vng MC ( nhy t 78-100% on MC ln nhng gim hn cn 31-55% MC xung). Siu m qua thnh ngc c th quan st thy hnh nh mng nt ni mc di ng, cc vt nt v lng gi ca MC ln hay quai MC, tng ng knh gc MC, gin quai MC, tng dy thnh MC... Tuy nhin kh nng ca siu m gim i rt nhiu trong trng hp khoang gian ved sn hp, bo ph, gin ph nang hoc bnh nhn ser e phi th my. Siu m tim qua thnh rngc khng ts gh tt.vn thnh phi l phng tin chn on om tch l ri MC, d l tch thnh on Al hoo.cln. . MC oev a b. Siu m qua thc qun (STQ) ngy nay tng inl 20@y F i ph bin, an08. y20 c th thc hin nhanh 0 ton, 2 t it chng v dt dngocti ging k c bnh nhn Po ghkhng n nh, vi chnh xc cao huyt pyri ng ( Co nhy ln ti 98%, c hiu t 63-96%). Hn na, phng tin ny cn cho php kho st v tr nt ni mc u tin, huyt khi trong lng gi, thay i v dng chy, tn thng ng mch vnh hoc quai MC phi hp, mc lan rng, dch mng tim, mc h van MC... Triu chng quan trng nht chn on tch thnh MC c th quan st thy qua STQ l di ni mch b tch trong lng MC, chia lng mch thnh lng gi v lng tht. Hn na, c th quan st thy ph dng chy Doppler mu khc hn nhau gia hai lng mch. Trng hp lng gi vi ho lu, s thy du hiu di chuyn vt vi ho ni mc vo gia v thnh mch dy ln. Chn on xc nh s d dng hn nu c km theo cc du hiu ca vt nt ni mc u vo, 150 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

ph Doppler mu trong lng gi, hoc c km gin gc MC. Nhc im chnh ca STQ l ph thuc nhiu vo kinh nghim ca ngi lm siu m, khng nh gi c MC on xa di ng mch thn tng, khng th lm c nu c gin tnh mch hoc cht hp thc qun, c th b st ( vng MC ln on xa hoc quai MC on gn do kh trong kh qun hoc nhnh ph qun gc tri, nm gia MC v thc qun lm gim hoc mt tn hiu siu m) thm ch chn on sai (nhm vi vt m trung tht, mng x va vi ho, m di ca siu m ...). 7. Chp ng mch ch bng thuc cn quang c nhy t 86-88% v c hiu t 75-94% chn on tch thnh MC ngc, vi cc biu hin: hnh ed erv sxon vn, nh ct thuc cn quang b tch ri hoc re hts .v ht dng chy l hoc khng, khnggngm n thuc i ll r com cn quang cc mch mu vchnh, o.h van MC... . A aho le y Chp ng mch ch c ionhy thp, c th b st F n020@ nu huyt khi lp008. y2 gi, huyt khi trong kn lng tng t thnh MC... Tuy 2 otoci c coi l phng tin hng t gh P u chnrion, nht l cho php nh gi c y op thng C ng mch vnh km theo nu c, song tn ngy nay chp MC bng thuc cn quang t c dng do ko di hoc tr hon khong thi gian qu bu phu thut kp thi. Hnh nh gii phu ng mch vnh ch ng vai tr quan trng i vi quyt nh m khi c tc l vo ng mch vnh do mnh ni mc hoc bnh nhn c bnh ng mch vnh mn tnh. Chp ng mch vnh trong giai on cp ch nn u tin cho bnh nhn bit chc chn hoc gn chc chn bnh ng mch vnh. 8. nh lng men trong huyt thanh: c hin tng gii phng c hiu cc myosin chui nng (Mhc) ca t bo c trn vo huyt tng khi c tch thnh MC (nng Mhc trong huyt tng bnh thng 151 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

trong khong 0.9 0.4g/l, ngng chn on tch thnh MC l 2.5g/l. Xt nghim nh lng Mhc (mt 30 pht) trong vng 3h sau khi khi pht c nhy 91%, c hiu 98% ngi bnh thng, nhy t 83% bnh nhn nhi mu c tim, chnh xc chung t khong 96%. Tuy nhin nhy gim theo thi gian: cn 72% trong vng 3 gi tip theo v ch l 30% sau 6 gi, d vy vi mc Mhc >10g/l th c hiu l 100%. Tuy cha c ng dng rng ri song phng php ny c th xc nh nhng trng hp nghi tch thnh MC trong vng 6 gi u (l tng l 3 gi) sau khi pht, hoc gip la chn cc bin php chn on c hiu khc. 9. hoch nh chnh xc chin lc can thip, cn ved ser b tch; nh gi cc thng tn nh: (1) on MC e sr (2) v tr vt rch ni mc u tin;righth.vvan MC; (3) m n ll thng tn vng (4) thng tn ng mch vnh; (5)oo.co v. A ah quai MC hoc ng mchoe @y (6) xut hin mu thn; inl 20 . F mng phi hay trung tht. 0 trong khoang mng 08 2 tim, y 0 2 Cn phn bit thm:otocit ht P ig a. Gia optch thnh MC v bnh thoi ho yr C MC: mng x va MC thng nhn thy r hn, b mt x x hn nu so vi mng rch ni mc MC thng nhn hn. Ch gp huyt khi bm thnh MC khi c tch thnh MC. Tuy nhin, mng x va MC khi v cng c th s dn n lot v tch thnh MC. b. Lng mch tht v gi: dng mu trong lng mch gi thng c nhiu m cun, chy chm li, thm ch chy ngc chiu so vi hng tng mu trong lng mch tht thi k tm thu. Tuy nhin, kh nng nhn thy r dng mu trong lng mch gi ph thuc vo mc thng thng gia hai lng mch: nu khng thng, s khng thy c tn hiu dng mu. Mt im quan trng khc l hnh thnh huyt khi ch thy trong lng mch gi. 152 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

c. V tr ca vt rch ni mc u tin: cc vt rch, nt ni mc u, cui cng nh nhiu vt rch nt on gia c th thy trc tip trn MRI hoc siu m qua thc qun. Dng chy qua cc vt rch ni mc thng theo hai chiu, vi nhiu loi ph a dng trong k tm trng. Chnh p qua vt rch u tin him khi cao do p lc trong lng gi cng ngang trong lng tht. d. Tch thnh MC khng thng gia hai lng tht v gi ch chim khong 10%, thng d hnh thnh huyt khi trong lng gi hn (cn phn bit vi huyt khi trong thnh MC). Loi tch thnh MC cn thng thng thy r dng mu v c th thy c vt rch u v cui trn vng tch ni mc. ved ser Nh vy c th thy rng: mi mt trong s cc re bin php chn on hnh nh nh siuightstim qua thc m .vn qun, chp CT, MRI v chp ng All r o.cch cn quang mch om o v. nht nh. La chn u c nhng u hay nhc im yah loe @ n bin php chn on s ph ithuc vo kh nng ngun . F 20 08 ty20 thun tu theo l thuyt. lc sn c ti ch hn 20 ch da l oci i vi phnh tch ht Pot tp A th mc ch chnh l a g MC ri py bnh nhn iom cng sm cng tt. C Bng 9-1. Kh nng chn on tch thnh MC. Kh nng chn on Chp Chp Chp Siu MC CT MRI m TQ V tr rch u tin ++ + +++ ++ Lng gi/ lng tht +++ ++ +++ + Thng tn nhnh bn +++ ++ + Trn dch mng tim ++ +++ +++ Thng tn MV +++ ++ H van MC km theo +++ + +++ nhy chung (%) 88 83-94 98 98-99 c hiu chung (%) 95 87-100 98 77-97 Siu m tim qua thc qun v chp CT c th thc hin nhanh nht i vi nhng tnh hung cp cu, trong 153 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

siu m c a chung hn do kh nng linh hot, nhanh chng, nhy cao, tng i an ton v cho nhiu thng tin. D sao nu ti ch khng c siu m qua thc qun, chp ct lp (CT) s l bin php ti u. Chp MRI s cho nhiu thng tin chi tit nht, nhy v c hiu cao nht song trong bi cnh cp cu cn nhanh chng v thun tin th MRI khng ph hp. MRI ph hp nht nh gi hng lot tin trin ca tch thnh MC mn, d c phu thut hay ch iu tr ni khoa. Chp ng mch ch ch c ch nh cho nhng bnh nhn khng th chn on xc nh bng phng tin khc hoc bt buc phi xc nh gii phu hay thng tn ca ng mch vnh phc v cho phu ethut. vd ser re V. Tin trin t nhin ts gh m.vn l ri co Tc ng ca dng mu lm khot lsuo.dn vo lp ni . A aho mc vi cc mc khc nhau nloev to thnh lng mch hoc y @ Fi 020vong. Tch thnh on gi, hoc thm ch v ra ngoi .gy t 08 ty2 2 MC ln thng nm v0trcibn phi, pha sau v trn so t oo ghphi. tKhi lan rng v pha quai MC, vi l ng mch vnh P ri oy vt tch thngCp pha sau. Tch thnh MC xung li hay gp pha sau v bn tri nn hay lm tn thng ng mch thn tri v ng mch chu hoc i tri. 21% bnh nhn tch thnh MC s t vong trc khi vo vin, t l t vong nhm tch thnh MC ln khng c iu tr khong 1-3% mi gi v t khong 25% trong vng 24 gi u k t khi khi pht, 70% sau tun u v 80% sau tun th hai. < 10% bnh nhn tch thnh MC on gn sng sau 1 nm, phn ln cht trong vng 3 thng u do h van MC cp, tc cc nhnh ng mch chnh, v phnh MC. 90% trng hp tch thnh MC on gn c nguy c v khi phnh, 75% s v vo khoang mng tim, mng phi tri hoc trung tht. Cc dng bnh lin quan n tch thnh MC: 154 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

1. Xut huyt v huyt khi trong thnh MC: a. Tin trin ca huyt khi trong thnh MC cng ging tch thnh MC kinh in, ph thuc vo v tr huyt khi. Huyt khi thnh MC nm gia lp ngoi v lp trong ca thnh MC, khc vi tch thnh MC ch khng c lu thng vi lng tht ca MC cho d c th nt mng ni mc v pht trin thc s thnh tch MC, hoc gy thng ra ngoi hoc to ti phnh MC. b. D dng chn on xc nh bng siu m qua thc qun v chp MRI. Xut huyt trong thnh MC lm tch thnh MC thnh nhiu lp, tng dy ca thnh MC (>5mm), tng khong d cch gia lng MC v thc qun. rve setrn siu re c. Biu hin ca huyt khi thnh MC ts vn gh mvng MC; m gm: dy ln khu tr thnh imt . ll r co c khong trng siu mAtrong thnh MC; . ahoo. ev khng thy vt tch Finlo 0@y ni mc song vn c tn hiu 2 8. dng chy Doppler; ty20lch vo gia cc vt vi 00 i y 2 t ho ni mc. Potoc gh i d. MRI opyr xc nh hng lot cc thay i bnh l cn C trong khi mu t, nh nh gi c mc thoi trin hay tin trin ca huyt khi. MRI cng nh gi c thi gian to thnh huyt khi da vo s hnh thnh methemoglobin. Cc tn hiu mnh trn cc mt ct T1 v T2 do methemoglobin cho thy tin trin bn cp ca khi mu t, ngc li chy mu mi s c cc tn hiu rt a dng v cng trong cc vng khc nhau ca khi mu t. 2. Mng x va lot MC: a. Thng gp nht MC xung, l mng x va c lot tin trin, khot dn vo lp x chun, lp gia, cui cng hnh thnh nn gin v ti phnh tht/gi MC, hnh thnh huyt khi ti ch hoc 155 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

v bung ra... song t khi gy thng hay thc s tch thnh MC (c th do tc dng bo v ca lp x ho thnh MC dy sau khi b x va). Bin chng thuyn tc mch do mng x va lot kh him. Cc yu t nguy c ca bnh l ny l tui cao hoc tng huyt p khng kim sot c. Biu hin lm sng cng ging nh cc dng tch thnh MC khc: khi pht au ngc hoc au lng t ngt. b. Chp CT nh gi chnh xc hnh nh lot tin trin ca mng x va MC, tuy nhin phi dng thuc cn quang trng y trong lng MC v vt lot. So vi chp CT c thuc cn quang, MRI c chnh xc cao hn, c bit c gi etr khi vd chng ch nh tim thuc cn quang.erMc d s re siu m thc qun cng c gi tr hts .vn g nht nh song i m l r rt d dng b st nhng mngl x.co lot on . A ahoo va ev ca xa ca MC ln v onouy quai MC. inl 20@ F 8. 0 3. Tin lng: 00 ity2 2 oc t a. T l t vong chung ti vin xp x 30% nu tch gh Pot i thnhopyr on gn, 10% vi tch thnh MC MC C on xa. T l ny khng h gim trong 3 thp k va qua d c rt nhiu tin b trong chn on v iu tr. Nhng yu t d bo t vong ti vin bao gm: tch thnh MC on gn, tui > 65, cn au c tnh cht di chuyn, c sc, c chnh lch mch gia cc chi, c du hiu thn kinh khu tr. b. T l sng ca nhng bnh nhn tch thnh MC on gn c phu thut v ra vin tt l 6580% sau 5 nm v 40-50% sau 10 nm. Tin lng ca bnh nhn tch thnh MC on xa rt a dng ph thuc vo tng nhm bnh nhn. Tuy nhin, tin lng xa ti hn bnh nhn c tch lan rng ngc dng v pha quai MC hoc 156 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

MC ln v bnh nhn khng c huyt khi trong lng gi MC. Nguyn nhn chnh gy t vong khi theo di lu di bnh nhn tch thnh MC l v khi phnh do tch thnh th pht hoc do to thnh ti phnh MC ri v. VI. iu tr A. La chn phng thc iu tr 1. T vong khi tch thnh MC khng phi do vt nt ni mc u tin m ch yu do tin trin ca phnh tch gy chn p cc mch mu quan trng hoc v. a. Tch thnh MC on gn (tp A) bt buc phi iu tr ngoi khoa cng sm cng tt gim nguy c bin chng (h van MC cp, suydtim e erv huyt, p tim, triu chng thn kinh) ng thi res s gim nguy c t vong (1%/gi). ight .vn r com ll . b. iu tr tch thnh MC . onooxa (tp B) hin v A ah e cn nhiu im chainlo 0@ynht song nn khi thng F 02 . u bng iu tr 8thuc. Phu thut thng ch 0 ty2 20 bnh nhn c bin chng hoc nh cho nhngotoci ht P rig khoa tht bi. V lu di, cn nghin iu try ni op cu C thm xc nh nhm bnh nhn no thc s c li nu m. c. T l t vong sau 5 nm ra vin bnh nhn c iu tr hp l l 75-82%. 2. Mt s bnh cnh cn lu : a. Tch thnh MC c tt huyt p: nguyn nhn hng u l v thnh MC hoc p tim. Cn lp tc b mu, dch v chuyn m ngay. Nu phi chc dch mng tim nng huyt p trc khi chuyn n phng m th cng khng nn ly nhiu m ch ly lng dch mng tim huyt p mc chp nhn c. Nu phi dng thuc vn mch nng huyt p th nn dng Norepinephrine hoc Phenylephrine (khng nh 157 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

b. Tch thnh MC c nhi mu c tim cp: chng ch nh dng thuc tiu si huyt. Chp MC trong giai on cp c nguy c rt cao tip tc gy tch thnh v lm chm tr khong thi gian qu bu dnh cho phu thut. B. iu tr ni khoa 1. Ch nh iu tr ni khoa: a. Tch thnh MC cp tnh tp III khng c bin chng. b. Tch thnh MC cp tnh on quai, n thun, huyt ng n nh. ved c. Tch thnh MC mn tnh, n nh. reser ts 2. Thc nghim cho thy dng chy righ m.vn s tip theo nhp l .co tc thc y qu trnh tch thnhl ng mch theo c v. A ahoo e hai chiu ln xung. V Finlo 0@yh huyt p cp cu th phi 2 . 20 bng cc thuc dng 8ng tnh mch mi bnh 0 20 ocity nhn ngay khi ht ong tch thnh MC tr khi nghi t P ig sc tim, nhm mc ch gim lc co bp ca tht tri, yr p Co gim mc tng p trong MC (dP/dt), gim huyt p ng mch xung ti mc thp nht c th c m khng gy nh hng n ti mu cc c quan sng cn, nh vy lm gim qu trnh tin trin ca tch thnh MC v gim nguy c v khi phnh. 3. Hin ti, phi hp chn giao cm v mt thuc gin mch (v d Nitroprusside Natri) c coi l phng thc iu tr ni khoa c bn i vi tch thnh MC. Nn dng thuc chn giao cm trc khi dng thuc gin mch trnh phn x gii phng catecholamine th pht khi dng thuc gin mch lm tng co bp tht tri v mc tng p trong lng ng mch, cng lm tch thnh MC tin trin. Liu thuc chn tng ti khi tc dng (nhp 158 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

tim 60 hoc huyt p trung bnh ng mch 6070 mmHg). Nu c chng ch nh vi chn , c th dng thuc chn knh canxi. Sau khi bnh nhn dng chn , c th thm dn Natri Nitroprusside ng tnh mch a huyt p ng mch ti ngng mong mun ri duy tr: khi u vi liu 20 g/pht, iu chnh dn duy tr huyt p ng mch trung bnh khong 60-70 mmHg. Trng hp khng tc dng, c th dng Labetalol (chn c v giao cm) hoc Trimetaphan (c ch hch thn kinh). Bng 9-2. Mt s thuc h huyt p ng tnh mch. Thuc Liu ban u Liu duy tr Thuc c la chn u tin ved sermch 4re Propanolol 1 mg TM/3-5 pht, ti a 2-6 mgstnh t gh m.vn 6,15 mg/kg 6h/lno i ll r c truyn Labetalol 10 mg TM/2 pht, sau v. A hoo. 2 mg/pht e a TM, chnh n 5-20 20-40 mg 10-15 Finlo 0@y 2 . mg/pht pht/ln, ti a008 ty20 300mg. 2 oci t Esmolol 30 mg TMht Po truyn 3-12 mg/pht ig yr 5 pht/ln Metoprolol 5 mg pTM 5-10 mg TM 4Co 6h/ln Nu c chng ch nh vi thuc chn giao cm Enalaprilat 0,625 mg tnh mch 0,625 mg TM 46h/ln Diltiazem 0,25 mg/kg TM/2 pht, Truyn 5 mg/gi, dn 2,5-5 nu khng c tc dng, tng ti a nhc li 0,35 mg/kg TM mg/gi 15mg/gi sau 15 pht Verapamil 0,075-0,1 mg/kg ti 2,5-5 5-15 mg/gi truyn mg/kg /2 pht TM 4. Bnh nhn tch thnh MC on xa, khng bin chng, c th ch iu tr ni khoa trong giai on cp do t l sng st vn t gn 75% d c m hay khng. Hn na, bnh nhn tch thnh MC 159 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

on xa thng tui cao, hay c cc bnh tim mch, h hp hoc tit niu km theo. Nhng bnh nhn tch thnh MC on gn c nhng bnh khc khng th phu thut c cng nn iu tr ni khoa. Mc ch ca iu tr ni khoa khi tch thnh MC giai on cp nhm n nh vt nt tch, phng v ch phnh tch, thc y qu trnh lin ca vt tch v lm gim nguy c bin chng. 5. Nguy c tim tng lun phi phng khi iu tr ni khoa m kp thi bao gm: vt tch thnh MC tip tc lan rng, khi phnh tch ngy cng phng hn, nguy c p vo cc t chc ln cn gy gim ti mu cc c quan - thng biu hin trong bnh cnh cn au ngc/bng ti pht, chng bng, toan d rve sesuy gim chuyn ho tng, men tim tng dn v/hoc e sr dn chc nng thn. Nguyn nhn right mgy t vong chnh .vn .co bnh nhn iu tr ni khoa . lllv okhi phnh tch v A aho oe quan. MC v gim ti mu cclc @y Fin020 . 08 2 C. Phu thut 20 ocity t 1. Ch nh m:gh Pot ri py a. MiCo bnh nhn c tch thnh MC cp on gn, tr trng hp khng th phu thut do cc bnh l nng km theo. Chng ch nh thng gp l t qu mi do nguy c vng nhn no chuyn thnh xut huyt no khi dng chng ng v do hin tng ti ti mu sau phu thut. b. Ch nh phu thut nhm tch thnh MC cp on xa bao gm: khi phnh tch phng ln nhanh chng, thm mu phc mc, do v, au ko di khng kim sot c v/hoc thiu mu chi hoc tng, tch lan ngc v MC on ln, c h van MC hoc bnh nhn c hi chng Marfan.

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2. T l t vong quanh phu thut bnh nhn tch thnh MC giao ng t 5-10%, c th ln ti 70% nu c bin chng. Cc yu t c lp tin lng t vong bao gm: p tim, tru tim mch, v tr vt nt, thi im phu thut, thiu mu thn hoc tng, ri lon chc nng thn v c bnh phi hoc bnh ng mch vnh km theo. Thi gian tin hnh chn on trc m cng di, t l t vong trong v sau phu thut cng cao. 3. Phng php m ti u ph thuc tng phu thut vin, a s u phi hp vi dn keo MC. Mc ch ca phu thut nhm ct b v thay th on MC c vt nt u tin, ch khng phi ton b phn MC b tch thnh. Nu van MC khng th sa li d p ve th ser v van dng phu thut Bentall (thay on gc MC re hts n MC, cm li ng mch vnh).igDn .vkeo MC r cm chim vai tr quan trng, dng All dnocc lp MC . hoo. v b tch v trm kn ch inloe @ya ca ming ni chy mu 0 F 8. MC, nh lm gim t02 thay van MC, gim l 00 ity2 chy mu trong t 2 otocm cng nh gim tn sut v v sau igh P rchng. mc bin py Co 4. Bin chng ca phu thut bao gm chy mu, nhim trng, hoi t ng thn cp v/hoc thiu mu mc treo. Bin chng ng s nht sau m tch thnh MC on xung l lit hai chi di do thiu mu vo ng mch tu sng qua cc ng mch gian sn. Cc bin chng mun bao gm h van MC tin trin (nu khng thay van MC lun), phnh mch ti ming ni v ti pht phnh tch MC. Khong 50% trng hp cn tn ti mt phn phnh tch sau m. Khong 15% bnh nhn m tch thnh MC phi m li do tin trin tip ca tch thnh MC cn st li; hoc do tch thnh MC mi ( vng ming ni hoc on MC khc); hoc do to thnh ti tha MC. Cc phng php nh chp 161 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

MRI, siu m tim qua thc qun rt c gi tr theo di on mch nhn to, ming ni hoc pht hin sm gin/phng MC. D. Can thip qua da theo ng ng thng 1. t gi (Stent) trong lng MC ch mi c thc hin trn s t bnh nhn c nguy c cao khi phu thut, a s l nhng bnh nhn tch thnh MC xung c triu chng gim ti mu chi di hoc cc tng bng (nh rut, gan, v/hoc thn). t gi c coi l thnh cng khi bt c vt nt ni mc u tin, gy ng lng gi trong vng 2 gi sau t: t l thnh cng trn lm sng t 76-100%, t l t vong sau 30 ngy l 25%. Cc bin chng gm nhi mu rut, suy thn, thuyn tc chirdi, v ved se lng gi, hi chng sau t Stent trongrelng MC hts n (tng thn nhit v protein C phn ig comthong qua, r ng .v ll . tng nh bch cu a nhn), viA ahoo giao ng t v. tn sut loe y 0 n 75%. Ti thi im ihin0nay, t Stent c coi F n02 @ . 08 2 nh mt bin php0iuytr tm thi nhng bnh 2 ocit nhn c triuight Pot chng gim tui mu chi di v hoc r th pht do tch thnh MC on xa. tng bng py Co t Stent v/hoc c l lng gi c th p dng cho nhng bnh nhn tch thnh MC on gn n nh ton trng trc khi phu thut. 2. Hin ti, khong 13% bnh nhn tch thnh MC c t on mch ghp c gi (Stent graft). Lu di, on mch ghp c gi c th tr thnh phng php c bn iu tr tch thnh MC on xa, trc khi xy ra bin chng. E. iu tr huyt khi trong thnh MC v mng x va lot MC 1. Bin php iu tr ph thuc vo v tr thng tn MC ging nh tch thnh MC. Huyt khi trong thnh MC v mng x va lot MC ch yu u 162 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

gp MC xung, do cn iu tr ni khoa tch cc nhm kim sot ti u huyt p, gim mc tng p (dP/dt) trong MC, kim sot cc yu t nguy c ca x va ng mch v theo di st v lu di. Nguy c t vong ca huyt khi trong thnh MC khong 21%, trong 2/3 t vong do tin trin thnh phnh tch hoc v phnh tch MC. 2. Phu thut c ch nh bnh nhn c huyt khi trong thnh hoc mng x va lot vng MC ln hoc quai MC v bnh nhn c gin tng dn hoc hnh thnh ti phnh bt k v tr no ca MC. F. iu tr v theo di lu di ved 1. Tch thnh MC ch nn coi l bin cercp tnh s re trong khi a s nguyn nhn hay yu hts nguy c ca t g m.vn bnh li l mt qu trnh mn All ri oton th v tin tnh, .co v. hgii quyt trit trin dn dn, vn tn ti choed ya o nlo tch thnh MC bng Fi 020@ phu thut. Nguy c hnh . 08 2 thnh ti phnh, tchcithnh MC tin trin, tch 20 o ty t thnh MC righ Pophi lun c cnh gic v theo ti pht t y op di cnCthn. 14-29% bnh nhn tch thnh MC on xa hnh thnh ti phnh mch. 2. iu tr giai on sau ca tch thnh MC on xa cng tng t nh trong giai on cp: kim sot huyt p ng mch tch cc bng thuc chn giao cm (Atenolol, Metoprolol, Labetalol) hay Diltiazem. Cc thuc gy gin mch (tng dP/dt) nh Hydralazine hay Minoxidil ch nn dng nu phi hp vi cc thuc lm gim sc co bp (nh chn giao cm). Trng hp iu tr ni khoa tht bi tc l tip tc c bng chng tch thnh MC tin trin, bin chng mch cc tng, au ti pht hoc h van MC tin trin th xem xt iu tr bng phu thut.

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3. iu tr chung v lu di cho cc bnh nhn tch thnh MC d c phu thut hay khng bao gm kim sot ti u huyt p ng mch vi mc tiu gim huyt p tm thu ng mch 130 mmHg: (cho php gim 2/3 t l ti pht). 4. V lu di, t vong (khong 30%) do v khi phng th pht hoc tch thnh MC ti pht, a s trong vng 2 nm u. Do vy mc ch ca theo di v ti khm l pht hin sm cc phnh mch th pht: khm lm sng, o huyt p, chp phim Xquang tim phi... tuy nhin bt buc phi lm nhiu ln cc xt nghim thm d MC nh siu m tim qua thc qun, chp CT, chp MRI... Chp MRI l tiu chun vng v l phng tin cung cp nhiu thng ved nht tin ser nh 3 v bnh. Thi gian ti khm nn vo ccremc s n thng, 6 thng sau khi ra vin, sauht.vtip tc 6 rig com l thuc vo nguy thng/ln trong vng 2 nm, ri ltuo. v. A aho c ca tng bnh nhn m loe khm 6 thng hoc 12 in ti @y . F 2020 8 thng/ln. 00 y 2 tocit Ti liu tham kho ight Po yr 1. Amstrong WF,pBach DS, Carey L et al. Spectrum of acute aortic Co
2. 3. 4. 5. 6. 7. 8. dissection of the ascending aorta: a transesophageal echocardiographic study. J Am Soc Echocardiogr 1996;9:646-656. Barbant S, Eisenberg M, Schiller N. Diagnostic value of imaging techniques for aortic dissection. Am Heart J 1992;124:2:541-543. Cigarroa JE, Isselbacher EM, DeSanctis RW et al. Diagnosis imaging in the evaluation of suspected aortic dissection: old standards and new directions. N Eng J Med 1993;328:35-43. Erbel R. Diseases of the thoracic aorta. Heart 2001;86:227-234. Hagan PG, Nienaber CA, Isselbacher EM et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000;283:879-903. Harris JA, Bis KG, Glover JL et al. Penetrating atherosclerotic ulcer of the aorta. J Vas Surg 1994;19:90-98. Khan IA, Nair Chandra. Clinical, diagnostic, and management perspectives of aortic dissection. Chest 2002;122:311-328. Maraj R, Rerkpattanapipat P, Jacobs LE et al. Meta-analysis of 143 reported cases of aortic intramural haematoma. Am J Cardiol 2000;86:664-8.

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9. 10. 11. 12. 13.

14. 15.

Meszaros I, Morocz J, Szlavi J et al. Epidemiology and clinicopathology of aortic dissection. Chest 2000; 117:1271-1278. Pitt MP, Bonser RS. The natural history of thoracic aortic aneurysm disease: an overview. J Card Surg 1997;12 (suppl):270-278. Pretre R, Segesser LV. Aortic dissection. Lancet 1997;349:146164. Spittell PC, Spittell JA Jr, Joyce JW et al. Clinical features and differential dignosis of aortic dissection: experience with 236 cases. Mayo Clin Proc 1993;68:642-651. Suzuki T, Katoh H, Tsuchio Y, et al. Diagnostic implications of elevated levels of smooth-muscle myosin heavy chain protein in acute aortic dissection: the smooth muscle myosin heavy chain. Ann Intern Med 2000; 133:537-541. von Kodolitsch Y, Schwartz AG, Nienaber CA. Clinical prediction of acute aortic dissection. Arch Intern Med 2000;160:2977-2982. Willens HJ, Kessler KM. Transesophageal echocardiography in the diagnosis of diseases of the thoracic aorta: part I. Chest d 1999;116:1772-1779. rve

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Iu tr Mt s ri lon nhp tim thng gp


I. Cc thuc chng lon nhp A. i cng 1. Ri lon nhp tim (RLNT) l mt trong nhng vn thng gp trong cc bnh ni khoa ni chung v tim mch ni ring. 2. Cc thuc cha lon nhp tim rt phong ph v khc bit nhau v c ch tc dng, cch dng, tc dng ph... 3. Vn s dng cc thuc chng lon nhp cng ht ved sc tinh t v kh phc tp, i hi s reser bit v hiu s bnh l cng nh c im ca ccright .vn thuc chng lon ll tm nhp. Cc nghin cu cng nhAthc .co lm sng v. ahoo loe y cho thy chnh cc thuc chng lon nhp cng c th Fin020@ trm trng hoc cc gy ra nhng ri lon 8. 2 khc 0 nhp 20 ocity bin chng nguyt him. h Pot rig hp c lon nhp tim i hi ngi 4. Trc mtpy trng Co phi c thi hp l trong vic nhn thy thuc nh kiu RLNT, la chn loi thuc ph hp, nm vng tc dng, c tnh, tc dng ph, tng tc thuc... B. Phn loi thuc chng lon nhp 1. V tnh cht phc tp ca cc thuc chng lon nhp, do vic phn loi cng c nhiu cch khc nhau. Tuy nhin cho n nay, hu ht cc bc s thc hnh lm sng s dng cch phn loi n gin ca Vaughan William (bng 10-1) v phn nhm ca Harrison trong vic phn chia mt cch chi tit nhm I ca Vaughan William.

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Bng 10-1. Phn loi thuc chng lon nhp theo Vaughan William. Nhm Tc dng ca thuc Tc dng u tin trn knh in hc I Tc dng trc tip Chn knh natri nhanh trn mng t bo (pha 0) II Chn bta giao cm ng khng trc tip knh canxi (pha IV) III Ko di thi gian ti Chn knh kali ra ngoi cc (pha III) IVa Chn knh canxi Chn dng canxi chm vo t bo ( nt nh tht) (pha II) IVb Chn khng trc tip M knh kali (tng kh cc) knh canxi ved ser re hts .v gnhm n Bng 10-2. Phn nhm ca Harrison ll ri com I. cho A hoo . Thay .i trn T Phn Tc dng oev a inl 20@y F nhm 8. 20 00 iknh Ko di QRS v QT. IA Ngn chn va phi c ty 2 o t natri nhanh (phah0) Pot g ri Ko di Copy gian ti cc qua thi con ng c ch knh kali IB Chn knh natri (nhiu hn t nh hng n QRS v QT. trn m bnh). Lm ngn thi gian ti cc (gim thi gian tr). IC Ngn chn ng k knh Lm di QRS (QT di ra theo do thay i natri nhanh. nh hng rt t n ti cc. QRS). C. Tm tt mt s loi thuc chng lon nhp thng dng (bng 10-3).

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Bng 10-3. Mt s thuc chng lon nhp (TCLN) thng dng. Tc dng ph Chuyn Thuc Liu khi Liu duy Bn ho v o u tr hu thi (gi) Nhm I Nhm IA Gan: 80% Ri lon tiu ho Quinidine 1,2 - 1,6 7-9 Thn: 20% (RLTH), vim (Serecor, Quinidex) g/ngy, gan, c quan mu, chia u tt HA, xon nh.

Tng tc thuc

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Procainamide (Procan SR, Procanbid) Disopyramide (Norpace, Rythmodan)

TM: 17 mg/kg TM: 2-6 3,5 trong 20-30 mg/pht pht 8 Ung: 300 mg Ung: 100-200 mg mi 6 gi

Gan : 40% Thn: 60% Gan: 50% Thn: 50%

RLTH, h TK, h mu, h HA, Lupus. Khng cholinergic, gim co bp c tim, h HA, xon nh.

nng Digoxin, tng tc dng ca Warfarin, tng nguy c xon nh nu phi hp vi TCLN nhm III. Vi nhm III lm tng nguy c xon nh. Vi nhm III lm tng nguy c xon nh.

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Nhm IB Lidocaine (Xylocaine) Copyright 2008. Finloev. All rights reserved Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn Potocity2020@yahoo.com.vn

Mexiletine (Mexitil)

TM: 1-1,5 mg TM: 2-4 2 /kg sau 0,5 mg/kg mg/kg mi 10 pht n tng liu l 3mg/kg 10-17 Ung: 400 mg Ung: 100-400 mg mi 8 gi 13,5 Ung: 400- Ung: 800 mg 400-800 mg mi 8 gi 24 TM: 10-15 Ung: mg/kg trong 1 400-600 mg mi gi ngy

Gan: 90% Thn: 10%

Gan: 90% Thn: 10%

H TK vi liu cao; gim dng mu ti gan khi b suy tim nng hoc sc H TK, h tiu ho, nhp chm, h HA

nng bi chn bta giao cm, Cimetidine

Gim nng bi Rifamycin Phenintoin; Tng nng do Theophyllin

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Torcainide (Tonocard)

Gan: 40% Thn: 60%

H TK, h tiu ho, h mu

Phenintoin (Dilantin)

Gan

H TK, h HA, Tng nng thiu mu bi Cimetidine Amiodarone, Fluconazole, Gim nng bi Rifamycin Carbamazepin

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170

Morcizine (Ethmozine) Copyright 2008. Finloev. All rights reserved Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn Potocity2020@yahoo.com.vn

6-13 Ung: 200-300 mg mi 8 gi Ung: 50- 12-27 200 mg mi 12 gi

Gan: 90% Thn: 10%

H TK, h tiu ho, c th gy lon nhp

Nhm IC Flecanide (Tambocor)

Gan: 65% Thn: 35%

H TK, gim co bp c tim, gy lon nhp. Chng ch nh khi c tn thng thc th cu trc tim

Propafenone (Rythmol)

2-32 Ung: 150-300 mg mi 8 gi

Gan: 50% Thn: 50%

RLTH, gim co bp c tim, gy lon nhp, tng nguy c t vong bnh nhn sng st sau t t

Tng nng bi: Amiodarone Tng bloc nh tht nu dng cng thuc chn bta giao cm hoc chn knh canxi. Tng nng Digoxin; tng hot tnh ca thuc chn bta giao cm.

Co

py

rig erv res ts n igh .v ll r .com v. A hoo loe ya Fin 0@ 8. 02 00 y2 2 cit ht Poto ed

Nhm II Metoprolol

TM: 5 mg mi Ung: 25- 3-4

Gan

Gim co bp c Tng hot tnh 171

(Betaloc, Lopressor) Copyright 2008. Finloev. All rights reserved Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn Potocity2020@yahoo.com.vn

5 pht

100 mg mi 8-12 gi Gan

Propranolol (Inderal)

TM: 5 mg mi Ung: 10- 3-4 5 pht 120 mg mi 8 gi

Esmolol (Breviloc)

TM: mg/kg

0,5 TM: 0,05- 9 pht 3 mg/kg/ph t

Dng esterases trong mu

tim, gim nhp tim, co tht ph qun, h TK, lit dng Gim co bp c tim, gim nhp tim, co tht ph qun, h TK, lit dng (ging nh trn)

bi thuc chn knh can xi

(ging nh trn)

Co

py rig erv res ts n igh .v ll r .com v. A hoo loe ya Fin 0@ 8. 02 00 y2 2 cit ht Poto

(ging nh trn)

Nhm III Amiodarone (Cordarone, Pacerone)

Ung: 1,2 -1,6 Ung: 200-400 g/ngy TM: 5mg/kg mg/ngy sau 10-20 mg/kg/ngy

25-110 Gan ngy

Phi, mt, tuyn gip, chc nng gan, ko di QT, gim co bp c tim

Tng hot tnh Warfarin; tng nng Flecanide v Digoxin; tng nguy c xon nh nu dng cng vi thuc

ed

172

Sotalol (Betapace) Copyright 2008. Finloev. All rights reserved Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn Potocity2020@yahoo.com.vn

Ung: 80- 15-17 120 mg mi 12 gi

Gim nhp tim, Khng chuyn ho, bloc nh tht, thi qua gim co bp c tim, xon nh, co thn tht ph qun

Bretylium torsylaye

Ibutilide (Corvert) Nhm IVa Diltiazem

TM: 5-10 TM: 1-2 7-9 mg/kg, nhc mg/pht li ti tng liu l 30mg/kg 2-12 TM: 0,015 0,025 mg/kg trong 5 pht TM: mg/kg 0,25 TM: 10-15 3-4 mg/gi Ung: 30120 mg mi 8 gi

Gan: 20% Thn: 80%

Gan: 90%

nhm IA Tng hot tnh ca thuc chn canxi, tng nguy c xon nh nu dng vi thuc nhm IA hoc li tiu H HA, RLTH Lm tng nguy c h HA khi dng vi li tiu hoc thuc gin mch dng Xon nh, h Trnh HA, au u, cng cc thuc lm ko di QT RLTH Gim nhp tim, gim co bp c tim, lm nng suy tim 173

Co py rig erv res ts n igh .v ll r .com v. A hoo loe ya Fin 0@ 8. 02 00 y2 2 cit ht Poto
Gan

ed

Verapamil Copyright 2008. Finloev. All rights reserved Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn Potocity2020@yahoo.com.vn

TM: mg

2,5-10 Ung: 80- 6-12 120 mg mi 8 gi 10 giy

Gan

(ging nh trn)

(ging nh trn)

Nhm IVb Adenosine (Adenocard)

TM: 6 mg tim nhanh, nu khng tc dng nhc li 12 mg tim nhanh TM/Ung: 0,25-0,5 mg

Nng bng, kh th, au ngc, v tm thu, co tht PQ

Tng hot tnh Dipyridamole; b thay i tc dng do Cafein, Theophylline

Co py rig erv res ts n igh .v ll r .com v. A hoo loe ya Fin 0@ 8. 02 00 y2 2 cit ht Poto

thuc khc Digoxin

TM/Ung: 36-48 0,1-0,75 mg mi 8 gi trong ngy

Thn

H TK, h tiu Tng nng ho, bloc nh tht, bi Quinidine, Verapamil, lon nhp Amiodarone, Propafenone.

Ghi ch: TM: tim Tnh mch; TK: thn kinh; RLTH: ri lon tiu ho; HA: huyt p

ed

174

II. Thm khm bnh nhn b ri lon nhp tim A. Lm sng 1. Khai thc k bnh s v nh gi lm sng rt quan trng, n gip cho iu tr tt cc ri lon nhp tim. 2. Hi k tin s xut hin lon nhp, hon cnh xut hin, thi gian, tn xut, cch bt u cng nh kt thc, p ng vi cc iu tr (xoa xoang cnh, n nhn cu...), cc triu chng khc i km (au ngc, ngt, xu...). 3. Hi v tin s gia nh xem c ai mc cc RLNT nh bnh nhn khng (mt s lon nhp bm sinh c trong cc bnh nh bnh c tim ph i, hi chng QT di gia nh, hi chng Wolff - Parkinson White...). ved ser 4. Hi k tin s cc bnh tim c t trce (bnh van r ts tim, bnh mch vnh...) hoc cc bnh .khng phi gh m vn i ll r tim c th lin quan n lonAnhp .co . ahoo (bnh ni tit, oev bnh vim nhim, nhim trng...). inl 20@y 5. Thm khm thc th 08. F ch n cc du hiu sinh cn 20 tn, nhp tim u 20tockhng, huyt p nh th no, hay ity t gh tim cc biu hinibnh Po mch, cc bnh khc... yr p 6. Cn lm sng cn ch : in gii , cng thc mu, Co mt s nng cc thuc ang dng m nghi c nh hng n nhp tim. Trong mt s trng hp nghi ng, c th lm thm cc xt nghim chn on bnh tuyn gip hoc cc c t... B. in tm (T): L mt xt nghim rt quan trng trong chn on ri lon nhp tim. 1. in tm 12 chuyn o: L bt buc, nu c T lc khng c lon nhp s gip ch rt nhiu cho chn on. 2. Theo di trn monitor lin tc gip theo di nhng bin i v tn s, hnh thi ca lon nhp; cc p ng vi iu tr...

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3. Cc trng hp khng r v hot ng ca nh trn T th c th lm mt s chuyn o c bit nh: a. Chuyn o Lewis: in cc m t b trn phi cnh xng c, in cc dng t b di tri cnh c. b. Chuyn o thc qun: a mt in cc c bit vo trong thc qun gn v tr nh tri, cho php nhn r sng hot ng ca nh. c. Chuyn o trc tip bung nh: dng in cc my to nhp tm thi a vo bung nh phi. C. Holter T: Phng php ghi li T trong sut 24 gi hoc hn, cho php ghi li c nhng on ri lon nhp m T bnh thng khng bt c (vd. cc ngoi ved tm thu, cc cn nhp nhanh kch pht...). ser re ts D. Mt s phng php khc gh m.vn l ri o 1. Nghim php gng sc i v. Al rto.c ch nh khi ho c a oe gi nhng lon nhp linFquan0@y gng sc, c bit inl 2 n l cc ngoi tm thu 8. y2hoc cc cn nhp nhanh 0 tht 0 20 ocit tht. N phn bit nhng ri lon nhp ny l do tn ht Pot rig (xut hin hoc nng ln khi gng thng thc th py Coc nng (khi gng sc mt i). sc) hoc 2. Thm d in sinh l tim (cardiac electrophysiology study) l phng php c ch nh khi cc thm d khng chy mu khng nh gi cc ri lon nhp hoc iu tr mt s ri lon nhp. Ngi ta s dng mt s dy in cc v a n nhiu v tr khc nhau trong bung tim nh gi bn hot ng in hc ca tng nh, nt nh tht, ng dn truyn nh tht, tng tht... Phng php ny cng cho php nh v c cc v tr hoc cc ng dn truyn bt thng, cc ngoi v v xc nh c ch ca cc loi ri lon nhp.

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III. Rung nh Rung nh (RN) l mt trong nhng ri lon nhp rt thng gp, chim khong 0,4 - 1,0% trong cng ng v gp khong 10% s ngi trn 80 tui. A. Nguyn nhn Tng huyt p. Bnh van tim (HHL). Suy tim. Bnh ng mch vnh. Cc nguyn nhn khc: nhi mu phi; bnh phi mn tnh tc nghn; cng gip; nhim trng; ri lon chuyn ho, bnh mng ngoi tim, Phud thut e erv tim mch... res hts n 6. Rung nh v cn. rig com.v ll . B. Sinh l bnh v. A ahoo loe y Fin020@ nh: 1. Cc gi thit v c ch. gy rung 08 2 20 ocity a. Vng vo li ti tnh, l c ch m ngy cng c t igh Po nhiu bng chng v c ch nht. yr op b. Gi C thit v ri lon s pht nhp, s hnh thnh ngoi v (mt hoc nhiu) nh gy tng tnh t ng hoc ny c hot ng. Vic t ngoi v ny bng sng cao tn qua catheter vng vo ca cc tnh mch phi thu c nhng thnh cng bc u h tr cho gi thit ny. 2. Nguy c tc mch bnh nhn rung nh s tng vt, c bit ngi c tui, bnh nhn c tiu ng, c bnh van tim, tng huyt p, suy tim... 3. Rung nh thng km theo nhp tht nhanh lm cho cung lng tim b gim i ng k, nht l khi bnh nhn c cc bnh thc tn tim km theo. Bn thn rung nh gim khong 20 % lng mu xung tht trong thi k tm trng. Do , khi RN km theo 177 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn 1. 2. 3. 4. 5.

nhp tht nhanh th cng lm cho thi k tm trong ngn, lng mu v tht gim i ng k. 4. Phn loi rung nh: c th phn ra cc th rung nh (da trn kiu xut hin rung nh) nh sau tin cho vic theo di v iu tr: a. Cn rung nh ln u mi xy ra, l rung nh mi thy xut hin ln u tin bnh nhn, c th thong qua do nhng nguyn nhn c th phc hi c hoc c th tn ti mi. b. Rung nh kch pht, l nhng rung nh xut hin v kt thc t pht (thng trong 48 gi) v d b ti pht. c. Rung nh dai dng, l nhng rung nh tn ti lu ved nhng vn c th ti to nhp xoang bng thuc ser re hoc sc in chuyn nhp. ts gh m.vn i d. Rung nh mn tnh, l nhng rrung nh lu m ll co . A ahoo.in u khng ev chuyn nhp bng thuclohoc sc in hocykhng duy tr c F hoc rt t thnh cng 020@ 8. 00 ity2 lu nhp xoang. oc 2 t ot ghsng C. Triu chng yri lm P p Co 1. C th khng c triu chng g. 2. a s bnh nhn thy hi hp nh trng ngc, kh th, au ngc, chng mt, v m hi... 3. C th c bin chng tc mch l biu hin u tin ca bnh. 4. Nghe tim: thy lon nhp hon ton, c th thy nhng du hiu ca bnh van tim km theo (nu c). D. Cc xt nghim chn on 1. in tm : a. Sng P mt, thay bng sng f= 400 - 600 ck/pht. b. Nhp tht rt khng u v khong cch, tn s.

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c. Bin ca cc sng QRS trn cng mt o trnh cng rt khc nhau. 2. Siu m tim gip chng ta nh gi xem c huyt khi trong cc bung tim hay khng hoc c th c nguy c hnh thnh huyt khi (gin cc bung tim, hin tng tng ng trong cc bung tim).

py Co Hnh 10-1. Rung nh: sng f nh r chuyn o V1. E. iu tr Nhm 3 mc ch: Gim p ng (tn s) tht. Gim nguy c tc mch. Chuyn nhp (a v nhp xoang) v duy tr nhp xoang. 1. Kim sot nhp tht: Thng thng th nhp tht c th c kim sot bng bng cc thuc lm chm ng dn truyn qua nt nh tht. a. Digitalis:

r ese sr n t gh .v l ri .com l . A oo oev yah inl @ . F 2020 8 00 y 2 tocit ht Po rig

ved

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L thuc kinh in hn ch tn s tht khi b rung nh nhanh. N l thuc l tng cho nhng bnh nhn b rung nh nhanh m c gim chc nng tht tri, hoc c chng ch nh vi cc thuc chn bta giao cm, chn knh calci. Thng dng loi tim tnh mch (Isolanide, Cedilanid 0,4 mg tim TM 1/2- 1 ng). Trong trng hp khng khn cp, c th cho dng ung Digoxin 0,25 mg (1-2 vin/ngy), iu chnh liu v sau theo p ng c th. Ch nu c ch nh sc in iu tr rung nh th phi dng Digitalis trc vi ngy. b. Chn bta giao cm: ved C th dng dng tim reser mch tnh (Metoprolol, Esmolol) hoc ights .vung. Cc dng n m l r thng c la l thuc chn bta giao .cm oo.co v A ah nh nhanh m chn nhng bnh loe @y rung nhn in c cn nguyn 8. F 20mch vnh hoc rung nh bnh 20 0 20 oc nhanh tin pht.ity ht ot Cnych P chng ch nh ca cc thuc cc rig p Co bta giao cm ( cp n bi cc chn thuc iu tr THA). c. Cc thuc chn knh canxi: Thng dng Verapamil hoc Diltiazem dng tim tnh mch hoc dng ung. Cc thuc ny lm gim p ng tht tt, c bit dng tim c tc dng kh nhanh. Chng ch nh dng khi c ri lon chc nng tht tri, c suy tim r. 2. Ngn nga tc mch: a. Ch nh v chng ch nh dng thuc chng ng bnh nhn rung nh c trnh by trong bng 10-4. Nguy c tc mch l rt d xy ra bnh nhn b rung nh. Tuy nhin, cn cn nhc 180 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

gia li ch v tc hi ca vic dng cc thuc chng ng tng bnh nhn rung nh c th. b. Thuc v cch dng: Khng Vitamin K l thuc c la chn hng u. Mc tiu cn t c khi dng l m bo t l INR mc 2,0 - 3,0. Bng 10-4. Ch nh v chng ch nh dng thuc chng ng bnh nhn rung nh Ch nh: Rung nh bnh nhn c: tin s tc mch no hoc tai bin thong qua, c suy tim huyt, bnh c tim gin, bnh ng mch vnh, hp van hai l, c van tim nhn to, cng tuyn gip, THA. Dng trc khi sc in iu tr rung nh (c k erved t hoch) res nht 3 tun v sau sc in t nht 4 tun. hts n Chng ch nh tng i: rig com.v ll . A hoo. Khng c kh nng kim sot, theovdiacc xt nghim v oe t l Prothrombin v INR. . Finl 20@y 0 Bnh nhn sa st tr tu. 2008 ity2 c Ph n ang mang thai. Poto ht rig Lot ng tiuopy ang tin trin. ho C C tin s chy mu trm trng hoc b ri lon ng mu. THA nng khng khng ch c. Nu ch nh chuyn nhp th cn dng mt thuc trong nhng thuc trn trc t nht 3 tun v sau t nht 4 tun. Trong trng hp cn chuyn nhp cp cu th cn cho Heparin v phi kim tra siu m qua thc qun bo m khng c mu ng trong nh tri mi chuyn nhp cho bnh nhn v sau chuyn nhp th tip tc cho khng Vitamin K thm 4 tun.

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Vi nhng bnh nhn tui di 65 v t nguy c tc mch hoc c chng ch nh dng khng vitamin K th c th cn nhc cho Aspirin thay cho khng Vitamin K. Bng 10-5. Cc thuc khng Vitamin K thng dng. Thi gian tc dng (gi) Loi thuc Bt u Ko di Thi gian tc dng ngn 28-24 24 48 EthyleBiscoumacetate (Tromexane) 48 - 96 Phenindione (Pindione) Thi gian tc dng va 24 - 48 48 - 96 Acenocoumarol (Sintrom) 48 - 72 Fluindione (Previscan) 48 - ved 96 Tioclomarol (Apegmone) ser Thi gian tc dng di re ts Warfarine (Coumadine) 36 righ m.vn 120 96 ll .co v. A ahoo loe 3. Chuyn nhp (a v nhp 20@y v duy tr nhp Fin0 xoang) . xoang: R rng l2008 chuyn v nhp xoang v duy vic ty2 i t mang tr nhp xoang hs Potoc li nhiu li ch cho bnh g i nhn v c yr p huyt ng v gim cc nguy c tc mch. Co Tuy nhin, phi lu l bnh nhn cn c nh gi k lng trc khi quyt nh chuyn nhp. Trong mt chng mc no , nu khng nh gi k lng bnh nhn, vic c gng chuyn nhp v dng thuc duy tr c th s tht bi hoc khng mang li li ch g hn m lm tng nguy c do dng thuc duy tr nhp lu di. Nhiu nghin cu chng minh rng, i vi nhng bnh nhn b RN lu, c nhiu yu t ti pht km theo... th vic khng ch nhp tht, ngn nga tc mch v chung sng ho bnh vi RN li l gii php ti u nht. Trong mi trng hp RN, cc bnh c bn phi c xem xt gii quyt trit trc khi iu tr rung nh.

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a. Chuyn nhp bng thuc: L phng php nn c la chn u tin trong vic chuyn nhp. T l thnh cng khc nhau ph thuc vo tnh trng c th tng bnh nhn cng nh nguyn nhn gy rung nh v thi gian rung nh. Nhn chung, t l thnh cng do chuyn nhp bng thuc thp hn chuyn nhp bng sc in. Trong trng hp dng thuc chuyn nhp khng thnh cng th nn ch nh sc in iu tr kp thi. Khi vai tr ca cc thuc ny kh quan trng v n gip kh nng sc in chuyn nhp thnh cng cao hn v duy tr tt nhp xoang sau . Cc thuc dng tim tnh mch (bng 10-3). Procainamide (nhm IA): l thuc ved th c serRN. C c chn chuyn nhp trong re ts khong 1/3 bnh nhn khi dng m.vn ny c gh thuc ri tc dng ph (ri lon tiullho,co . A ahoo. huyt hc, hi oev chng ging Lupus...). @y inl 20 F Amiodarone 08. 20 (Cordarone): l thuc c la 0 ity 2 chn khi cctothuc khc khng dng c t o c gh bi. Lu l thuc c thi gian bn i hoc rtht P py Co cc k di (120 ngy). Thn trng vi cc hu bin chng khi dng lu di (ri lon tuyn gip, nhn m, vim phi k, vim gan, co git...). Amiodarone c chng minh l lm gim t l t vong do ri lon nhp tht. Tuy nhin, trong cc ri lon nhp nhanh nh n cng c tc dng rt tt c bit l bnh nhn rung nh. Thng dng di dng truyn tnh mch pha trong dung dch ng hoc mui ng trng. Ibutilide: l mt thuc mi v rt hu hiu trong iu tr rung nh. Bin chng c th gp l cn xon nh (gp 1-2%). Cc thuc dng ung (bng 10-3). 183 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

C Amiodarone v Procainamide u c dng ung, trong Amiodarone l thuc hay c s dng hn c, nht l duy tr nhp xoang sau khi c chuyn nhp. Lu nhng tc dng ph ca Amiodarone khi dng lu di v thi gian bn hu cc k di ca n. Procainamide khi dng lu di s km dung np hn, nn thng khng dng loi ny duy tr nhp xoang. Quinidine l thuc trc y thng c dng nht chuyn nhp v duy tr nhp xoang. Tuy nhin Quinidine c rt nhiu tc dng ph v bn thn n cng l yu t c th gy ra cc ri lon nhp khc. N d tng e erv khng tc vi mt s thuc khc nh Digoxin, res vitamin K, Verapamin, lm tngstcndng cc ht .v ig thuc ny khi dng cngAll r nhau. vi o.com . ho Sotalol l thuc thuc vnhm III nhng c tc loe @ya Fin 0 dng chn bta. giao 2cm. N c th dng 08 ty20 bnh nhn 20 ocinh, nhng cn ch cc tc rung t o gh lint quan n chn bta giao cm v dngrph P i y c p gy xon nh do lm QT ko di. Co th Flecainide v Propafenone l thuc thuc nhm IC (bng 10-3) c tc dng tt bnh nhn rung nh. Chng l thuc c kh nng dung np tt nhng c th lm tng t l t vong bnh nhn c ri lon nhp tht do bnh ng mch vnh. Do , cc thuc ny thng khng c ch nh bnh nhn rung nh do cn nguyn bnh ng mch vnh hoc bnh c tn thng cu trc tim. Disopyramide thuc nhm IA, c tc dng tng t Procainamide v Quinidine. Tuy nhin thuc ny gy gim co bp c tim nhiu, do khng nn dng nhng bnh nhn c ri lon chc nng tht tri.

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b. Chuyn nhp bng sc in: L bin php c hiu qu cao trong chuyn nhp t rung nh v nhp xoang vi t l thnh cng trn 80%. Sc in iu tr rung nh nn c ch nh khi dng thuc tht bi, c du hiu thiu mu c tim, kh khng ch nhp tht, suy tim... c bit khi c nhng ri lon huyt ng trm trng th cn ch nh sm. Sc in s thnh cng cao hn khi c dng cc thuc trc (v d Amiodarone). Sc in chuyn nhp ch tin hnh khi bnh nhn c dng chng ng y (xem phn trn). Trong trng hp cp cu th cho Heparin v phi lm siu m qua thc qun ed loi tr khng c mu ng trong reserv nh. Sc in phi c tin hnhghts .vn ni c nhng l ri tt m tim mch, kh nng cp cu v theo l o.co v Adi ev. tt.o bnh nhn c gyom yah Cc nhn vin y inl @ . F 2020 t phi thnh tho trong vic p dng cc bin 08 y php h hp 0 octr. 2 h it t ot P Ccyyuht nh hng n kt qu ca chuyn rig p bng sc in l: thi gian b rung nh nhp Co lu hay nhanh, ln ca sng f, kch thc nh tri, c h van hai l phi hp, c suy tim khng ? Thi gian b rung nh cng lu, sng f cng nh, nh tri o trn siu m ln hn 45 mm l nhng yu t d bo tht bi ca sc in hoc kh nng ti pht rung nh cao. Nng lng dng trong sc in iu tr rung nh thng bt u bng liu nh 100J sau c th tng ln ti 200J, 300J v phi l sc in ng b. 4. Cc phng php iu tr khc: a. t my to nhp vnh vin: Phng php ny c ch nh khi bnh nhn khng p ng vi cc cch iu tr trn hoc khi nhp tht b chm 185 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

b. Trit ph rung nh qua ng ng thng (catheter ablation): Qua ng ng thng a cc in cc v dng sng radio cao tn t trong nh tri thnh tng kha to hiu qu ging nh phu thut Maze trit ph cc vng vo li ti c nh. Phng php ny c t l thnh cng khng cao lm v c th c nhng bin chng, nhiu khi phi cn n cy my to nhp vnh vin. Ngy nay, cng vi s tin b ca k thut v cc dng c mi cho php t l thnh cng ngy cng ved cao hn v ha hn y s l mt phng php ser re iu tr tt cho nhng rung nh dai hts .vn g dng mn tnh. l ri om c. Phu thut ct cc kha . lcoonh (phu thut A h .c oev Maze), phu thut tonhnh ya nh, phu thut i l 20@ lang F 0 8 c lp nh l nhng. phu thut c thc hin 00 ity2 iu tr ht 2 otoc tuy nhin t l thnh cng rung nh, ig rthuc Pnhiu vo k thut v tnh trng cn ph py Co bnh nhn. Phu thut trong iu tr rung nh thng ch c thc hin trong khi tin hnh cc cuc phu thut khc bnh nhn (v d khi m thay van tim, m lm cu ni...). IV. Cung ng nh Cung ng nh (atrial flutter) l mt hnh thi nhp nhanh trn tht kh hay gp v thng khng tn ti lu di v c xu hng chuyn v nhp xoang hoc chuyn sang rung nh. A. Triu chng lm sng 1. Biu hin lm sng rt khc nhau tu theo bnh tim thc tn c sn, theo p ng tht chm hay nhanh m bnh nhn c th c cm gic hi hp trng ngc.

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2. Cung nh thng ch tn ti vi gi n vi ngy, t khi ko di hn v sau n s chuyn v nhp xoang hoc thnh rung nh. B. Sinh l bnh 1. Cung nh xut hin l do vng vo li nh, thng thng nh phi v rt t khi nh tri. 2. in hnh nht l vng vo li nh phi v i theo ngc chiu kim ng h xung theo thnh t do ca nh phi v ln li vch lin nh. 3. Cung nh c th chia lm 2 th (type): Type I l loi cung nh c th ct c bng to nhp nh vt tn s v tn s nh thng mc 240-340 chu k/pht khi cha dng thuc. Type II l loi cung nhed khng erv ct c bng to nhp nh vt tn s vestn s nh r ts thng mc cao hn 340-430 chu k/pht. gh m.vn i ll r .co o . Acho ophp chn on C. in tm : L thm d c bn ah oev cung nh. inl 20@y F 8. 20 00 itysng P v thay bng sng F 1. in hnh, ta s thy mt 2 oc hnh rng ca, ht Pn, rt r cc chuyn o sau g u ot i yr di (DII,pDIII, aVF). Co 2. Tn s F t 240-340 ck/pht, trung bnh 300 ck/pht. 3. Phc b QRS thng ging nh lc cn nhp xoang (khng gin rng). 4. Tn s tht thng kh u v l c s so vi nhp nh v c th c bloc 2:1; 3:1... Tuy nhin, i khi tn s tht khng u do s thay i mc bloc nh tht trong cung nh.

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ved ser re ts gh m.vn i Hnh 10-2. Cung nh 2:1. ll r co . A ahoo. 5. Trong trng hp cung nh emyc bloc nh tht 2:1 ov inl 20@ F th i khi kh chn on2do sng F ln vi sng T. 8. 0 00mt s nghim php lm chm Khi cn thitt lm ocity 2 gh lm tl ra sng F r hn (v d xoa p ng tht i Po r py xoang cnh, tim Adenosin...). Co
D. iu tr 1. Lm gim p ng tht: a. L bc u tin cn thc hin cho mi bnh nhn cung nh, c bit khi p ng tht nhanh c th gy nh hng n huyt ng. b. Cc thuc c th dng l Digitalis loi tim, tc dng nhanh (Cedilanide, Isolanide), hay mt s thuc chn knh canxi hoc chn bta giao cm. c. Digitalis nn l thuc c la chn hng u lm gim p ng tht. 2. Cc thuc chuyn nhp v duy tr:

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3.

4.

5.

6.

a. Thng dng cc thuc nhm IA (Quinidin, Procainamid), IC (Flecainid, Propafenone) hoc nhm III (Amiodaron). b. Thng thng cc thuc ny c t l thnh cng khng cao trong chuyn nhp nhng rt quan trng gip cho sc in thnh cng, v c mt t l nht nh khi sc in cung nh s tr thnh rung nh v nu khng c dng cc thuc ny trc th kh c th a v c nhp xoang. Chng ng trong cung nh nn ch nh cho nhng bnh nhn c nguy c tc mch cao (tin s tc mch, nh tri ln...). Sc in chuyn nhp: l phng php rt c hiu qu v nn c la chn cho bnh nhn cung nh. ved ser Thng dng nng lng thp, bt u ts r50J. Mt s t e gh m.vn trng hp sc in lm cung nhi bin thnh rung ll r co . A ahoo. tr rung nh nh, khi cn sc tip nh trong iu v loe chuyn v nhp xoang. . Fin 20@y 8 20 To nhp nh vt 0 citys: C th thc hin bng 20 tn t o in cc p rtrc tipt vo thnh c nh trong khi m igh Po py hoc a oin cc qua ng thc qun. Vi in cc C qua ng thc qun th cn phi c dng in ln (ti 30 mA), nn c th gy au n cho bnh nhn. Thng dng cch to nhp tim p theo my vi tn s nhanh hn tn s tim ca bnh nhn khong 10 20 nhp gy c ch vng vo li ri tt my t ngt, nhp xoang ca bnh nhn s c ti lp li. Trit ph vng vo li qua ng ng thng: y l bin php hu hiu vi t l thnh cng trn 95 % v t ti pht. Trc tin dng cc in cc thm d bn in hc ca nh pht hin ra vng vo li, sau nh v v tin hnh t bng sng radio cao tn qua mt dy in cc.

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7. Vi mt s trng hp cung nh tn ti dai dng v khng p ng vi cc phng php iu tr trn, c th cn phi t trit ph nt nh tht v cy my to nhp vnh vin. V. Cn nhp nhanh kch pht trn tht (CNNKPTT) Thc t tim nhanh trn tht bao gm nhiu loi ri lon nhp khc nhau nh: rung nh, cung nh, tim nhanh nh, nhp nhanh trn tht c vng vo li nt nh tht hay qua ng dn truyn ph... Tuy vy, trong thc hnh t trc n nay ngi ta gi l cn nhp nhanh kch pht trn tht ch nhng cn tim nhanh bn cht trn tht v c vng vo li nt nh tht hoc vng vo li nh tht qua ng dn truyn ph. A. Sinh l bnh: thng c hai loi ch yu: ved ser 1. Cn nhp nhanh kch pht trn tht (CNNKPTT) re ts c vng vo li ngay ti nt nh tht:m.vn vo li gh vng i l r co chy qua ng dn truyn nhanhl v .chm nt nh . A ahoo ev tht hoc qua ng dn itruynychm nt nh tht nlo 0@ F v ng dn truyn08. 202 ph rnh nh tht (trong hi 0 ity 2 chng WPW). Trongtoc a s cc trng hp (95%) t o i gh (xui) ca vng vo li l qua ng ri ng i xung P py Co chm ca nt nh tht v i ngc ln theo dn truyn ng dn truyn nhanh. Vic khi pht ra cn nhp nhanh thng l do hin tng ny c khi c mt ngoi tm thu nh hoc ngoi tm thu tht. Ngoi tm thu nh lm bloc dn truyn xui ng dn truyn nhanh v khi xung ng ch xung theo ng dn truyn chm, vng li kh cc ng dn truyn nhanh gy vng vo li. Kt thc cn nhp nhanh l kt qu ca vic bloc ng dn truyn chm. 2. CNNKPTT c vng vo li nh tht c lin quan n mt ng dn truyn ph v n: khng th hin trn in tim b mt.

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B. Triu chng lm sng 1. CNNKPTT thng xy ra nhng bnh nhn khng c bnh tim thc tn. Tuy nhin c mt s trng hp cng c th xy ra cc bnh nhn c bnh tim thc tn. 2. Khai thc tin s c th thy bnh nhn c nhng cn hi hp nh trng ngc, tim p nhanh, s xut hin v kt thc cn nhp nhanh kh t ngt. 3. Trong cn bnh nhn c cm gic hi hp nh trng ngc, lo lng, tim p rt nhanh. 4. CNNKPTT thng t nh hng n huyt ng v thng khng ko di. Song c mt s t trng hp, ed cn c th ko di hng ngy v c th eserv tt p gy r ts hoc suy tim. gh m.vn l ri o 5. Nghe tim thy nhp tim thngAl hoo.c tn s trung . rt u, ev a bnh 180 - 200 ck/ pht. Finlo 0@y 8. 02 6. CNNKPTT c th200 city2 t ngt hoc khi bo kt thc t o bnh nhn ht h Pot ri th ra nhng ng cht rig su vo py thanh mn (rn th) hoc khi c bc s xoa xoang Co cnh hay n nhn cu... C. in tim 1. Phc b QRS thng thanh mnh, u, tn s 180 200 ck/pht. 2. Sng P khng nhn thy do ln vo QRS hoc i khi c th nhn thy ging nh sng r nh V1. 3. Khi kt thc cn c th thy mt on ngng xoang ngn hoc nhp chm trc khi ti lp nhp xoang.

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ved ser re ts v ghtht. n i Hnh 10-3. Cn nhp nhanh kch pht ltrn om. l r c . A ahoo. D. iu tr oev inl 20@y 1. Ct cn nhp nhanh: 8. F 20 00 y 2 toc t a. Cc bin php gyi cng ph v c th ct c t igh Po cn nhprnhanh: C th bo bnh nhn ht su vo y p Co ri th ra nhng ng thanh mn (ng tc rn); c th xoa xoang cnh (ch trc khi xoa phi nghe khng thy hp ng mch cnh v xoa tng bn mt. Xoang cnh nm v tr ngang sn gip, khi xoa bo bnh nhn nghing u mt bn, bc s dng ngn tay ci n ln xoang cnh v day). n nhn cu l mt bin php kh hiu qu v hay c dng nhng cng kh th bo, i khi c th gy bong vng mc ca bnh nhn. b. Thuc u tay nn dng l Adenosine dng ng tim 6mg. Adenosine gy bloc nh tht hon ton tm thi v nhiu khi gy tm ngng xoang, do lm ngng dn truyn trong nt nh tht v lm ct t vng vo li nt nh tht. V tr tim
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c.

d.

e.

f.

g.

nn ch tnh mch nn v khi tim phi bm tht nhanh v thi gian bn hu ca thuc cc nhanh. Ln u dng 6 mg, nu khng kt qu th tim nhc li 6 mg v nu vn khng c kt qu th dng tip 12 mg (2 ng). Cc thuc chn knh canxi v chn bta giao cm c th c dng khi dng Adenosine tht bi. Thc t ngi ta thng dng Verapamil dng tim tnh mch. Verapamil lm ko di thi gian tr ca nt nh tht v chm dt vng vo li ca nt nh tht. Liu lng ca Verapamil t 510 mg tim tnh mch trong 2-3 pht. Chng ch nh bnh nhn c suy gim chc nng tht tri, c tt p, cn thn ngi gi. ved ser Chn bta giao cm thng dng l rPropranolol e s hoc Esmolol dng tim right m.vLiu ca TM. n o ll Propranolol l 0,15 mg/kgAtim.cTM tc 1 v. ahoo mg/pht. Ch cc tcoedng ph v chng ch inl @y . F 2020 nh ca cc thuc8ny. 0 20 oc y chmitdn truyn trong nt nh tht Digitalis, lm ot t gh P v c othrict c cc CNNKPTT do vng vo li y p C ti nt nh tht. Tuy nhin, cn thn trng khi bnh nhn c hi chng WPW hoc c nh xoa tip xoang cnh sau v Digitalis c th lm tng nhy cm ca xoang cnh. Amiodarone l thuc c th cn nhc khi cc bin php trn tht bi. Nhiu khi bn thn Amiodarone cng khng ct cn c nhng sau khi dng thuc ny th c th tin hnh li cc bin php gy cng ph v, khi s c hiu qu. Sc in ct cn c ch nh khi CNNKPTT dai dng, c nh hng n huyt ng (gy suy tim, tt huyt p) hoc cc thuc khng ct c cn.

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Thng ch cn nng lng nh (50J) v ng b l c th ct c cn. 2. iu tr trit : a. Hin nay, nh phng php thm d in sinh l pht hin cc ng dn truyn ph v qua dng sng radio cao tn trit ph (t) (catheter ablation) cc ng dn truyn ph c th gip cha khi bnh hon ton. y l phng php nn c la chn hng u cho cc bnh nhn c CNNKPTT ti pht nhiu khng p ng vi cc iu tr ni khoa thng thng. i vi tt c cc bnh nhn c chn on l c CNNKPTT nn gi n nhng trung tm c th thm d in sinh l xem xt vicviu tr ed ser trit cc CNNKPTT cho bnh nhn.e r ts vn gh m.CNNKPTT b. Cc thuc c th dng dl phng ri o Al l c . ththoo. chn bta giao c vng vo li ti nt nh a ev nlo 0@y cm, Digitalis, hocFiVerapamil... Tuy vy, vic 2 . 08 lu dng cc thuc 0nyty20 di phi c ch ti 2 oci cc tc dngtph tca chng. gh Po ri c. Hin opy hu ht cc nghin cu u cho thy li C nay, ch vt tri ca trit ph ng dn truyn ph so vi dng thuc v y chnh l phng php c th cha khi bnh hon ton. VI. Ngoi tm thu tht Ngoi tm thu tht (NTTT) l mt trong nhng ri lon nhp tim cng kh thng gp. Tuy NTTT c th xut hin trn ngi bnh thng v khng gy nguy him, nhng nhiu trng hp NTTT thng xy ra trn mt bnh nhn c bnh tim v c th gy nguy him n tnh mng ngi bnh nu khng c pht hin v x tr kp thi. Vic quyt nh iu tr cng cn phi c cn nhc k v thng phi da trn cc triu chng do NTTT gy ra, s c mt ca bnh tim km theo v nht l phi da trn mt s c 194 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

im ca NTTT trn T xem c phi l NTTT nguy him hay khng. A. Nguyn nhn 1. NTTT ngi bnh thng: hay gp ph n v thng l mt dng, mt . Tin lng lnh tnh v thng khng cn phi dng thuc chng lon nhp. 2. NTTT bnh nhn c bnh tim thc tn: hay gp trong mt s bnh l sau: a. Nhi mu c tim: kh hay gp v cn cnh gic trong giai on cp cng nh phi theo di st sau NMCT. b. Bnh c tim gin. c. Bnh c tim ph i. ved ser r d. Bnh van tim (do thp, sa van hai l...).e ts gh m.vn i e. Tng huyt p. ll r o co o . A atim. (Digitalis, cc f. Dng cc thuc iu trev o suy h inl 2ccy thuc li tiu, cc thuc ging giao cm), 0@ F 8. 0 0 nhp... thuc chng lon 0 city2 2 t o g. Ri lon rin gii mu... gh Pot i py Co lm sng B. Triu chng 1. Bnh nhn c th khng thy c triu chng g c bit c. Nhng a s bnh nhn thy c cm gic hi hp nh trng ngc, hoc l cm gic hng ht trong ngc. 2. Thm khm lm sng c th thy: s mch c nht rt yu hoc khng thy, tip l khong ngh di hn. C trng hp thy mch chm bng mt na so vi tn s ca tim nu nghe tim ng thi (khi bnh nhn c NTTT kiu nhp i). Nghe tim c th thy nhng nht bp xy ra sm v sau thng hay c mt khong ngh b. Khi bnh nhn b rung nh th trn lm sng kh bit c l c NTTT hay khng. Khi , T mi gip chn on chc chn c. 195 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

C. in tm 1. T l thm d rt quan trng trong chn on NTTT. 2. Nht NTT c biu hin l mt nht bp n sm, phc b QRS thng gin rng, hnh th khc bit so vi nht bp t nhin ca bnh nhn, sng T v on ST o hng so vi QRS, khng c sng P i trc. 3. Phc b QRS ca NTTT ny thng n kh sm. Mt NTTT in hnh thng hay c thi gian ngh b, tc l khong RRR = 2RR. 4. NTTT c th c nhiu dng (hnh dng khc nhau trn cng chuyn o), nhiu (cc khong ghp khc nhau). ved ser NTTT 5. Khi c mt nht bp nhp xoang xen kremt ts th gi l NTTT nhp i, v khi hai hnhp n rig com.v xoang c l mt NTTT gi l NTTT nhp ba...l hoo. v. A a loe y Fin020@ . 08 2 20 ocity ht Pot rig py Co

Hnh 10-4. Ngoi tm thu tht.

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D. Cc thm d khc 1. Cn lm y cc xt nghim c bn, nht l ch cc ri lon in gii mu. 2. Siu m tim rt hu ch gip ta pht hin cc tn thng thc th tim. 3. Holter in tim xc nh cc thi im xut hin, mc nguy him v s lng NTTT trong 24 gi. 4. Nghim php gng sc th lc c th c ch nh trong mt s tnh hung nht nh phn bit cc NTTT c nng (khng c bnh tim thc tn) hay thc tn (c bnh tim thc tn)... E. Cc du hiu bo hiu mt NTTT nguy him 1. Xy ra bnh nhn c bnh tim thc tn. ved 2. S lng NTTT nhiu. ser e sr 3. NTTT i thnh tng chm hoc nhpight mnhp ba. i, .vn lr o Al h .c 4. NTTT n sm (sng R (l . sngooR ca phc b ev a NTTT) s ri trn sng T inlo phc b tht trc . ca 0@y . F 02 5. NTTT a dng, a 2008 ity2 . c ht Poto F. iu tr rig py 1. i viCo NTTT c nng ( bnh nhn khng c bnh tim thc tn): a. Thng l lnh tnh, tin lng tt v khng cn iu tr c hiu. b. Ch nn iu tr khi bnh nhn c triu chng c nng dn dp (au ngc, kh th...). c. Vic iu tr nn bt u bng loi b cc cht kch thch (cph, ru, thuc l...). Tp th dc u n. Nu bnh nhn ang dng cc thuc khc cn lu n kh nng cc thuc ny c th gy ra NTTT (li tiu, cocaine, thuc cng giao cm...). Ch iu chnh in gii trong mu. d. Thuc la chn (nu cn) hng u cho iu tr NTTT c nng l mt loi chn bta giao cm liu thp. 197 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

2. i vi NTTT thc tn (trn bnh nhn c bnh tim thc tn) trong giai on cp tnh ca bnh: a. Thng gp nht l trong NMCT cp v bo hiu c th sp chuyn thnh nhp nhanh tht hoc rung tht. NTTT cn c th xy ra khi bnh nhn c ph phi cp do cc bnh van tim, vim c tim cp, vim mng ngoi tim... Mt s bnh cnh cng cn c quan tm: bnh nhn c hi chng Prinzmetal, hi chng ti ti mu sau dng thuc tiu huyt khi hoc sau can thip MV. b. Thuc hng u l: Lidocain (Xylocain) tim TM thng 80 - 100 mg sau truyn TM 1-4mg/ pht. C th gp cc tc dng ph ca Lidocain nh chng mt, nn, o gic... c. Procainamid l thuc c chn thay vth cho ed ser hoc Lidocain khi Lidocain khng c tcredng hts n bnh nhn khng th dung np ic..vLiu dng r g com ll TM l cho ngay 100mg tim thngoo. mi 5 pht v. A ah cn nng, sau cho n tng liu l 10-20@mg/kg loe y Fin020 . truyn TM 1-4mg/pht. 08 ty2 20 ocgn y cho thy Amiodarone d. Mt s nghin cu i ht P t c th lmggim ot l t vong bnh nhn NMCT ri y cp cpNTTT (liu lng xem bng 10-3). Co e. Ch iu chnh tt cc ri lon in gii (nu c) v nhanh chng gii quyt cc cn nguyn nu tm thy. 3. NTTT bnh nhn c bnh tim mn tnh: a. Vic la chn cc thuc chng lon nhp cho cc bnh nhn ny phi da trn tnh trng bnh c th, c bit l chc nng tim cn tt khng, tc dng ca thuc v kh nng gy lon nhp ca cc thuc. b. i vi NTTT sau NMCT: cc thuc nhm IC (Flecanide, Encainid) hoc IB (Mexitil) khng nhng khng ci thin t l t vong m c khi cn lm tng t vong do kh nng gy ra lon nhp ca chnh cc thuc ny (th nghim 198 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

CAST). Do vy cc thuc nhm IC nhn chung l chng ch nh trong NTTT sau NMCT. Thuc c la chn l nhm chn bta giao cm hoc Amiodarone. Nghin cu CAMIAT v EMIAT chng minh Amiodarone c th lm gim t l t vong bnh nhn NMCT c NTTT. c. Bnh c tim l mt trong nhng nguyn nhn quan trng gy NTTT. Nguy c t t s tng cao vt nhng bnh nhn ny khi c NTTT. Trong giai on mn tnh th nn dng Amiodarone. d. Khi gp NTTT bnh nhn b bnh van tim c suy tim nng th cn c x l ngay. Ch cc ri lon in gii v bnh nhn c b ng c Digitalis khng. Trong trng hp bnh nhn ng c Digitalis c NTTT (hay gp nhp ved th i) er ngng Digitalis ngay v cho Lidocain,sng thi re iu chnh tt cc ri lon inights .Cc trng gii. vn hp khc c NTTT bnh nhn c obnh tim mn ll r c m . A ahoo. hoc Sotalol. tnh ta c th la chn Amiodarone oev inl 20@y VII. Cn nhp nhanh tht 08. F 20 20 ity Cn nhp nhanh tht ht otoc cn tim nhanh khi c t nht (NNT) l P g ba nht NTTT i lin yri vi tn s trn 100 ck/pht. C th p nhau Co chia NNT ra lm hai loi da trn thi gian ko di ca NNT: NNT thong qua (hoc khng bn b): l NNT xut hin tng on ko di khng qu 1 pht. NNT bn b: l khi c NNT ko di trn 1 pht. A. Nguyn nhn 1. Bnh tim thiu mu cc b. 2. Bnh c tim (bnh c tim gin, bnh c tim ph i, ph i ng ra tht phi, sarcoid c tim...). 3. Bnh van tim, c bit khi tht tri gin v gim chc nng co bp. 4. NNT do dng thuc hoc c t: thuc chng lon nhp nhm IC, Digitalis...

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5. NNT bn b tin pht: thng xy ra bnh nhn khng c bnh l thc tn tim. 6. Trong hoc sau phu thut tim... B. Triu chng lm sng 1. Biu hin lm sng rt khc nhau bnh nhn c cn NNT. N tu thuc vo hon cnh lm sng, tn s tht, s c mt ca cc bnh tim thc tn km theo... 2. Mt s bnh nhn c th khng cm thy c triu chng g c bit. Tri li mt s khc li c th biu hin ngay bng ngt hoc t t. C. in tm 1. Tn s tim thng t 130 -170 ck/pht. 2. Thng thng th nhp tim khng tht u nhdtrong e erv cn nhp nhanh kch pht trn tht, nhtesl khi m r trc c NNT a dng hoc c nht ts .vn ghhn hp. l ri .com di dng l 3. Phc b QRS thng gin rng, biu hin . A a oo oevhochphi. ging nh ca bloc nhnhinl @y tri 2 . F 2vi0 tn s chm hn ca 8 4. Sng P c th nhn 0thy 0 0 ity 2 QRS. Trong trng ohp khng nhn r sng P, nu t oc gh thctqun s thy r rng c s phn ri lm chuyn o P py Co nh v tht. Trong mt s trng hp ta ly gia nhp thy c s dn truyn ngc dng lm cho sng P m ngay sau QRS.

Hnh 10-5. Cn nhp nhanh tht, c lm chuyn o thc qun bc l sng P.

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D. Chn on phn bit quan trng nht l vi nhp nhanh trn tht c phc b QRS gin rng (do dn truyn lch hng, bloc nhnh...), ngi ta c th: 1. S dng chuyn o thc qun. 2. S dng tiu chun loi tr ca Brugada (hnh 10-6): Khng c hnh nh dng RS cc chuyn o trc tim? C
NNT

Khng

Khong cch R n S > 100 ms 1 chuyn o trc tim? ved ser re C Khng ts gh m.vn NNT i ll r co . A ahoo. oev y inlhn l P ? C nhiu phc b QRS 020@ F 8. 00 ity2 2 t oc gh Pot i C r Khng py Co
NNT

C tiu chun hnh thi ca NNT(*) t nht 1 chuyn o trc tim? C


NNT

Khng

Nhp nhanh trn tht c dn truyn lch hng Hnh 10-6. Tiu chun Brugada chn on phn bit NNT vi nhp nhanh trn tht c dn truyn lch hng. 201 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

(*) Tiu chun hnh thi ca NNT l: a. Thi gian QRS rng > 0,14 giy b. Trc QRS quay trn c. Hnh thi cc chuyn o trc tim: Ging bloc nhnh phi hon ton V1, v R/S <1 V6. Ging bloc nhnh tri : V1 c RT>RS; V6 c dng qR. d. Phn ly nh tht, c nht bp hn hp, nht thot tht. E. iu tr 1. Chuyn v nhp xoang: Trong giai on cp ca cn NNT, mc khn cp ca vic chuyn v nhp ved se xoang tu thuc vo tnh trng lm sngr v nh re ts hng n huyt ng. gh m.vn l ri co a. Cc u tin trong iu tr:Al hoocn NNT m c . Khi . oev a nh hng huyt ngnnhiu, c ngt hoc mt i l 20@y F thc th cn x tr 8. y20 mt ngng tun hon 00 ngay nh 2 it v phi nhanh chng sc in ct cn. Sc in t oc gh Pot r cn c ich nh trong trng hp cn NNT lc py Co nh nhng dng thuc tht bi v c xu u n hng nh hng n huyt ng. Thuc s c ch nh khi c cn NNT nhng tnh trng huyt ng cn tng i n nh. b. Thuc: Lidocaine (Xylocaine) l thuc c la chn u tin: Tim thng TM 1 - 1,5 mg/kg cn nng sau truyn TM 1-4 mg/pht. Procainamid: c dng khi Lidocaine tht bi hoc c th cho ngay t u. Amiodarone l thuc nn la chn, nht l trng hp cn NNT do bnh tim thiu mu cc b hoc khi dng cc thuc trn tht bi.

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c. Sc in trc tip c ch nh khi tnh trng huyt ng khng n nh v dng liu u tin l 100J. i vi nhng trng hp c cn NNT m mt mch th sc in ngay 200J. Nu bnh nhn cn tnh, nn dng sc in ng b. d. To nhp vt tn s c th hu ch trong mt s trng hp. e. Cc bin php h tr khc: Th xy h tr. iu chnh ngay cc ri lon in gii nu c. Tm hiu cc nguyn nhn gy ra cn NNT iu chnh kp thi nu c th. c bit trong NMCT cp, gii quyt kp thi cc th thut ti ti mu cho ng mch vnh l bin php ved ser trit nht iu tr i vi cn eNNT. r ts gh m.vn 2. iu tr duy tr: i ll r co . A ahoo. a. Thuc: oev inl 2so y Nghin cu ESVEM 0@ snh tc dng ca 7 F 8. 0 loi thuc200 city2 lon nhp (Imipramine, chng o ht Mexiletine,PotPimenol, Quinidine, Sotalol, rig py Procainamide, Propafenone) iu tr ngn Co nga ti pht cn NNT th thy l Sotalol c tc dng ngn nga NNT hiu qu nht. Cc nghin cu CAMIAT v EMIAT cho thy Amiodarone c th ngn nga c cn NNT sau NMCT cp v gim t l t vong. Tuy nhin, khi dng Amiodarone lu di chng ta phi ch n cc tc dng ph kh phong ph ca n. Vai tr ca cc thuc chng lon nhp trong iu tr duy tr ngn nga ti pht cn NNT cn cha thc s c thng nht. Thm vo , chng ta cn ch n tc dng gy lon nhp ca mt s thuc.

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b. Cy my ph rung t ng trong bung tim: Nghin cu MADIT v AVIT l hai th nghim ln chng t rng vic cy my ph rung t ng trong bung tim l thc s c ch v gim t l t t r rt nhng bnh nhn thng c cn NNT. My s c tc dng nhn bit cn NNT xy ra v t ng pht ra sc in ct cn. Tuy nhin, cc loi my ny cn kh t tin. c. iu tr bng cch trit ph (hu) vng vo li bt thng trong NNT bng sng Radio qua ng ng thng. Thnh cng ca phng php t c khong 50 -70%. Hin nay phng php ny ang ngy cng c hon thin hn v cho kt qu cao hn. ed erv sm khng d. Phu thut: i vi mt s bnh nhn e sr khng ch c bng thuc duy ht mvnc cc g tr .v i ll r co so tn thng sau nhi mu gy olon nhp, ngi . A aho . v ta c th phu thut ctloe @y mc vng so ca in b ni 0 F tm tht gy lon 8. 202 c nh v bng nhp m 00 ity thm d in 2 otoc l trc . Ngy nay nh t sinh igh trit ph cc xung ng bt rphp P phngy p Co thng qua ng ng thng, phu thut iu tr NNT t cn c dng n. VIII. Xon nh (Torsades de points) Xon nh (X) chnh l mt loi nhp nhanh tht a hnh thi c lin quan n hin tng ti cc chm tr ca c tim. Hu ht xon nh c biu hin ko di on QT trc . Cn xon nh thng ch ko di vi chc giy nhng cng c trng hp kh bn b hoc thoi ho thnh rung tht. Biu hin v din bin lm sng ca cn xon nh c th l mt thc hoc t t. Trn T l hnh nh nhp tht nhanh ti trn 200 ck/pht vi hnh thi a dng v cc nh ca QRS xon xut quanh trc ng ng in (c lc cc nh ca phc b QRS quay ln trn, c lc li quay xung di trc ng ng in). 204 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

A. Nguyn nhn 1. Bm sinh: a. Hi chng QT ko di bm sinh c km theo ic (Hi chng Jervell-Lange-Niesel). b. Hi chng QT ko di bm sinh khng km theo ic (Hi chng Romano-Ward). 2. Mc phi: a. Thuc: mt s thuc sau i khi c th gy nn xon nh: Cc thuc chng lon nhp: nhm IA, Sotalol, Amiodarone, Mexiletine, Flecainide... Mt s thuc hng thn v chng trm cm (Haloperidol, Amitriptiline...). ved Thuc khng sinh (Ampicillin, ser re ts Erythromycine...). gh m.vn i l r Ketoconazol, Astemizole...l oo.co . A ah oev b. Cc ri lon nhp chm c QT ko di. inl 20@y F 0 c. Ri lon in gii8.mu, c bit l h kali hoc 00 ity2 magi mu. t 2 otoc mu cng c th gy xon h HP canxi rig nh. py o d. MtCs nguyn nhn khc: Tai bin mch no, dng thuc cn quang cha Iod...

Hnh 10-7. Xon nh. B. iu tr 1. Ct cn: 205 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

a. C m mnh trc ngc bnh nhn i khi cng c hiu qu. b. Nu X ko di hoc gy ri lon huyt ng nng cn sc in bng nng lng bt u t 50100J v c th tng ln n 360J nu cn. 2. iu chnh ngay cc ri lon in gii mu: a. Tim Magi sulfate thng vo tnh mch vi liu 1-2 g v c th nhc li n tng liu 2-4 g trong vng 15 pht. Vic ny c th ct c cn X trong 75% s bnh nhn. b. Bi ph kali v canxi theo yu cu. c. Ngng ngay cc thuc c th gy X hoc ri lon in gii mu. ed 3. iu tr cc ri lon nhp chm nu c:reserv s a. Dng Isoproterenol truyn TM. right m.vn o l b. t my to nhp tm thi:Al hoo.c php rt hu v. l bin e a ch trong cc trng Finlony.y hp 0@ 2 . 08 c. C th dng Lidocain. 20 20 ocity h Pot IX. Mt s ri lon nhptchm rig py Co Cc ri lon nhp chm v cc bloc nh tht l nhng lon nhp tim kh thng gp. Rt nhiu trong s cc ri lon nhp ny thng khng c triu chng v cng khng nguy him. Tuy vy, c mt s loi nhp chm rt nguy him c th e do tnh mng bnh nhn. Chng ti s trnh by di y hai vn kh quan trng trong nhp chm, l hi chng suy nt xoang v bloc nh tht. A. Hi chng suy nt xoang Hi chng suy nt xoang hay cn gi l nt xoang bnh l (SSS: Sick Sinus Symdrom) hoc ri lon chc nng nt xoang (Sinus Node Dysfunction) l tnh trng nt xoang khng kh nng duy tr hot ng bnh thng ca ch nhp. Trn lm sng chng ta c th gp cc biu hin t

206 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

nhp chm xoang, ngng xoang, nhp thot nt hoc cn nhp nhanh-nhp chm xen k. 1. Triu chng lm sng: a. Ngt hoc tin ngt (xu) l nhng triu chng ng ch , ngoi ra c th thy chong vng, chng mt, kh th... b. Vi nhng bnh nhn c hi chng nhp nhanh nhp chm c th c nhng cn hi hp nh trng ngc. 2. Nguyn nhn: C th do nhng nguyn nhn thc th hoc nhng nguyn nhn bn ngoi (bng 10-6). Bng 10-6. Nguyn nhn ca suy nt xoang. Nguyn nhn ni ti: ved ser Bnh l thoi ho nt xoang re ts Bnh ng mch vnh gh m.vn i ll r co Bnh c tim . A ahoo. oev Tng huyt p inl 20@y Cc bnh thm nhim c8. F 20 0 tim (amyloidosis, khi u...) 20 ocity Bnh cht to keo t t h o Bnh l vim yrig c tim) (vim P p Co Chn thng do m x Bnh tim bm sinh Nguyn nhn ngoi sinh: Do mt s thuc: Chn bta giao cm, chn knh canxi, Digoxin, cc thuc chng lon nhp nhm IA, IC, III... nh hng h thn kinh t ng: cng trng lc ph v qu mc, hi chng xoang cnh, chm xoang ca lc s... Ri lon in gii mu v cc cn nguyn khc: tng kali mu, ri lon ni tit, tng p lc ni s, h thn nhit, sc nhim khun... 3. in tm :

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a. Nhp chm xoang thi qu (< 60 chu k /pht), phc b QRS thanh mnh v sng P i trc. b. C th thy nhng nht ngng xoang. Nu ngng xoang > 3 giy l mt du hiu c gi tr v bo hiu nguy him. c. C th thy nhng nhp thot nt. d. Nu thy hnh nh nhp nhanh - nhp chm xen k th cng l mt du hiu kh c trng trong suy nt xoang. 4. Cc xt nghim chn on: a. Cc thm d khng chy mu: in tm thng quy 12 chuyn o l mt thm d c bn. ed Holter in tim cho php theo diserv bin din re in tim trong 24 gi v c hts .tr chn gi g m vn l ri .co on, nht l khi thy hi lchng nhp nhanh o . Angng xoang. nhp chm hoc cc lonyaho oev in @ Nghim php Atropine: dng phn bit l . F 2 20 08 hay 0do cng thn kinh ph 0 suy nt xoang city 2 to ht Bnh thng khi tim 0,04 mg/kg giao rcm. Po ig py Atropine cho bnh nhn th nhp tim ni sinh Co ca bnh nhn s tng ti thiu theo cng thc: Nhp tim tng = 118,1 - (0,57 x tui) Nu sau tim m nhp tim thp hn nhp ni trn th chng t c suy yu nt xoang (nghim php dng tnh). Nghim php bn nghing (Tilt-table testing): gip phn bit ngt do cng ph v hay do suy nt xoang. Nu c nhng cn nhp chm xut hin khi lm bn nghing, chng t ngt lin quan n h thn kinh t ng (cng ph giao cm) hn l do suy nt xoang. Xoa xoang cnh gip phn bit nhng on ngng xoang l do cng xoang cnh hay do suy nt xoang. Trong cng xoang cnh, khi 208 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

xoa ta c th thy c nhng on ngng xoang di hn 3 giy. y l mt thm d kh nguy him b. Thm d nt xoang qua ng ng thng: thm d rt c gi tr trong chn on suy nt xoang. Thi gian phc hi nt xoang: l khong thi gian phc hi li nhp p xoang sau khi kch thch nh vt tn s v dng li. Khi thi gian ny trn 1400 ms (mili giy) th c th coi l c suy nt xoang. Thi gian phc hi nt xoang c hiu chnh l thng s c gi tr hn sau khi hiu chnh thi gian trn theo nhp tim thc t ca bnh nhn. Nu thi ved gian ny di trn 550 ms l suy nteser xoang. r Thi gian dn truyn xoangtsnh (SACT): gh m.vn ri Bnh thng khong cchllgiaco sng P c . A ahoo. cc bn l A1-A1. Khincev @y thch to nht bp lo kch Fi (A2) v n nht tip theo ngoi tm thu 8. 2020 0 nh 20 onh gi l A3, ta s c: p tr li ca city ht Pot SACTig (khong A2-A3) - (khong A1-A1) yr = p Co Thi gian dn truyn xoang nh ny ni ln tnh t ng ca nt xoang v khng nh hng bi pht nhp, thi gian dn truyn n nt bng thi gian dn truyn ra khi nt, v khng c thay i trong nguyn l to nhp. 5. iu tr: a. iu tr trong cn cp cu khi suy nt xoang nng gy nhp chm trm trng c triu chng: Atropine: 0,04 mg/kg tim thng tnh mch. C th t my to nhp tm thi khi khng ci thin c bng thuc. Isopreterenol (Isuprel) c th cho vi liu bt u 1 mcg/ pht truyn tnh mch. Bin php ny c th l cu ni trong lc ch cy my 209 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

to nhp. Khng nn dng nhng bnh nhn c tin s cp cu ngng tim. b. Ch nh cy my to nhp ni chung c p dng cho mi bnh nhn suy nt xoang c triu chng (ngt, xu...) hoc khi bt buc vn phi dng thuc lm chm nhp tim: bng 10-7. c. Tt c cc thuc lm chm nhp xoang cn phi c ngng li nu c th. Nu khng th ngng c th cn cn nhc t my to nhp ngay. d. i vi nhng bnh nhn c hi chng nhp nhanh - nhp chm, thng th cn t my to nhp iu tr nhng lc nhp chm v cho thuc iu tr cc ri lon nhp nhanh. B. Ri lon dn truyn nh tht (bloc nh tht)ed erv res Bloc nh tht l s dn truyn t nh xung hts .b chm li tht vn g l ri .com hay ngng hn. l . A oo oev yah nh tht thnh 3 1. Phn loi: ngi ta thng lchia bloc in @ . F 20 mc nh sau: 08 ty20 0 i a. Bloc nh tht 2 cI: L hin tng dn truyn ht Poto g chm pyri t tm nh xung tm tht, biu hin tr Co bng on PQ trn in tim ko di trn 0,20 giy. Hin tng ny c th gp ngi bnh thng hoc mt s bnh l ca tim. b. Bloc nh tht II: Kiu Mobitz I hay cn gi l chu k Wenckebach, biu hin bng on PQ trn in tm b di dn ra v n mt lc no s ch cn sng P m khng c QRS i km (tc l c mt nhp ngh tht). Sau chu k li c lp li ging nh trn. Kiu Mobitz II: biu hin bng nhng nht bp ca tim b bloc xen k vo nhng nht nhp xoang bnh thng, mc bloc c th l 2/1; 3/1... v d, nu bloc tun theo quy lut 210 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

c 2 sng P mi c mt QRS i km theo th ta gi l bloc 2/1. c. Bloc nh tht cp III hay bloc nh tht hon ton l tnh trng ng dn truyn t nh xung tht b nghn hn, nh s p theo nhp ca nt xoang kch thch cn tht s p theo nhp ring ca n. 2. in tm : a. Sng P khng ng trc cc tht (QRS) v cng khng c lin h g vi cc tht , m n c th ri vo trc, sau hay trng ln cc phc b QRS mt cch ngu nhin m thi. b. Tn s ca cc sng P vn bnh thng, khong 60-80 chu k/pht. ved ser re c. Tn s cc phc b QRS rt chmh(khong 30-40 ts g m.vn chu k/pht) nhng rt u. ll ri .co A o d. Hnh dng ca QRS c v.thaho loe @y thanh mnh bnh n thng, nhng cng Fi 020 QRS b gin rng nu . c khi 2 08ca tht xut pht t pha di trung tm ch nhpcity 20 o t ca b ni. h Pot ig yr op e. ChC: i khi ta thy c sng P ri trng pha trc QRS vi mt khong QRS bnh thng v lm cho nht bp ny hi sm hn so vi nhp c s, ta gi l nht bt c tht. 3. Triu chng lm sng: a. Triu chng c nng: Nu nhp tht ch chm t, bnh nhn c th khng c triu chng g c. Nhng nu nhp tim chm nhiu th lng mu t tim n cc c quan, trong c no b gim st. Do , bnh nhn c th thy chong vng thong qua, mt thng bng v c khi b xu hay thm ch b ngt (trong bnh cnh ca hi chng Adams-Stokes). 211 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Khi xy ra cn ngt, th bnh nhn mt thc, tay chn co qup, si bt mp b. Triu chng thc th: Nghe tim thy nhp tim chm (30-40 ck/pht) v u. C th nghe thy ting i bc do c s trng hp i gn nhau gia co bp tm nh v tm tht. Huyt p ti a thng tng v huyt p ti thiu thng gim v nhp tht chm s lm cho thi gian tm trng di ra. 4. Nguyn nhn: a. Tc dng ca mt s thuc: Digoxin. ved ser re Chn bta giao cm. ts gh m.vn i Chn knh canxi. ll r co . A ahoo. Mt s thuc chng lon nhp oev in 20 b. Bnh tim thiu mu. cc lb:@y F 0 8 Nhi mu c 0 ity2 0tim cp. 2 c Bnh ight mch vnh mn tnh. ng Poto r c. Thoiopy tin pht ng dn truyn nh tht: C ho Bnh Lenegre d. Bnh tim bm sinh: Bloc nh tht hon ton bm sinh. Thng lin nh l th nht. o gc cc ng mch ln. Bnh h thng. e. Bnh van tim. f. Bnh c tim: Bnh c tim thm nhim: Nhim bt. Sarcoidosis, Hemochromatosis g. Nhim trng, vim c tim: Vim ni tm mc nhim khun. Vim c tim (Chagas, bnh Lyme, thp tim, lao, si...). 212 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

h. Bnh van tim do bnh cht to keo. i. Ri lon chuyn ho: Tng kali mu. Tng magi mu. j. Bnh ni tit (bnh Addison). k. Chn thng: M tim. iu tr phng x. Thng tim v cc iu tr can thip, c bit t cc ng dn truyn l. Khi u. m. Bnh h thn kinh t ng: Hi chng xoang cnh. ved Ngt do cng ph v. ser re n. Ri lon thn kinh c: ts gh m.vn i Ph i c. ll r co . A ahoo. 5. Cc xt nghim chn on:eVic chn on ch yu ov inl 20@y da vo in tim . 8. F 20 00 y cp t a. Bloc nh tht 2 otociI: Ch yu da vo o on ht P rig PR trnyT, PR ko di trn 0,20 giy ngi p Co ln v trn 0,18 giy tr em vi hnh dng ca sng P v QRS bnh thng.

Hnh 10-8. Bloc nh tht cp I: PR=0,36 giy. b. Bloc nh tht cp II: Mobitz I (chu k Wenckebach): (a) on PR s ko di dn v kt thc bi mt nht bp khng c QRS. 213 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

(b) Khong cch RR s ngn dn. (c) Khong RR ni nht bp khng c QRS s nh hn tng 2 khong RR cnh . (d) C s nhc li theo chu k (chu k Wenckebach).

Hnh 10-9. Bloc nh tht cp II, Mobitz d I. e erv Mobitz II: Cc khong PP vn eu v c rs nhng nht bp khng dn ghts .vn ngoi (khc vi i tm thu nh b bloc, khong r o.cokhng u). ll ny m . A aho c. Bloc nh tht cp III (hon y oev ton): inl 20@ Tn s nh vn8. F 20 0 bnh thng, u. Tn s tht 20tochm v cng u. rt city ht Po Khnggc mi lin h no gia nh v tht ri py Co Phc b QRS thng gin rng v nu bloc cng thp th QRS cng rng v tn s tht cng chm.

Hnh 10-10. Bloc nh tht cp III. 6. iu tr: 214 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Vi bloc nh tht cp I hoc bloc nh tht cp II kiu Mobitz I thng khng cn iu tr g c hiu. Vi cc bloc nh tht cao (Mobitz II hoc cp III) dai dng thng cn phi cy my to nhp (xem phn sau). a. Thuc: Dng trong trng hp cp cu, c bit khi bnh nhn c ngt hoc xu. Thuc thng ch c tc dng tm thi ch cy my to nhp hoc trong giai on cp ca mt s bnh ch khi hi phc. Thuc khng c li ch nu dng ko di trong cc trng hp bloc nh tht cao c triu chng. Nu bnh nhn c ngt do nhp chm. (a) Atropine l thuc nn th dng u tin, ved ser n c th lm gim mc bloc bnh re ts nhn bloc do cng ph v hqu.vch khng g m n ri c tc dng vi nhngll oo.thng thc th tn co . A ah ov ng dn truyn.e N c tc dng tt hn inl 20@y F 0 bnh nhn. c2nhi mu c tim sau di. 8 00 ity (b) C th 2 toc Dopamine vi liu bt u 5 dng ht Po mcg/kg/pht nhng bnh nhn c km rig py Co huyt p thp. Nu bnh nhn trong tnh trng rt trm trng, c th dng ngay Adrenaline truyn tnh mch thay v Dopamine, Liu 1-2 mcg/pht. Isoproterenol hydrochlorid (Isuprel), c th c ch bnh nhn bloc nh tht khng phi do thiu mu c tim v lm tng nhp tim kh chn lc. Tuy nhin cn lu l bnh nhn c bnh mch vnh th khng nn dng v n lm tng nhu cu xy c tim. Liu ban u nn t 2 mcg/pht tng theo p ng nhp tim cho n 10 mcg/pht. b. To nhp tim tm thi: 215 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

My to nhp qua da (hai in cc p thnh ngc) rt c hiu qu nhng gy au n. y l my xch tay lu ng, thng gn vi h thng ph rung cp cu. Nhng bnh nhn ngt cn t ngay to nhp tm thi trong lc vn chuyn n bnh vin. Cp cu: dng my to nhp p thnh qua da (nu c) trong lc ch tin hnh t my to nhp tm thi qua ng tnh mch. To nhp tm thi qua ng tnh mch l gii php cp cu ti u cho nhng trng hp nhp chm c triu chng nng. c. Ch nh cy my to nhp (bng 10-7). Nhn chung ch nh khi bnh nhn c nhp chm m c triu chng (ngt, xu, mtd l do e erv nhp chm...). res Nu bloc nh tht hon ton hts .NMCT sau do vn g di thng ch cn t torinhp tm thi, v l .com Al o c th hi phc saulogiaiyon cp do bloc ev. aho bnh nhn ny . thng @ cng ph v qu Fin020 do 08 tycp III m do nhi mu c mc. Nu l0bloc 2 2 i t tim trc bnoc nn ch nh cy my to gh Pot th i nhp r py sm. Co trng hp bloc nh tht hon ton mc Cc phi thng cn cy my to nhp, trong khi bloc nh tht bm sinh thng khng cn cy my to nhp do bnh nhn c s thch nghi bng cc nhp thot. Bng 10-7. Cc ch nh cy my to nhp lu di. Nhm bnh Ch nh bt buc C th ch nh Suy nt SNX km triu chng nng, - Khng c bng khng hi phc sau khi chng chng t xoang dng thuc hoc cn phi nhp chm < 40 (SNX) ck/pht lin quan dng thuc gy nhp chm. n SNX v cc triu chng c th khng ch c. 216 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

- Bnh nhn c triu chng nh hoc khng nhng c nhp tim < 30 ck/pht (khi thc gic). Bloc nh tht Bloc nh tht cp III c mt - Bnh nhn bloc nh tht cp III mc phi trong cc c tnh sau: m khng c triu - C triu chng. - C ri lon nhp km theo chng v nhp tim hoc bnh l km theo cn trung bnh lc dng thuc c th gy nhp thc gic l hn 40 ck/pht. chm. - C on ngng tim trn 3 - Bloc nh tht cp ved Mobitz II giy hoc nhp tim < 40 II kiu eser r ts ck/pht bnh nhn khng khng .vn triu gh m c ri co llchng. c triu chng. . A ahoo. v - Bloc sau khi iu troety - Bloc nh tht cp inl 20@ F cc ng dn truyn2trong I nhng nhp tim 8. 0 00 ity rt chm v c tim (cathetert ablation). 2 oc gh Pot triu chng hoc - Sau mritim. py - Bnh l thn kinh c c khi t my tm Co km theo bloc nh tht cp thi c hi chng III (hi chng Kearns Sayre, my to nhp. ph i Erb...) b. Bloc nh tht II c km theo triu chng do nhp chm (bt k th v v tr). Bin chng - Bloc nh tht cp II kiu - Tn ti bloc nh sau nhi Mobitz II tn ti sau nhi tht cp II cao mu c tim ti v tr b His hoc cp III ti v mu c tim tr xung m c km theo tr nt nh tht. bloc 2 nhnh hoc Bloc nh tht cp III ti v tr b His tr xung sau NMCT. - Tn ti bloc nh tht cp II 217 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Bloc 2 nhnh hoc 3 phn nhnh mn tnh Hi chng - Ngt ti pht nhiu ln do cng xoang kch thch xoang cnh. Kch cnh v ngt thch nh xoang cnh c th gy ngng tht trn 3 giy. Ti liu tham kho
1.

Mobitz II hoc cp III c triu chng. - C km theo bloc nh tht cp III tng lc. - Bloc nh tht cp II Mobitz II.

Benditt G, Remole S, Milatein S, et al. Syncope: causes, clinical evaluation, and current therapy. Annu Rev Med 1992;43: 283-300. ved 2. Braunwald E, ed. Heart disease: a textbook of cardiovascular ser medicine, 5th ed. Philadelphia: WB Saunders, 1997. s re 3. Domanski MJ, Zipes DP, Schron E. Treatmentght sudden cardiac of .vn l ri trials death. Current understandings from randomized.com and future l . A oo research direction. Circulation 1997;95:269~2699. oev yah cardiac death: past, 4. Donbar SB, Ellenbogen K, Epstein iAB. Sudden nl @ present, and future. American 8. F Association Monograph Series. Heart 020 00 ty2 Armonk, NY: Futura Publishing,i1997. 2 toc effects of antiarrhythmic drugs. t 5. Kowey PR. Pharmacological igh Po Review and update.rArch Intern Med 1998;158:325-332. y 6. Marcus Fl, OpiepLH Antiarrhythmic agents. In: Opie LH, ed. Drugs Co for the heart, 4th ed. Philadelphia: WB Saunders, 1997:207-247 7. Marso SP, Griffin BP, Topol EJ, eds. Manual of Cardiovascular Medicine. Philadelphia: LippincottRaven, 2000. 8. Nattel S. Antiarrhythmic drug classifications. A critical appraisal of their history, present status, and clinical relevance. Drugs 1991;41:672-701. 9. Singh BN. Antiarrhythmic drugs: a reorientation in light of recent developments in the control of disorders of rhythm. Am J Cardiol 1998;81:3D-13D. 10. Task Force of the Working Group on Arrhythmias of the European Society of Cardiology. The Sicilian gambit. A new approach to the classification of antiarrhythmic drugs based on their actions on arrhythmogenic mechanisms. Circulation 1991;84:1831-1851. 11. Wein AL, Grimm RA, Black 1W, et al. Cardioversion guided by transesophageal echocardiography: the ACUTE pilot study. Ann Intern Med 1997;126:200-209. 12. Zipes DP, Jalife J, eds. Cardiac electrophysiology: from cell to bedside, 2nd ed. Philadelphia: WB Saunders, 1995.

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thp tim

Thp tim hay cn gi l thp khp cp hoc st thp khp (rheumatic fever) c coi l mt trong nhng bnh ca h min dch m lin kt hay thuc h thng to keo. Cho ti nay, bnh vn kh thng gp cc nc ang pht trin (trong c Vit nam) v l nguyn nhn hng u ca bnh van tim ngi tr tui. Bnh thng gp la tui t 6-15 tui, nhng khng t trng hp xy ra la tui 20 hoc hn na. Ngy nay, ngi ta tm ra nguyn nhn gy bnh l do nhim Lin cu khun tan huyt nhm A ng h hp trn (Streptococcus A). I. Tiu chun chn on bnh ved ser Jones Cho n nay, th gii thng nht dng tiu re ts chun gh m.vnxc nh c iu chnh nm 1992 (Bng 11-1). Chn on i ll r co thp tim khi c bng chng ca nhim linAcu o. ng h hp . aho A ev (biu hin lm sng ca vim ng lo 0@y trn v/hoc lm in h hp F 8. 02 phn ng ASLO dng tnh v/hocycy dch hng tm thy lin 00 it 2 2 cu), km theo c t nht ghtiu otoc chnh hoc c 1 tiu chun 2 t P chun i chnh km 2 tiu chun r py ph. Co Bng 11-1. Tiu chun Jones c iu chnh nm 1992 trong chn on thp tim. 1. Vim tim: gp 41-83% s bnh nhn thp tim. Tiu Vim tim c biu hin lm sng t nhp nhanh, chun ri lon nhp (hay gp bloc nh tht cp 1), h van chnh hai l hoc van ng mch ch, vim mng ngoi tim, vim c tim, n suy tim... 2. Vim khp: Gp khong 80 %, l triu chng rt c ngha nhng khng phi c hiu hon ton. Biu hin l sng au khp kiu di chuyn v khng bao gi li di chng khp. 3. Ma git ca Sydenham: l ri lon vn ng ngoi thp, vi vn ng khng mc ch v khng c . 219 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

4. Nt di da: nt c ng knh 0,5-2cm, ni di da, di ng t do, khng au, c th n c hoc tp trung thnh m, thng thy gn v tr cc khp ln nh khp gi. 5. Hng ban vng: l nhng ban khng hoi t, nht mu gia, v tr thng thn mnh, mt trong cc chi v khng bao gi mt. Thng mt i sau vi ngy. 1. St. Tiu chun 2. au khp: au mt hoc nhiu khp nhng khng c cc triu chng in hnh ca vim khp. ph 3. Tng cao protein C-reactive huyt thanh. 4. Tc mu lng tng. 5. on PQ ko di trn in tm . ed Bng chng ca nhim lin cu khun nhm A trcv ser re 1. Cy dch ngoy hng tm thy lin cu ghts .vn nhanh hoc test ri khng nguyn lin cu dng tnh.All oo.com . ah 2. Tng nng khng th khng y oev lin cu trong mu inl 20@ (Phn ng ASLO > 310 v F 20 . Todd). 08 20 ocity II. Sinh l bnh ht Pot rig gia vim hng v thp tim c Mi lin h cht ch py Co bit r t nm 1930. Ngi ta thy rng: (1) C bng chng ca s tng r rt khng th khng streptolysin O trong huyt thanh bnh nhn b thp tim. (2) Hiu qu r rt ca khng sinh trong phng bnh thp tim l mt trong nhng bng chng h tr cho c ch trn. Thp tim khng phi do trc tip lin cu gy ra m thng qua c ch min dch. Thng thng, sau khong 3 tun vim ng h hp trn bnh nhn mi c biu hin ca thp tim. Mt kha cnh na l thp tim rt t khi xy ra bnh nhn di 5 tui, khi m h min dch cha hon thin y nn phn ng cho ca c th cha hiu lc gy ra thp tim. Khng nguyn l cc protein M,T v R lp v ngoi ca lin cu A l yu t quan trng nht gy phn ng cho vi c th. Khi lin cu xm nhp vo c th chng ta, c th s sinh ra 220 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

cc khng th chng li vi khun , nhng v tnh chng li lun cc protein cc m lin kt ca c th, nht l cc m lin kt van tim. Trong , protein M l yu t khng nhng c hiu min dch m cn l yu t gy thp mnh nht. C khong 3% s bnh nhn b vim ng h hp trn do lin cu nhm A m khng c iu tr trit s tin trin thnh thp tim, v c khong 50% s bnh nhn b thp tim s b ti pht cc t thp tim sau . Nhim lin cu ngoi da thng t khi gy thp tim. III. Triu chng lm sng A. Cc biu hin chnh 1. Vim tim: a. Vim tim l mt biu hin bnh l nng rca thp ved se s bnh tim v kh c hiu. C khong 41-83% re ts v gh tim. nCc biu nhn thp tim c biu hin vim m. l ri o Al ho .c hin ca vim tim c th l. vim omng trong tim, ev a vim mng ngoi tim,ivim@y tim. nlo 0 c .F 2 b. Vim tim c th 08 ty20 t th khng c triu 0 biu hin 2 oci t chng g n Potdu hiu suy tim cp nng hoc gh cc i t vong. r py Co c. Cc triu chng lm sng c th gp l: tng nhp tim, ting thi tm thu, ting thi tm trng, ting rung tm trng, ri lon nhp, ting c mng tim, suy tim d. Suy tim thng t gp giai on cp, nhng nu gp th thng l biu hin nng do vim c tim. e. Mt trong nhng biu hin phi ch v l bin chng nng ca thp tim l vim van tim. H van hai l l mt trong nhng biu hin thng gp nht, trong khi h van ng mch ch t gp hn v thng km theo h van hai l. f. Vim mng ngoi tim c th gy au ngc, ting c mng tim, ting tim m 2. Vim khp: 221 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

a. Vim khp l mt biu hin hay gp nht trong thp tim (80%) nhng li t c hiu. b. Biu hin ca vim khp l sng, nng, , au khp, xut hin cc khp ln (gi, c chn, c tay, khuu, vai...) v c tnh cht di chuyn. c. Vim khp p ng rt tt vi Salycilate hoc Corticoid trong vng 48 gi. Nu trong trng hp cho Salycilate y m trong vng 48 gi vim khp khng thuyn gim th phi ngh ti nguyn nhn khc ngoi thp tim. d. Vim khp do thp tim thng khng bao gi li di chng khp. 3. Ma git Sydenham: d a. y l biu hin ca tn thng ngoirve se thp v re kh c hiu cho thp tim. ts gh m.vn l ri co b. Cc biu hin l nhng ng ltc ovn ng khng . A aho . mc ch v khng t ch v cc c mt, chi; gim loe y Fin020@ trng lc c, ri lon cm ng. . 08 2 20 ocity c th l kh vit, kh ni c. Cc biu hin ban u ht Pot hoc iyrig li. op d. Cc C biu hin ny thng r khi bnh nhn b xc ng hoc thc tnh v mt i khi bnh nhn ng. e. Ma git Sydenham l mt trong nhng biu hin mun ca thp tim, n thng xut hin sau khong 3 thng sau khi vim ng h hp trn. Ma git Sydenham thng biu hin n c trong thp tim v gp khong 30%. Triu chng ny thng mt i sau 2-3 thng. f. Cn phi chn on phn bit vi mt s bnh l khc nh ng kinh, ri lon hnh vi tc phong... 4. Nt di da: a. l nhng nt c ng knh khong 0,5-2 cm, cng, khng au, di ng v thng xut hin ngay trn cc khp ln hoc quanh cc khp. Nt 222 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

di da c th gp khong 20% s bnh nhn b thp tim v thng bin mt sau khong vi ngy. b. Da trn nt ny thng vn di ng bnh thng v khng c biu hin vim trn. 5. Hng ban vng (erythema marginatum): a. y l mt loi ban trn da, c mu hng v khong nht mu gia to thnh ban vng. Thng khng hoi t v c xu hng mt i sau vi ngy. b. Hng ban vng l mt du hiu kh c hiu trong thp tim v t gp (5%), thng ch gp nhng bnh nhn c da mn v sng mu. Hng ban vng thng xut hin thn mnh, bng, vd mt trong cnh tay, i v khng bao gi remt. se re km theo c. Khi c hng ban vng th thngtscvn gh m. i vim c tim. ll r co . A ahoo. 6. Cc du hiu ph: oev inl 20@y F a. St thng xy ra0trong 0 on cp. giai 8. 0 ity2 2 txc nh l ch au khp ch oc b. au khp ht o c P g khngpc ivim (sng, nng, ). yr Co c. Ngoi ra, c th gp cc biu hin nh au bng, vim cu thn cp, vim phi cp do thp tim, i mu, hoc vim mng no y l nhng du hiu khng trong tiu chun chn on thp tim. B. Cc xt nghim chn on 1. Cc du hiu l bng chng ca nhim lin cu nhm A (GAS): a. C th xc nh thng qua ngoy hng tm thy lin cu (nui cy hoc xt nghim khng nguyn nhanh) hoc cc phn ng huyt thanh thy tng nng khng th khng lin cu. b. Xt nghim ASLO (AntiStreptoLysin O) l mt phn ng thng dng hin nay. S tng nng 223 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

c. xc nh bng chng nhim GAS trc c th dng xt nghim ASLO nhc li nhiu ln hoc mt s khng th khc nh: anti-DNAase B; anti-hydaluronidase; anti-streptokinase; antiNADase d. Hin nay c mt s que th nhanh c sn th vi mt s khng th khng GAS, nhng chnh xc khng cao v c ngha tham kho. ved r ese 2. Sinh thit: sr n ht v rig c hnh a. Sinh thit c tim c th choll thyom. nh ht . A o. Aschoff, l hnh nh htevthm onhim gp trong o yah l thp tim. Ht ny . gp 20@ Fin0 khong 30% s bnh 8 nhn c cc t 0thp 2 phi v thng thy y ti 0 2 tocit ht thnh tht, tiu nh. o vch lin itht, P rg py nh t bo hc cn cho thy hnh nh b. Cc Co hnh vim ni mc tim vi c trng l ph v thm nhim t chc mng van tim. c. Sinh thit c tim khng c ch trong giai on cp ca thp tim, n ch nn ch nh v c gi tr phn bit khi thp tim ti pht v kh phn bit vi cc bnh thp khp mn khc. 3. Mt s xt nghim mu khc: a. Tng bch cu, thiu mu nhc sc/bnh sc. b. Tc mu lng tng v protein C phn ng tng. 4. Xquang tim phi: Thng th khng c bin i g c bit trong thp tim. Mt s trng hp c th thy hnh tim to, rn phi m hoc ph phi. 5. in tm : 224 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

a. Thng hay thy hnh nh nhp nhanh xoang, c khi PR ko di (bloc nh tht cp I). b. Mt s trng hp c th thy QT ko di. c. Khi b vim mng ngoi tim c th thy hnh nh in th ngoi vi thp v bin i on ST. 6. Siu m Doppler tim: a. C th gip nh gi chc nng tim. b. Hnh nh h van tim ngay c khi khng nghe thy c trn lm sng. c. C th thy tn thng van hai l v van ng mch ch. Giai on sau c th thy hnh nh van dy ln, vi ho cng cc t chc di van. IV. iu tr ved ser re A. iu tr t cp ts gh m.vn i Mt khi c chn on xc nh thp All r thocc bin php tim c . ahoo. sau l cn thit: oev inl 20@y F 1. Loi b ngay s nhim lin cu: (xem Bng 11-3) 8. 0 00 ity2 bng thuc kinh2 in Benzathine Penicillin G t oc gh Pot 600.000 nriv (v) tim bp su 1 ln duy nht cho py Co bnh nhn di 27 kg, v 1,2 triu v cho bnh nhn trn 27 kg, tim bp su 1 ln duy nht. Nu bnh nhn b d ng vi penicillin th dng thay bng Erythromycine 40mg/kg/ngy, ung chia 2 ln/ngy, trong 10 ngy lin tc. 2. Chng vim khp: phi c bt u cng sm cng tt ngay khi c chn on. a. Aspirin: l thuc c chn hng u v hiu qu nht. Liu thng dng l 90 - 100 mg/kg/ ngy, chia lm 4-6 ln. Thung dng ko di t 4-6 tun tu thuc vo din bin lm sng. C th gim liu dn dn sau 2-3 tun. Nu sau khi dng Aspirin 24-36 gi m khng ht vim khp th

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cn phi ngh n nguyn nhn khc ngoi thp tim. b. Prednisolone c khuyn co dng cho nhng trng hp c km vim tim nng. Liu dng l 2 mg/kg/ngy chia 4 ln v ko di 2-6 tun. Gim liu dn trc khi dng. c. Mt s thuc gim vim chng au khng phi corticoid c th c dng thay th trong mt s hon cnh nht nh. 3. iu tr ma git Sydenham: bao gm cc bin php ngh ngi ti ging, trnh cc xc cm, dng cc bin php bo v v c th dng mt s thuc nh: Phenobarbital, Diazepam, Haloperidol, hoc ed steroid. Vic phng bnh tip tc theo ch vcng l ser re bin php trnh c ti pht ma git Sydenham. ts gh m.vn rt quan 4. Ch ngh ngi trong giai oni cp l ll r co . A ahoo. l vn ng trng. u tin l ngh tiloev ging, sau in 20@yngoi tri v tr v nh trong nh ri vn . F 0 nh ng 8 bnh thng (Bng200 city2 11-2). Ch ny tu thuc vo ht Po o mc nng inh cat bnh. rg y Bng 11-2. Cop ngh ngi i vi bnh nhn thp tim. Ch Ch Ch vim Vim Vim Vim tim khp tim nh tim va nng Ngh ti 1 - 2 tun 2 3 4-6 2 - 4 thng ging tun tun Vn ng nh 1 - 2 tun 2 3 4-6 2 - 3 thng trong nh tun tun Vn ng 2 tun 24 1-3 2 - 3 thng nh ngoi tri tun thng Sau 4 - 6 Sau 6 Sau 3 - 6 Thay i Tr v sinh tun 10 tun thng tu trng hot bnh hp thng 5. iu tr suy tim (nu c): ngh ti ging, th xy, vi suy tim tri cp cho Morphin, li tiu, tr tim. Hn ch n mn, hn ch ung nhiu nc, c th 226 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

dng li tiu. Digoxin c th dng nhng phi thn trng v qu tim ca bnh nhn thp tim rt nhy cm, nn dng liu ban u ch nn bng na liu quy c. 6. Phng thp: Vn cc k quan trng l nhc nh bnh nhn v gia nh s cn thit v tn trng ch phng thp tim cp hai khi bnh nhn ra vin. B. Phng bnh: (Bng 11-3) 1. Phng bnh cp I: Mt bc cc k quan trng l loi tr ngay s nhim lin cu khun ( nu trn), hay cn gi l ch phng thp cp I. Bng 11-3. Ch phng bnh cho thp tim. Phng thp cp I ved ser Thuc Liu nge Thi gian r ts dng gh m.vn ri c Benzathine 600.000 v (<27kg) AllTimobp Liu duy nht . ahoo. Penicillin G 1,2 triu v (27kg) ev y lo Hoc 250mg 2-3. Fin 20@ Ung ln/ngy 10 ngy 0 Penicillin V (tr em) 2008 ity2 t 2-3 500mg otoc ln/ngy igh P (ngi ln) yr p Erythromycin (choCo 40 mg/kg/ngy Ung 10 ngy
bnh nhn d ng vi Penicillin) Thuc Benzathine Penicillin G Hoc Penicillin V Sulfadiazine Phng thp tim cp II Liu lng ng dng 1,2 triu v Tim bp 250 mg Ung Ung Ung Khong cch dng 3-4 tun/1 ln 2 ln/ngy hng ngy 2 ln/ ngy

0,5g (<27kg) 1,0g (27kg) Erythromycin (cho 250 mg bnh nhn d ng vi Penicillin hoc Sulfazidine)

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a. Cn thit phi iu tr tht sm nu c th. b. Penicillin l thuc la chn hng u v tnh hiu qu v gi r. Nn dng Benzathine Penicillin G liu duy nht tim bp (Bng 11-3). C th dng thay th bng ung Penicillin V trong 10 ngy. c. Cc thuc ph rng nh Ampicillin khng c li ch g hn so vi Penicillin trong iu tr thp tim. d. Vi bnh nhn d ng vi Penicillin, thay th bng Erythromycin ung trong 10 ngy. C th dng Marcrolide mi nh Azithromycin thay th rt c tc dng, dng trong 5 ngy vi liu 500 mg trong ngy u sau 250 mg mi ngy cho 4 ngy tip theo. e. C th thay th bng ch khc l d dng e erv Cephalosporin th h I dng ung (Cephalexin, res s Cephadroxil), ung trong 10 ngy.ht m.vn rig co ll . 2. Phng bnh cp II: Phi bt .u ngay khi chn v A ahoo on xc nh l thp tim.inloe @y 0 F 8. 02 a. Thuc dng c0nuytrong Bng 11-3. 0 it 2 2 b. Thi gian ght P(Bng 11-4), ni chung ph thuc dng otoc i vo tngrc th bnh nhn. py Co c. Ni chung nn dng ng tim. Ch nn dng ng ung cho cc trng hp t c nguy c ti pht thp tim hoc v iu kin khng th tim phng c, v t l ti pht thp tim bnh nhn dng ng ung cao hn ng tim nhiu. Bng 11-4. Thi gian tin hnh ca phng thp cp II. Tnh trng bnh Thi gian ko di
Thp tim c vim c tim v li di chng bnh van tim. Thp tim c vim tim nhng cha li di chng bnh van tim. Thp tim khng c vim tim. Ko di t nht 10 nm v t nht phi n 40 tui. C th tim rt lu di (nn p dng). 10 nm hoc n tui trng thnh, mt s trng hp ko di hn. 5 nm hoc n 21 tui, c th di hn tu trng hp.

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Ti liu tham kho


1. 2. 3. 4. 5. 6. Bisno AL. Group A streptococcal infection and acute rheumatic fever. N Engl J Med 1991; 325:783-793. da Silva NA, de Faria Pereira BA. Acute rheumatic fever. Pediatr Rheumatol 1997;23:545-568. Dajani AS. Rheumatic fever. In: Braunwald E, ed. Heart disease: a textbook of cardiovascular medicine, 5th ed. Philadelphia: WB Saunders, 1997:1769-1775. Dijani AS, Ayoub E, Bierman FZ, et, al, Guidelines for the diagnosis of rheumatic fever: Jones criteria. Updated 1993. Circulation 1993; 87: 302-307. Nader S. Rheumatic fever. In: Marso SP, Griffin BP, Topol EJ, eds. Manual of Cardiovascular Medicine. Philadelphia: LippincottRaven, 2000. Stollerman GH. Rheumatic fever. Lancet 1997;349: 935-942.

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r ese sr n t gh .v l ri .com l . A oo oev yah inl @ . F 2020 8 00 y 2 tocit ht Po rig

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Hp van hai l

Hp van hai l (HHL) vn cn l bnh rt ph bin nc ta cho d t l mc bnh ny gim nhiu cc nc pht trin khc. I. Triu chng lm sng A. Triu chng c nng 1. a s bnh nhn khng h c triu chng trong mt thi gian di. Khi xut hin, thng gp nht l kh th: mi u c trng l kh th khi gng sc, sau l kh th kch pht v m v kh th khi nm vd (do tng p lc mch mu phi). Cn hen tim ev ph ser e phi cp kh thng gp trong HHLhts lvn - r mt im g m. c bit ca bnh: biu hin suy timi tri m bn cht ll r co . A ahoo. li l suy tim phi. oev inl 20@y .F 2. Cc yu t lm bnh 8nng0thm: s xut hin rung 00 ity2tht p ng rt nhanh l nh trong HHL t 2 tn s vi toc igh Po yu t kinh rin dn n ph phi cp. S gin nh py Co tri l yu t d on xut hin rung nh bnh nhn HHL. Thai k ca ph n HHL cng lm cho triu chng nng thm. 3. C th gp cc triu chng lin quan vi nh tri gin to nh: a. Ho ra mu do tng p lc nh tri v tng p lc ng mch phi. b. Khn ting (hi chng Ortner), do nh tri gin to vo dy thn kinh qut ngc hoc nut nghn do nh tri to vo thc qun. c. Tc mch i tun hon (mch no, thn, mc treo, mch chi) do huyt khi hnh thnh trong bung nh tri gin nht l khi c km rung nh. 231 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

d. Rung nh (cn kch pht hoc dai dng) gy biu hin hi hp trng ngc, c th gy chong hoc ngt (rung nh nhanh), gp phn hnh thnh huyt khi v gy ra tc mch i tun hon... 4. Lu dn s c cc triu chng ca suy tht phi (gan to, ph chi di ) do tng p ng mch phi. Khi tng p lc ng mch phi, bnh nhn c th au ngc gn ging cn au tht ngc, do tng nhu cu xy tht phi. 5. Mt cng l triu chng hay gp do cung lng tim gim thp. B. Triu chng thc th 1. Chm pht trin th cht nu HHL c t khi nh: du ved hiu ln hai l. ser re ts gh m.vn t nh. 2. Lng ngc bn tri c th bin dng inu HHL lr o Al ho .c .ngoi obin khi c suy 3. Du hiu ca tr tun honv a loe y tim phi: tnh mch c. Fin 20@ hi gan tnh mch ni, phn 08 20 c dng tnh, ph 0chiitdi, ph ton thn, gan to, 2 oc y ht Po trn dch cc imng... t rg opy 4. Cc duChiu ca km ti mu ngoi vi: da, u chi xanh tm. 5. S c th thy rung miu tm trng mm tim. Mt s trng hp khi tng p ng mch phi nhiu c th thy ting T2 mnh v tch i cnh c tri. 6. G din c ca tim thng khng to. 7. Nghe tim: l bin php quan trng gip chn on bnh HHL. a. Ting clc m van hai l, nghe r mm tim, khong cch t T2 n ting ny cng hp th mc HHL cng nhiu (<80 ms trong HHL kht). Tuy nhin, mt s trng hp khng nghe thy ting ny khi van hai l vi cng, m km. 232 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

b.

c. d. e.

f.

g.

Ting ny cng c th gp trong HoHL, thng lin tht, teo van ba l km theo thng lin nh. Ting rung tm trng mm tim: m sc trm thp, gim dn, nghe r nht mm, thi gian ph thuc vo chnh p (di khi HHL kht), c ting thi tin tm thu nu cn nhp xoang. Nghe tim sau gng sc hoc ngi Amyl Nitrate lm tng cng ting thi do tng chnh p khi tng dng chy qua van hai l. Tuy nhin ting rung tm trng ny c th khng c nu van hp qu kht hoc dy chng ct c b vi ho x cng nhiu, hoc khi suy tim nng, km theo hp van ng mch ch lm gim dng mu qua van. ved ser re ts gh gpvn Ting rung tm trng cn cl ri om. trong mt th l o.c . A ahotng cung lng s trung hp khc nhev HoC, o qua van hai l... Ting 2thi tin tm thu cng inl 0@y .F thng gp nht 08 ty20bo bnh nhn gng sc 0 l ikhi 2 hoc dng ht Potockh Amyl Nitrate. Ting thi g mt t i yr ny spkhng c khi bnh nhn b rung nh. Co Ting T1 anh kh quan trng trong HHL. Ting T1 c th khng r anh na khi van vi ho nhiu hoc gim s di ng ca l van. Nghe y tim c th thy ting T2 mnh v tch i, biu hin ca tng p ng mch phi. Mt s tnh trng c th ging biu hin ca hp van hai l nh u nhy nh tri hoc tim ba bung nh. Ting p ca u nhy c th nhm vi ting clc m van. Khi bnh nhn c rung tm trng lun cn chn on phn bit vi u nhy nh tri. Cc tnh trng khc c th gy nn ting rung tm trng bao gm: thng lin nh, hoc thng lin tht, ting thi Austin-Flint ca h ch (gim khi

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gim hu gnh) hoc ca hp van ba l (nghe r nht b tri xng c v tng ln khi ht vo). II. Nguyn nhn A. a s trng hp HHL u l do di chng thp tim d 50% bnh nhn khng h bit tin s thp khp. 1. t thp tim cp thng hay gy ra h van hai l. Sau mt s t thp tim ti pht, hp van hai l bt u xut hin, tip tc tin trin nhiu nm cho ti khi biu hin triu chng. 2. Thng tn chnh l thm nhim x, dy l van. Dnh mp van, dnh v co rt dy chng gp phn gy nn HHL. Xut hin vi ho lng ng trn l rved dy van, e chng, vng van, tip tc lm hn ch chcsnng bnh re ts thng ca van. Nhng thng tn rny to n ighom.v thnh van l .c hai l hnh phu nh hnh mingAl hm. v. c oo loe ya B. Cc nguyn nhn gy hp 020@ hai l Fin van . 08 2 2 1. Di chng thp tim.0 ocity ht Pot 2. Bm sinh: yrig op a. VanChai l hnh d: do c mt ct c xut pht cc dy chng cho c hai l van, dn n h hoc hp van. b. Vng tht trn van hai l. 3. Bnh h thng c th gy x ho van hai l: a. U carcinoid. b. Lupus ban h thng. c. Vim khp dng thp. d. Lng ng mucopolysaccharide. e. Vim ni tm mc nhim khun lin so.

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Hnh 12-1. Thng tn van hai l do thp. III. Sinh l bnh 1. Bnh thng din tch l van hai l l 4-6 cm2. Khi din tch l van hai l < 2cm2, dng chy qua van hai l b cn tr to thnh chnh p qua van hai l gia nh tri v tht tri trong thi k tm trng. Chnh p ny v p lc nh tri s cng tng khi dinetch l vd van cng gim. Tu theo mc din tcheser l van ca sr hai l m ngi ta chia thnh cc loi: ht .vn g m l ri o a. HHL rt kht khi din tch v. Al hoo.c1,0 cm2. l van < loe ya b. HHL kht khi din tchnl2van t 1 n < 1,5 cm2. Fi 0 0@ . 08 c. HHL va khi din tch 2 van t 1,5-2,0 cm2. 20 ocity l t P hai 2. Dng chy quahvan ot l tng lm chnh p qua van rig py s nhn (v chnh p l hm bc hai ca tng theoocp C dng chy). V vy, gng sc hoc thai nghn (tng th tch v dng mu lu thng) s lm tng ng k p lc nh tri. Nhp tim nhanh lm gim thi gian y tm trng cng lm tng chnh p qua van v p lc trong nh tri. Do trong giai on sm, hi chng gng sc rt thng gp bnh nhn HHL. 3. Tng p lc nh tri dn n tng p trong h thng mch phi gy ra cc triu chng huyt phi. Tng p lc th ng trong h mch phi s gy tng sc cn mch phi (tng p ng mch phi phn ng, hng ro th hai). Tnh trng ny c th mt i v tr v bnh thng nu tnh trng hp van c gii quyt. Tuy nhin, nu hp van hai l kht ko di s dn n bnh cnh tc nghn mch mu phi. 235 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

4. Mc d tht tri t b nh hng bi cc qu trnh bnh sinh trn nhng 25-30% s trng hp c gim phn s tng mu tht tri, c l l do gim tin gnh tht tri v gim dng chy v tht tri lu ngy. 5. Nhng trng hp hp van hai l kht c th gy gim cung lng tim n mc gy triu chng gim ti mu. Tnh trng cung lng tim thp mn tnh s gy phn x tng sc cn mch i tun hon v tng hu gnh, cng lm tip tc gim chc nng co bp tht tri hn na. Phn s tng mu s tr li bnh thng nu gii quyt ch hp van hai l (khi phc tin gnh v hu gnh). Mt s bnh nhn vn tip tc ri lon co bp c tim ko di sau khi m ch hp, nguyn nhn hay c ngh ti l tnhdtrng e erv vim c tim m do thp tim. res hts n IV. Cc xt nghim chn on rig com.v l Al h . v.phpoo A. Siu m Doppler tim: l bin ya thm d cc k loe Fin020@ chn on mc quan trng chn on 8. 2 xc nh v 0 20 city hp van hai l, chntonohnh thi van, t chc di van h Pt hai l v cc thng tn okm theo (thng c trong HHL) rig py gip ch nhoiu tr. C 1. Kiu TM: l van dy, gim di ng, bin m van hai l km, hai l van di ng song song, dc tm trng EF gim (EF < 15 mm/s l HHL kht). 2. Siu m 2D: hnh nh van hai l hn ch di ng, l van hnh vm (hockey-stick sign), vi ho l van v t chc di van. Siu m 2D cn cho php o trc tip din tch l van hai l, nh gi chc nng tht tri v cc tn thng van khc c th km theo. 3. Siu m Doppler c bit quan trng nh gi mc hp: a. Vn tc nh dng chy qua van hai l > 1 m/giy gi c HHL, song du hiu ny khng c hiu, c th xy ra do nhp nhanh, tng co bp. H hai 236 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

l v thng lin tht cng gy tng dng chy d khng c HHL. b. Chnh p qua van hai l (o vin ph dng chy qua van hai l) cho php c lng mc nng ca hp van. HHL nh: chnh p trung bnh qua van < 5 mmHg, HHL va: chnh p trung bnh qua van t 512 mmHg, HHL kht: chnh p trung bnh qua van > 12 mmHg. c. c tnh p lc ng mch phi (MP), thng qua vic o ph ca h van ba l km theo hoc h van MP km theo (thng gp trong HHL). d rve sekm theo d. Cho php nh gi tn thng thc s re tn t gh m.vn rt quan nh HoHL, HoC v mc , iu ny l ri o Al hoo.c trng gip cho quyt nhv.la chn phng php l e ya can thip van hai l thcho hp. Fin020@ . 0 4. Siu m Doppler tim 8 ity2 nh gi din tch l 20 odng c van hai l kh ht Potxc, t xc nh v nh gi igchnh rThng c hai cch o trn lm sng: mc hp. py Co a. o trc tip l van trn siu m 2D: Mt ct trc ngn cnh c tri, ct qua mp van, ly l van hai l vo trung tm, dng hnh trong thi k tm trng khi l van m rng nht. Sau dng con tr o c trc tip din tch van hai l.

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Hnh 12-2. o din tch l van hai l trn siu m 2D. Hnh nh m (do thnh ngc dy, kh ph thng), van, t chc di van dy, vi, mo m hoc bin dng sau m tch van... l e nhng yu t khin rt kh xc nhd c erv res gc s chnh xc l van. Nu ct khng svung ht vn rig (tng c lng sai din tch lllvan com. ln). Vi . .A hoc x dy mp van ecng hoo sai lch (gim o v ya lm l i). phn giiin 20@lm m mp van v thp . F 20 8 tng qu din0tch, phn gii cao lm din y 0 2 tocit ht Po tch gim i. Tuy vy phng php ny vn rig py c dng rng ri. Co b. Phng php PHT (thi gian bn gim p lc): Thi gian bn gim p lc (thi gian p lc gim mt na so vi gi tr ban u), l thi gian vn tc gim cn 70% vn tc nh. Hp hai l lm thi gian gim p lc ca dng chy qua van hai l b ko di ra. Cng hp nhiu th mc thi gian ny cng di, Sng E ca ph hai l c dng tnh din tch l van theo PHT: Din tch l van hai l = 220/PHT

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Hnh 13-3. o din tch l van hai l bng PHT. Nu khng tnh t ng th PHT = 0,29 thi gian gim tc sng E. Nu dng erved tm chy s redng dng trng khng tuyn tnh, c th n hts chy gia tm trng cig om.v ra vn tc r lng ll .c ti a. Nu c rung nh, A aholy trung bnh t v. cn o oe y 5-10 nht bp lininl 20 tnh. F tip @ . 20 0 Phi m bo8dng Doppler song song vi 20 ocity hng ght dng chy. ca Pot i yrb thay i khng phn nh ng thc t PHT p Co nu c thay i nhanh chng ca huyt ng qua van nh ngay sau nong van hai l. PHT cng b sai lch nu nhp tim nhanh (EA gn nh trng nhau). H van ng mch ch, lm tht tri y nhanh, cng gy gim PHT tng din tch l van hai l gi to. 5. Siu m tim gng sc ch nh cho bnh nhn c triu chng song siu m tim khi ngh khng biu l HHL kht r hoc khi c HHL kht m cha c biu hin lm sng. C th nh gi chnh p qua van hai l trong khi thc hin gng sc (bng xe p lc k) hoc ngay sau khi gng sc (bng thm chy). Siu m Doppler cng dng o vn tc dng h

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van ba l, dng h qua van ng mch phi c lng p lc ng mch phi khi gng sc. 6. Siu m tim qua thc qun: vi u d trong thc qun cho thy hnh nh r nt hn, dng nh gi chnh xc hn mc hp van cng nh hnh thi van v t chc di van, hnh nh cc mu ng trong nh tri hoc tiu nh tri. T gip ch nh phng thc iu tr can thip van hai l. Siu m qua thc qun nn c ch nh thng quy trc khi quyt nh nong van hai l nu c iu kin. Tuy nhin, vi cc trng hp nhp xoang v khi hnh nh kh r trn siu m qua thnh ngc th cng nh gi cho ch nh nong van hai l. B. Thng tim: l phng php rt chnh xc ved cc er o resp lc nh thng s nh: p lc cui tm trng tht tri, n hts tri (trc tip hoc gin tip qua p llcgmao.v ri com mch phi l . bt), p lc ng mch phi, cung ahoo tim (phng v. A lng loe y php Fick hoc pha long nhit),2nhp tim v thi gian Fin0 0@ . 08 2 y tm trng (giy/nhp tim). Trn c s hai ng p 20 ocity lc ng thi ight tri v nh tri, c th tnh c tht ot r hai Pl (bng phn din tch gia hai chnh p quapy van Co ng p lc h s o). Nu dng ng p lc mao mch phi bt, nn dch ng p lc sang tri 50-70 ms l phn thi gian truyn p lc t nh tri n mng li mao mch phi. 1. Din tch l van hai l c c tnh theo cng thc Gorlin:
Dintchl vanhail = Cungl ngtim / Th igiandd ytamtrong * Nhptim 37 ,7 * Ch nh ptrungbinh quavanhail

H s 37,7 c tnh t hng s Gorlin 44,3 0,85 (h s hiu chnh ca van hai l). Ngoi ra c th da vo cng thc n gin ho do Hakki xut:

240

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Dintchlvanhail =

Cungl ngtim Ch nh ptrungbinhquavanhail

2. Khng th dng p lc mao mch phi bt tnh din tch l van hai l nu bnh nhn c hp ng mch hoc tnh mch phi, tc mao mch phi hoc tim ba bung nh hay khi cung lng tim qu thp. ng thi ng thng o p lc mao mch phi bt phi t ng v tr. Hn th na, phng php pha long nhit t chnh xc nu c h van ba l hoc tnh trng cung lng tim thp. Dng h van hai l hoc lung thng do thng lin nh gy ra ngay sau nong c th lm c lng sai dng chy qua van hai l. C. in tm : hnh nh P hai l (sng P rng do dy nh ved tri) thng gp nu bnh nhn cn nhp xoang. Trc ser re in tim chuyn sang phi. Dy tht phits .vn hin khi gh xut i c tng p lc ng mch phi. Rungll r o.thng xy ra nh com . A aho bnh nhn HHL. oev inl 20@y F D. Chp Xquang ngc:008. y20 2 ocit 1. Giai on u,ht Pth cha thy bin i no quan g c ot i trng, bopyr bn tri ging nh ng thng. Tip tim C lc MP tng s thy hnh nh cung MP , khi p ni v c bit l hnh nh 4 cung in hnh b bn tri ca tim (t trn xung: cung MC, cung MP, cung tiu nh tri, cung tht tri). Mt s trng hp c th thy hnh nh 5 cung khi nh tri to v l ra bn tri di cung tiu nh. 2. Hnh nh 2 cung phn di b tim bn phi do nh tri mu nhiu c 3 giai on: giai on u l hnh nh song song hai cung vi cung nh tri vn bn trong cung nh phi, giai on tip l hai cung ny ct nhau, v sau cng l nh tri to nhiu vi hnh nh hai cung song song, cung nh tri ngoi cung nh phi. 3. Mt s trng hp HHL rt kht c th thy tht tri rt sng trong thi k tm trng do mu vo tht tri t. Cng c th thy hnh nh vi ho van hai l. 241 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

ng Kerley B xut hin trn phim chp thng khi c tng p lc ng mch phi. Tht phi gin (gim khong sng sau xng c trn phim nghing tri). 4. Hnh nh gin tip khc nh nhnh ph qun gc tri b y ln trn hoc nh tri thc qun 1/3 di, thc qun b y ra sau trn phim chp nghing c ung thuc cn quang. 5. C th thy hnh nh vi ho ca van hai l hoc t chc di van trn phim chp hoc chiu di mn tng sng. V. iu tr A. iu tr ni khoa 1. Nu bnh nhn khng c triu chng c nng th ch cn iu tr khng sinh d phng vim nierved mc tm res khi c km HoHL hoc HoC. hts n rig com.vsc mc 2. Nu bnh nhn mi ch kh th khi gng ll . nh th iu tr thuc lioev. A oo tiu ah lm gim p lc l y nh tri. Phi hp thucFin 20@ giao cm (tc dng . chn 0 khi gng sc) s tng 08 t tim gim p ng tng0nhpy2 i 2 tsc. Trnh dng cc thuc gin t o c kh nng hgng oc P g ng mch. ri py Co 3. Rung nh l nguyn nhn r rng gy nng bnh, v th cn iu tr trit rung nh (chuyn v nhp xoang) hoc t nht phi khng ch nhp tht tng thi gian tm trng y tht tri v gim chnh p qua van hai l. Nhng thuc thng dng l digitalis v nhm chn giao cm. Dng cc thuc chng lon nhp hoc sc in chuyn nhp c th chuyn rung nh v nhp xoang song hiu qu lu di trnh ti pht rung nh cn ph thuc vo vic gii quyt mc hp van. 4. Bt buc phi iu tr chng ng bnh nhn HHL c rung nh v nguy c huyt khi gy tc mch cao: nn duy tr INR trong khong t 2-3. Vic iu tr d phng huyt khi nh tri v tc mch bnh nhn nhp xoang cn cha thng nht, song nn iu tr 242 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

nu bnh nhn c tin s tc mch i tun hon, c cn rung nh kch pht hoc khi ng knh nh tri ln ( 50-55 mm) s d dng chuyn thnh rung nh. Mt s tc gi khc c xu hng iu tr thuc chng ng cho tt c bnh nhn HHL cho d mc hp v kch thc nh tri ti u. 5. Nu triu chng c nng nng ln (NYHA 2) bnh nhn cn c ch nh m hoc can thip qua da. Mt s tc gi cn coi tng p lc MP ( 55 mmHg) hoc rung nh cng l ch nh can thip hoc m do vic can thip sm gip kim sot rung nh tt hn v gim bt t l nguy c, bin chng v lu di. Nu khng can thip hoc m th t l t vong sau 10 nm l 40% bnh nhn tr, tng ln gp i sau 20 nm v t l ny l 60-70%vesau 10 d ser nm bnh nhn gi. re ts gh m.vn B. Nong van bng bng qua da i ll r co . A ahoo. thut a ng 1. Nong van bng bng qua oev l k da inl 2triy qua ch chc vch thng u c bng voFnh 0@ 8. 20 lin nh ri li xung0tht tri v i ngang qua van hai 20 ocity t ot l, sau bnghs c bm ln-xung dn theo tng P rig c tng Copy lm n phn eo ca bng gy tch hai dn mp van cho n khi kt qu nong van t nh mun. Nong van hai l qua da (NVHL) tr thnh phng php c la chn hng u cho cc bnh nhn HHL trn ton th gii v y l th thut chim v tr th 2 (v s lng cng nh ngha) trong can thip tim mch. Ti Vit nam, NVHL bt u t 1997, n nay tr thnh phng php iu tr thng quy. Kt qu nong bng bng (tch hai mp van b dnh) thng tt, din tch l van tng 1-2 cm2, chnh p qua van hai l v p lc ng mch phi gim khong 1/3 so vi p lc ng mch phi trc . NVHL c u tin la chn v: a. NVHL c t l thnh cng cao, t bin chng qua nhiu nghin cu. 243 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

b. NVHL ci thin ng k tnh trng huyt ng v din tch l van. c. NVHL c kt qu trc mt v khi theo di lu di tng t hoc thm ch cn hn nu so vi m tch van c trn tim kn ln tim m. d. NVHL l th thut t xm phm, nhiu u th so vi m nh: thi gian nm vin ngn, t au, khng c so trn ngc, tm l thoi mi hn... e. NVHL c th thc hin c trong mt s tnh hung c bit m phu thut kh thnh cng trn vn hoc nguy c cao nh: ph n c thai, ngi suy tim nng, bnh nhn ang trong tnh trng cp cu... ved ser re ts gh m.vn i ll r co . A ahoo. oev inl 20@y F 8. 0 00 ity2 2 t oc gh Pot ri py Co Hnh 12-4. Nong van hai l bng bng Inoue.

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HHL (NYHA 1-2) HHL nh (MVA >1,5cm2) Siu m gng sc PAP > 60 mmHg MVG > 15 mmHg Khng Theo di hng nm Nong van hai l C Khng Hnh thivan tt cho NVHL C HHL kht (MVA <1,5cm2)

Hnh 12-5a. Ch nh nong van hai l theo AHA/ACC. ved ser re HHL (NYHA 3-4) ts gh m.vn i ll r o HHL nh (MVA >1,5cm2) HHLvkht hoo.c <1,5cm2) . A a (MVA loe y Fin020@ . Siu m gng sc 08 2 20 ocity ht Pot rig py PAP > 60 mmHg Co C Hnh thi van tt cho NVHL MVG > 15 mmHg Khng Khng Nguy c cao nu m Khng Tm nguyn nhn khc M sa/thay van C Nong van hai l C

Ghi ch: MVA: din tch l van hai l; PAP: p lc tm thu MP; MVG: chnh p trung bnh qua van hai l; NVHL: nong van hai l qua da Hnh 12-5b. Ch nh nong van hai l theo AHA/ACC. 245 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

2. Chn la bnh nhn NVHL bao gm: a. HHL kht (din tch l van trn siu m < 1,5 cm2) v c triu chng c nng trn lm sng (NYHA 2). b. Hnh thi van trn siu m tt cho NVHL, da theo thang im ca Wilkins: bnh nhn c tng s im 8 c kt qu tt nht. c. Khng c huyt khi trong nh tri trn siu m qua thnh ngc (hoc tt hn l trn siu m qua thc qun). d. Khng c h hai l hoc h van ng mch ch mc va-nhiu km theo (> 2/4) v cha nh hng n chc nng tht tri. d 3. Chng ch nh NVHL: bnh nhn h svane hai l erv e va-nhiu (3/4) hoc c huyt khihts r vn mi trong nh g m. i tri hay tiu nh tri. ll r co . A ahoo. 4. Thang im Wilkins trnoev @y m: lng ho siu inl . F 202 gip cho d bo thnh tnh trng van v dy8chng 0 0 20 city cng ca NVHL (dotoWilkins xut nm 1988) c t o gh hu nhy cao,ric P ht cc trung tm trn th gii y p s dngCo nh mt tiu chun quan trng trong chn bnh nhn NVHL. Trong thang im ny th tnh trng dy ca l van v t chc di van c nh hng nhiu n vic ci thin din tch l van sau nong. Cc nghin cu theo di ngn hn v trung hn u ch ra rng vi im Wilkins trn siu m 8 th t l thnh cng rt ng k. C mt khong xm t 9 - 11 im, khi kt qu NVHL vn c th tt nu c kinh nghim. Tuy nhin, vi im Wilkins > 11 th khng nn nong van hai l bng bng do kt qu NVHL khng ti u, t l bin chng, suy tim, ti hp sau nong rt cao. Hin nay phng php NVHL bng dng c kim loi do Cribier xut vn cho kt qu tt ngay c bnh nhn c tnh trng van xu (im siu m cao). 246 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Bng 12-1. Thang im Wilkins trn siu m nh gi van hai l.


im T chc dy Mc di van van vi ho mt nh C t, Gn Van di ng Dy im vi phn ngay bnh tt, ch st b st b van. thng: 4 - ho. van hn ch. 5 mm. Phn gia Dy ti 1/3 Dy t pha Vi ha di thn van v chiu di b van: 5 - rc pha b van. chn van cn dy chng. 8 mm. di ng tt. ti Dy lan Vi ho lan Van vn cn Dy xa xung c n on di ng v on pha trc dy chng. thn l van: gia l van. 5 - 8mm. trong thi k ved ser re tm trng, ts (ch yu l gh m.vn i ll r co gc van). . A ahoo. v ho Khng di Dy nhiu nDy y loe nhiu Vi i ton@ b c nhiu lan ng hoc rt v co 8. F 020 rt 2 t. ct c 0dyy l van: > 8 to ton b 20 ocit t van. - 10mm. chng. t igh Po Di ng van

Co

py

Hnh 12-6. L van hai l trc v sau nong bng bng. 5. Bin chng sau nong van hai l: a. T vong (< 1%) thng do bin chng p tim cp hoc tai bin mch no. 247 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

b. p tim cp do chc vch lin nh khng chnh xc gy thng thnh nh hoc do thng tht khi NVHL bng bng/dng c kim loi (< 1%). c. HoHL lun l bin chng thng gp nht (h hai l nng sau nong ch t 1-6%, theo nghin cu ti Vin Tim mch Vit nam l 1,3%). d. Tc mch c bit l tc mch no (< 1%). e. Cn tn lu thng lin nh: phn ln l thng ny t ng trong vng 6 thng; nhng trng hp cn tn lu (10%) th l nh, shunt b v dung np tt. 6. Siu m qua thc qun: c vai tr rt quan trng trong nong van hai l: nhm xc nh khng c huyt khi nh tri v tiu nh tri trc khi nong.ed erv Trong resthc qun mt s trng hp c bit, siu m qua n hts hng dn li bng nong v nhlgigkt qu sau mi ri com.v l . ln nong (din tch l van, mc. aho hai l, chnh p v A ho loe y qua van hai l...). Fin020@ 8. 2 7. Din tch l van 200 city nong: nn c nh gi hai l sau o t bng cch oigh Pot trn siu m 2D. Din tch l r trc tip y van hai Coptnh bng phng php PHT thng t tin l cy trong vng 24-48 gi sau nong (do huyt ng thay i nhanh chng). 8. HoHL: l bin chng kh kim sot nht (1-6% theo cc nghin cu). HoHL c xu hng tng ln sau NVHL v th HoHL > 2/4 l chng ch nh tng i ca NVHL, tuy nhin, mc HoHL nh sau nong l hon ton chp nhn c v d dung np. Cc yu t nh HoHL trc nong, tnh trng van vi ho gc mp van... c kh nng thp trong vic d bo HoHL sau NVHL. Thang im ca Padial v Palacios xut c kh nng d bo kh tt HoHL nng sau NVHL.

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Khi im Padial >10, kh nng HoHL nng sau NVHL s tng ln nhiu. Nghin cu ti Vin Tim mch Vit nam cho thy, vi im Padial > 10, kh nng bnh nhn b HoHL (RR) tng 53 ln. C ch chnh gy h van hai l sau nong l thng tn ca t chc di van, ca mp l van hoc do l van b co rt gy ng khng kn. Dng HoHL nh sau nong thng xut pht t mp van trong khi dng HoHL nng thng do t dy chng hoc rch l van. Mt s trng hp kt qu rt tt sau nong van, khng c hoc HoHL rt nh ngay sau nong nhng sau mt thi gian li xut hin HoHL nhiu hn thng do hin tng co rt l van, hoc t chc di van di chng thp tim. ved Bng 12-2. Thang im ca Padial d onser HoHL. re ts Thng s gh m.vn im i ll r co dy l van trc 14 . A ahoo. v loe @y dy l van sau 14 Fin 20 Tnh trng vi ho 008. y20 mp van 14 2 dit van oci t Tnh trng tgchc ot 14 i h P yr Tng p 4 16 Co 9. Ti hp sau nong van hai l: l khi nong van thnh cng v kt qu nhng qua theo di th (1) din tch l van hai l gim i nh hn gi tr tng din tch l van hai l trc nong v mt na s din tch gia tng sau nong v (2) triu chng lm sng r (NYHA > 2). V d: mt bnh nhn c din tch l van hai l trc nong van l 1 cm2 v ngay sau nong t c 2 cm2, phn gia tng l 1 cm2, 1/2 lng gia tng l 0,5 cm2 nn gi l hp li khi din tch l van < 1,5 cm2. T l ti hp van hai l ni chung thay i t 6-21%, sau 4 nm t l sng cn l 84%. Nghin cu bc u ti Vin Tim mch Vit nam (trn 600 bnh nhn, trung bnh 2 nm) cho thy 100% s bnh nhn sng st sau 2 nm, trong 85% bnh nhn khng 249 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

c nhng triu chng c nng gy ra do hp hai l, ch c 3,4% bnh nhn ti hp van. a. Tui cao, NYHA cao, rung nh, din tch l van trc nong nh, p lc ng mch phi cao, h van ba l nhiu, h van hai l tng sau nong, din tch l van hai l sau nong thp l nhng yu t tin lng xu v lu di. b. Kt qu lu di (>10 nm) sau nong van tuy rt n tng (tng ng vi m sa van tim m) song mi ch dng li nhng bnh nhn tr tui, van cn cha vi m cha c nghin cu mt cch y nhng bnh nhn ln tui hn. C. Phu thut ed 1. M tch van tim kn: l bin php dngsmt dng erv re ts c tch van hoc nong van bng tay hqua.vng m g m n i nh, thng qua ng m ngc (khng o tun hon ll r c cn . A ahoo. ny hu nh ngoi c th). Hin ti phng php oev inl 20@y hai l bng bng F khng c dng v .c nong van 8 20 00 itim m. M tch van hoc m qua da hoc phu thutc ty 2 t oto g sa van tim rch trPgip ca tun hon ngoi c th i py cho php oquan st trc tip b my van hai l, ly cc C vi, x v to hnh mp van v dy chng van hai l. 2. Bnh l di van nng thng u tin la chn phu thut so vi can thip. Bnh l van tim khc km theo HHL cn iu tr (nh h hoc hp van ng mch ch) cng l mt u tin cho phu thut. i vi bnh nhn tng p lc ng mch phi v h van ba l nng th pht, nong van bng bng n thun lm gim p lc ng mch phi cng khng lm gim h van ba l nht l nhng bnh nhn ln tui, v th phu thut van hai l kt hp vi to hnh van ba l c th l chin lc iu tr ph hp hn. 3. Phu thut thay van hai l:

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a. Thay van hai l thng c ch nh khi van vi v co rt nhiu hoc c km HoHL phi hp. b. La chn thay van hai l c hc hoc sinh hc tu thuc vo nguy c ca vic dng thuc chng ng ko di khi c van c hc so vi mc d thoi ho ca van sinh hc. T l sng st sau thay van 5 nm t 80-85%. c. Quan im bo tn t chc di van trong m hp van hai l cng ging nh h van hai l nhm duy tr cu trc v chc nng tht tri sau m. 4. M sa van hai l: tuy kh hn song vn thc hin c mt s trng hp. Sau 10 nm t l sng st > 95%, t l m li do ti hp sau m < 20%. vd 5. Tng p lc ng mch phi lm tng nguy ec ca ser e phu thut song tin lng ca bnh nhnrsau m cn ts gh m.vn tt hn nhiu so vi ch iu tr ni ri .co ll khoa. o v. Anh omn tnh c th 6. Phu thut Maze iu tr lrungyah oe in @ .F 2 kt hp ngay khi tin hnh2m0van hai l. 08 ty 0 0 2 D. Theo di sau thtthutci h Poto rig p sau Theo diy m hoc sau nong van hai l phi tin Co hnh t nht 1 nm/1 ln, hoc nhanh hn nu nh xut hin triu chng lm sng, nht l khi c cc du hiu gi c ti hp van hai l hoc h van hai l phi hp. Siu m tim cn c lm nh k theo di din bin lm sng ca bnh nhn. Ti liu tham kho
1. 2. 3. Alpert JS, Sabik J, Cosgrove DM III. Mitral valve disease. In: Topol EJ, ed. Textbook of cardiovascular medicine. Philadelphia: Lippincott-Raven, 1998:503-532. Braunwald E. Valvular heart disease. In: Braunwald E, sd. Heart disease: a textbook of cardiovascular medicine, 5th ed. Philadelphia: WB Saunders, 1997:1007-1076. Carabello B, Grossman W. Calculation of stenotic valve orifice area. In: Baim DS, Grossman W, eds. Cardiac catheterization,

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4. 5. 6.

7. 8. 9.

10. 11. 12. 13.

14. 15. 16. 17.

18.

angiography and intervention, 5th ed. Baltimore: Williams & Wilkins, 1996:151-166. Carabello BA, Crawford FA. Valvular heart disease. N Engl J Med 1997;337:32-41. Crawford MR, Souchek J, Oprian CA. Determinants of survival and left ventricular performance after mitral valve replacement. Circulation 1990;81:1173-1181. Dean LS, Mickel M, Bonan H, et al. Four-year follow-up of patients undergoing percutaneous balloon mitral commissurotomy: a report from the National Heart, Lung, and Blood Institute balloon valvuloplasty registry. J Am Coll Cardiol 1996;25: 1452-1457. Farhat MB, Ayari M, Maatouk F, at al. Percutaneous balloon versus surgical closed and open mitral commissurotomy: seven year followup results of a randomized trial. Circulation 1995;97:245-250. Glazier JJ, Turi ZG. Percutaneous balloon mitral valvuloplasty. Prog Cardiovase Dis 1997;40:5-26. Griffin BP, Stewart WJ. Echocardiography in patient selection, operative planning, and intra operative evaluation of mitral valve repair. In: Otto CM, ed. The practice of clinical echocardiography. Philadelphia: WB Saunders, 1997:355-372. ved Grossman W. Profiles in valvular heart disease. In: er s Baim DS, e Grossman W, ads. Cardiac catheterization, hts r n angiography and g m.v intervention, 5th ed. Baltimore: Williams & Wilkins, 1996:735-756. ri Mpert JS, Sabik J, Cosgrove DM III. Mitral ll oo.co . A valve disease. In: Topol v EJ, ed. Textbook of Cardiovascular yah loe Medicine. Philadelphia: Lippincott-Raven, 1998:503-532. Fin 20@ Olesen KH. The natural history .of 271 patients with mitral stenosis 08 20 2 Heart J under medical treatment. Br 0 ocity 1962;24:349-357. ht Po Reid CL. Echocardiographyt in the patient undergoing catheter rig balloon mitral commissurotomy. In: Otto CM, ed. The practice of py Co clinical echocardiography. Philadelphia: WB Saunders, 1997:373388. Reyes VP, Raju BS, Wynee J, et al. Percutaneous balloon valvuloplasty compared with open surgical commissurotomy for mitral stenosis. N Engl J Med 1994;331: 961-967. Stewart WJ: Intraoperative echocardiography. In Topol EJ, ed. Textbook of cardiovascular medicine. Philadelphia: LippincottRaven, 1998: 1492-1525. Thamilarasan M. Mitral valve disease. In: Marso SP, Griffin BP, Topol EJ, eds. Manual of Cardiovascular Medicine. Philadelphia: LippincottRaven, 2000. Tuzcu EM, Block PC, Griffin B, Dinsmore H, Newell JB, Palacios IF. Percutaneous mitral balloon valvotomy in patients with calcific mitral stenosis: immediate and long-term outcome. J Am Coll Cardiol 1994;23:1604-1609. Wilkins GT, Weyman AE, Abascal VM, Block PC, Palacios IM. Percutaneous balloon dilatation of the mitral valve: an analysis of echocardiographic variables related to outcome and the mechanism of dilatation. Br Heart J 1985;60:299-308.

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H van hai l

H van hai l (HoHL) l bnh kh thng gp. HoHL thng chia thnh hai loi: HoHL thc tn (do thp tim, vim ni tm mc, bin chng ca NMCT...) hoc HoHL c nng I. Triu chng lm sng A. Triu chng c nng 1. Ph phi (kh th khi ngh, khi nm) hoc sc tim (do gim th tch tng mu) l triu chng chnh ca h van hai l (HoHL) nng, cp, mi xut hin. 2. HoHL mn tnh thng khng biu hin triued chng v c nng g trong nhiu nm ngoi mt reser thi ting tim. t tin trin ca HoHL thnghts .vnhin kh ig xut l r o. m th khi gng sc hay gim dungl npcokhi gng sc, A ev. khio nng hn s xut hin khloth yah nm v cn kh Fin @ th kch pht v m.. Lu 20 08 ty20 ngy s xut hin triu 0 i chng suy tim tri,2cng nh cc triu chng suy tim c ht Poto ig phi do tng rp ng mch phi. py Co hon ton (rung nh) thng gp do hu 3. Lon nhp qu ca gin nh tri. Triu chng hay gp khc l mt (do gim th tch tng mu v cung lng tim). B. Triu chng thc th 1. S: Mm tim p mnh v ngn nu chc nng tht tri cn tt. Mm tim p lch tri khi tht tri gin. C th cm thy hin tng y tht nhanh v gin nhanh nh tri. 2. Nghe tim: a. Ting tim: m sc T1 thng gim (HoHL mn) nhng cng c th bnh thng nu do sa van hai l hoc ri lon hot ng dy chng. 253 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

T2 thng tch i rng (do phn ch ca T2 n sm), m sc s mnh khi c tng p ng mch phi. Xut hin ting T3 khi tng dng chy tm trng cho d khng phi lun lun l biu hin ri lon chc nng tht tri. i khi c th nghe thy ting T4 nht l trong t HoHL cp. b. Ting thi tm thu: ton th tm thu, m sc cao, kiu tng mu, nghe r nht mm, lan ra nch (xut hin gia th tm thu nu do sa va hai l hoc ri lon chc nng c nh). Ting thi tm thu ny c th ngn, n sm khi HoHL cp/ nng phn nh tnh trng tng p lc nh tri. Tuy ved vy nu p lc nh tri tng qu nhiu es khng sr re cn nghe r thi tm thu na. gCn .vn hts chn on ri om phn bit ting thi ton tmllthu.cca HoHL vi . A ahoo h ba l (HoBL) v thng lin tht (TLT): tt c oev inl 20@y . u c m sc cao,F nhng ting thi ca TLT 08 20 thng th rp 20 ocinghe r b tri xng c v hn, ty t ot P lan ra vnghtrc tim; ting thi ca HoBL nghe rig py b di tri xng c, lan v b phi r nht Co xng c v ng gia n tri, tng ln khi ht su trong khi thi tm thu HoHL nghe r nht mm v lan ra nch (cng c th lan ra y tim do dng chy hng ra trc). c. Cc triu chng thc th ca suy tim tri v suy tim phi (tnh mch c ni, gan to, c chng, ph chi di) xut hin khi bnh tin trin nng. II. Nguyn nhn v c ch bnh sinh A. Nguyn nhn gy ra HoHL 1. Bnh l l van: a. Di chng thp tim: x ho, dy, vi, co rt l van. b. Thoi ho nhy: lm di ng qu mc l van. 254 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

c. Vim ni tm mc nhim khun (VNTMNK) gy thng l van, co rt l van khi lnh bnh. d. Phnh l van do dng h van MC (do VNTMNK) tc ng ln van hai l. e. Bm sinh: X (nt) van hai l: n thun hoc phi hp (thng sn nh tht). Van hai l c hai l van. f. Bnh c tim ph i: van hai l di ng ra trc trong k tm thu. 2. Bnh l vng van hai l: a. Gin vng van: Gin tht tri do bnh c tim gin, bnh tim ed thiu mu cc b, tng huyt p. eserv r ts b. Vi ho vng van: gh m.vn i ll c Thoi ho ngi gi, thc ryodo tng huyt . A ahoo. p, i ng, suy nloev y thn. Fi 020@ chng Marfan, hi . Do bnh tim do thp, hi 08 2 20 chng Hurler. ocity ht Pot 3. Bnh l dyrig chng: py Co ho nhy gy t dy chng. a. Thoi b. Di chng thp tim: dy, dnh, vi ho dy chng. 4. Bnh l ct c: a. Nhi mu c tim gy t ct c nh. b. Ri lon hot ng c nh: Thiu mu c tim: cm c nh trc c cp mu t nhnh m v nhnh lin tht trc, cm c nh sau t nhnh xung sau (PDA). Bnh l thm nhim c tim: amyloid, sarcoid. c. Bm sinh: d dng, van hnh d... B. C ch bnh sinh 1. HoHL cp tnh: gy tng th tch cui tm trng tht tri (v thm mt lng mu do HoHL t nh tri 255 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

v), tng di si c (tin gnh) v tng co bp c tim theo nh lut Frank-Starling d hu qu l tng p lc y tht tri v gy huyt phi. Hu gnh gim do mu thot v nh tri v th cng lm tht tri bp khe, tng ng tuy th tch tng mu vn gim. Nu dung np c, bnh nhn s tin trin thnh HoHL mn tnh. 2. Trong trng hp HoHL mn tnh, tht tri gin v ph i lch tm. Sc p ln thnh c tim s tr li bnh thng do ph i c tim, ng thi mc gim hu gnh do thot mu v nh tri khng cn nhiu nh trong pha cp. Tin gnh vn mc cao lm nh tri gin. Tht tri khng co bp tng ng nh trong pha cp song vn ngng bnhved thng ser cao. Ri lon chc nng tht tri s tin trin m re ts thm trong nhiu nm d khng rchhocn c rt t g m.v i ll co triu chng. Nhng thng s truyno.thng nh gi . A aho ev co bp c tim (nh phn los @tng mu) s vn in 20 y F ngng bnh thng 08. 20 gian di do tng tin trong thi 0 ity c gnh v gim/bnh2thng ho hu gnh. Lu dn ri ht Poto rig km vi gin tin trin bung tht tri lon chc py nng o v tng Csc p ln thnh tim cng lm HoHL tng ln, thnh mt vng xon tip tc gy gim chc nng tht tri, gy mt b. Khi cc triu chng c nng r th c khi ri lon chc nng tht tri khng hi phc, lm tng nguy c suy tim, tng t l bin chng v t vong d phu thut gii quyt bnh van hai l. III. Cc xt nghim chn on A. in tim: cc biu hin khng c hiu nh dy nh tri, dy tht tri, rung nh u c th gp bt k giai on no ca HoHL. B. Xquang ngc: thng c gin tht tri v nh tri nu HoHL mn tnh. Hnh nh ph khong k v ph ph nang gp khi HoHL cp hoc khi suy tht tri nng. 256 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

C. Siu m Doppler tim: (qua thnh ngc v qua thc qun) ng vai tr rt quan trng, c s dng rng ri chn on xc nh v nh gi mc h van hai l. Mc h hai l trn siu m Doppler tim thng chia lm 4 (t 1/4 n 4/4) hoc cc mc : nh (1+), va (2+), nhiu (3+) v rt nhiu (4+). 1. Siu m Doppler mu: chn on HoHL bng hnh nh dng mu pht ngc v nh tri. HoHL c th c tnh da vo s lan ca dng mu pht ngc trong nh tri. Lng gi mc h hai l: da vo cc thng s nh:

ved ser re ts gh m.vn i ll r co . A ahoo. oev inl 20@y F 8. 0 00 ity2 2 Hnh 13-1. Dng ght PotocHoHL trn siu m Doppler. mu ca ri py Co

Hnh 13-2. Sa van hai l v ba l trn siu m 2D. a. di ti a ca dng mu (h) pht ngc trong nh tri hoc % din tch dng h so vi din tch nh tri. Rt ng tin cy nu HoHL kiu trung tm, song thng nh gi thp mc h van nu dng h lch tm. Vi nhng dng 257 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

h lch tm ln, HoHL c c tnh tng thm 1 . Hng ca dng h cho php nh gi nguyn nhn gy HoHL. Bng 13-1. Lng gi mc h van hai l. Din tch dng Chiu di ti a ca h so vi din HoHL dng h (cm) pht tch nh tri (%) ngc vo nh tri 1 < 1,5 < 20 2 1,5 2,9 20 40 3 3,0 4,4 4 > 4,4 > 40 Cn ch : vi phng php ny, khi dng siu m qua thc qun nh gi HoHL, nu dng an thn (gim hu gnh) s lm gim mc ved sernh gi HoHL so vi bnh thng. Tng t,snu re t n gh ivnhiu ph HoHL ngay trong m, h thay m. l ri o thuc vo tin gnh v hu. Al hooc tim. Do vy, gnh .c oev a ngi ta thng phinlhp y i 20@ thm nhiu phng .F php khc nh8gi 20 HoHL. 00 ity mc 2 t b. rng dng Potoc gh h (ch hp nht) khi qua l h ri (venaocontracta): l mt ch s ng tin cy. Nu py C rng > 0,5 cm l bng chng ca HoHL nng. Tuy nhin phng php ny i hi my siu m phi c phn gii cao v phi phng hnh to, nn d c xu hng nh gi qu mc h. c. Din tch l h hiu dng (ERO) tnh theo phng php PISA (Proximal Isovelocity Surface Area): da trn hin tng dng chy qua l hp hnh phu: khi ti gn l h, vn tc ca dng h gia tng hi t c dng bn cu, ti phn ra vng hi t vn tc dng chy chm, dng cu ln trong khi ti vng st l h vn tc dng chy nhanh, dng cu nh. C th o chnh xc vn tc dng chy v ng knh vng cu ti im u tin c hin tng aliasing ca ph Doppler (tn 258 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

s gii hn Nyquist), t tnh din tch l h hiu dng (ERO = 2r2V/Vmr) v th tch dng h (RV = ERO VTImr) trong r l chiu di t b ngoi vng cu hi t n mt phng van hai l, V l vn tc ti vng aliasing, Vmr l vn tc ti a dng h xc nh bng Doppler lin tc, VTImr l tch phn vn tc thi gian ca dng h. Din tch l h hiu dng (ERO) l thng s nh gi chnh xc h: nh (ERO: 010 mm2), va (10-25 mm2), nng (25-50 mm2), rt nng (> 50 mm2). Tuy nhin thc t li c mt vi sai s khi chn vng hi t dng cu dt, xc nh mt phng l h, khi dng h li khng ng nht, lch tm... v lm tng gi to h. ed D vy hin tng PISA thng bo hiu vmc ser e sr h hai l va nht l khi s dng tDoppler xung gh m.vn i (PRF). ll r co . A ahoo. v 2. Siu m Doppler xung: cloe @y nh gi mc in th gip 0 h van hai l, nht l 8. F 20nhng trng hp HoHL trong 2 00 ity 2 oc nng, c th dat vo tdng chy tnh mch phi. Hin o gh tm thu ca dng chy tnh mch i tng gim rph P y p C phi khi ochc nng tht tri bnh thng bo hiu HoHL nng, tuy nhin khng chnh xc nu rung nh hoc ri lon chc nng tht tri nng. Hin tng o ngc ph tm thu dng chy tnh mch phi bo hiu HoHL rt nng. D. Thng tim 1. Sng v trn ng cong p lc nh tri (tng ng giai on y nh tri t cc tnh mch phi trong thi k tm thu) cho php c lng mc HoHL, c bit l HoHL cp tnh. Bin sng v gp 2-3 ln p lc trung bnh nh tri gi HoHL nng. Tuy nhin nu HoHL mn tnh hoc khi gim hu gnh, c th khng thy bt thng sng v. Khng c sng v cng khng th loi tr HoHL nng. Mt khc sng 259 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

v cao cng c th gp trong nhng trng hp nh ri lon chc nng tht tri m nh tri km gin, thng lin tht sau nhi mu c tim hoc nhng tnh trng tng lu lng phi. 2. Chp bung tht tri: cho php c lng mc HoHL theo phn ca Seller: 1/4: Ch c vt cn quang m vo nh tri, khng vin r hnh nh tri. 2/4: Cn quang trn khp nh tri nhng m khng bng tht tri, mt i nhanh chng sau 2-3 nht bp. 3/4: m cn quang nh tri v tht tri bng nhau. 4/4: Cn quang nh tri m hn rtht tri, ved se xut hin c cn quang tnh mch phi. re hts . gngvn 3. Thng tim cng dng kho sti om thi bnh ll r c . A ahoo. ng mch vnh khi HoHL:evbnh nhn nam tui o 40, n tui 50 d khngnl 20@y chng hoc yu t Fi c triu . nguy c ca bnh2008 ty20 cng nn chp ng mch vnh oci mch vnh trct m.tCh nh thng tim gm: gh Po ri a. Khi Copy tng xng gia triu chng lm sng khng v kt qu thm d khng chy mu, b. Khi d nh phu thut nhng bnh nhn cn nghi ng v mc nng ca h van hai l hoc bnh mch vnh, c. Bnh nhn h van hai l c nguy c mc bnh mch vnh hoc nghi ng bnh mch vnh l cn nguyn gy h van hai l. IV. iu tr Nm bt c ch sinh bnh l vic rt cn thit la chn bin php iu tr ph hp. A. H van hai l cp tnh 1. iu tr ni khoa: nu huyt p trung bnh ng mch vn trong gii hn bnh thng, s dng cc 260 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

thuc h hu gnh c th lm n nh tnh trng HoHL cp. Truyn tnh mch Nitroprusside v Nitroglycerin lm gim p lc mch phi v tng cng th tch tng mu. Nu cha cn phu thut ngay, c th chuyn sang dng thuc ung, phi hp thuc c ch men chuyn v Hydralazin. Trong nhng trng hp HoHL nng, cp (m tht tri cha kp gin, ph i nh HoHL do t ct c nh sau nhi mu c tim) nu xut hin triu chng ph phi, sc tim th nn t bng trong ng mch ch n nh tnh trng huyt ng trc khi gi i m. 2. iu tr ngoi khoa: a s bnh nhn HoHL nng, cp tnh u phi m cp cu. B. H van hai l mn tnh ved ser re 1. Chn phng php v thi im iuts .vph hp: tr gh m n i l r co a. Bnh nhn HoHL t va nl nng nu c triu . A ahoo. chng th c ch nh m.ev @y lo Fin020 . b. Bnh nhn HoHL8nng khng c hoc c rt t 0 y2 20chitnh phc tp hn. Vn triu chnghtth otoc rig xc nh c thi im can thip mu cht l P py Co trc khi chc nng tht tri gim n mc khng hi phc. Nu ch theo di st ti khi xut hin triu chng th vn c nguy c b qua ri lon nng chc nng tht tri v tin lng s km i hn. u th ca sa van i vi tnh trng suy tim v t l t vong sau m khin cho ngy cng c khuynh hng ch nh m sa van hai l sm hn nu thng tn gii phu cho php. c. Rt nhiu phng tin v thng s c xut d bo tin trin ca ri lon chc nng tht tri, suy tim v t vong sau m bnh nhn HoHL nng. Song la chn thi im v bin php iu tr cn phi hp tu tng c nhn:

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Triu chng lm sng: bnh nhn tui trn 75, c km bnh l mch vnh hoc ri lon chc nng thn c tin lng km hn sau m v th nn gi i m trc khi biu hin r triu chng cc bnh km theo. Rung nh cng l mt l do cn nhc ch nh m sm. Thng s o bng siu m tim: rt c ch nh gi xem bnh nhn cn gi i m hay cha. Thng thng phn s tng mu (EF) trn ngng bnh thng. V th EF < 50% cho thy tnh trng ri lon chc nng tht tri nng nn gi i m sm cho d cha c triu chng. Ngay c khi EF t 50-60% cng lm tng nguy c suy tim v t l t vong ed sau m. Cc thng s d bo nguy rv khc se c re t bao gm: ng knh cui tms thu tht tri gh m.vn i (LVESD, Ds) 45 mm, All r osut co ngn si phn co . aho . c tht tri FS 31%,ev y i p lc tht tri lo thay @ Fin021343. theo thi gian dp/dt < 0 . 08 ty2 2 sng (a) Khi lm 0 oci v siu m tim khng l r, t P siu ghlm ot m tim gng sc: gim p nn ri py vi gng sc, EF tht tri khng tng Co ng khi gng sc, ch s th tch cui tm thu tht tri (LVESVI) 25 cm3/m2 l nhng ch s gi cn ch nh m sm. (b) Bnh nhn c sa l van hai l gy HoHL nng nn ch nh m sm d khng c hoc c rt t triu chng. Thng s o bng thng tim: (a) p lc trung bnh ng mch phi 20 mmHg, ch s tim (CI) < 2 l/pht, p lc cui tm trng tht tri 12 mmHg l cc du hiu d bo tin lng ti sau m. (b) Cung lng tim khng tng hoc p lc mao mch phi bt tng khi gng sc l

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du hiu cho bit c ri lon chc nng tht tri n. (c) gin (elastance) tht tri (ng cong tng quan gia th tch v p lc) l thng s nh gi chc nng co bp tht tri tt nht song t c ng dng rng ri v phi dng cc thit b c bit. 2. iu tr ni khoa: a. HoHL do ri lon chc nng tht tri (c gin vng van) c iu tr bng cc thuc cha suy tim nh : Cc thuc gim hu gnh, c bit l c ch men chuyn, lm gim th tch dng h v tng th tch tng mu. Nhm ny cng d tc e c erv dng vi bnh nhn HoHL do bnh sl van tim re ts c triu chng ang ch m. igh m.vn r co ll Thuc li tiu v nhm .Nitrate. c tc dng tt v A ahoo le y trong iu tr huyto phi. Fin020@ . 2 Rung nh phi8c iu tr kim sot tn s 0 20 ocity tht bng cct thuc chng lon nhp, nht l t igh Po Digitalis v thuc chn giao cm. yr op b. Vai C ca thuc vi bnh nhn HoHL mn tnh tr do bnh van tim, cha c triu chng, ni chung cn cn nhiu th nghim chng minh nht l v kh nng lm chm tin trin ca HoHL hoc phng ri lon chc nng tht tri. iu tr cc thuc gim hu gnh qu tch cc c th che bt cc triu chng, t a ra cc quyt nh sai lm v thi im v bin php can thip. c. Phi d phng vim ni tm mc nhim khun cho tt c trng hp HoHL do bnh van tim ngoi tr h do gin tht tri m cc van tim bnh thng. 3. iu tr phu thut:

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a. Kinh in l ct b b my van hai l ri thay bng van hai l nhn to. Tuy nhin, sau m thng c gim chc nng tht tri v suy tim huyt. Cc k thut mi c xu hng bo tn t chc di van nhm gim th tch tht tri v sc p trn c tim sau m (tht tri cng c dng elp th cng ci thin EF sau m). b. K thut sa van lm gim ng k t l t vong v bin chng: t l sng cn sau 5 nm > 85% v ch c 10% bnh nhn phi m li trong 5 nm. Cc k thut bc l ti thiu cng lm gim hn na t l bin chng v t vong. Tuy cha c th nghim no so snh m sa v thay van song cc nghin cu u cho thy u th ca m sa ved van (phn no do s la chn bnh nhn): ser e sr T vong ca m sa van l ight so n 5-8% 2% .v vi ll r com ca thay van. . A ahoo. oev Phn s tng munsau @y thng cao hn i l 20 m . nhm bnh nhn F 20c van. 08 tsa y 20mch bnh nhn sa van thp Nguy ct tc toci h Po hny(5% trong 5-10 nm so vi 10-35% nu rig p Co thay van). Nguy c vim ni tm mc cng gim hn (0,4% so vi 2,2%). Sau m sa van khng cn dng thuc chng ng ko di (ch 3 thng) nn gim nguy c khi dng thuc chng ng. T l phi m li tng t gia hai nhm bnh nhn m sa v thay van. Mt s bnh nhn ri lon chc nng tht tri nng hoc h van hai l th pht c th p dng th thut Batista (ti cu trc tht tri kt hp vi m sa van) cho kt qu sm rt tt trong khi khng th m thay van. Tuy nhin ch nh m sm (nht l sa van) nhng bnh nhn HoHL nng m cha c triu chng cn gy nhiu tranh ci. 264 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

c. Kh nng sa van thng ph thuc vo nguyn nhn gy HoHL, d nh gi trc m bng siu m tim qua thnh ngc hoc qua thc qun. Thnh cng v cc bin chng ca m sa van/thay van c th nh gi bng siu m tim ngay trong m. HoHL tn d l bin chng hay gp nht sau khi ngng my tim phi nhn to. Nu HoHL cn 2/4 nn chy li tim phi nhn to sa tip hoc thay van hai l. Chy my tim phi nhn to ln th hai khng tng thm t l t vong ti vin. d. Cn loi tr mt bin chng sau m l hp ng ra tht tri do tha m l van sau (> 1,5 cm) y vng ng hai l van ra trc di chuyn vo ved ng ra tht tri trong thi k tm ser Bin thu. re t chng ny rt hay gp nhng bnhsnhn c tha gh m.vn ri m l van v tht tri nh v ll oo.co . Atng ng. K thut s bt m l van sau nloev @yah dng hn ch c p i bin chng ny, 08. Fnhin nu c cn tr ng tuy 2020 ra tht tri qu 20tocity nn m thay van hai l. nhiu th ht Po rig 4. Theo di sau m: py Co Siu m tim sau m 4-6 tun c dng lm mc theo di. HoHL ti pht do sa khng tt hoc do nguyn nhn gy bnh tip tc tin trin. Bnh nhn nn c theo di lm sng v siu m tim (nh gi kt qu m sa van, c ch v mc h van, chc nng tht tri, huyt khi hay vim ni tm mc) t nht 1 nm/1 ln. Ti liu tham kho
1. 2. Alpert JS, Sabik J, Cosgrove DM III. Mitral valve disease. In: Topol EJ, ed. Textbook of cardiovascular medicine. Philadelphia: Lippincott-Raven, 1998:503-532. Bach DS, Boiling SF. Improvement following correction of secondary mitral regurgitation in end-stage cardiomyopathy with mitral annuloplasty. Am J Cardiol 1996;78:966-969.

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3. 4.

5. 6. 7. 8.

9. 10. 11.

12.

13. 14. 15. 16. 17. 18.

Braunwald E. Valvular heart disease. In: Braunwald E, sd. Heart disease: a textbook of cardiovascular medicine, 5th ed. Philadelphia: WB Saunders, 1997:1007-1076. Carabello B, Grossman W. Calculation of stenotic valve orifice area. In: Baim DS, Grossman W, eds. Cardiac catheterization, angiography and intervention, 5th ed. Baltimore: Williams & Wilkins, 1996:151-166. Carabello BA, Crawford FA. Valvular heart disease. N Engl J Med 1997;337:32-41 Cohn LH, Couper OS, Aranki SF. Long-term results of mitral valve reconstruction for regurgitation of the myxomatous mitral valve. J Thorac Cardiovasc Surg 1994;107:1453-151 Enriquez-Sarano M, Schaff HV, Orszulak TA, et al. Valve repair improves the outcome of surgery for mitral regurgitation: a multivariate analysis. Circulation 1995;91: 1022-1028. Griffin BP, Stewart WJ. Echocardiography in patient selection, operative planning, and intra operative evaluation of mitral valve repair. In: Otto CM, ed. The practice of clinical echocardiography. Philadelphia: WB Saunders, 1997:355-372. Grossman W. Profiles in valvular heart disease. In: Baim DS, ved Grossman W, eds. Cardiac catheterization, angiography and ser re intervention, 5th ed. Baltimore: Williams & Wilkins,s1996:735-756. t vn gh I, Grayburn PA. Hall SA, Brickner E, Willett DL, Irani WN, Mridi m. ri co Assessment of mitral regurgitation severityAll Doppler color flow of . byhoo. v the vena contracta. Circulation 1997;95:636-642. loe ya Leung DY, Griffin BP, Stewart Fin 20@ WJ, Cosgrove DM, Thomas JD, 8. 20 Marwick TH. Left ventricular0function after valve repair for chronic 20 oc value preoperative assessment of mitral regurgitation: predictive ity contractile reserve by ht Pot echocardiography. Am Coll Cardiol exercise rig 1996;28:1195-1205. py Co Leung DY, Griffin BP, Stewart WJ, et al. Left ventricular function after valve repair for chronic mitral regurgitation: predictive value of preoperative assessment of contractile reserve by exercise echocardiography. J Am Coll Cardiol 1996;28:1195-1205. Mpert JS, Sabik J, Cosgrove DM III. Mitral valve disease. In: Topol EJ, ed. Textbook of Cardiovascular Medicine. Philadelphia: Lippincott-Raven, 1998:503-532. Stewart WJ. Choosing the golden moment for mitral valve repair. J Am Coll Cardiol 1994;24: 1544-1546. Stewart WJ: Intraoperative echocardiography. In Topol EJ, ed. Textbook of cardiovascular medicine. Philadelphia: LippincottRaven, 1998: 1492-1525. Thamilarasan M. Mitral valve disease. In: Marso SP, Griffin BP, Topol EJ, eds. Manual of Cardiovascular Medicine. Philadelphia: LippincottRaven, 2000. Thomas JD. How leaky is that mitral valve? simplified Doppler methods to measure regurgitant orifice area. Circulation 1997;95:545-550. Zuppiroli A, Rinaldi M, Kramer-Fox R. Natural history of mitral valve prolapse. Am J Cardiol 1995;75:10281032.

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H van ng mch ch

H van ng mch ch (HoC) c th chia thnh 2 loi: cp tnh v mn tnh. HoC mn thng do van ng khng kn v b ca l van b dy ln v cun li, do gin vng van-gc ng mch ch (MC) hoc c hai. HoC cp thng do chn thng ngc, vim ni tm mc, tch thnh ng mch ch gy thng, sa l van hoc gin cp tnh vng van v gn nh lun phi m cp cu. I. Triu chng lm sng A. Triu chng c nng d 1. Nu HoC cp do vim ni tm mc nhimvekhun, ser re mc h ban u c th khng ln, songvc th tin ts gh m. n i trin rt nhanh chng v mc HoC.co suy tim, cn ll r v . A ahoo theo di st. oev inl 20@y F 2. HoC mn tnh thng 20 8. khng biu hin g trong 00 itc nng khi xut hin thng 2 nhiu nm. Triu chng y t otoc ghhuyt phi nh kh th khi gng sc, lin quan ni P r py Co dn xut hin kh th khi nm, cn kh sau dn th kch pht v m, cui cng l cc du hiu ca suy tim ton b. 3. au tht ngc xut hin nhng bnh nhn HoC nng (do gim ti mu mch vnh trong thi k tm trng v gim chnh p qua li mch vnh khi tng p lc cui tm trng tht tri v suy tim). B. Triu chng thc th 1. HoC cp, mc nng thng c bnh cnh cp tnh. Cn ngh ti tch thnh ng mch ch bnh nhn HoC cp c km au ngc. Cng cn xc nh bnh s v cc yu t nguy c ca vim ni tm mc nhim khun. Triu chng suy tim huyt (ph phi...) bo hiu tin lng xu trong bnh HoC cp. 267 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

2. HoC mn tnh thng khng biu hin triu chng g trong mt thi gian di ngoi mt ting thi tm trng b tri xng c. Cn tm biu hin HoC nhng bnh nhn c hi chng Marfan hoc phnh gin ng mch ch ln. 3. Cc triu chng bn ngoi c th gp trong HoC mn tnh l: a. Kiu hnh Marfan: thng ngi tr, c d tt nhiu c quan: nt rui son, bn chn - tay v cc ngn di nh chn tay nhn, ngc hnh phu... b. C th km triu chng ca vim ni tm mc nhim khun. c. Nhn thy vng p rng trc tim hoc mm tim ved lch tri do tht tri gin. ser re ts HoC nh. d. S o huyt p vn bnh thng hnuvn g m. i Khi HoC nng, bung tht tril gin, con s huyt l r co . Aphoo. trng gim p tm thu tng cao, huyt ya tm oev inl 20@ s o huyt p ln. nhiu, to ra chnh F 0 v 8. lch 00 ity2 hon ny c th gy ra Tnh trng tng ng tun 2 t oc mt lot righ duohiu nh: cc P t py Du hiu Musset: u gt g theo nhp p Co ca tim. Du hiu Mller: li g p theo nhp tim. Du hiu Hill: huyt p chn ln hn cnh tay > 60 mmHg. Mch Corrigan: mch p ny nhanh mnh, chm su. Mch Quincke: hin tng nhp nhy ca li mao mch mng tay, mi. Du hiu Duroziez: ting thi i ng mch i khi p ng nghe vo. Du hiu Trobe: ting tm thu v tm trng ni bt ng mch i Khi suy tim tin trin, co mch ngoi vi s lm tng con s huyt p ti thiu, huyt p ti a 268 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

gim do ri lon chc nng tht tri. Trng hp tch thnh ng mch ch km trn dch mng tim, c th gp hin tng mch nghch thng. 4. S: mm tim thng p mnh, tng ng, lch tri, khoang lin sn V ngoi ng gia n, do tht tri gin. Thng c rung miu tm trng khoang lin sn II tri, i khi c c rung miu tm thu (do tng lu lng qua van MC). ny v thi gian khi bt mch quay, mch i c th xc nh c mc HoC. Kinh in l mch Corrigan (ny nhanh, mnh, chm xung nhanh). C th gp mch hai nh ny trong trng hp hp phi hp h van ng mch ch. Nhp tim vn nm trong gii hn bnh thng cho ti giai on mun ca bnh, nhp ved tim thng tng ln b tr cho th tchser tng mu re ts khi gim qu mc. gh m.vn i ll r co 5. Nghe tim: . A ahoo. oev inl 20@y nh mc HoC: a. Ting tim c th dng xc F 8. 0 0 khi HoC Ting T1 m 0 city2 nng v ri lon chc 2 t o nng tht tri tdo hin tng ng sm van hai gh Po ri py locng nh gim lc gy ng van. C Thnh phn ch ca ting T2 thng m do cc l van MC ng khng kn, thnh phn phi ca T2 cng hay b ting thi tm trng ln p. T2 tch i st nhau hoc tch i nghch thng (trn tm thanh c ng , thnh phn ch i sau thnh phn phi) do thi gian tng mu tht tri b ko di v th tch tng mu tng. Ting T3 nghe c khi gim nng chc nng tm thu tht tri. T4 hay c, do nh tri phi bp mu xung bung tht tri gim gin. b. Thi tm trng kiu pht ngc, bt u ngay sau ting T2, cng gim dn, nghe r nht 269 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

b tri xng c khi bnh nhn ngi nghing ngi v pha trc v th ra ht sc. Mc HoC lin quan cht vi di hn l cng ca ting thi: giai on u, ting thi thng ngn, n khi bnh tin trin, ting thi tr thnh ton tm trng, tuy vy khi suy tim nng, giai on cui, ting thi thng ngn li do p lc cui tm trng tht tri tng dn ln. Vn c tnh (bp cht tay...), ngi xm, dng thuc tng co c tim s lm tng ting thi trong khi ang ngi xm ng thng dy, nghim php Valsalva hoc ht Amyl Nitrite li lm gim ting thi ny. c. Thi tm thu y tim lan ln cc ng mch cnh do tng lu lng tng mu qua vand ng e erv mch ch. res hs d. Rung tm trng Austin Flint:t m.vn thy rig co nghe mm tim trong trng hp All oo. nng: do dng HoC v. h loe @ trc HoC pht ngc gy rung l ya van hai l hoc in . F 20 dng HoC lm ng sm van hai l v to dng 08 ty20 20 ci xoy qua van hai ol gy rung. Khi , cn phn ht Pot bit viyrig tm trng do hp hai l phi hp. p rung Co II. Nguyn nhn v c ch bnh sinh A. Nguyn nhn gy ra HoC 1. Bnh l gc ng mch ch lm ng van khng kn gy h: a. H van ng mch ch cp tnh: Phnh tch thnh ng mch ch. Tch thnh ng mch ch do chn thng ngc. b. H van ng mch ch mn tnh: Hi chng Marfan. Gin phnh ng mch ch. Gin vng van ng mch ch.

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Vim thnh ng mch ch do bnh giang mai. Lupus ban h thng. Lon sn xng. Hi chng Ehlers-Danlos. Lng ng mucopolysacharide. Vim ct sng dnh khp. Hi chng Reiter. Vim ng mch t bo khng l. Hi chng Takayashu. 2. Bnh l ti l van ng mch ch: a. H van ng mch ch cp tnh: Vim ni tm mc nhim khun. Sa l van do chn thng. ved ser b. H van ng mch ch mn tnh: ts re n h Di chng van tim do thp. l rig om.v l c . ho nhy. Thoi ho vi hoc thoiA ahoo. oev y Phnh gin xoang Valsalva. inl @ . F 2020 8 Van ng mch ch hai l, bn l hoc mt l 00 y 2 tocit van. ght Po i iurtr thuc methysergide. py Co B. C ch bnh sinh 1. HoC mn tnh lm tng gnh th tch tht tri, gy ph i lch tm, gin v tng th tch cui tm trng ca tht tri. Nu chc nng tht tri cn b, th tch tng mu ni chung s tng ln ng k, th tch tng mu thc s vn cn bnh thng, tht tri c th chu c th tch mu pht ngc m khng tng qu p lc cui tm trng tht tri. Bnh nhn s khng thy r cc biu hin triu chng lm sng. 2. Dn dn ri lon chc nng tht tri pht trin, gin tht tri tng dn, ri lon qu trnh tng mu tht tri, lm gim phn s tng mu, tng th tch v p lc cui tm trng tht tri, gim th tch tng mu. Qu trnh tng gnh c th tch v p lc gy ph i 271 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

tht tri lch tm phi hp ng tm. Thi im ny cng l lc xut hin cc triu chng lm sng. 3. HoC cp tnh gy tng th tch cui tm trng tht tri nhanh chng, trong khi c tht tri cha th ph i dung np, nn d dng vt qu p lc nh tri to ra tnh trng ph phi cp. ng thi p lc cui tm trng tht tri tng nhanh, c th gy ng sm van ng mch ch, gim th tch tng mu, gim cung lng tim a n tnh trng sc tim. III. Din bin t nhin 1. Bnh nhn HoC mn tnh khi xut hin triu chng s c khuynh hng tin trin bnh kh nhanh. Cc yu t tin lng xu bnh nhn HoC mn ved gm: ser e sr a. Triu chng c nng (NYHA >II),t conns huyt gh m.v ri p ng mch chnh lch ln.ll oo.co . A ah ev b. Ch s nh gi chc inng @y tri: phn s tng nlo 0 tht .F mu < 50-55%,0phn 202 co ngn si c < 2508 ty sut 2 ci 30%, ng tknhtocui tm thu > 55 mm, ng gh Po r knh cui itm trng > 75-80 mm. py Cophn s tng mu khi gng sc. c. Gim d. in tim c ri lon ti cc, ST chnh xung > 0,1 mV khi gng sc. e. Rung nh. Ni chung phn s tng mu tht tri l thng s quan trng nht xc nh t l sng cn nhng bnh nhn c HoC. Khi ri lon chc nng tht tri, triu chng s xut hin trong vng 2-3 nm, trung bnh > 25%/nm. Bnh nhn HoC mc nh-va c t l sng sau 10 nm t 85-95%. Bnh nhn HoC va-nng iu tr ni khoa c t l sng sau 5 nm l 75% v sau 10 nm l 50%. Nu c au ngc, iu tr ni khoa cng ch ko di thi gian sng khong 5 nm. 272 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

i vi nhm bnh nhn HoC nng cha c triu chng, nhng nghin cu gn y cho thy t l bin c (t t, xut hin triu chng phi phu thut, ri lon co bp tht tri) khong 6,2%/nm, t l xut hin triu chng khong 10%/nm. T l t vong tng tuyn tnh hng nm: vi bnh nhn c triu chng khong 9,4% cn vi bnh nhn cha c triu chng l 2,8%. Din bin t nhin ca HoC nng mn tnh khng h tt nh trc y m t. ng ch ch triu chng c nng tin trin khng tng ng vi bt k ch s chc nng tht tri no. t t c th xy ra bnh nhn HoC nng c triu chng, thng do cc ri lon nhp tht lin quan n ph i v ri lon chc nng tht tri hoc ved ser th pht do thiu mu c tim. re ts v gh cc n thuc 2. T l sng cn s tng nu iu tr ri m. cc tch l co gin mch nh Nifedipine, thuc lcoch men chuyn, . A ah o. ev Hydralazine, ch nh smlo 0@yim phu thut v in thi F 02 ci tin k thut m. 08. yd thuc ci thin phn no 0 Mc 2 2 o t tin lng sng tnhngcitc dng chnh ch l ko di gh Pot thi gian opyrim. ch C IV. Cc xt nghim chn on A. in tm : Hnh nh in hnh l dy tht tri, T cao v ri lon nhp nh. Dng ri lon nhp nh hay gp nht l rung nh, nht l khi c bnh van hai l phi hp. Bloc dn truyn cc mc c th gp khi p xe vng van MC. B. Xquang tim phi: bnh nhn HoC mn c hnh nh tim to. C th gp hnh nh gin nh tri hoc gin ng mch ch ln. C. Siu m tim: siu m 2D cho php xc nh nguyn nhn HoC cp, kho st c gc MC, kch thc v chc nng ca tht tri. Siu m Doppler tim cho php chn on xc nh HoC v lng gi mc HoC (bng 273 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

nhiu phng php s dng Doppler mu, Doppler xung v Doppler lin tc). 1. Xc nh dng pht ngc ca HoC da trn mt ct dc cnh c v mt ct 5 bung t mm. ng thi phi hp cc mt ct khc nh gi hnh dng van MC (cnh c trc ngn), phn gc MC v MC ln (trn 1 khoang lin sn so vi mt ct cnh c trc di), quai MC v MC xung (trn hm c v di mi c) cng nh nh gi c ch, nguyn nhn gy h, chc nng tht tri, mc HoC nh hng n cc bung tim v tn thng van phi hp. Du hiu rung cnh van hai l, ng sm van hai l (trn siu m tim kiu TM) c gi tr chn on cao. ved ser re ts gh m.vn i ll r co . A ahoo. oev inl 20@y F 8. 0 00 ity2 2 t oc gh Pot ri A Copy B

Hnh 14-1: Dng pht ngc ca h van MC trn Doppler mu. (A: Mt ct dc cnh c tri. B: Mt ct ngang qua gc MC. C: Mt ct 5 bung tim t mm. D: Hnh nh siu m TM mu ca mt trng hp h van MC).

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2. nh gi mc HoC c rt nhiu phng php da vo siu m Doppler song khng phng php no c chp nhn lm tiu chun chung. Mt khc, nhiu yu t c th nh hng ti vic dng siu m Doppler o: thay i tu theo gin n ca tht tri, ca MC v sc cn i tun hon. Ci chnh l c lng mc nng ca HoC da trn c s tng hp ca nhiu thng s trn siu m. Song cn ch : cc thng s tng i thng nht nu mc HoC nh hoc nng nhng thng khc nhau nhiu nu HoC mc va, do cn phi hp thm cc triu chng lm sng. Mt s thng s sau thng c s dng nh gi mc h van MC: a. Da vo siu m Doppler mu: ng knh dng HoC/ng knh ng ra ved tht tri (RTT). ser e sr Din tch dng HoC/din tch tng ra tht gh m.vn i tri. ll r co . A ahoo. t MC ln: Hin tng dng chyvgn hi loe tng ng vi HoCn3+0@y 4+. Fi 02 hay . Chiu di v 08 ty2 dng HoC pht ngc din tch 20 oci vo trong ot tri: tuy nhin kt qu tnh giao t tht gh P ngrirt nhiu, ph thuc vo tnh trng ti y p Co ca c tim v hng ca dng h. Dng HoC thng b trn vi dng chy qua van hai l v lm cho vic c lng mc h ch b qu ln. b. Da vo siu m Doppler lin tc: Tng quan tn hiu gia ph Doppler lin tc ca dng h MC so vi dng tng mu t tht tri vo ng mch ch. Dc gim p v thi gian bn gim p lc[PHT] (thi gian chnh p gia ng mch ch v tht tri gim cn mt na so vi gi tr ban u): dc gim p cng dc, PHT cng ngn th HoC cng nng. Dng chy ngc trong thi k tm trng on u ng mch ch xung: tng ng vi HoC nng. 275 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

T s gia tch phn vn tc theo thi gian ca dng chy tm trng (VTId) trn tch phn vn tc theo thi gian ca dng chy tm thu (VTIs): VTId / VTIs > 50% tng ng vi HoC nng. c. Da vo huyt ng: tnh phn s h (RF) da trn hiu s dng chy qua van ng mch phi so vi dng chy qua van MC nu khng c lung thng trong tim. Qa Qp RF = / 100 Qa Trong : Qa = LVOTvti 0,785 Da v Qp = RVOTvti 0,785 Dp Da l ng knh ng ra tht tri (LVOT) o mc van MC; Dp l ng knh ng ra tht phi (RVOT) o mc ngang van ng dmch e ev phi; vti l tch phn vn tc theo thir gian ti res LVOT hoc RVOT. hts n rig com.v d. Cc thng s siu m tim callHoC mn tnh mc . A oo. nng: oev yah nl @ ng knh dng iHoC / ng knh ng ra . F 2020 08 tht tri 65%.city 20 o t Din rtcht dng HoC / din tch bung tht tri igh Po y op C 60%. Dc gim tc trn ph Doppler lin tc dng HoC 3m/giy. PHT 300 ms. C dng chy ngc ton tm trng on u ng mch ch xung. Hin tng dng chy gn hi t trn siu m Doppler mu. Mt tn hiu Doppler lin tc dng h MC ging dng tng mu ln MC. Ph dng chy qua van hai l c dng hn ch. Phn s h > 50%. Th tch h > 60 ml. ng knh cui tm trng tht tri > 65 mm. 276 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Bng 14-1. Cc phng php nh gi mc HoC.


Mc HoC Phng php ng knh HoC / ng ra tht tri (%) Din tch HoC / Din tch tht tri (%) PHT (ms) Nh (1+) < 25 Va (2+) 25-45 Vanng (3+) 46-64 Nhiu (4+) 65

4-25

25-59

60

400 300-400 300-400 300 400170 37070 25080 14030 Dc gim tc 2 2-3 2-3 3 nht, nht t cng Mt ph ca nht, hon ton hn, dng h so vi khng ed vmt ser hon ton mt ph dng hon ton re ts tng mu ln gh m.vn i ll r co MC . A ahoo. oev Chiu di dng ngay khng 0@y ti tn ti tn inl 2 F 0 .qu 1/2 HoC pht ngc di cc008 y2 vng cc mm t 2 l v tht tri l van otoci trc c nh tim ht P rig van hai l pyMC Co < 8 mm 8-12 mm 12-16 >16 ng knh dng mm mm HoC trn siu m mu kiu TM 0% 1-10% 11-20% >20Vn tc dng 25% chy cui tm trng/vn tc ti a dng chy tm thu Vn tc dng < 0,1 0,1-0,2 0,2-0,4 > 0,4 chy cui tm trng (o ti eo MC) (m/s)

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D. Siu m tim qua thc qun: rt c gi tr bnh nhn vim ni tm mc nhim khun pht hin cc si hoc p xe vng van MC. Nu HoC n thun, si in hnh thng mt nhn v pha tm tht ca l van. Vim ni tm mc nhim khun d lm tn thng c l van (thng) v cc cu trc ca gc MC gy tnh trng HoC cp, tin trin nhanh. Siu m qua thc qun cng cho php nh gi nguyn nhn gy HoC, xc nh cc tn thng bm sinh v loi tr phnh tch MC. E. Siu m gng sc: nh gi p ng ca tht tri vi gng sc. Phn s tng mu tht tri bnh thng khi ngh nhng khng tng khi gng sc chnh l du hiu ri lon tim n chc nng tht tri v c ch nh m. F. Chp x hnh kiu nhiu cng (MUGA): nh gi chc nng tht tri, tnh phn s v th tch h. erved res G. Thng tim v thm d huyt ng: ch nh khi: hts .vn rig m 1. Bnh nhn nam tui 40 v .nlltuico 50 nn chp A oo. ng mch vnh loi nloevbnhh ng mch vnh tr ya @ trc khi thc hin bt8kican 0 . F 2 thip no. 0 ty20 0 ch 2. Chp ng mch 2 toci nh gi mc HoC (t ht Po ig th nghing rtri chch u vi ng thng trn l van py Cn cn thn khi li ng thng (do quai MC 1 Co cm). ng mch ch thng gin, nht l trong hi chng Marfan) trnh gy sang chn. Cng cn ch bnh l hp l vo ng mch vnh phi hoc tri. Bng 14-2. Mc h van MC khi chp MC. Mc HoC Mt cn quang Tc cn tht tri quang nht dn Nh (1+) Nht, khng vin hon Nhanh ton Va (2+) Nht, vin hon ton Nhanh Va-nhiu Bng cn quang Va (3+) MC Nhiu m hn cn quang Chm (4+) MC 278 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

3. Huyt ng: bnh nhn HoC mn tnh cn b s c tng p lc tm thu v gim p lc tm trng MC trong khi p lc cc bung tim bn phi bnh thng. Bnh nhn HoC nng s c tng p lc cui tm trng tht tri, tng p lc mao mch phi bt, tng p lc ng mch phi tu theo mc suy tim v cc tnh trng bnh l van tim phi hp khc. Cng nn c gng o chnh p qua van ng mch ch nh gi mc hp van MC phi hp (nu c). V. iu tr A. La chn phng hng iu tr: ch yu l phi xc nh nguyn nhn, n nh tnh trng huyt ng, ved xc nh nhu cu v thi im phu thut tu thuc vo ser re bnh cnh HoC cp tnh, HoC mn tnh, cn bnhoc mt ts gh m.v b. Phu thut l iu tr tt yu cho i bnh nhn HoC ll r o.co . Akhio suy tim. nng cho d nguyn nhn g, nhtvlyah loe Fin020@ 1. Ch nh m gm: 08. 2 y 0 2 it a. H van ngt mchcch nng, cp tnh. h Poto rig py b. Bnh oMC: khi ng knh gc MC 50 mm C d h van mc no. c. H van ng mch ch mn tnh c km theo: Triu chng suy tim huyt (NYHA 2) hoc c au ngc. Phn s tng mu tht tri EF 50%. ng knh tht tri cui tm thu 55 mm. ng knh tht tri cui tm trng 75mm. Phn s tng mu gim khi gng sc. B. iu tr ni khoa 1. HoC mn tnh: bao gm: a. Phi iu tr d phng vim ni tm mc nhim khun nht l HoC nng. 279 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

b. C th duy tr hot ng th lc bnh thng (gng sc nh, chi th thao) song nn trnh dng gng sc tnh nu chc nng tht tri bnh thng v cha biu hin triu chng. Nn lm nghim php gng sc nh gi kh nng hoc mc dung np gng sc vi yu cu hot ng c th. c. Cc thuc gin mch nh Nitroprusside, Hydralazine, Nifedipine tc dng chm v thuc c ch men chuyn: c tc dng gim th tch h v tng th tch tng mu, gim ti, gip ti cu trc tht tri, gim th tch cui tm thu v tng phn s tng mu. Thuc gin mch c ch nh bnh nhn HoC c: ved ser Tng huyt p ng mch. e sr Suy tim v/hoc ri lon chc tnng tht tri gh m.vn l ri o nhng chng ch nh m.l hoo.c . Aa ev Ci thin tnh trnglolmysng v huyt ng in 20@ F 8. 0 trc m bnhtnhn ri lon chc nng tht 00 i y2 2 t tri cha xutochin triu chng c nng v gh Pot i bnhr nhn c triu chng lm sng nhng py Co chc nng tht tri cn tt hoc bt u gim. Khng nn iu tr lu di thuc gin mch nu c ch nh m v nhm bnh nhn ny nn c m ngay, khng tr hon. HoC nng, cha c triu chng, tht tri gin (ng knh cui tm trng > 60-65 mm) vi mc ch ci thin tin lng v tr hon thi im phi m. Tuy nhin, khi: (a) HoC mc nh-va: nu cha c triu chng khng cn iu tr. (b) HoC nng: nu cha c triu chng, chc nng tm thu tht tri bnh thng, tht tri khng to hoc gin nh (ng knh 280 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

cui tm trng < 60 mm) th cha phi m, nn cng khng cn iu tr thuc. d. Thuc c ch men chuyn cn c ch nh bnh nhn c ri lon chc nng tm thu tht tri ko di sau m thay van. Nifedipine (so vi Digoxin) chng t li ch r rt, gim t l xut hin triu chng, bo tn chc nng tm thu tht tri sau m song hin cha y thng tin v cc tc dng ca cc thuc khc nh Hydralazine v c ch men chuyn. Khng nn dng ko di Digoxin, Nitrate, thuc li tiu hoc cc thuc tng co bp c tim nhm bnh nhn khng c triu chng. Liu dng thuc phi c ed iu chnh lm gim huyt p ngrv se mch. e sr e. Nhng bnh nhn h van MC ht .vn g nng mn tnh i ll r com cn phi theo di thng vxuyn onhm pht hin . A aho . loe chng v s thay i s xut hin ca cc itriu @y F n020 kch thc cng 08. ty2 0 nh chc nng tht tri ch 2 toci Khong thi gian gia cc nh thay ght Po van MC. i yrdi s tu thuc vo bnh cnh v chc ln theo p Co nng ca tht tri. Hnh 14-2.Theo di bnh nhn HoC cha c triu chng. Bnh cnh Ch nh Xut hin triu chng c nng Phu thut Chc nng tht tri gim (EF < 50%) Phu thut Chc nng tht tri bnh thng, Theo di & Siu m v khng c triu chng c nng lm sng tim Ds < 45mm hoc Dd < 60mm (*) 12 thng 12 thng Ds: 45-50mm hoc Dd: 60-70mm(*) 6 thng 6-12 thng Ds: 50-55mm hoc Dd: 70-75mm(*) 3 thng 3-6 thng Ds > 55mm hoc Dd > 75mm Phu thut

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(*)

Khi mi o ln u tin hoc khi cc gi tr cha n nh (chng hn khi gi tr o ln trc thp hn), cn phi o li nh k 3 thng/ln. i vi bnh nhn HoC khng nng, phn s tng mu tht tri bnh thng, bung tim khng gin hoc gin rt t, ch cn lm siu m kim tra nh k 2-3 nm mt ln. Nhng bnh nhn HoC nng nn c kim tra siu m nhiu hn, ti thiu 1 ln/nm. Siu m Doppler tim nn c kim tra li 2-3 thng sau ln khm u tin m bo tin trin ca bnh khng qu nhanh. Khi ng knh tht tri thay i so vi ln o trc, nn lp k hoch khm lm sng v siu m tim 3 thng mt ln. Nu hnh nh ved siu m tim khng r, nn theo di bngr chp x se re ts hnh bung tht. Chp x hnh bung htht.vcng c g m n ri ch nh nu phn s tng mu All oo.co trn siu m . tht tri h ev mc ranh gii. Nu hnhnlo 0@ya m tt, khng cn i nh siu F 02 8 tin hnh chp x hnh. thm. Siu m cng c ch 00 ity2 2 nh theo di ht nh gi kch thc gc MC otoc P g i nhng bnh r py nhn c gin gc MC. Mt khi cc du Co hiu ca tnh trng ri lon chc nng tm thu tht tri xut hin, cn xem xt kh nng phu thut ngay c khi bnh nhn cha c triu chng. Bnh nhn sau m thay van hoc sa van th chm sc v theo di nh quy trnh bnh thng. 2. HoC cp tnh: a. Trng hp HoC cp do phnh tch ng mch ch, nu tnh trng huyt ng cn n nh, cn iu tr tch cc bng thuc chn giao cm kim sot c huyt p trc khi khi dng thuc gin mch. b. Cn nhc ch nh m ngay nu chn on HoC cp do phnh tch ng mch ch hoc do chn

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thng. Mc ch ca iu tr ni khoa ch l tng ti a th tch tng mu v hn ch ti a tin trin lan ca phnh tch MC. Dng ng tnh mch cc thuc gin mch v chn giao cm nu bnh cnh c tnh cht cp tnh. Nu n nh, c th dng thuc ung nh Nifedipine, c ch men chuyn, Hydralazine lm gim tin gnh, ci thin th tch tng mu v cung lng tim. c. HoC cp lin quan n vim ni tm mc nhim khun, cn iu tr thuc khng sinh ngay (sau khi cy mu). Nu tnh trng huyt ng km, vn c th phu thut thay van MC nhned d to erv ng mi ch dng khng sinh. (Khi vanres MC hts .vn loi/t thn thng c a chung). ig ll r o.com 3. iu tr can thip: chng ch A ho t bng trong nh ev. y loHoC a va-nhiu. Bnh ng mch ch (IABP) Fin 0@ t khi 2 8. van 0hp 20 MC khng nn nong nhn phi hp h 20 ity v t toc van bng bnghqua oda do khuynh hng tng nhiu P rig mc Copy cp sau nong. HoC 4. Phu thut: a. Thi im phu thut ph thuc vo nhiu yu t bao gm triu chng c nng, kch thc v chc nng tht tri. C th l: Vi HoC cp, phu thut vn c li cho d chc nng tht tri ra sao. HoC khng c triu chng: (a) Bnh nhn khng c triu chng nhng ri lon chc nng tht tri khi ngh s d c nguy c cao xut hin cc triu chng suy tim trong vng 2-3 nm, do nn c m c chun b. 283 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

(b) Bnh nhn khng c triu chng, chc nng tht tri bnh thng, kh nng dung np gng sc bnh thng (t mc 8 MET theo quy trnh chun) th ch nn theo di st v c th dng cc thuc gin mch. (c) Bnh nhn khng c triu chng v bt thng dung np gng sc hoc tng ng knh cui tm thu tht tri (> 55mm) s nhanh chng c ri lon chc nng tht tri, do nn c xt m c chun b. Thay van MC phi c tin hnhd ngay e erv trc thi im m nu tip tc tr hon c th res dn ti kt cc khng tt sau ts .vn(ch yu gh m l ri .com nng tht lin quan vi mc ri l oo chc . A lon h oev thut nhng bnh tri). Thi im iphu @ya nl 0 F 0 nhn khng c .hoc 2c rt t triu chng v 8 00 ity2 2 tri chc nng thtoc trong gii hn bnh thng t gh Pot vnyri nhiu bn ci. Chc nng tm thu tht p cn Co thng s c ci thin ng k sau m tri nu ch mi ri lon trong vng 18 thng. Chc nng tm thu v kch thc cui tm thu tht tri l nhng yu t d bo quan trng nht i vi thi gian sng, tin lng v chc nng tht tri sau phu thut nn thng c cc thy thuc dng theo di v quyt nh thi im m trn lm sng. b. Cc kh nng phu thut cng tng t nh hp van ng mch ch. Nhiu bnh nhn c sa l van MC hoc vim ni tm mc nhim khun gy h ch th c th xem xt kh nng m sa van MC nu thng tn ph hp. 284 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Ti liu tham kho


1. Borer JS, Hochreiter C, Herrold EM, et al. Prediction of indications for valve replacement among asymptomatic or minimally symptomatic patients with chronic aortic regurgitation and normal left ventricular performance. Circulation 1998;97:525-534. 2. Brener SJ, Dufly CI, Thomas JD, Stewert WJ. Progression of aortic stenosis in 394 patients: relation to changes in myocardial and mitral valve dysfunction. J Am Coll Cardiol 1995;25:305-310. 3. Carabello BA, Crawford FA. Valvular heart disease. N Engl J Med 1997;337:32-41. 4. Carabello BA, Stewart WJ, Crawford FA. Aortic valve disease. In: Topol EJ, ed. Comprehensive cardiovascular medicine. Philadelphia: Lippincott-Raven, 1998: 563-585. ved ser 5. Carabello BA. Timing of valve replacement in aortic stenosis: re ts moving closer to perfection [Editorial]. Circulation 1997;95:2241gh m.vn i ll r co 2243. . A ahoo. ev 6. Deedy M. Aortic valve disease. In:inlo 0@SP, Griffin BP, Topol EJ, Marso y F 8. 02 eds. Manual of Cardiovascular Medicine. Philadelphia: Lippincott00 ity2 2 t oc Raven, 2000. gh Pot ri 7. Gaasch WH, Sundaram M, Meyer TE. Managing asymptomatic py Co patients with chronic aortic regurgitation. Chest 1997;111:17021709. 8. Kelly TA, Rothbart RM, Cooper CM, Kaiser DL, Smucker ML, Gibson RS. Comparison of outcome of asymptomatic to symptomatic patients older than 20 years of age with valvular aortic stenosis. Am J Cardiol 1988;61:123-130. 9. Otto CM, Burwash IG, Legget ME, et al. Prospective study of asymptomatic valvular aortic stenosis: clinical, echocardiographic, and exercise predictors of outcome. Circulation 1997;95:2262-2270. 10. Otto M. Aortic stenosis: echocardiographic evaluation of disease severity, disease progression, and the role of echocardiography in clinical decision making. In: Otto CM, ed. The practice of clinical echocardiography. Philadelphia: WB Saunders, 1997:405-32.

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11. Pellikka PA, Nishimura RA, Bailey KR, Tajik AJ. The natural history of adults with asymptomatic, hemodynamically significant aortic stenosis. J Am Coll Cardiol 1990;15:1012-1017. 12. Weyman AE, Griffin BP. Left ventricular outflow tract: the aortic valve, aorta, and subvalvular outflow tract. In: Weyman AE, ed. Principles and practice of echocardiography, 2nd ed. Philadelphia: Lea & Febiger, 1994:498-574.

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r ese sr n t gh .v l ri .com l . A oo oev yah inl @ . F 2020 8 00 y 2 tocit ht Po rig

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Hp van ng mch ch

Hp van ng mch ch (HC) l nguyn nhn thng gp nht gy tc nghn ng tng mu ca tht tri. Cc nguyn nhn khc bao gm hp di van ng mch ch do mng x, hp di van ng mch ch do c tim ph i v hp trn van ng mch ch. I. Triu chng lm sng Nn ngh n chn on HC trc bt k bnh nhn no c ting thi tm thu tng mu b phi pha trn xng c, lan ln ng mch cnh. Phn ln bnh nhn khi i khm cha c triu d chng c nng tuy nhin buc phi hi k pht hinvetin s ser ca suy au ngc, chong vng, ngt hoc cc du hiu ts re khc gh c .vn l van, tim. Tin s hp eo MC gi bnh van MC om hai i ll r c ngc li nu bnh nhn c chn onAvan oMC c hai l . aho . ev van, phi o huyt p ng mch tFchio loi tr hp eo MC. inl 20@y . Tin s thp tim gi nguyn nhntHC l di chng thp tim. 08 20 20 oci y A. Triu chng cht Pot thng ch gp khi hp van nng: rig MC mc py Co nng. 1. au ngc do tng tiu th xy c tim trong khi cung cp xy cho c tim b gim hoc do x va mch vnh. 25% s bnh nhn khng au ngc c bnh mch vnh, trong khi 40-80% s bnh nhn HC au ngc c km bnh mch vnh. 2. Chong vng, ngt: do tc nghn c nh ng tng mu tht tri v gim kh nng tng cung lng tim, bnh nhn HC c th tt huyt p nng trong cc tnh hung gim sc cn ngoi vi dn n chong vng hoc ngt. 3. Biu hin ca suy tim: do ri lon chc nng tm thu hoc chc nng tm trng. Theo tin trin ca bnh, x ho c tim s dn ti gim co bp. Cc c 287 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

ch b tr nhm lm tng th tch trong lng mch s lm tng p lc tht tri cui tm trng, tng p lc mao mch phi bt gy huyt phi. Cc tnh trng gy ri lon y tht tri nh rung nh hoc tim nhanh n thun c th gy biu hin suy tim. B. Triu chng thc th 1. Bt mch: triu chng ni bt ca HC l mch cnh ny yu v tr (pulsus parvus et tardus), l du hiu tt nht cho php c lng mc HC ti ging. Mt s bnh nhn ln tui bt mch li vn thy gn ging bnh thng do gim chun gin ca thnh mch, nn gy c lng thp mc HC. Bt mch ngoi vi u gim khi c HC nng. i khi s thy rung miu tm thu dc theo ng mch cnhved bnh er res nhn HC kht. C th s thy rung miu tm thu ts gh m.vn khoang lin sn II bn phi bnhrinhn HC. ll .co v. Ataoo 2. S thy mm tim p rng,oelanyah nu tht tri ph nl i nhng cha ln hn.Fi 020@ mt s trng hp, . i vi 08 2 s thy mm tim pop, tng ng vi sng a hay 20 city t ot ting T4 do ththtriPgin n km. ig yr p Co 3. Nghe tim: cc ting bnh l chnh bao gm: a. Thi tm thu tng mu pha trn bn phi xng c, lan ln c, t cng cao nht vo u-gia tm thu. Mc HC cng nng, ting thi cng di hn, mnh hn v t cc i chm hn (cui k tm thu). Tuy nhin cng ting thi khng lin quan cht vi mc hp do cng ting thi c th gim nh i nu cung lng tim gim nhiu hoc chc nng tht tri gim nng. Trng hp van MC c hai l van, cn di ng, c th nghe c ting m van MC trc ting thi tm thu. b. Ting T1 ni chung khng thay i khi HC, tuy nhin nu chc nng tm thu tht tri ri lon 288 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

nng v tng p lc cui tm trng tht tri, m sc T1 gim do hin tng ng sm v gim lc tc ng ng van hai l. Thnh phn ch ca ting T2 gim i khi HC kht, T2 tr nn nh v gn (n c) do ch nghe thy thnh phn phi ca ting T2. Mt s bnh nhn HC nng c ting T2 tch i nghch thng do ko di thi gian tng mu tht tri qua l van hp kht. T2 tch i nghch thng cng gp trong cc tc nghn ng tng mu tht tri khc v trong bloc nhnh tri. Ting T3 l du hiu chc nng tm thu tht tri km. Ting T4 xut hin do nh tri co bp tng mu vo bung tht tri c gin km khi hp van MC kht. ved c. Ngoi ra, c th gp cc ting thi rca h van ser e MC do hp thng i km hights .Hin tng van. vn r com Gallevardin xy ra trong mtllso.trng hp hp . A aho van MC nng, vi ho:ev @y phn m sc cao thnh nlo 0 Fixung mm tim, d ln vi . ca ting thi li0lan 202 8 20 van hai ting thi ca h tocity l km theo. t gh Po d. Nhp timrinhanh lc ngh bnh nhn HC nng l y op mt C trong nhng du hiu u tin ca tnh trng cung lng tim gim thp. II. Nguyn nhn v c ch bnh sinh A. Cc nguyn nhn gy hp van ng mch ch 1. Hp van MC bm sinh: dng hp van MC hay gp nht ngi ln l bnh van MC c hai l van, chim 1-2% dn s, ch yu nam gii. Van MC thng thoi ho v vi sm. Mt s dng HC khc nh dnh l van, van mt cnh... 2. Hp van MC mc phi: a. Hp do thoi ho v vi ho l dng bnh thng gp nht, ni tri tui 70-80. Qu trnh ri lon chuyn ho canxi trong bnh Paget, bnh thn 289 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

giai on cui lm tng qu trnh vi ho. Cc yu t nguy c ca bnh mch vnh thc y nhanh qu trnh vi ho cc l van b thoi ho. b. Hp van MC do thp tim t khi n thun m khng km bnh van hai l. Thp tim gy x ho, vi ho, dnh cc l van v mp van MC, dy l van nht l ti b.

ved ser re ts gh m.vn i ll r co . A ahoo. oev inl 20@y F 8. 0 00 ity2 2 Hnh 15-1. Van MC vi ho. t oc gh Pot i B. Sinh l bnhyr p Co 1. Hp van MC c trng bi qu trnh hp dn l van MC gy tng dn hu gnh cho tht tri. duy tr cung lng tim, tht tri phi bp vi sc bp tm thu cao hn, lm tng p lc ln thnh tim, dn n ph i ng tm, nh bnh thng ho sc p ln thnh tim (theo nh lut Laplace: sc p ln thnh tim = p lc ng knh + 2 dy tim), song li lm gim gin n ca tht tri. 2. Tht tri gin km s lm gim qu trnh y tht tri th ng trong giai on u ca thi k tm trng. Tin gnh tht tri ph thuc rt nhiu vo co bp nh tri. Tht tri cng dy, lc bp cng gia tng, thi gian tm thu ko di, cng lm tng mc tiu th xy c tim. Khi suy tim, p lc cui tm
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trng tht tri tng lm gim p lc ti mu ng mch vnh, gy p cc ng mch nh trong c tim hoc pha di ni tm mc, do cng lm gim hn na cung cp xy cho c tim, gy biu hin au ngc... C. Din bin t nhin ca bnh 1. Tin trin ca hp van MC c trng bi mt giai on ko di khng biu hin triu chng c nng cho ti khi din tch l van MC < 1,0 cm2. Ni chung, chnh p trung bnh qua van MC tng khong 7 mmHg/nm v din tch l van gim khong 0,12-0,19 cm2/nm. Do tc tin trin rt khc nhau, tt c bnh nhn HC cn c tuyn truyn k v cc triu chng bo hiu tin etrin ca ved sr re bnh. T l sng cn gn nh bnh thng khi khng ts gh t.vn 2%/nm c triu chng c nng. Nguy c rt om < l i Al ho .c .MConng m khng ngay c bnh nhn hp van a v loe c triu chng c nng.. Fin 20@y 08 20 2. Nhng khi pht 0trinytriu chng c nng, t l 2 ocit t sng cn gim h Pot nhanh chng nu khng m: rig xung py a. Khi Co bnh nhn c au ngc th t l sng cn ch t 50% sau 5 nm, b. Khi c ngt th t l sng cn ch t 50% sau 3 nm, c. Khi c suy tim th thi gian sng trung bnh < 2 nm. d. t t c th xy ra nhng bnh nhn HC c triu chng c nng do cc ri lon nhp tht trn bnh nhn ph i v ri lon chc nng tht tri hoc ri lon nhp th pht do thiu mu c tim. III. Cc xt nghim chn on A. in tm : thng c dy nh tri (80%) v ph i tht tri (85%). Ri lon nhp t khi xy ra, ch yu giai on cui v a s l rung nh, nht l khi c km bnh 291 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

van hai l. Bloc nh tht c th gp khi c pxe vng van bin chng ca vim ni tm mc. B. Xquang ngc: t c gi tr chn on do hnh nh c th hon ton bnh thng. Bng tim ging hnh chic ng nu ph i tht tri ng tm. Hnh tim thng to nu c ri lon chc nng tht tri hoc c HoC phi hp. Mt vi hnh nh khc c th bt gp l hnh nh vi ho van MC ngi ln tui (phim nghing) hoc gin on MC ln sau hp. C. Siu m Doppler tim: siu m Doppler tim l phng php c la chn chn on xc nh v nh gi mc nng ca hp ch. Cc mt ct cnh c (2D hoc TM) l nhng v tr tt nht nh gi c ch, nguyn ved nhn HC v o c kch thc bung tim, thnh etim. sr re ts 1. nh gi v tnh trng van, nguynhnhn gy hp g m.vn i van v nh hng n cc bung r o.co ll tim: . A aho ov a. Cc l van dy, m dnge vm trong thi k tm inl 20@y thu gp trong HC 8. F 20 bm sinh v do thp tim, phn 00 2dy ity l van (mt ct trc di bit bng kiu toc ca ht Po cnh cytri): HC do thp thng dy khu tr b rig p C t doo nhiu hn so vi thn l van, rt hay c HHL km theo. Ngc li, HC do thoi ho th qu trnh vi ho thng tin trin t thn cho ti b mp van, lm gim dn di ng l van n gn nh c nh. C th s b nh gi mc HC da vo bin m van trn siu m TM (bnh thng l 16-22 mm): HC nh: bin m van MC t 13-15 mm. HC va: bin m van MC t 8-12 mm. HC nng: bin m van MC < 8 mm. Tuy nhin gi tr ny c tnh cht gi , ch khng hon ton chnh xc, v ch nh gi c khong cch gia 2 trong s 3 l van MC. K thut o v v tr mt ct c th lm sai lc kt qu o. Cung lng tim gim nhiu cng lm 292 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

gim bin m ca van MC d khng c HC thc s. b. S lng mp van, ng ng van v hnh dng l van (mt ct trc ngn cnh c tri) cho php chn on cc loi HC bm sinh: van MC c hai l van, van MC dng mt l-mt mp hoc dng mt l-khng c mp van... Tuy nhin, khi van MC vi ho nng th vic xc nh nguyn nhn HC tr nn rt kh khn. c. Ph i v gin tht tri, gin nh tri trn mt ct trc di cnh c tri nhng nu hp van MC n thun, tht tri thng nh tuy c ph i. Mt ct bn bung hoc nm bung t mm cho php nh gi chung chc nng co bp v vnd ng rve thnh tht. Cc mt ct ny cng chosephp xc re s nh mc h van MC km right m.vn siu m theo bng ll .co Doppler mu. v. A ahoo e 2. nh gi v huyt ng:inlo 0@y F 02 8. a. Chnh p qua 0 van 2 MC: thng o bng 20 ocity h P Doppler lint tcots dng mt ct nm bung t rig py mm ov mt s mt ct khc nh: khoang lin C sn II b phi xng c, trn hm c... da trn cng thc Bernoulli sa i (P = 4 V2) xc nh chnh p trung bnh v chnh p ti a (tc thi nh-nh) gia MC v tht tri. Mc HC c phn loi da vo chnh p qua van MC: HC nh: chnh p ti a < 40 mmHg hoc chnh p trung bnh < 20 mmHg. HC va: chnh p ti a: 40-70 mmHg hoc chnh p trung bnh: 20-40 mmHg. HC nng: chnh p ti a > 70 mmHg hoc chnh p trung bnh > 40 mmHg. Mt s yu t lm tng gi to chnh p qua van MC nh: c km h van MC, mng ngn di 293 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

van MC, tnh trng tng cung lng tim, o sau nht ngoi tm thu, ly nht bp khng i din (khi rung nh) hoc ln vi ph ca h van hai l.

Hnh 15-2. Ph Doppler lin tc ca hp van MC. ved ser l ca b. Din tch l van MC: o theo nguyn re ts gh m.vn phng trnh lin tc: l ri .co 2 Al . VTITT / VTIMC Din tch van MC = erv ahoo lo y Trong : VTITTnl 0@ phn vn tc theo Fi 02 tch . 08 2 thi gian ca dngcichy tm thu ti v tr bung 20 o ty tng muight tht tri (Doppler xung vi ca s ca Pot yr p Doppler cch van MC 1 cm ti mt ct 5 bung Co tim); VTIMC l tch phn vn tc theo thi gian ca dng chy qua v tr van MC b hp; r l bn knh ca bung tng mu tht tri (mt ct trc di, ngay st vng van MC). Mc hp van MC c phn loi da vo din tch l van nh sau: HC nh: din tch l van > 1,5 cm2. HC va: din tch l van t 1-1,5 cm2. HC nng: din tch l van < 1 cm2, khi din tch < 0,75 cm2 (< 0,5 cm2/m2 din tch da) th c coi l hp van MC rt kht. c. Ch s VTITT/VTIMC: khi < 0,3 tng ng vi hp van MC nng, khi < 0,25 tng ng vi HC kht. Ch s ny khng ph thuc vo lu lng 294 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

tim v trnh c cc sai st khi o ng knh bung tng mu tht tri, c ch trong trng hp hp van MC kht v ri lon chc nng tht tri nng. Tuy nhin, cn lu ch s ny c t l sai st cao khi ng knh bung tng mu tht tri rng > 2,2 cm hoc hp < 1,8cm. 3. Siu m tim qua thc qun: c th o trc tip din tch l van (2D), nhng kh ly c ph Doppler ca dng chy qua van b hp hn. Cng c ny rt c ch nh gi hnh thi van MC trong bnh hp van MC bm sinh. 4. Siu m gng sc: nhm phn bit nhng trng hp hp van MC thc s c ri lon chc nng tm thu tht tri nng (nn chnh p qua van thp) vied nhng erv trng hp gi hp (bnh l nh hngts res c tim t n n trc, c km hp van MC nh,l righocng ri lon nn m.v Al ho .c chc nng tm thu tht tri vv.chnhop thp qua van a oe khng h c ci thin l MC) bi trng hp ginhp @y Fi 020 . sau khi c m. Dobutamine truyn vi liu tng 08 2 20 ocity dn t 5 n ght g/kg/pht tng dn cung lng 20 Pot ri siu m tim kim tra tng bc din tim, sau y p dng Co v chnh p qua van MC. Cn ngng tch l van ngay nghim php khi bnh nhn tt p, au ngc hoc xut hin ri lon nhp tim. D. Thng tim: trc y thng tim l tiu chun vng chn on v lng gi hp van ng mch ch. Tuy nhin ngy nay, siu m tim dn dn c chp nhn rng ri nh mt phng tin chn on v nh gi HC thay th cho thng tim. 1. Thng tim c ch nh khi c nghi ng v mc hp van trn siu m tim hoc chp ng mch vnh cho bnh nhn nam tui > 40 v n tui > 50 trc khi m thay van. 2. Cn cn nhc gia cc li ch ca thng tim v nguy c bin chng nht l bnh nhn HC kht. Nguy c 295 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

t vong sau thng tim bnh nhn hp kht van MC l 0,2%. Bnh nhn HC nng nn dng thuc cn quang loi trng lng phn t thp, khng ionic hn ch bt cc nguy c tt huyt p do gin mch ngoi vi, ri lon nhp chm, ri lon chc nng c tim thong qua, hn ch tc dng li tiu thm thu, nh gim bt nguy c ca th thut. i vi bnh nhn hp kht van MC, nn trnh chp bung tht tri. 3. Gi tr chnh p trung bnh qua van MC o bng thng tim rt ging vi siu m trong khi gi tr chnh p ti a nh nh o qua thng tim thng thp hn so vi siu m. C th lm th nghim kch thch bng truyn Nitroprusside tnh mch d nh rve gi s thay i v chnh p qua van v rdin tch l ese s n van mi khi c thay i cung lngght m.nhm phn ri tim v ll .co bit cc trng hp hp van MC thc s vi nhng v. A ahoo loe y trng hp gi hp. Fin020@ . 2 4. Khi HC khng kht 008phn s tng mu, cung lng 2 thcity cc tim khi ngh, p tlc oto bung tim bn phi v p lc h rig btPu bnh thng. p lc cui tm mao mchpy phi Co trng tht tri thng tng do tht tri ph i gim gin. Sng a trn ng cong p lc nh tri, p lc mao mch phi bt thng ni r. Khi mc HC tng ln, p lc cui tm trng tht tri, p lc cc bung tim phi v ng mch phi cng tng ln. Phn s tng mu v cung lng tim s gim khi bnh tin trin n giai on cui. Trng hp HC kht, chc nng tht tri gim nng th chnh p qua van MC s gim. Khng bao gi nh gi mc hp van MC ch da trn gi tr chnh p qua van n thun m phi ch n chc nng tht tri v mc h van hai l km theo.

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IV. iu tr A. La chn bin php iu tr: ct li ca iu tr hp van MC nng l phu thut thay van MC. Ni chung phu thut u tin cho nhng bnh nhn c triu chng c nng, do thay van MC c nguy c bin chng kh cao v t l sng cn ch thc s ci thin r rt khi bnh nhn bc l triu chng c nng. Ngy cng c nhiu bng chng cho thy khi hp van MC ti mc nng, th xu hng s xut hin triu chng v phi m thay van ch trong vng 3 nm. i vi bnh nhn ln tui hp kht van MC, vic m khi cha c triu chng xem ra c li hn so vi vic i n khi xut hin triu chng c nng. M sm cng c li i vi nhng bnh nhn tr m chnh p qua van MC rt caoed hn v erv ch c nguy c cao xut hin t t. Tng t, bnh res s 2t nhn c din tch l van MC 1,0 cmh kmntheo hp rig com.v ll . ng k ng mch vnh v cn lm cu oni ch-vnh th v. A aho oe nn tnh c n vic m thayFvan MC. inl 20@y 8. 0 B. iu tr ni khoa 200 city2 ht oto 1. Bt buc phigiuPtr khng sinh d phng vim ni ri y tm mc op Cnhim khun. 2. Vi bnh nhn cha c triu chng c nng (din tch l van MC > 1,0 cm2) th iu tr c mc ch phng tin pht bnh l ng mch vnh, duy tr nhp xoang v khng ch huyt p. Tt c bnh nhn phi c hng dn v cc du hiu v triu chng ca au tht ngc, ngt hoc suy tim i khm li ngay v xt m nu xut hin cc triu chng c nng ny, v khi nguy c phu thut thp hn cc nguy c ca vic tip tc iu tr ni khoa. 3. iu tr suy tim nhm vo vic kim sot cn bng dch gim huyt phi, thng bng thuc li tiu. Tuy nhin, cung lng tim bnh nhn HC nng ph thuc nhiu vo tin gnh, nn cn rt thn 297 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

trng khi dng li tiu trnh dng liu qu cao, gy tt huyt p (do gim cung lng tim) v gim ti mu ngoi vi. Trnh dng cc thuc nhm Nitrates bnh nhn suy tim do HC nng v thuc lm gim tin gnh ng k, c th gy gim ti mu no v ngt. Digoxin thng ch c ch nh cho bnh nhn HC suy tim nht l khi rung nh. iu tr HC c suy tim bng thuc khng h ci thin tin lng sng lu di ca bnh nhn. Hn na, iu tr ni khoa bnh nhn hp van MC nng v ri lon chc nng tht tri qu tch cc khng h c li m cn nguy him. 4. Trnh dng cc thuc gin mch cho bnh nhn hp ch n thun. ved ser r a. Trong mt s bnh cnh hp h van eMC, HC hts bnh ghp .vn mch phi hp h van hai l, HC phi om i ll r c vnh th c th cn nhc vic dng cc thuc gin . A ahoo. ev mch song nn ht Finlothn trng, i khi phi sc 0@y 8. 02 theo di huyt ng tcho bnh nhn ti phng hi 00 i y2 2 sc. Trn l t Potoc bnh nhn h van nhiu s c gh thuyt, i yr li khipdng thuc gin mch; bnh nhn c bnh Covnh cng c li v gim hu gnh s lm mch gim nhu cu xy c tim. D vy, thuc gin mch ch l bin php iu tr tm thi trc khi m lm cu ni ch vnh. b. Liu khi u nn dng rt thp ti phng hi sc (tt nht l nitroprusside d chnh liu), sau khi n nh liu gin mch s chuyn dn sang thuc ung (c ch men chuyn, Hydralazine). 5. Bnh nhn hp van MC nng chu ng rt km tnh trng rung nh (v tin gnh tht tri ph thuc rt nhiu vo co bp nh), nhanh chng-d dng gy gim cung lng tim v huyt phi, ng thi tng nhu cu xy (do nhp nhanh). Bi vy, cn iu tr

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tch cc rung nh ngay t lc mi khi pht bnh nhn HC nng nhm chuyn v nhp xoang. 6. i vi bnh nhn hp van MC nng v chc nng tht tri ri lon nng, c chnh p qua van MC thp: phu thut ch ci thin triu chng khong 50%, 50% cn li khng h ci thin triu chng v cht trong giai on hu phu m khng t trong s l cc trng hp gi hp ch (ri lon chc nng c tim nng t trc km theo gi hp van MC do cung lng tim thp). Tuy cn nhiu im cha thng nht song trc khi i n vic la chn bnh nhn ph hp v quyt nh m, th: a. Nn lm siu m tim gng sc hoc nghim php kch thch khi thng tim nh gived nhng er res trng hp hp van MC thc s sgy ri lon t gh vn chc nng tht tri nng bng cch om.din tch l l ri .co Al o van v chnh p qua vanv.MC okhi cung lng a oe timhtng ng k m tim tng. Nu cung Finl 0@y lng 2 . khng gy thay0ity20 p th l gi hp, 08 chnh 2 oci t ngc li nu cung lng tim tng gy tng chnh t igh Po yr p quapvan th l hp tht. Co b. Nn th nong van bng bng qua da: nu triu chng suy tim v cung lng tim ci thin sau can thip th kh nng hi phc sau m thay van MC s ln hn. C. iu tr can thip 1. t bng trong ng mch ch (IABP): nhm n nh tm thi tnh trng huyt ng bnh nhn hp van ng mch ch nng, suy tim mt b chun b m. Hiu qu ca t bng trong ng mch ch l nh tng ti mu mch vnh trong k tm trng, lm gim tnh trng thiu mu ca ton th c tim khi hp van MC kht, suy tim mt b.

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2. Nong van ng mch ch bng bng qua da: c vai tr r rt i vi hp van MC bm sinh tr em tuy khng c p dng tuyt i bnh hp van MC mc phi. Mc d k thut ny c nhiu ha hn nhng so vi m th vn cha hiu qu bng: sau th thut, din tch l van tng ln 50% song sau 6 thng c ti 50% ti pht. V th nong van MC bng bng ch c ch nh trong mt s trng hp nht nh nh: hp van MC bm sinh tr em, bnh nhn khng th m do tui cao hay c bnh phi hp, iu tr tm thi trc khi m c chun b, iu tr th bnh nhn c ri lon chc nng tht tri nng (xem liu bnh nhn c ci thin sau m hay khng). T l t vong ca th thut ny khong 2-5%. d e erv D. iu tr ngoi khoa res hts n 1. Ch nh m thay van MC: ll rig com.v A o. a. Bnh nhn c triu chngev. yaho o c nng: inl @ au ngc. . F 2020 8 00 y Ngt. 2 tocit t Suy tim. Po igh yr b. Bnh op C nhn khng c triu chng c nng: Tui tr v chnh p qua van MC > 100 mmHg. Cn lm th thut/phu thut ln, c nguy c cao. C ch nh bc cu ni ch vnh. Ri lon chc nng tm thu tht tri. 2. Cc loi phu thut thay van ng mch ch: thay van ng mch ch c a chung hn m sa van v sau khi gt mng v ly vi l van, cc l van hay co rt, gy h van ngay sau phu thut v dn dn mc h s tng ln. Tuy nhin, vi hp van MC bm sinh m van cha vi th vn c th sa van tu theo tng trng hp c th. M thay van MC n thun khng km bnh mch vnh hoc 300 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

cc bnh nng khc th t l t vong quanh phu thut khong 2-3%. T l sng cn sau m thay van MC vo khong 85% sau 10 nm. S la chn loi van thay ph thuc vo rt nhiu yu t nh tui, nguy c dng/khng dng thuc chng ng, c im gii phu, chc nng tht tri, mc hot ng th lc, d tnh m li... Ni chung, bao gm cc loi nh: a. Phu thut Ross (ghp van t thn): van v thn ng mch phi c ct lun c khi ri thay vo v tr ca van ng mch ch ng thi cm li hai ng mch vnh. Ch van ng mch phi b ct s c thay th bng mt van ng mch phi ng loi. Van ghp t thn kiu nyed tt rt v ser v huyt ng, khng cn dng thuc chng e sr ng, t vi ho hn so vi cc van t .vn khc, ghsinh hc ri om c th ln ln theo pht trinllca.cc th, c c . A ahoo v tnh chng nhim trngloe @y in rt cao nn rt ph hp 0 lm tr nh 08. F 202 hoc bnh nhn vim ni tm 0 ity 2 mc nhim khun csong i hi k thut cao v t oto gh di, d gy ra nhiu ri lon sau thi gian i ko P r py Co lng lu di ph thuc vo mc h m. Tin van ng mch ch, bnh l van ng mch phi (h, hp) hay cc ri lon chc nng tht phi (th pht sau bnh van MP). b. Thay van MC ng loi: c dng rng ri cc bnh nhn tr tui do c im huyt ng tt v khng cn dng thuc chng ng. Tuy nhin theo thi gian, cc van loi ny khng h ln ln, s b thoi ho, vi v gy h. Bn thn k thut thay van loi ny cng kh phc tp v thng phi hp vi vic to hnh mt phn gc ng mch ch v cm li ng mch vnh, cho d vn n gin hn so vi phu thut Ross. Tui th trung bnh ca van l 15 nm. Phu thut ny c t l nhim trng rt t khi ang c vim ni 301 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

tm mc v y l thay van ng loi c ch nh khi vim ni tm mc nhim khun trn van nhn to. c. Thay van sinh hc (d loi): thng c ch nh cho bnh nhn tui > 70. Trong vng 10 nm, 8090% van thoi ho gy h hoc hp do thng l van, gim vn ng, r quanh chn van. Khng cn dng chng ng lu di sau thay van v nguy c huyt khi thp. Phn ln u c chnh p qua van ngay sau m (v b vng van, khung cn tr mt phn), mc nhiu hn so vi van c hc v th khi thay, cn chn loi van c kch thc ln nht c th c gim bt chnh p qua van. ved ser l St. d. Thay van c hc: cc loi van thng edng sr Jude Medical, Metronic-Hall rvhtCarbomedics. g m.vn i ll co Bnh nhn sau thay van loiAny ophi ung thuc . aho . oev chng ng gim nguy cy huyt khi van inl 20@ to F v cc bin chng 8. mch khc. bn ca loi tc 0 00 ity2 van ny lht 2 otoc nu duy tr c iu tr cao nht rig v d phng khng sinh cn thn chng py ng P Co trong nhiu nm. 3. Bin chng: nhng bin chng tim tng sau m thay van MC l h hng cu trc van, ri lon hot ng (huyt ng) van, huyt khi kt van, tc mch, chy mu do dng thuc chng ng, vim ni tm mc nhim khun van MC nhn to, huyt tn v bloc nh tht. Phi dng thuc chng ng cn thn (i vi bnh nhn no c ch nh) v phi dng ko di sut thi gian tn ti van nhn to (n c i). Bnh nhn hot ng th lc mc thp s t nh hng hn n huyt ng ca van v do tc thoi ho van cng s chm hn.

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E. Theo di 1. Bnh nhn hp van ng mch ch nng cha c triu chng c nng nn c theo di st v hng dn ti khm ngay khi c bt k triu chng c nng no. 2. Siu m Doppler tim 1-6 tun sau m thay van MC nh gi hot ng ca van v chnh p qua van nhn to lm mc theo di. Sau bnh nhn c kim tra siu m nh k 1-2 ln/nm. 3. Kim tra hiu qu chng ng mu (t l prothrombin, INR) nh k iu chnh liu ph hp bnh nhn c ch nh dng thuc chng ng. Ti liu tham kho
1. Borer JS, Hochreiter C, Herrold EM, et al. Predictionrof eindications es for valve replacement among asymptomatic ts orvn minimally h . ig symptomatic patients with chronic aortic regurgitation and normal ll r o.com . A aho left ventricular performance. Circulationv1998;97:525-534. loe @WJ. Progression of aortic Brener SJ, Dufly CI, Thomas JD, Stewert y Fin 20 stenosis in 394 patients: relation .to changes in myocardial and mitral 08 ty20 0 valve dysfunction. J Am Coll Cardiol 1995;25:305-310. 2 oci ht FA. tValvular heart disease. N Engl J Med Carabello BA, Crawford Po rig 1997;337:32-41.py Co Carabello BA, Stewart WJ, Crawford FA. Aortic valve disease. In: Topol EJ, ed. Comprehensive cardiovascular medicine. Philadelphia: Lippincott-Raven, 1998: 563-585. Carabello BA. Timing of valve replacement in aortic stenosis: moving closer to perfection [Editorial]. Circulation 1997;95:22412243. Deedy M. Aortic valve disease. In: Marso SP, Griffin BP, Topol EJ, eds. Manual of Cardiovascular Medicine. Philadelphia: LippincottRaven, 2000. Gaasch WH, Sundaram M, Meyer TE. Managing asymptomatic patients with chronic aortic regurgitation. Chest 1997;111:17021709. Kelly TA, Rothbart RM, Cooper CM, Kaiser DL, Smucker ML, Gibson RS. Comparison of outcome of asymptomatic to symptomatic patients older than 20 years of age with valvular aortic stenosis. Am J Cardiol 1988;61:123-130.

rve

2. 3. 4. 5. 6. 7. 8.

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9.

Otto CM, Burwash IG, Legget ME, et al. Prospective study of asymptomatic valvular aortic stenosis: clinical, echocardiographic, and exercise predictors of outcome. Circulation 1997;95:2262-2270. 10. Otto M. Aortic stenosis: echocardiographic evaluation of disease severity, disease progression, and the role of echocardiography in clinical decision making. In: Otto CM, ed. The practice of clinical echocardiography. Philadelphia: WB Saunders, 1997:405-32. 11. Pellikka PA, Nishimura RA, Bailey KR, Tajik AJ. The natural history of adults with asymptomatic, hemodynamically significant aortic stenosis. J Am Coll Cardiol 1990;15:1012-1017. 12. Weyman AE, Griffin BP. Left ventricular outflow tract: the aortic valve, aorta, and subvalvular outflow tract. In: Weyman AE, ed. Principles and practice of echocardiography, 2nd ed. Philadelphia: Lea & Febiger, 1994:498-574.

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vim ni tm mc nhim khun

Vim ni tm mc nhim khun (VNTMNK) l tnh trng bnh l do vim nhim vi thng tn ch yu lp ni mc ca tim. Biu hin i th thng gp l nhng tn thng lot v si cc van tim. y l bnh rt nng, nu khng c pht hin v iu tr sm bnh thng dn n t vong. Ngy nay d c nhiu tin b trong cc khng sinh iu tr cng nh phu thut nhng t l t vong ca bnh vn cn kh cao. I. Nguy c mc VNTMNK A. Nguy c cao 1. Van nhn to. ved ser re 2. Tin s b VNTMNK. ts gh m.vn i 3. Tim bm sinh c tm. ll r co . A ahoo. ev 4. Bnh h van ng mch chov/ hoc hp van MC. inl 20@y F 5. H van hai l. 8. 0 00 ity2 2 6. Hp van hai l km h cvan hai l. t o gh Pot ri 7. Cn ng ng mch. py Co 8. Thng lin tht. 9. Hp eo ng mch ch. 10. Cc phu thut tim m vn tn ti tnh trng huyt ng bt n sau m. B. Nguy c va 1. Sa van hai l c gy h van hai l. 2. Hp hai l n thun. 3. Bnh l van ba l. 4. Hp ng mch phi. 5. Bnh c tim ph i lch tm. 6. Bnh van MC c hai l van hoc vi ho van ng mch ch m cha nh hng nhiu n huyt ng. 7. Bnh thoi ho van ngi gi. 305 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

8. Cc phu thut tim m tnh trng huyt ng sau m t bin ng (trong thi gian 6 thng sau m). C. Nguy c thp 1. Sa van hai l khng gy h hai l. 2. H ba l trn siu m tim m khng km theo bt thng van. 3. Thng lin nh l th hai n thun. 4. Mng x m ng mch. 5. Bnh ng mch vnh. 6. Cy my to nhp. 7. Cc phu thut tim m tnh trng huyt ng sau m khng bin ng, thi gian > 6 thng sau m. II. Nguyn nhn ved ser re ts A. Vim ni tm mc bnh nhn vanht nhin: hay g m.vn gp nht l lin cu khun (viridansAll ri o.co Streptococcus v cc v. 60%, Staphylococcus phn nhm khc) chim khong yaho loe F n HACEK (Haemophilus, 25%, Enterococcus, nhmi 020@ . 08 2 Actinobacillus, Cardiobacterium, Eikenella, v Kingella) 20 ocity ht Pot khong 3%. rig opy B. Vim ni C tm mc bnh nhn dng ma tu ng tnh mch: thng hay b tn thng van tim bn phi v hay gp nht l t cu vng (S. aureus), ngoi ra i khi c th gp nm. C. Vim ni tm mc bnh nhn van nhn to: c th xy ra sm hoc mun. Thng hay xy ra trong 6 thng u sau thay van. Thng hay gp t cu vng (S. aureus), vi khun gram m, c th do nm lm tin lng bnh thm phn nng. D. Vim ni tm mc c cy mu m tnh (10-30%): thng gp bnh nhn dng khng sinh trc , cng cn ch nhm c vi khun gy bnh mc mun: do nm, nhm HACEK, Legionella, Chlamydia psittaci, Coxiella, Brucella, Bartonella... 306 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

E. Vim ni tm mc do nm: thng gp Candida v Aspergillus, hay gp bnh nhn van tim nhn to, c thit b c hc ci ghp trong tim, suy gim min dch, dng thuc ma tu ng tnh mch. Bnh cnh phc tp v tin lng rt nng. III. Triu chng lm sng v xt nghim chn on L biu hin bi 3 hi chng: (Bng 16-1) 1. Nhim trng h thng. 2. Tn thng ni mc mch. 3. Phn ng h min dch vi nhim trng. Ni tm li: trc mt bnh nhn vi tam chng kinh in nh: st, thiu mu, ting thi tim cn ngh ti kh nng VNTMNK. ved Vn cy mu: l mt xt nghim cc k quan rtrng se re chn on bnh cng nh nh hng iu tr. hts .vn g Phi thc hin i sm ngay khi c chn on lm sng. Ly ll r nht 3 mu mu t com . A ahoo. ring bit trong 24 gi, nhng v tr tnh mch khc nhau, mi oev inl 20@y F ln nn ly 2 ng nghim i kh .v k kh ring. V VNTMNK 8 20 00 itc trong mu nn khng cn l hin tng c mt vi khun2lin ty toc ht ly phi ch lc st nh caogmi Po mu cho d cy mu khi bnh ri y nhn ang st th top dng tnh s cao hn. Cn lu l khi C l cy mu gi l m tnh trong nhng ngy u th phi tip tc cy tip v mt s vi khun nh ni trn mc rt mun. IV. Tiu chun chn on VNTMNK Ngy nay, hu ht cc tc gi dng tiu chun Duke ci tin v c nhy v c hiu cao nht (Bng 16-2a v16-2b). Tiu chun bao gm: VNTMNK chc chn (v gii phu bnh v v lm sng), VNTMNK c th v loi tr VNTMNK. i vi VNTMNK chc chn trn gii phu bnh th ch cn 1 trong 2 tiu chun l . i vi VNTMNK chc chn trn lm sng th cn c 2 tiu chun chnh, hoc 1 tiu chun chnh v 3 tiu chun ph, hoc c 5 tiu chun ph. 307 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

VNTMNK c th khi khng tiu chun ni trn nhng cng khng tiu chun loi tr. Loi tr VNTMNK khi cc du hiu lm sng c gii quyt sau 4 ngy dng khng sinh, hoc khng c bng chng gii phu bnh sau 4 ngy dng khng sinh.

ved ser re ts gh m.vn A B l ri co Al h phi .mchoo. (A); Si Hnh 16-1. Si ni mc thn ng a oev inl 20@y van ng mch phi (B). F 8. 0 00 ity2 2 t oc gh Pot ri py Co

C D Hnh 16-2. Si van ng mch ch (C) gy h van ng mch ch nng (D). LA: nh tri, MV: van hai l, V: si, AV: van ng mch ch, Ao: ng mch ch, RV: tht phi, LV: tht tri, AR: h van ng mch ch.

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Bng 16-1. Cc biu hin lm sng v cn lm sng ca VNTMNK. Biu hin Triu chng c nng Thm khm Nhim trng St ko di, rt run, v m St. h thng. hi, kh chu, yu c, ng Xanh ti. lm, m sng, au u, mt St cn. ng, st cn, au lng, au Suy nhc. khp, au c... C th khai Lch to. thc thy ng vo: mi Thiu mu. hng, rng ming, ngoi da, tit niu, tim chch... Tn thng Kh th, au ngc, lit khu Ting thi mi tim. ni mc tim tr, tai bin mch no, au Suy tim. m xut huyt di da, mt, bng, au v lnh u chi. mch. c. Nt Roth. Nt Osler. Tn thng Janeway. m xut huyt. Tai bin mch no. Phnh vi mch no. Thiu mu hoc tc mch chi.

Cc thm d Tnh trng thiu mu. Tng bch cu mu. Tng tc lng mu. Cy mu dng tnh. Bt thng dch no tu.

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Bng 16-1. Cc biu hin lm sng v cn lm sng ca VNTMNK (tip theo). Protein niu, Phn ng au khp, au c, vim Vim khp. Hng cu niu, tr niu, min dch. bao gn. Cc du hiu tng ur mu. Tng ur mu, Mng tay khum Nhim toan mu. Tng gramma globulin. Thy c yu t dng thp, gim b th v phc hp min dch trong mu. Tm khng th khng t cu trong mu.

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Bng 16-2a. Tiu chun Duke chn on chc chn VNTMNK trn gii phu bnh. Tm thy vi khun (nm) bng nui cy hoc soi t bo : Cc si trong tim. Cc si bn i gy tc mch. p xe trong tim. Hnh nh tn thng gii phu bnh: Thy cc si hoc pxe trong tim c hnh nh t bo hc ca vim ni tm mc ang tin trin.

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Bng 16-2b. Tiu chun Duke trn lm sng. Tiu chun chnh: Cy mu dng tnh c trng cho VNTMNK: Loi vi khun in hnh ( t nht 2 mu mu): viridant Streptococcus; S. bovis; nhm HACEK; S. aureus hoc Enterococcus. Cy mu dng tnh bn vng: Tn ti loi vi khun hai mu mu khc nhau t nht 12 gi, hoc Tn ti loi vi khun c 3 mu mu, hoc phn ln trong 4 hoc hn cc mu mu cch bit m thi im ca mu u v mu cui cch nhau t nht 1 gi. Bng chng tn thng ni tm mc: Bng chng siu m tim: Khi si di ng lc lc trong tim, dnh vi van tim hoc cc cu trc trong tim, hoc cc cu trc nhn to (van) m khng gii thch c v hnh dng gii phu thng thng ca tim, hoc Hnh nh pxe, hoc Hnh nh t tch mi mt phn van nhn to, hoc Hnh nh h van tim mi xy ra. Tiu chun ph: 1. Tin s: C bnh van tim t trc. Tim chch ma tu Copyright 2008. Finloev. All rights reserved Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn Potocity2020@yahoo.com.vn

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Bng 16-2b. Tiu chun Duke trn lm sng (tip theo). 2. St trn 38oC. 3. Tn thng mch mu: Tc mch ln. Nhi mu phi nhim khun. Phnh mch hnh nm. Xut huyt ni s. Xut huyt m lin kt. Tn thng Janeway. 4. Hin tng min dch: Vim cu thn. Nt Osler. Chm Roth. Yu t dng thp. 5. Bng chng vi khun: Cy mu dng tnh nhng khng tiu chun chnh. Xt nghim huyt thanh vi cc tc nhn gy VNTMNK c bng chng ang hot ng. 6. Siu m tim nghi ng hnh nh ca VNTMNK nhng khng bng chng quy nh trong tiu chun chnh Copyright 2008. Finloev. All rights reserved Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn Potocity2020@yahoo.com.vn

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V. iu tr A. Nguyn tc iu tr 1. Khng sinh cn c cho sm ngay sau khi cy mu kt thc. Trong lc ch kt qu cy mu th cho khng sinh theo quy c: thng dng quy c l Ampicilin 2g tim tnh mch (TM) mi 4 gi kt hp vi Gentamycin 1,0 mg/kg cn nng TM mi 8 gi. C th thay th bng Nafcillin 1,5 g tim TM mi 4 gi hoc Vancomycin 1 g tim TM mi 12 gi. 2. Khi c khng sinh cn iu chnh khng sinh theo ch chun (trnh by k phn sau). 3. Ch kim tra v theo di cc chc nng thn, gan... chn khng sinh v liu thch hp. ved ser re 4. Khng nn dng chng ng ngnhngantc mch ts g m.v i trong VNTMNK. ll r co . A ahoo. 5. iu tr VNTMNK do nmloev y phi kt hp iu thng Fin020@ . tr ni ngoi khoa. 08 2 20 ocity 6. Ch nh iu ht ngoi khoa can thip thng kh tr ot P rig rt cn thit trong nhng hon cnh khn nhng cng py Co nht nh. 7. Vic phng nga VNTMNK nhng bnh nhn c nguy c l vic ht sc cn c ch n. B. iu tr c th 1. iu tr ni khoa: a. Ch dng khng sinh cho cc loi cu khun (Bng 16-3). b. Ch dng khng sinh cho Trc khun m xanh (Pseudomonas aeruginosa) v cc vi khun gram m khc. Nn dng loi Penicillin c ph rng (Penicillin mi): Ticarcillin hoc Piperacillin), hoc Cephalosporin th h 3, hoc Imipenem Phi hp vi Aminoglycoside. 313 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Bng 16-3. La chn khng sinh cho cc loi cu khun. Loi vi Ch Thi khun gian Lin cu 1. Penicillin G 4 triu v tim TM mi 6 2 tun gi, kt hp vi Gentamycin 1 mg/kg viridant, mi 12 gi TM, hoc bovis 2. Penicillin G 4 triu v tim TM mi 6 4 tun gi kt hp Gentamycin 1 mg/kg TM mi 12 gi (ch cho 2 tun u), hoc 3. Penicillin G 4 triu v tim TM mi 6 4 tun gi, hoc 4. Ceftriaxone 2 g tim TM hoc TB 1 4 tun ln trong ngy, hoc 5. Vancomycine 10 mg/kg tim TM mi 4 tun 12 gi. Enterococ 1. Ampicillin 2g tim TM mi 4 gi kt 4-6 hp vi Gentamycin 1 mg/kg TM mi tun -cus v 8 gi, hoc cc cu 2. Vancomycine 15 mg/kg, tim TM mi 4-6 khun 12 gi kt hp vi Gentamycin 1 tun khng mg/kg tim TM mi 8 gi Penicillin

Lu Ch chun, cho bnh nhn < 65 tui, khng c suy thn, khng c bin chng. Cho bnh nhn c bin chng hoc lin cu khng Penicillin mc va. Cho bnh nhn > 65 tui, c suy thn. Cho bnh nhn b d ng vi Penicillin. Cho bnh nhn b d ng vi nhm Lactamine. 4 tun thng cho cc trng hp c triu chng < 3 thng. Cho cc trng hp d ng vi Penicillin.

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Bng 16-3. La chn khng sinh cho cc loi cu khun (tip theo). Ch chun. T cu 1. Nafcillin 1,5 g, tim TM mi 4 gi, 4-6 tun hoc vng (S. Cho bnh nhn nhim t cu nng. 2. Nh trn kt hp vi Gentamycin 1 4-6 aureus) mg/kg tim TM mi 8 gi trong 3-5 tun ngy, hoc D ng vi Penicillin. 3. Cefazolin 2 g tim TM mi 8 gi, hoc 4-6 tun D ng vi Penicillin v 4. Vancomycin 15 mg/kg tim TM mi 4-6 Cephalosporins; cho loi t cu khng tun 12 gi vi Methicillin. Lin cu 1. Penicillin G, 2 triu v tim TM mi 6 2-4 tun gi, hoc nhm A, 2-4 Lin cu 2. Cefazolin, 1 g tim TM mi 8 gi. tun pneumon -iae Nhm 1. Ampicillin 2 g, tim TM mi 4 gi kt 4 tun Gentamycin c th ngng nu vi khun nhy cm vi Ampicillin. HACEK hp vi Gentamycin 1 mg/kg TM mi 12 gi, hoc Cho bnh nhn b d ng vi 2. Ceftriaxone 1-2 g tim TM hoc tim 4 tun Penicillin. bp 1 ln trong ngy.

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c. iu tr VNTM do nm. Thng dng Amphotericin B, c th kt hp vi Flucytosine. (a) Amphotericin B: ho trong Dextro 5% truyn TM trong 2-4 gi vi liu 0,5 mg/kg/ngy. (b) Thuc c c tnh nhiu n thn. (c) Flucytosine c c tnh lm c ch tu xng, cn theo di cng thc mu khi iu tr thuc ny. Sau khi dng thuc 1-2 tun nn tnh n vic phu thut thay van. Mt s thuc dng ung nh Fluconazole hoc Itraconazole c th dng phi hp.d e erv 2. iu tr ngoi khoa: res ts n a. Mc ch c bn ca iu tr ighom.v khoa cho r ngoi ll .c VNTMNK l ly i nhng .mnhosi hoc hoi t v A aho e y m khng th iu trinlo 0khoa c, sa li van F ni @ 2 . hoc thay van b0tn tthng. 08 20 2 oci y b. Ch nh ight Pot ngoi khoa cho VNTMNK l iu tr r nh kh khn nhng rt cn thit mt quyt py Co trong mt s hon cnh. Khi ch nh phi cn nhc nhiu yu t v phi ch ti thi im can thip (bng 16-4). c. Suy tim tin trin l mt trong nhng ch nh chnh, v c ti 90 % cht v suy tim nu khng c can thip kp thi. d. VNTMNK van nhn to thng i hi kt hp iu tr ni v ngoi khoa. e. Thi khong dng khng sinh sau khi m bnh nhn VNTMNK cn cha thng nht. Cc tc gi cho rng, nu mnh si (hoc p xe ly ra trong m cy c vi khun th thi gian iu tr sau m phi di bng mt liu trnh y cho iu tr VNTMNK. 316 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Bng 16-4. Ch nh phu thut khi VNTMNK. Ch nh r rng: Suy tim khng khng ch c do tn thng van. Van nhn to khng n nh. Khng khng ch c hoc khng th khng ch c nhim khun (v d do nm hoc Enterocuccus khng thuc khng sinh). Tc mch ti pht. Ch nh tng i: Tn thng lan rng quanh van (d, pxe). Tn thng van t nhin sau khi iu tr ti u. VNTMNK m cy mu m tnh c st dai dng khng gii thch c. ved se Mnh si to (>10mm) vi nguy c tc mchr cao. re ts gh m.vn VI. Phng nga VNTMNK l ri co Al .i hoo. tt c cc thy y l cng tc c bit quan trng a hi oev inl 2c y c trnh by thuc thc hnh cn nm r. V .nguy 0@ F 0 8 0 ity bng 16-5, trong nhng bnh0nhn2c nguy c cao v va cn 2 oc phi c phng nga ngt mct khi lm cc th thut. gh Po i yr Bng 16-5. Cop thut c nguy c VNTMNK cao v va. Th Cc th thut rng ming, hng: Cc th thut rng ming c th gy chy mu. Ct amidan hoc no VA. Soi thanh qun bng ng soi cng. Cc th thut tiu ho: Cc phu thut lin quan n nim mc rut. Th thut gy x trong gin tnh mch thc qun. Phu thut ng mt. Ni soi ng mt. Cc th thut ng tit niu: Soi bng quang. Nong niu o. Phu thut tin lit tuyn. Cc th thut khc: Chch, dn lu cc nhim trng. 317 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Bng 16-6. Ch khng sinh phng nga VNTMNK trong mt s th thut. Bnh cnh Loi khng sinh Liu dng A. Ch cho cc th thut rng,ming, ng h hp, thc qun Ch phng chun. Amoxicillin 2g, ung 1 gi trc khi lm th thut. Trng hp khng Ampicillin 2g, tim TM hoc TB 30 pht trc ung c khng sinh. th thut. Trng hp d ng vi Clindamycin hoc 600mg, ung 1 gi trc th thut. Penicillin. 2g, ung 1 gi trc th thut. Cephalexin hoc 500 mg, 1 gi trc th thut. Azithromycin. B. Cho cc th thut ng sinh dc tit niu, d dy rut 2g, tim TM hoc tim bp. bnh nhn nguy c Ampicillin kt hp vi Gentamicin (30 pht trc th thut) 1,5mg/kg, tim TM hoc tim bp. cao. 1g, tim TM hoc tim bp. tip theo dng Ampicillin 1g, ung. hoc Amoxicillin (6 gi sau). 1g, truyn TM trong vng 1-2 gi. nhng bnh nhn Vancomycin kt hp vi Gentamycin (trong vng 30 pht 1,5mg/kg tim TM hoc TB nguy c cao, d ng vi trc th thut). Penicillin. 2g, ung 1 gi trc th thut. bnh nhn nguy c Amoxicillin hoc Ampicillin. 2g, tim TM hoc tim bp trong vng va. 30 pht trc th thut. Bnh nhn nguy c va, Vancomycin. 1g, truyn TM trong 1-2 gi v kt d ng vi Penicillin. thc 30 pht trc khi lm th thut.

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1. Baue A, Geha AS, Hammond GL, Laks H, Naunheim KS, eds. Glenn's thoracic and cardiovascular surgery, 6th ed. Norwalk, CT: Appleton & Lange, 1996:1915-1930. Braunwald E, ed. Heart disease: a textbook of cardiovascular medicine, 5th ed. Philadelphia: WB Saunders, 1997:1077-1104. Child JS, ed. Diagnosis and management of infective endocarditis. Cardiol Clin North Am 1996;14. Dajani AS, Taubert KA, Wilson W, et at. Prevention of bacterial endocarditis: recommendations by the American Heart Association. Circulation 1997;96:358-366. Durack DT, Lukes AS, Bright DK. New criteria for diagnosis of infective endocarditis: utilisation of specific echocardiographic ved ser findings. Am J Med 1994;96:200-209. re ts gh m.vn J Med Durack DT. Prevention of infective endocarditis. N Engl i ll r co . A ahoo. 1995;332:38-44. ev y nlo Opin Farmer JA, Torre G. Endocarditis. iCurr0@ Cardiol 1997;12:123F 8. 02 130. 00 ity2 2 t oc Fauci AS, ed. Harrison's principles of internal medicine, 14th ed. gh Pot ri py New York: McGraw-Hill, 1998:785-791. Co Mandell GL, Bennett JE, Dolin R, eds. Principles and practice of infectious diseases, 4th ed. New York: Churchill-Livingstone, 1995:740-799. Mexander RW, Schlant RC, Fuster V, eds. Hurst's the heart. New York: McGraw-Hill, 1998:2205-2239. Murphy M. Infective endocarditis. In: Marso SP, Griffin BP, Topol EJ, eds. Manual of Cardiovascular Medicine. Philadelphia: Lippincott-Raven, 2000. Otto C. The practice of clinical echocardiography. Philadelphia: WB Saunders, 1997:389-403. Topol EJ, ed. Textbook of cardiovascular medicine. Philadelphia: Lippincott-Raven Publishers, 1998:607-637.

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14. Von Reyn CF, Levy BS, Arheit RD, Friedland G, Crumpacker CS. Infective endocarditis: an analysis based on strict case definitions. Ann Intern Med 1981;94: 505-518. 15. Wilson WR, Karchmer AW, Dajani AS, et al. Antibiotic treatment of adults with infective endocarditis due to streptococci, enterococci, staphylococci, and HACEK microorganisms. JAMA 1995;274: 1706-1713.

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Van tim nhn to

I. Cc loi van tim nhn to Cc loi van tim nhn to c chia thnh 2 nhm ln: van c hc v van sinh hc. Mi loi van li c bn, nguy c to huyt khi, v c im huyt ng khc nhau. Bng 17-1. c im ca cc loi van tim nhn to. Nguy Din tch l van hiu 2 c dng (cm ) Loi van bn V tr van V tr van huyt khi MC hai l Van bi ++++ 1,2-1,6 1,4-3,1 erved ++++ res (Starr-Edwards) hts .vn rig com +++/ 1,5-2,1 +++ Van a mt cnh ll1,9-3,2 . ++++ (Bjrk-Shiley, v. A ahoo loe y Medtronic-Hall, Fin020@ . 08 2 Omnicarbon) 20 ocity ht ++++ Pot2,4-3,2 2,8-3,4 ++ Van a hai cnh rig (St. Jude Medical,Copy Carbomedics) ++ 1,0-1,7 1,3-2,7 +/++ Van sinh hc d loi (IonescuShiley, Hancock, CarpentierEdwards) Van sinh hc +++ 3,0-4,0 + ng loi A. Van c hc 1. Van a mt cnh: (van Bjrk-Shiley, MedtronicHall v Omnicarbon) c cu to gm mt vng van bng kim loi gn vi mt cnh a bng pyrolytic carbon di ng t do mt gc 60-85o xung quanh mt trc, to thnh hai l ln mu lu thng. 321 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

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Hnh 17-1a. Cu trc mt s loi van tim c hc. 2. Van a hai cnh: (van St. Jude Medical, Carbomedics) gm hai cnh a bn nguyt di ng t do mt gc 75-90o hai bn, to thnh mt din ch nht v hai l ln hai bn cho mu lu thng khi van m. Van c thit k c mt dng h nh trong van nhm gim hnh thnh huyt khi trn a. 322 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Hin l loi c dng ph bin do nhiu u im v huyt ng. 3. Van bi (lng) (van Starr-Edwards): gm mt vin bi bng silicon di ng t do trong lng chp kim loi, mu s i xung quanh vin bi. Loi ny hin gn nh khng cn s dng do nhiu nhc im v huyt ng.

ved ser re Hnh 17-1b. Cu trc mt s loi van bi (lng).n ts gh m.v B. Van sinh hc: mc d rt ging vanritco ll . nhin song v v. A ahoo thc van b huyt ng vn cha phi ti eu y kch lo do Fin020@ cc thnh phn vng van, phn chng van lm nh i. . 08 2 20 ocity 1. Van d loi: bng cch ph ln mt gi v mt ht ot vng van kimgloi P mng tim b hoc van tim ln ri py Co nh van Carpentier-Edwards. Cc loi van qua x l mi nh Hancock II hoc Medtronic Freestyle, St. Jude-Medical c ci tin huyt ng do cch gn van trc tip vi MC hoc t van ngi trn vng van... 2. Van ng loi: ch yu v tr van MC bng cch ly van t ngi hin tng, c th km thm mt on MC, bo qun lnh trong ngn hng m. Vic pht trin cn gp nhiu kh khn v hn ch.
II. La chn loi van thay 1. Sa van: Cn phi xem xt kh nng van cn sa c hay khng trc khi quyt nh thay van, do sa van c u th hn hn nh: bo tn c chc nng tht tri 323 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

v gi c cc t chc di van, t l t vong chu phu thp, khng cn dng thuc chng ng, t l sng cn lu di tt. Hin nay, ch yu mi p dng rng ri cc k thut sa van hai l, cn i vi van MC th kh sa hn rt nhiu, ch nn lm hn ch trong mt s trng hp khng do thp tim nh van MC hai l bm sinh gy HoC do sa van, van khng vi, khng hp Bng 17-2. So snh gia m thay van v sa van. Nn thay van Nn sa van 1. Di chng do thp 1. Bnh sa van hai l. 2. HoHL do bnh tim thiu tim. 2. Vim ni tm mc. mu. 3. Tn thng van hai 4. Gin vng VHL, l ed van v l phc tp (x, vi bnh thng. ser re t nhiu, co rt l van, 5. Tn thng chs yu l sau gh m.vn i t chc di van van HL. All r o.co . l ovan hai l qu 6. Di lngyah thng tn nng...). oev in 20@ F 4. Phu thut vin t mc. 0 8. 007.ity2 MC hai l bm sinh, Van kinh nghim. 2 t oc gh Potsa van gy h. i yr 2. Van sinh phc d loi: ch nh thay cho bnh nhn Co khng th dng thuc chng ng ko di, bnh nhn tui cao (> 70), cng nn cn nhc thay van sinh hc cho nhng bnh nhn n cn mun c thai. Cn ch nguy c thoi ho van phi m thay van li (t l m li 40% nu tui bnh nhn < 40, 20-30% nu tui 40-60, v 10% nu tui > 70). 3. Van ng loi (sinh hc): c bn cao hn, chnh p qua van thp nht so vi cc loi van sinh hc khc nhng sau 20 nm ch 10% van hot ng cn tt. Van MC ng loi c la chn cho bnh nhn tui < 50, ph n cn mun c thai, bnh nhn khng th dng thuc chng ng ko di, bnh nhn cn thay c van v on MC v c bit l bnh 324 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

nhn vim ni tm mc nhim khun ti van MC c bin chng (pxe, d...). 4. Van c hc: ch nh cho bnh nhn tui < 60 (do bn cao, t cn m li), bnh nhn phi dng thuc chng ng (do ri lon nhp hoc t qu). Bnh nhn cn thay c van hai l v ng mch ch nn thay van c hc v van hai l sinh hc nhanh thoi ho. Do cu trc gn nn bnh nhn c kch thc tht nh nn thay van c hc. Quyt nh la chn tng loi van c th cn ph thuc vo cu to v c im huyt ng tng loi van: van St. Jude Medical v Metronic-Hall c a chung nht do u th v huyt ng, bn cao v t l bin chng thp... III. Theo di sau m thay van ved ser e sr Vic theo di sau m thay van tim nhn to tl .ht sc cn gh m vn i thit, gm theo di triu chng lm sng vAxt nghim, d bnh ll r co . ahoo. nhn khng c triu chng c nng. Kt qu siu m Doppler oev inl 20@y dng lm mc tim trong vng 1-6 tun ngay sau Fm c . 08 20 2 nn y theo di v sau. Thng thng 0 ocitkim tra nh k siu m tim t ot 1 nm mt ln hoc mauigh nu c triu chng c nng, nht l r hn P y giai on 5 nm sauop tr i. Tuyn truyn cho bnh nhn v C m nguy c v s cn thit phi iu tr d phng vim ni tm mc. Ring vi bnh nhn c van c hc, cn theo di nh k hiu qu ca thuc chng ng bng xt nghim t l Prothrombin v INR. 1. Dng thuc chng ng sau m thay van: a. i vi van c hc: Ngay sau m thay van c rt nhiu cch dng thuc chng ng. Dng sm qu s lm tng nguy c trn mu mng tim, p tim hoc chy mu sau m. Mt s ni ch bt u dng thuc chng ng ng ung 3-4 ngy sau m thay van. Mt s khc dng Heparin tnh mch liu thp ( aPTT t ngng bnh 325 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

thng cao) ngay t 6-12 gi sau m, tng Heparin ln liu sau rt dn lu ngc, bt u ung thuc chng ng t 24-48 gi sau m. D sao nn xt k nguy c huyt khi ca tng bnh nhn v v tr van (van hai l cao hn van MC). V lu di: ung thuc chng ng (thuc khng vitamin K) duy tr gi tr INR trong ngng tc dng. Bng 17-3. Ngng tc dng chng ng cho cc loi van tim nhn to. Loi van INR Nguy c Phi hp tc mch Thp * Van c hc: ved 4,0-5,0 reser- Van bi - Van a 1 cnh 3,0-4,0hts .vn ig ll r o - Van a 2 cnh 2,5-3,0.com A ho v.3,0-4,5 - Nhiu van loe @ya Fin020 * Van sinh 8. hc: 2 0 - ng20 ocity loi t t Aspirin 2,0-3,0 -righloi o D P py 325 Co mg/ngy 3,0-4,5 Aspirin Cao (km rung - Van c hc 80-160 nh, tin s tc mg/ngy mch, huyt 2,0-3,0 khi nh, ri - Van sinh hc lon chc nng tht tri nng) Dng thuc chng ng lu di c nguy c chy mu nh (2-4%/nm), chy mu nng (1-2%/nm), t vong 0,2-0,5%/nm. Nguy c chy mu tng tui gi (5-6% bnh nhn > 70 tui). Nguy c xy ra tc mch cho d vn dng thuc chng ng l 1%/nm.

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b. i vi van sinh hc: vic dng thuc chng ng sau m thay van sinh hc cn nhiu bn ci. Nguy c tc mch cao nht sau m v gim dn trong 3 thng sau m, t l huyt khi v tr van hai l (7%) cao hn so vi v tr van MC (3%). V th cn dng thuc chng ng ng ung sau m thay van sinh hc trong 3 thng u sau m, ri chuyn sang Aspirin 325 mg/ngy. Nhng bnh nhn c tin s tc mch, rung nh, ri lon chc nng tht tri nn ung thuc chng ng sut i. 2. iu chnh liu chng ng khi lm cc th thut khng phi tim mch: a. i vi cc th thut ln, mt mu nhiu, nn ved ser nht 3 dng thuc chng ng ng ung t re ts gh m.vn 1,6. Cn ngy trc khi lm th thut i INR ll r co iu tr gi bng Heparin vtimhtnh mch bnh . A a oo. le nhn c van bi, rung inho 0@y khi nh tri, ri F n0, huyt 2 8 lon chc nng tht.tri nng, tin s tc mch. 00 ity2 2 t th b. i vi nhngPotoc thut nh (nh nh rng...), gh i nguy oc rchy mu t, c th vn duy tr tip liu py C chng ng ang dng. c. Sau m, dng li Heparin ngay khi c th, sau gi tip bng thuc chng ng ng ung duy tr lu di. 3. iu chnh qu liu chng ng: a. Liu thuc chng ng khi u nn l 5 mg Warfarin (tng ng 1 mg Acenocoumaron (Sintrom) hay 5 mg Fluindione (Previscan). Phi gim bt liu ngi gi, ngi c bnh gan mt phi hp hoc c nguy c chy mu cao. b. Nu INR vt ngng iu tr v < 5,0 th nn h bt liu iu tr hoc tm dng mt ngy v ung vi liu h thp hn. 327 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

c. Nu INR > 5,0 v < 9,0 m khng chy mu ng k, tm ngng thuc chng ng mt hoc hai ngy, theo di thng xuyn INR, ung li thuc vi liu thp hn khi INR v ngng iu tr hoc tm dng mt ngy thuc, ung 1-2,5 mg vitamin K1 nht l khi nguy c chy mu cao. d. Nu cn nhanh hn (chng hn cn m cp) th ung 2-4 mg vitamin K1 (INR s gim ng k sau 24h). Nu INR vn cn cao th ch ung thm 1-2mg vitamin K1 m thi. e. Nu INR > 9,0 m khng chy mu ng k, th dng ngay thuc chng ng, phi hp ung 35mg vitamin K1 (INR s gim ng k sau 2448h), lp li nu cn, theo di st v dng li ved ser nm thuc chng ng vi liu thp khi INR re ts trong ngng iu tr. gh m.vn l ri o f. Nu INR > 20 c km chy Al hoo.c . mu nng, dng ngay oev a thuc chng ng, truyn 0@y mch chm 10 mg inl 2 tnh F 0 vitamin K1, phi 08. yvi truyn huyt tng ti 0 hp 2 2 it hoc ta prothrombin tu trng hp, c th lp t oc gh Pot ri li 12h/ln. py Co 4. Thuc chng ng v thai nghn: t l bin chng tc mch do huyt khi tng ln khi c thai. Tuy nhin do tc dng gy d tt bm sinh, nn ngng thuc chng ng ng ung (khng vitamin K) trong ba thng u sau khi c thai, thay bng Heparin tim di da 15.000 n v 2 ln/ngy nhm duy tr thi gian aPTT gp 1,5-2,0 ln so vi chng (ly xt nghim sau tim 6 gi) t nht cho n 3 thng gia, khi c th quay li ung thuc chng ng tip cho ti gia 3 thng cui. n lc , chuyn li tim di da Heparin 5.000 n v 2 ln/ngy cho ti lc chuyn d. C th phi hp vi Aspirin liu thp. IV. Triu chng lm sng v xt nghim bnh nhn c van tim nhn to 328 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

A. Triu chng lm sng: biu hin ca ri lon hot ng van nhn to tng i phc tp (xem thm phn bin chng van nhn to). 1. Tin s v bnh s: nn hi k hoc kim tra h s ra vin v cc vn lin quan n van nhn to nh: ch nh thay van; v tr van nhn to; loi v kch thc van; thi gian k t khi thay; cc bin chng lin quan n dng thuc chng ng, bin chng tc mch, vim ni tm mc, st hoc thay i m sc ting p ca van. 2. Khm thc th: pht hin cc ting thi mi, m nght hoc cc biu hin huyt khi kt van. Bn thn van nhn to lm thay i ting bnh thng do di chuyn cnh van hoc do thay i tnh rcht ca ved sevan nhn dng chy qua van. Cc ting, m scts re ca n ighom.v to che lp nhng ting tim bnhrthng. Mt khc l .c l . h thay nhng m sc ny c th khng A ahoo i cho d oev y nl van. ri lon nng hot ng ica 0@ Tuy nhin nu . F 202 quen vi cc ting 2008tim nhn to th nghe tim cng van ty i gip ch cgnhiuotoc vic chn on bnh l ca ht P cho i van nhnopyr trc khi s dng cc bin php chn to C on hnh nh khc. B. Cc xt nghim chn on: xc nh ri lon hot ng van nhn to ch yu da trn hnh nh siu m Doppler tim, cho php nh gi sm trc khi biu l ra triu chng lm sng. 1. Siu m Doppler tim: cn nh gi y cu trc ca van, cc thnh phn ca b my van nhn to, chnh p trung bnh v ti a qua van, dng h trong van hoc quanh van. Siu m tim qua thc qun c ch nh cho nhng trng hp nghi ng hoc c triu chng ca vim ni tm mc nhim khun. Ni chung, k thut lm siu m khng khc g so vi cc van t nhin, song kh hn do van nhn to gy ra cc bng cn m. 329 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

a. Ri lon hot ng ca van thng biu hin ch cc l van ng khng kn (do huyt khi, do vi ho van sinh hc hay do ni mc tng sinh qu mc), di ng qu mc vng van (biu hin ca long van, c th km theo cc tn thng xung quanh nh pxe, d, gi phnh cnh vng van gy ra do vim ni tm mc van nhn to). b. Siu m Doppler mu cung cp cc kt qu o c gin tip nhng ng tin cy v hot ng ca van nhn to: nh chnh p qua van (t c tnh din tch l van hiu dng), dng h trong van hoc quanh van, c ch gy h van... c. nh gi h van nhn to: i vi van c hc, dng h c coi el sinh vd 2 serdng h l nu din tch h < 2 cm v re di ts < 2,5 cm v tr van hai l hoc din tch h < gh m.vn l ri o 1 cm2 v di dng hAl hoo.ccm v tr van . <a 1,5 oev ng mch ch. Phn0@y cc van sinh hc inl 2 ln F 8. u c dng 0h y20 (sinh l) ngay sau khi 0 it nh thay van.t 2 otoc gh P Dng ih van bnh l thng rng v di hn yr p Co nhiu, c th c nhiu dng h, thng lin quan n hin tng vi, so ho vng van, h hi cu trc van, p xe vng van, t chc ln cn... Siu m tim qua thc qun s gip lng gi kh chnh xc mc h van c bit l trong trng hp h chn (quanh) van. HoHL c coi l nng khi vn tc ti a u tm trng 2,5 m/giy hoc PHT dng chy qua van hai l 150 miligiy. HoC c coi l nng khi PHT dng chy qua van MC 250 miligiy hoc c dng chy ngc trong ng mch ch xung. d. nh gi hp van nhn to: Chnh p qua van: 330 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

van. Chnh p qua van tnh trn siu m Doppler lin tc sau m vi tun c coi l gi tr tham chiu theo di sau ny. (b) Chnh p qua van cao khng nhng do hp van m cn do tnh trng tng cung lng, thiu mu, nhp nhanh, h van nhn to nhiu hoc hin tng phc hi p lc (rt hay gp van c hc hai cnh v tr van MC, c hin tng p lc tng th pht sau khi dng chy i qua l hp, lm tng chnh p thc s qua van ln khong 1/3 song nu hp van, th ved hin tng ny gim i). ser re t Din tch l van: Phng trnhs lin tc cho gh m.vn i php c tnh din tch l vanochc nng: ll r co . A aho . Din tchvan MC = nloev @y knh vng van)2 (ng Fi 020 0,785 VTIRTT./VTIvan MC 8 00 y2 HL = t Din tchvan2 otoci(ng knh RTT)2 0,785 t gh VTI VTIiRTT / P van HL yr p Co Trong RTT l ng ra tht tri, VTI l tch phn vn tc theo thi gian dng chy tnh bng siu m Doppler lin tc. Thi gian bn gim p lc (PHT): c ch nh gi din tch l van hai l nhn to (=220/PHT), ng thi cho php phn bit nguyn nhn gy tng VTI dng chy qua van hai l (nu PHT cng tng, nguyn nhn l hp van), nu PHT khng ko di, th nguyn nhn ch l tng dng chy qua van. Tuy nhin din tch l van tnh theo PHT i khi s ln hn gi tr thc. Ch s t sut gia vn tc dng chy ng ra tht tri v van MC nhn to cho php 331

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nh gi c hp van hay khng nht l khi khng bit r ng knh vng van. Ch s VRTT/Vvan MC ny cng ln th din tch l van cng ln, nu < 0,23 th hp van ng k. Bng 17-4. Mt s thng s bnh thng ca cc loi van tim nhn to khi o bng siu m Doppler tim. Loi van nhn to Vn tc Chnh p ti a trung bnh (m/s) (mmHg) V tr van MC 24 0,4 3,1 0,5 Starr-Edwards 2,5 0,6 14 5 Bjrk-Shiley 3,0 0,8 11 6 St. Jude 2,6 0,3 12 d 3 Medtronic-Hall e 2,4 0,4 7erv 3 Hancock res Carpentier-Edwards 2,4 0,5 ghts .1n 2 v1 Van ng loi l ri .com 14 6 l 0,8 0,4 o .A o V tr van hai l oev yah inl @ 0,4 1,8 52 Starr-Edwards . F 2020 08 ty 1,6 0,3 52 0 Bjrk-Shiley 2 ci ht Poto 1,6 0,3 52 St. Jude rig py 1,7 0,3 31 Medtronic-Hall Co 1,5 0,3 42 Hancock Carpentier-Edwards 1,8 0,2 72 2. Soi di mn tng sng: ch c ch trong trng hp cc van c hc. Nu chnh chm tia X i song song vi mt phng ca van th hnh nh ng m cc cnh van l r nht. Di ng cnh van gim l du hiu ca tc nghn van, ngc li di ng vng van qu ln (> 7o i vi van MC v > 11o i vi van hai l) l du hiu ca long (hng) van mt phn. 3. Thng tim tri vo tht tri c th tin hnh an ton bnh nhn c van MC sinh hc o chnh p qua van, nhng i vi van MC c hc (chng ch nh a ng thng qua) th phi xuyn vch lin nh ri a ng thng xung tht tri. i vi van hai 332 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

l cng phi lm tng t o c chnh p. Chng ch nh a ng thng qua cc van c hc (lng bi, lng a, mt hay hai cnh). 4. Chp cng hng t (MRI): cho php xc nh h van, r quanh van, hoc pxe vng van nu c chng ch nh lm siu m qua thc qun. Chp ct lp theo t trng (CT) khng c gi tr trong vic nh gi hot ng van nhn to. C. Ri lon hot ng ca van nhn to v cc bin chng lin quan 1. Rung nh: c ti mt na s bnh nhn thay/sa van xut hin rung nh sau m. iu tr loi rung nh ny khng khc g so vi iu tr rung nh ni chung. ved a. i vi bnh nhn cha c tin s rung nh th ser re t thng t tr v nhp xoang. Nhngsnu rung nh gh m.vn ri c dai dng, ko di > 24 gi, All cno xem xt iu . thhoo. tr thuc chng ng voev @ya nhp bng thuc chuyn inl . F 20 0 chng lon nhp hoc sc2in. 8 00 y b. iu tr dht 2 otocitrc m bng thuc chn phng t P r giao cmig py hoc Amiodarone c tc dng r rt o lm C gim t l rung nh sau m tim. 2. Ri lon dn truyn: bloc nh tht phi t my to nhp chim khong 2-3% sau m thay van v khong 8% sau m li van. Nguyn nhn thng do sang chn b His trong m hoc ph n t chc quanh van sau m. Cc yu t nh vi ho vng van MC hoc hai l, ri lon dn truyn trc m, tui cao, vim ni tm mc nhim khun, phu thut van ba l lm tng nguy c ri lon dn truyn sau m, c th dn ti phi t my to nhp vnh vin. 3. Vim ni tm mc nhim khun (VNTMNK): T l VNTMNK bnh nhn thay van nhn to xp x 3-6%, vi c im cc si rt ln (do vi khun gy

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bnh c tr trn van, nn c th trnh khi cc c ch bo v ca c th). Thng chia lm 2 loi: a. VNTMNK trn van tim nhn to sm: trong vng 60 ngy sau m: ch yu do t cu da (S. epidermidis), din bin rt nng, d dng a n t vong (20-70%). b. VNTMNK trn van tim nhn to mun: thng xy ra bnh nhn c nhiu van nhn to hoc v tr van MC. Lm sng ni chung ging VNTMNK trn van t nhin. Tc nhn hay gp nht l lin cu, sau l vi khun Gram m, t cu rut v S. epidermis. c. Chn on xc nh da vo siu m tim qua thc qun do nhy v c hiu cao (90-95%); ng ved ser xe vng r thi xc nh cc bin chng khc nh ep ts gh m.vn m van, long van, r van..; cng nhi dng siu ll r co theo di hiu qu iu tr.ev. A hoo. a lo d. iu tr: nu ch dngin 20@y F khng sinh n thun, t l . 0 t vong ln ti 2008 ity2 vi 38% nu thay van) do 61% (so c kh nng ithnhPcng rt thp (ct st) vi cc tc ht oto r g cu, vi khun gram m hoc nm, nhn onh t py C cn vi lin cu p ng cng ch khong 50%. e. Bnh nhn VNTMNK van tim nhn to vn nn dng thuc chng ng. Nu khng dng thuc chng ng, nguy c t qu khi c thm VNTMNK tng ln ti 50% trong khi nu dng chng ng th t l tc mch ch l 10%. Hin cha c kt lun chc chn no v vic tng nguy c xut huyt no bnh nhn VNTMNK van nhn to c dng thuc chng ng. f. Ch nh m thay li van tim nhn to khi: Tip tc nhim khun huyt d iu tr khng sinh rt tch cc. VNTMNK n thng cc t chc xung quanh hoc to ng d. 334 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Cc tc gy nghn mch ti pht. VNTMNK do nm. Long van hoc tc van nhn to. Tc nghn ng dn truyn mi hoc ri lon dn truyn nng hn. Suy tim huyt tin trin hoc ri lon huyt ng nng. 4. Tan mu: gp rt nhiu bnh nhn thay van c hc nhng him khi biu hin ra triu chng lm sng. a. T l thiu mu do tan mu gp 6-15% bnh nhn thay van bi, song him gp hn van a hoc van sinh hc. Thiu mu do tan mu thng gp bnh nhn c nhiu van nhn to, van nhn to c nh, h quanh van v VNTMNK trn van ved ser nhn to... vi c ch lin quan ne dng mu r hts . n xoy c p lc cao p vo cc tgchcvkim loi. i ll r com b. Chn on xc nh khi ev. A hoomen LDH, tng c tng . a hng cu li, Finlo 0@y tng bilirubin gin tip, 2 . haptoglobin niu 08 txut hin cc mnh v hng v 20 20 oci y cu trn lamt mu. Siu m tim thng pht hin h Pot rig tng va p ca dng mu c tc thy cyhin p Co cao (dng h lch tm hoc quanh van) va vo cc t chc van nhn to. c. Thiu mu tan mu nh c th iu tr b sung vi st, acid folic v truyn mu. Dng thuc chn bta giao cm v kim sot tt huyt p c th lm gim mc nng ca tn huyt. d. M li sa h quanh van hoc thay van c ch nh cho nhng bnh nhn thiu mu tan mu nng cn phi truyn mu nhiu ln hoc c suy tim huyt. 5. Huyt khi: t l huyt khi ti van chim khong 0,2-1,8%/nm, hay gp nht v tr van ba l, sau l v tr van hai l v cui cng l v tr van MC. 335 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

a. Nn ngh ti huyt khi kt van bnh nhn c triu chng khi pht t ngt, c tin s tc mch hoc dng thuc chng ng khng . Siu m tim qua thc qun l bin php thng dng nht chn on huyt khi ti van, tuy c th pht hin hnh nh hn ch vn ng ca van nhn to khi soi trn mn chiu Xquang. Hnh nh trn siu m gi huyt khi l mt khi di ng, mt mm, khng ng u. b. iu tr: cch thc x tr ph thuc vo v tr huyt khi ca van ch khng ph thuc vo loi van hay thi gian gi nh hnh thnh huyt khi. Trc khi iu tr: (a) Heparin c dng sm ngay t khi ngh ved ser ti v kho st bnh. Tip tc rdng chng e hts .v ng ng ung (thucgkhngn vitamine i m ll r K) tr phi c ch nh m o.co r. . A aho li v (b) Siu m tim qualoe @yqun hoc t nht l in thc 0 soi di 08n 202 sng nn lm trong m . F tng 0 ity 2 toc vngt24 gi k t khi khi pht v lp li o gh xuyn nu cn huyt khi. i thng P yr p Ctr c. iu o ni khoa: Ch nh dng thuc tiu si huyt cho huyt khi van nhn to tim phi do hu qu t nghim trng nu huyt khi bn i xa khi so vi bn tim tri. T l thnh cng ln ti 82%, t l bin chng tc mch khong 12% v bin chng chy mu nng khong 5%. Cc thuc hay dng nht l: Streptokinase (250.000 n v tim trc tip tnh mch/30 pht, sau truyn tnh mch 100.000 n v/gi) hoc Urokinase (4.400 n v/kg/gi). Thi gian dng thuc tiu si huyt thng t 2 n 120 gi, song nn dng nu khng ci thin v huyt ng sau 24 n 72 gi. 336 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Sau khi dng thuc tiu si huyt thnh cng, cn theo di st hiu qu iu tr chng ng ng ung cng nh siu m Doppler tim li nhiu ln. Chng ng bng Heparin v Wafarin ni chung c khuyn dng cho cc huyt khi nh ( 5mm): s dng Heparin tim tnh mch, sau tim di da 17.000 n v 2 ln/ngy kt hp ung thuc khng vitamin K (duy tr INR t 2,5-3,5) trong vng 3 thng. d. Phu thut: t l t vong quanh phu thut thp nht cng l 5% v th cn cn nhc nguy c ca tng bnh nhn so vi kh nng v iu kin ca tng trung tm. Ch nh thay van v ly bdhuyt e khi cho trng hp huyt khi van nhservto tim re n tri tr phi huyt khi nh hoc khngvth m do hts n rig com. nh m nguy c phu thut qu cao.llCng ch A oo. ev. y khng thnh cng, nu iu tr tiu huytlokhi ah in @ m sau khi ngng 8. F 2020 truyn thuc 24 gi. 0 ty 0 bong 6. Hng hc c hc: 2 otoci vng van nhn to c th gp ht P ngay trong yrig on sm sau phu thut do k thut p giai Co m km, vng van qu vi ho, bnh nhn dng steroid lu di, m van qu mn (c bit nu m li) hoc nhim trng. Hin tng bong van cng c th xy ra mun do nhim trng. Hnh nh van ung a (lc l) trn siu m tim hay khi soi di mn tng sng l mt ch nh m li cp cu. 7. Mt tng xng gia kch thc van nhn to so vi bnh nhn: a. Tt c cc loi van nhn to tr van t thn MC (khng c vng kim loi) u c din tch l van hiu dng thp hn hn do vi van t nhin. V th lun lun c hin tng chnh p qua van nhn to v hp van tng i. Nu thay vo mt van nhn to c ng knh qu nh th s gy ra 337 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

tnh trng gim ng k cung lng tim, gy ra cc triu chng lm sng. Hin tng ny hay gp nht khi thay van ng mch ch bnh nhn hp van ng mch ch. b. V vy, nu bnh nhn c vng van nh, nn dng van ng loi hoc van a v tr van MC do cc u th v huyt ng. Van MC nhn to c ng knh 21mm cng khng nn thay cho bnh nhn cao ln hoc hot ng th lc nhiu. Nguyn l chung l nn c gng thay van bng mt van nhn to c ng knh ln hn, nu cn th phi hp vi to hnh (m rng) vng van. 8. Pannus (hin tng tng sinh ni mc qu mc ph trm ln van): thng phi hp vi huyt khi ved serc hc). gy tc van (t l c th ti 5% vis van re t C ch hnh thnh pannus cn cha hr, .c th lin g m vn l ri co quan vi hin tng tng sinhAlnguyn bo si do . ahoo. oev phn ng min dch vi dnvt0@y van nhn to) hoc i l 2 (l F 0 phi hp vi cc tc8.nhn nh dng thuc chng 00 ity2 2 ng khng hliu,otoc ni tm mc nhim khun, t vim P g r tc ng cai dng mu xoy qua van hai l... Ni py Co chung, phi lm siu m tim qua thc qun xc nh v kho st cn nguyn gy tc van nhn to. 9. t qu do cc mu ng bnh nhn c van tim nhn to: a. Nguy c t qu ti pht khong 1%/ngy trong 2 tun u. Nu chp phim CT trong vng 24 v 48 gi m khng c chy mu no hoc nhn no din ln th nn dng Heparin ng tnh mch. Duy tr ung thuc chng ng s lm gim nguy c ti pht t qu xung mt phn ba song li tng t 8-24% nguy c chuyn dng nhn no thnh xut huyt no nht l trong vng 48 gi u tin. B sung Aspirin hoc Clopidogrel nu

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ti pht t qu d dng liu thuc chng ng. b. Vi bnh nhn c nhn no ln, nn tm dng thuc chng ng trong vng 5-7 ngy ng thi cng nn ngng thuc chng ng 1-2 tun nu c chuyn dng nhn no thnh xut huyt. Ti liu tham kho
1. Acar J, Iung B, Boissel JP, et al. Multicenter randomized comparison of low-dose versus standard-dose anticoagulation in patients with mechanical prosthetic heart valves. Circulation 1996;94:2107-2112. 2. Akins CW. Results with mechanical cardiac valvular prosthesis. Ann Thorac Surg 1995;60:1836-1844. 3. Cannegieter SC, Rosendaal FR, Wintzen AR, et al. Optimal oral anticoagulant therapy in patients with mechanical heart rvalves. N ved se re Engl J Med 1995;333:11-17. ts gh m.vn versus 4. Davis EA, Greene PS, Cameron DE, et al. ri o ll Bioprosthetic c . A ahoo. in the elderly. mechanical prosthesis for aortic valveev replacement o y l Circulation 1996;94:II-121-125. Fin 20@ . 20 5. Garcia MJ. Principles of 2008 ty In: Topol EJ. Comprehensive Imaging. ci Cardiovascular Medicine.Poto ht Philadelphia: Lippincott-Raven, 1998: g ri 609-35. py Co 6. Green CE, Glass-Royal M, Bream PR, et al. Cinefluoroscopic evaluation of periprosthetic cardiac valve regurgitation. Am J Radiol 1988;151:455-459. 7. Israel DR, Sharma SK, Fuster V. Anti-thrombotic therapy in prosthetic heart valve replacement. Am Heart J 1994;127:400-411. 8. Jaeger FJ, Trohman RO, Brener S, et al. Permanent pacing following repeat cardiac valve surgery. Am J Cardiol 1994;74:505-507. 9. Lengyal M, Fuster V, Keitni M, et al. Guidelines for management of left-sided prosthetic valve thrombosis: a role for thrombolytic therapy. J Am Coll Cardiol 1997;30:1521-1526. 10. Lin S, Wong J. Prosthetic heart valves. In: Marso SP, Griffin BP, Topol EJ, eds. Manual of Cardiovascular Medicine. Philadelphia: LippincottRaven, 2000.

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11. Rahimtoola SH. Prosthetic heart valve performance: long-term follow-up. Curr Probl Cardiol 1992:33406. 12. Shaff IW. Prosthetic Valves. In: Giuliani ER, Oersh BJ, McOoon MD, et al., eds. Mayo Clinic Practice of Cardiology, 3rd ed. St. Louis: Mosby, 1996:1484-1495. 13. Vogel W, Stoll HP, Bay W, et al. Cineradiography for determination of normal and abnormal function in mechanical heart valves. Am J Cardiol 1993;71:225-232. 14. Vongratanasin W, Hillis LD, et al. Prosthetic heart valves. N Engl J Med 1996;335: 407-416. 15. Zabalgoitia M. Echocardiographic assessment of prosthetic heart valves. Curr Probl Cardiol 1992:270-325.

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suy tim

Suy tim l mt hi chng bnh l thng gp trong nhiu bnh v tim mch nh cc bnh van tim, bnh c tim, bnh mch vnh, bnh tim bm sinh v mt s bnh khc c nh hng nhiu n tim. Bnh thng khi chng ta cn lm mt hot ng gng sc no (lao ng, chy nhy...) th lp tc tim s tng tn s v tng sc co bp a c nhiu mu (tc l a c nhiu xy) n cho cc m ca c th. Nhng khi tim b suy, th tim khng cn kh nng cung cp mu theo nhu cu ca c th na. V vy ngi ta c th nh ngha: Suy tim l trng thi bnh l ed trong cung lng tim khng p ng vi nhureserv ca c cu th v mt xy trong mi tnh hung sinh hot ghts bnh nhn. ca .vn l ri .com trn lm l Suy tim l mt tnh trng bnh l rtAthng gp . a oo oev c hkhong 2,3 triu sng. Theo nghin cu Framingham l th@y Fin 0 ngi M b suy tim (1981) v 08. 202 mi nm c khong cng M y 20 400.000 bnh nhn mi mc suytocit (thng k nm 1983). ht Po tim rig Gn y, trn cys nhng hiu bit su sc hn v c ch p Co bnh sinh ca suy tim, v tnh nng v tc dng ca mt s loi thuc mi trong iu tr suy tim, ngi ta thu c nhng kt qu kh quan trong vic iu tr hi chng ny. I. Sinh l bnh Chng ta bit trong suy tim thng l cung lng tim b gim xung. Khi cung lng tim b gim xung th c th phn ng li bng cc c ch b tr ca tim v ca cc h thng ngoi tim, c duy tr cung lng ny. Nhng khi cc c ch b tr ny b vt qu s xy ra suy tim vi nhiu hu qu ca n.

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A. Cc yu t nh hng n cung lng tim: Qua nghin cu, ngi ta hiu r c cung lng tim ph thuc vo 4 yu t: Tin gnh, hu gnh, sc co bp ca c tim v tn s tim. Sc co bp c tim Tin gnh Cung lng tim Hu gnh

Tn s tim 1. Tin gnh: (Preload) a. Tin gnh c nh gi bng th tch hoc p ved lc cui tm trng ca tm tht. ser e sr b. Tin gnh l yu t quyt nhight .vn ko di mc r m si c tim trong thi k tm All oo.co trc lc tm . trng, v ah tht co bp. Tin gnhinloe thuc vo: ph @y . F 2020 l lng mu tnh 8 p lc y tht, tc 00 y 2 toc tht. mch trtv tmit h o yrig ca tm tht, nhng mc t quan gin P p Co trng hn. 2. Sc co bp ca c tim: a. Trc y bng thc nghim ni ting ca mnh, Starling cho ta hiu r c mi tng quan gia p lc hoc th tch cui tm trng trong tm tht vi th tch nht bp. C th l: Khi p lc hoc th tch cui tm trng trong tm tht tng, th s lm tng sc co bp ca c tim v th tch nht bp s tng ln. Nhng n mt mc no , th d p lc hoc th tch cui tm trng ca tm tht c tip tc tng ln i na, th th tch nht bp s khng tng tng ng m thm ch cn b gim i. 342 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

b. Qua y ta c th hiu c mt vn quan trng trong suy tim l: p lc hoc th tch cui tm trng trong tm tht tng do cc nguyn nhn khc nhau, s lm th tch nht bp tng, nhng sau mt thi gian s dn n suy tim v sc co bp ca c tim km dn v khi th tch nht bp s gim i. Tim cng suy th th tch nht bp cng gim. 3. Hu gnh (Afterload): Hu gnh l sc cn ca cc ng mch i vi s co bp ca tm tht. Sc cn cng cao th s co bp ca tm tht cng phi ln. Nu sc cn thp qu c th s lm gim s co bp ca tm tht, nhng nu sc cn tng cao s lm tng cng ca tim cng nh tng mc tiu th xy eca c vd ser tim, t s lm gim sc co bp ca c etim v lm r ts gim lu lng tim. gh m.vn i ll r co 4. Tn s tim: Trong suy tim, ev. A u. nhp tim tng lc hoo a ln, s c tc dng b trinlo 0@y tnh trng gim th F tt cho 2 . tch nht bp v qua08 ty20duy tr c cung lng s 20 oci tim. Nhng nu tnhpt tim tng qu nhiu th nhu cu h Po rig s li tng ln, cng ca c tim cng xy ca cytim p Co phi tng cao v hu qu l tim s cng b suy yu i mt cch nhanh chng. B. Cc c ch b tr trong suy tim 1. C ch b tr ti tim: a. Gin tm tht: Gin tm tht chnh l c ch thch ng u tin trnh qu tng p lc cui tm trng ca tm tht. Khi tm tht gin ra, s lm ko di cc si c tim v theo lut Starling, s lm tng sc co bp ca cc si c tim nu d tr co c vn cn. b. Ph i tm tht: Tim cng c th thch ng bng cch tng b dy cc thnh tim, nht l trong trng hp tng p lc cc bung tim. 343 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Vic tng b dy ca cc thnh tim ch yu l i ph vi tnh trng tng hu gnh. Ta bit rng khi hu gnh tng s lm gim th tch tng mu, do b li c tim phi tng b dy ln. c. H thn kinh giao cm c kch thch: Khi c suy tim, h thn kinh giao cm c kch thch, lng Catecholamin t u tn cng ca cc si giao cm hu hch c tit ra nhiu lm tng sc co bp ca c tim v tng tn s tim. 2. Bng ba c ch thch ng ny, cung lng tim s c iu chnh li gn vi mc bnh thng. Tuy nhin cc c ch ny cng ch c th gii quyt trong mt chng mc no m thi. Thc vy, nu tm tht gin n mc ti a v d tr co c ved gim b ser tng e th lut Starling s tr nn rt t hiu lc. rCng ts t nh vy, ph i cc thnh tim rs hlmvn g m. tng cng l i o A hoo.c ca tim. H thn kinh giao cm. bl kch thch lu ngy oev a cng s dn n gim mtn0cm th bta trong cc i l 2 @y .F 0 si c tim v gim dn8p ng vi Catecholamin. 00 ity2 2 c 3. C ch b tr ht Pototim: Trong suy tim, i ph g ngoi ri vi vic gim cung lng tim, h thng mch mu py Co ngoi vi c co li tng cng th tch tun hon hu ch. C th c ba h thng co mch ngoi vi c huy ng: a. H thng thn kinh giao cm: Cng giao cm s lm co mch ngoi vi da, thn v v sau khu vc cc tng trong bng v cc c. b. H Renin-Angiotensin-Aldosteron: Vic tng cng hot ha h thn kinh giao cm v gim ti mu thn (do co mch) s lm tng nng Renin trong mu. Renin s hot ha Angiotensinogen v cc phn ng tip theo tng tng hp Angiotensin II. Chnh Angiotensin II l mt cht gy co mch rt mnh, ng thi n li tham gia vo kch thch sinh tng hp v gii 344 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

phng Nor-adrenalin u tn cng cc si thn kinh giao cm hu hch v Adrenalin t ty thng thn. Cng chnh Angiotensin II cn kch thch v thng thn tit ra Aldosteron, t lm tng ti hp thu Natri v nc ng thn. c. H Arginin-Vasopressin: Trong suy tim giai on mun hn, vng di i - tuyn yn c kch thch tit ra Arginin - Vasopressin, lm tng thm tc dng co mch ngoi vi ca Angiotensin II, ng thi lm tng ti hp thu nc ng thn. d. C 3 h thng co mch ny u nhm mc ch duy tr cung lng tim, nhng lu ngy chng li lm tng tin gnh v hu gnh, tng ved v nc ser c tim, Natri, tng cng v mc tiu th xyre ca s to nn mt "vng lun qun" bnht l.vn lm cho gh m v ri suy tim ngy mt nng hn. All oo.co . ah ev 4. Ngoi ra, trong suy tim, Finlo 0c gng b p li vic nhm @y 2 . co mch khu tr hay08 ty20 ni trn, cc h thng 0 ton b 2 i gin mch vi ht Potoc g Bradykinin, cc Prostaglandin (PGI2 , i PGE2) vopyr t nh lm tng o thi Natri (Atrial Yu C Peptid) vit tt l APN, cng c huy Natriuretic ng song hiu qu thng khng nhiu. C. Hu qu ca suy tim: Khi cc c ch b tr (c ch thch ng) ni trn b vt qua th s xy ra suy tim vi cc hu qu nh sau: 1. Gim cung lng tim: cung lng tim gim s gy: a. Gim vn chuyn xy trong mu v gim cung cp xy cho cc t chc ngoi vi. b. C s phn phi li lu lng mu n cc c quan trong c th: lu lng mu gim bt da, cc c, thn v cui cng mt s tng khc u tin mu cho no v ng mch vnh.

345 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

c. Nu cung lng tim rt thp th lu lng nc tiu c lc ra khi ng thn cng s rt t. 2. Tng p lc tnh mch ngoi vi: a. Suy tim phi: Tng p lc cui tm trng tht phi s lm tng p lc nh phi ri t lm tng p lc cc tnh mch ngoi vi v lm cho tnh mch c ni, gan to, ph, tm ti... b. Suy tim tri: Tng p lc cui tm trng tht tri s lm tng p lc nh tri, ri tip n lm tng p lc tnh mch phi v mao mch phi. Khi mu cng cc mao mch phi s lm th tch kh cc ph nang b gim xung, s trao i xy phi s km i lm bnh nhn kh th. c bit khi p lc mao mch phi tng nemt mc ved s r mch no s ph v hng ro ph nang re mao hts n phi v huyt tng s c th rig om.v cc ph trn vo ll c nang, gy ra hin tng ph A ahoo. v. phi. loe y II. Phn loi v nguyn nhn. Fin020@ 08 2 20 thy A. Phn loi suy tim: Ctocit c nhiu cch phn loi suy ht o tim khc nhau,yrig trn c s: da P p Co 1. Hnh thi nh khu: Suy tim phi, suy tim tri v suy tim ton b. 2. Tnh trng tin trin: Suy tim cp v suy tim mn tnh. 3. Lu lng tim: Suy tim gim lu lng v suy tim tng lu lng. 4. Suy tim do tng tin gnh v suy tim do tng hu gnh. 5. Tuy nhin, trn lm sng ngi ta thng hay chia ra ba loi: suy tim tri, suy tim phi v suy tim ton b. B. Nguyn nhn suy tim 1. Suy tim tri: 346 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

a. Tng huyt p ng mch: l nguyn nhn thng gp nht gy ra suy tim tri. Chnh tng huyt p lm cn tr s tng mu ca tht tri tc l lm tng hu gnh. b. Mt s bnh van tim: H hay hp van ng mch ch n thun hoc phi hp vi nhau. H van hai l. c. Cc tn thng c tim: Nhi mu c tim. Vim c tim do thp tim, nhim c hay nhim khun. Cc bnh c tim. d. Mt s ri lon nhp tim: c ba loi rri lon ved secnh ca nhp tim ch yu c th a n bnh re ts gh m.vn suy tim tri: i ll r co Cn nhp nhanh kch vphthoo. tht, nht l . A a trn e cn rung nh hayFinlo cung ng nh. cn 0@y 2 . Cn nhp nhanh tht. 08 20 20 ocity Bloc nh t tht hon ton. - t igh Po yr e. Mt s bnh tim bm sinh: p Co Hp eo ng mch ch. Cn ng ng mch. ng nh - tht chung... f. Ch : Trng hp hp van hai l, do tng cao p lc trong nh tri v mao mch phi nn dn n nhng triu chng ging nh suy tim tri. Nhng s thc th hp hai l n thun khng gy c suy tim tri theo ng ngha ca n v hp hai l to nn mt s cn tr dng mu i ti tht tri, lm cho p lc (hay th tch) cui tm trng ca tht tri li b gim hn bnh thng; tm tht tri khng b tng gnh nn khng suy c. 2. Suy tim phi: 347 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

a. Cc nguyn nhn v phi v d dng lng ngc, ct sng: Cc bnh phi mn tnh : Hen ph qun, vim ph qun mn, gin ph nang, gin ph qun, x phi, bnh bi phi... dn dn a n bnh cnh ca tm ph mn. Nhi mu phi gy ra bnh cnh tm ph cp. Tng p lc ng mch phi tin pht. G vo ct sng, cc d dng lng ngc khc. b. Cc nguyn nhn tim mch: Hp van hai l l nguyn nhn thng gp nht. Mt s bnh tim bm sinh: hp ng mch phi, tam chng Fallot. Mt s bnh tim bm ved ser sinh khc c lung shunt triphi (thng e sr lin nh, thng lin tht vv...)ht .vn g n giai on ri m mun s c bin chng llca.co . A ahoo tng p ng v mch phi v gy inloetim phi. suy @y 0 Vim ni tm . F 202 nhim khun gy tn 8 mc 00 ity 2 c thng nng ovan ba l. t gh Pot nhn t gp: u nhy nh tri, v Mt s nguyn ri py Co phnh xoang Valsalva vo cc bung tim ti bn phi, tng p lc ng mch phi tin pht v v... c. Ch : Trng hp trn dch mng ngoi tim hoc vim mng ngoi tim co tht s c biu hin ging nh suy tim phi, nhng thc cht ch l nhng trng hp thiu nng tm trng ch khng phi suy tim phi theo ng ngha ca n. 3. Suy tim ton b: a. Thng gp nht l cc trng hp suy tim tri tin trin thnh suy tim ton b. b. Cc bnh c tim gin. 348 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

c. Vim tim ton b do thp tim, vim c tim. d. Cui cng cn phi nhc n mt s nguyn nhn c bit gy suy tim ton b vi "lu lng tng": Cng gip trng. Thiu Vitamin B1. Thiu mu nng. D ng - tnh mch. III. Triu chng A. Suy tim tri 1. Triu chng c nng: a. Kh th: L triu chng hay gp nht. Lc u ch kh th khi gng sc, v sau kh th xy ra thng xuyn, bnh nhn nm cng kh ved nn th ser mc thng phi ngi dy th. Din bine v r ts kh th cng rt khc nhau: cigh m.vn th mt khi kh l r co cch dn dn, nhng nhiu Al hon t ngt, d . khi o. ev di nh trong cn heninlo 0@yaph phi cp. tim hay .F 2 b. Ho: Hay xy ra 008 tban m hoc khi bnh nhn vo y20 2 i gng sc. ght Potoc ho khan nhng cng c khi Thng l i ho ra opyr ln t mu. m C 2. Triu chng thc th: a. Khm tim: Nhn, s thy mm tim p hi lch sang tri. Nghe tim: Ngoi cc triu chng c th gp ca mt vi bnh van tim gy nn suy tht tri, ta thng thy c ba du hiu: Nhp tim nhanh. C th nghe thy ting nga phi. Cng thng nghe thy mt ting thi tm thu nh mm, du hiu ca h van hai l c nng v bung tht tri gin to. b. Khm phi: Thng thy ran m ri rc hai bn y phi. Trong trng hp cn hen tim c th nghe c nhiu ran rt v ran m hai phi, cn 349 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

trong trng hp ph phi cp s nghe thy rt nhiu ran m to, nh ht dng nhanh t hai y phi ln khp hai ph trng nh "thy triu dng". Trong a s cc trng hp, huyt p ng mch ti a thng gim, huyt p ti thiu li bnh thng nn s huyt p chnh lch thng nh i. 3. Cc xt nghim chn on: a. Xquang: Tim to ra nht l cc bung tim bn tri. Trn phim thng: tm tht tri gin biu hin bng cung di bn tri phng v ko di ra. C hai phi m nht l vng rn phi. ved khi i er c th bt gp ng Kerley s(do ph cc res ht .v ca khong k ca h thng bchghuyt n phi) l ri .com hoc hnh nh "cnh v. Al hookinh in hai bm" a loehp c ph phi. rn phi trong trng 0@y Fin02 . b. in tm : Thngych thy du hiu tng gnh 08 2 20 ocit t cc bunggtim bn tri: Trc tri, dy nh tri, dy t i h Po y tht tri. r p Co c. Siu m tim: Thng thy kch thc cc bung tim tri (nh tri, tht tri) gin to. Ngoi ra siu m cn gip ta bit c s co bp ca cc vch tim cng nh nh gi c chnh xc chc nng tm thu ca tht tri. Trong nhiu trng hp siu m tim cn gip cho ta khng nh mt s nguyn nhn gy ra suy tim tri. d. Thm d huyt ng cho php: nh gi mc suy tim tri thng qua vic o ch s tim (bnh thng t 2-3,5 l/pht/m2) v o p lc cui tm trng ca tht tri. nh gi chnh xc mc nng nh ca mt s bnh van tim.

350 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

B. Suy tim phi 1. Triu chng c nng: a. Kh th: t hoc nhiu, nhng kh th thng xuyn, ngy mt nng dn v khng c cc cn kch pht nh trong suy tim tri. b. Ngoi ra, bnh nhn hay c cm gic au tc vng h sn phi (do gan to v au). 2. Triu chng thc th: a. Ch yu l nhng du hiu mu ngoi bin: Gan to u, mt nhn, b t, au mt cch t pht hoc khi s vo gan th au. Lc u gan nh i khi c iu tr v gan to li trong t suy tim sau, nn cn gi l gan "n xp". V ved sau, do mu lu ngy nn ganeser khng th r ts nh li c na v tr nn cng. .vn gh m ri Tnh mch c ni to v ll oo.chiu phn hi du o . A ah gan-tnh mch cnloev @y tnh. p lc tnh dng i . F 20 0 mch trung ng v 2p lc tnh mch ngoi 8 00 bin tng cao.tocity 2 t igh Po Tm da v nim mc: Tm l do mu b tr yr p Co ngoi bin, nn lng Hemoglobin kh tng ln trong mu. Ty mc suy tim m tm nhiu hay t. Nu suy tim nh th ch thy tm t mi v u chi. Cn nu suy tim nng th c th thy tm r ton thn. Ph: Ph mm, lc u ch khu tr hai chi di, v sau nu suy tim nng th c th thy ph ton thn, thm ch c th c thm trn dch cc mng (trn dch mng phi, c chng...). Bnh nhn thng i t (khong 200 - 500ml/ngy). Nc tiu sm mu. b. Khm tim: S: c th thy du hiu Hartzer (tm tht phi p vng mi c), nhng khng phi bnh nhn no cng c du hiu ny. 351 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Nghe: ngoi cc triu chng ca bnh gy ra suy tim phi ta cn c th thy: (a) Nhp tim thng nhanh, i khi c ting nga phi phi. (b) Cng c khi nghe thy ting thi tm thu nh trong mm hoc vng mi c do h van ba l c nng. Khi ht vo su, ting thi ny thng r hn (du hiu Rivero-Carvalho). (c) Huyt p ng mch ti a bnh thng, nhng huyt p ti thiu thng tng ln. 3. Cc xt nghim chn on: tr trng hp suy tim phi do hp ng mch phi c nhng c im ring ca n, cn trong a s cc trng hp khc ta ethy: vd ser a. X quang: re ts gh m.vn Trn phim tim phi thng: ri o l (a) Cung di phi (tm Al hoo.c gin. v. nh phi) e a (b) Mm tim nng locao yhn pha trn vm Fin020@ honh tri, 8. y2 tht phi gin. 00 do tm 2 tocit (c) Cungt ng mch phi cng gin to. gh Po (d)pyri m nhiu do mu phi. Phi Co Trn phim nghing tri: Tht phi to lm cho khong sng sau xng c b hp li. b. in tm : Thng thy cc du hiu ca trc phi, dy nh phi, dy tht phi. c. Siu m tim: ch yu thy kch thc tht phi gin to. Trong nhiu trng hp c th thy cc du hiu ca tng p ng mch phi. d. Thm d huyt ng: c th thy: p lc cui tm trng ca tht phi tng (thng l trn 12 mmHg). p lc ng mch phi cng thng tng. C. Suy tim ton b: Thng l bnh cnh ca suy tim phi mc nng: 1. Bnh nhn kh th thng xuyn, ph ton thn. 352 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

2. Tnh mch c ni to, p lc tnh mch tng rt cao. 3. Gan to nhiu.. 4. Thng c thm trn dch mng phi, mng tim hay c chng. 5. Huyt p ti a h, huyt p ti thiu tng, lm cho huyt p tr nn kt. 6. X quang: Tim to ton b. 7. in tm : C th c biu hin dy hai tht. IV. nh gi mc suy tim C nhiu cch nh gi mc suy tim, nhng trn y vn th gii ngi ta thng hay dng cch phn loi mc suy tim theo Hi Tim mch hc New York (New York dHeart e erv Association) vit tt l NYHA, da trn s nh gi mc hot res ng th lc v cc triu chng c nng ca bnh hts .vn ig nhn. ll r o.com A. Phn loi mc suy tim theoANYHA v. ho loe @ya Bng 18-1. Phn loi mc .n 20tim theo NYHA. Fi suy 0 08 hin Biu ity2 20 oc t ot I Bnh nhn c bnh h Pnhng khng c triu chng c rig tim y nng no, vn psinh hot v hot ng th lc gn nh Co bnh thng. II Cc triu chng c nng ch xut hin khi gng sc nhiu. Bnh nhn b gim nh cc hot ng v th lc. III Cc triu chng c nng xut hin k c khi gng sc rt t, lm hn ch nhiu cc hot ng th lc. IV Cc triu chng c nng tn ti mt cch thng xuyn, k c lc bnh nhn ngh ngi khng lm g c. Trong thc t lm sng, cch phn loi ny rt tt i vi suy tim tri, nhng khng tht thch hp lm i vi cc bnh nhn suy tim phi. B. Phn loi mc suy tim trn lm sng nc ta, s lng cc bnh nhn suy tim phi thng chim mt t l kh ln trong s cc bnh nhn b suy tim. V 353 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

vy, s b trn lm sng cc thy thuc thng qui c mc suy tim theo khuyn co ca Hi Ni khoa Vit nam nh sau: Bng 18-2. Phn loi mc suy tim trn lm sng. Biu hin I Bnh nhn c kh th nh nhng gan cha s thy. II Bnh nhn kh th va, gan to di b sn vi cm. III Bnh nhn kh th nhiu, gan to gn st rn nhng khi c iu tr gan c th nh li. IV Bnh nhn kh th thng xuyn, gan lun to nhiu mc d c iu tr. V. iu tr iu tr suy tim bao gm: Nhng bin php iu tr chung cho tt c cc loi ed erv nguyn nhn gy ra suy tim, nhm gim trstun hon e sr v tng cng kh nng co bp ca c tim. t .vn gh m l ri co Nhng bin php iu tr c bit l po.dng cho tng . A aho oev trng hp c th ty theo nguyn @y ca suy tim. inl 20 nhn F 8. 0 00 ity chung A. Nhng bin php iu tr 2 2 t otoc ghkhng dng thuc: 1. Cc bin php P ri py Co ngh ngi: Ngh ngi l mt vic kh a. Ch quan trng v n gp phn lm gim cng ca tim. Ni chung bnh nhn cn gim hoc b hn cc hot ng gng sc. Trong trng hp suy tim nng th phi ngh ti ging theo t th na nm na ngi. Tuy nhin, trong trng hp suy tim m bnh nhn phi nm iu tr lu ngy th khi hon cnh cho php, nn khuyn khch bnh nhn xoa bp, lc u l th ng, sau l ch ng cc chi, nht l hai chi di lm cho mu tnh mch tr v tim c d dng hn, gim bt cc nguy c huyt khi tnh mch thng hay gp nhng bnh nhn ny. b. Ch n gim mui: 354 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Ch n gim mui l cn thit, v mui n (NaCl) lm tng p lc thm thu trong mu, do lm tng khi lng tun hon, t gy tng gnh nng cho tim. Mt ngi bnh thng hp thu khong 6 18g mui NaCl/ ngy, tc l 2,4 - 7,2g (100 300mmol) Na+ / ngy. i vi bnh nhn suy tim, ty tng trng hp c th m p dng ch n gim mui hoc ch n gn nh nht hon ton. Ch n gim mui: Bnh nhn ch c dng < 3g mui NaCl /ngy, tc l < 1,2g (50 mmol) Na+ /ngy. Ch n gn nh nht hon ton: Bnh nhn ed ch c n < 1,2g mui NaCl /ngyrv l < se tc re 0,48g (20mmol) Na+ /ngy. ghts .vn i ll dng c. Hn ch lng nc v dchr o.com cho bnh . A aho nhn: oev inl 20@y F Cn hn ch 0lng0 nc v dch dng cho 8. 0 ity2 bnh nhn 2hng ngy nhm gim bt khi c ht Poto lngitun hon v gim gnh nng vi tim. rg py Co Ni chung ch nn dng cho bnh nhn khong 500 - 1000ml lng dch a vo c th mi ngy. d. Th xy: l bin php cn thit trong nhiu trng hp suy tim v n tng cung cp thm xy cho cc m, gim bt mc kh th ca bnh nhn, ng thi lm hn ch s co mch phi thng gp nhng bnh nhn thiu xy. e. Loi b cc yu t nguy c khc: B ru, thuc l, c ph... Gim cn nng nhng bnh nhn bo ph. Trnh cc xc cm mnh (stress). Ngng nhng thuc lm gim sc bp ca c tim nu ang dng, v d: cc thuc chn bta 355 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

giao cm hoc Verapamil hay Disopyramide, Flecainide... iu tr nhng yu t lm nng thm tnh trng suy tim nh nhim trng, ri lon nhp tim... B. Cc thuc trong iu tr suy tim 1. GLUCOSID tr tim: a. Cc dng Glucosid tr tim c dng trn lm sng l: Digitalis vi cc dng Digitalin hay Digitoxin ly t Digitalis Purpurea; Digoxin v Isolanid ly t Digitalis Lanata. Strophanthus vi cc dng G Strophantin (tc d Uabain) ly t Strophantus Kombe. serve e Trong thc hnh lm sng r hin nay ts . gh timvn ri DIGOXIN l loi thucll tr.com tiu biu . A ahoo hay s dng thng c cc thy thuc oev inl 20@y nhiu nht. F 8. 0 00 ity2 b. C ch tc dng: c 2 t o gh P t Digoxin lmotng sc co bp ca c tim gin ri py tip thng qua vic c ch men Natri - Kali Co Adenosine Triphosphatase (Na+-K+-ATPase) ca bm ion mng t bo c tim, t cn tr vic ion Na+ thot ra ngoi mng t bo. Do s c ch ny lm cho nng Na+ trong t bo tng cao, v vy s vn chuyn Na+ Ca++ qua mng t bo cng b ri lon, lm tng nng Ca++ trong t bo c tim, t thc y cc si c tim tng cng co bp. Mt khc Digoxin cn tc ng trn h thng thn kinh t ng ca tim, lm gim nhp tim v gim tc dn truyn nh - tht. Ngoi ra Digoxin cn lm tng trng lc h ph giao cm v lm gim hot tnh ca h giao cm. 356 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

c. Dc ng hc: Digoxin thng c dng di dng ung (vin nn, vin nang, dng cn) hoc tim. dng ung, phn ln Digoxin c hp thu rut non sau s c phn b tip ti mt s m. Nng Digoxin thng c tp trung ch yu thn, tim, gan, tuyn thng thn, ng tiu ha... Digoxin c chuyn ha ch yu ti gan. Phn ln Digoxin c thi tr qua ng nc tiu, ch c mt phn nh (khong 25%) c thi tr qua ng phn. ngi ln, vi chc nng gan, thn bnh thng th thi gian bn hy trung bnh ca ed Digoxin (theo ng ung) l 36 gi.rv se re ts Mt s nghin cu cho thy .ln nng gh m v i ll r co trung bnh trong huyt tngo.ca Digoxin c . A aho tc dng iu tr thngy oev trong khong t 0,5 inl 20@ . F 20 hoc 0,8 n 82,0ng/ml. Tuy nhin khong 00 it iu tr v nng ng 2 c cch gia nng y ht Poto grt hp. C bnh nhn phi dng trn cyl ri p 2,0 ng/ml mi c tc dng iu tr, ngc li Co mt s bnh nhn khc nng 0,8 - 1,5 ng/ml c triu chng ca ng c Digoxin. d. Liu lng v cch dng: Trc y ngi ta hay dng bt u bng liu tn cng sau chuyn sang liu duy tr. Liu tn cng thng l 0,25 - 0,5mg, ri c sau 6 gi c th cho thm 0,25mg t tng liu l 1 - 1,5 mg/ngy. Khi t c hiu qu, thng chuyn sang liu duy tr t 0,125 - 0,375mg/ngy. Ngy nay ngi ta thng khng cn dng liu tn cng vi mt lng thuc ln trong mt thi gian ngn nh trn v cch ny rt d gy nguy him cho bnh nhn. Trong a s 357 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

cc trng hp, cc thy thuc thng bt u ngay bng liu duy tr nh trnh by trn t dn ti liu c hiu lc iu tr. Vic theo di nng Digoxin trong huyt tng s gip ta iu chnh c ti liu iu tr ti u. Nng Digoxin huyt tng trong khong t 1,8 - 2 ng/ml c coi l nng c hiu lc iu tr, qu nng th d b nhim c Digoxin. e. Tng tc thuc: Mt s thuc c th lm gim vic hp thu Digoxin nh: Cholestyramine, Cholestipol, Kaolin-pectin, Sulfasalazine, Neomycine v.v... Ngc li, mt s thuc c th lm tng vic ved hp thu Digoxin nh Tetracycline hoc ser re hts n Erythromycine. Mt s thucgkhc.vc th lm l ri om gim ng k thanh .thi Digoxin, do c Al hoo.c th lm tng nng nloev @ya ca Digoxin trong mu i . 2020 nh: Quinidine, FVerapamil, Spironolactone, 8 00 Amiodarone...ocity 2 t ht Po Cnyc bit ch khng bao gi c dng rig p Co phi hp Digoxin vi cc mui Canxi (ng tnh mch) v s phi hp ny c th gy nn nhng ri lon nhp tim nng n, thm ch c th gy t vong. f. Ch nh: Suy tim vi cung lng tim thp, c bit khi c rung nh nhanh. Cc ri lon nhp trn tht, c bit trong rung nh hay cung ng nh. Ch : Nhng trng hp suy tim vi cung lng tim cao (thiu mu nng, nhim c gip, d ng - tnh mch, bnh thiu vitamin B1...) hoc suy tim c lin quan n mt tc nghn c hc hay suy tim trong tm ph mn khng phi l nhng ch nh ca Digoxin. 358 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

g. Chng ch nh: Nhp tim chm. Bloc nh - tht cp II, cp III cha c t my to nhp. Ngoi tm thu tht. Nhp nhanh tht v rung tht. Hi chng Wolff - Parkinson - White. Bnh c tim tc nghn. Cn thn trng trong trng hp: Nhi mu c tim cp (v Digoxin lm tng nhu cu xy ca c tim) v cc ri lon in gii, c bit l h K+ mu v / hoc h Mg ++ mu. h. Nhim c Digoxin: mt s thng k cho thy s bnh nhn dng Digoxin b nhim c chim khong 5 - 15% tng s bnh nhn dng thuc. ved ser Yu t thun li cho nhim c Digoxin l : re + mu, (a) Ri lon in gii: h Kghts .vn h Mg++ i mu, tng Ca++ mu.All r o.com . aho nhy cm vi (b) Tui cao: lm loev y tng Fin0 Digoxin do8gim 20@lc ca thn, t d . 2 0 lm ng cthuc. 20 o ity ht kim (c) Nhim Pot chuyn ha. rig (d)py Gim xy mu. Co (e) Suy thn, suy gan... Biu hin lm sng ca nhim c Digoxin: khi bnh nhn ang dng Digoxin, t nhin thy mt s biu hin sau : (a) Ri lon tiu ha: chn n, bun nn, nn ma, a chy. (b) Ri lon thn kinh: c th ch l au u, chng mt nhng c th nng hn nh o gic, mt phng hng, m sng... (c) Ri lon tim mch: do tng tnh kch thch, tng tnh t ng v gim tnh dn truyn ca t bo c tim: i. Ngoi tm thu nh v tht, hay gp l ngoi tm thu tht nhp i, ngoi tm thu tht a dng hoc tng chm. 359 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

ii. Nhp nhanh b ni, nhp nhanh tht. iii. Bloc xoang - nh. iv. Bloc nh - tht cc loi. v. Xon nh, rung tht. X tr nhim c Digoxin: (a) Ngng ngay vic iu tr bng Digoxin. (b) Theo di cht ch nhng din bin trn in tm . (c) iu chnh kp thi cc ri lon v in gii v thng bng toan kim, trong cn c bit lu c tnh trng h K+ mu khng? Nu c h K+ mu cn cho bnh nhn ung khong 20 - 50 ml dung dch Kalichlorua 10%. Trng hp cn thit c th truyn nh git Kalichlorua vo tnh ved mch sau khi pha thuc trong dung ser e dch ng trng, nhng hts r n vi iu kin .v + g mkhng c m K truyn tnh ri co ll mch . vt qu 13 - 15mmol/gi. v. A ahoo oe y (d) C th dngFAtropin tim tnh mch vi inl @ . 2020 liu t 0,5 8 1mg khi c nhp chm xoang 00 - ity 2 tchm do Bloc nh - tht. hoc tnhp oc gh Po (e)pyri cc loi ri lon nhp tht, c bit l Vi Co ngoi tm thu tht, ta c th iu tr bng cch truyn Lidocaine vi m 2mg/pht. (f) Gn y ngi ta cn dng mt phng php kh mi na iu tr nhng trng hp nhim c Digoxin. l dng khng th c hiu ca Digoxin (Fab fragments, Digibind) v thng c vit tt l Fab. Thng Fab c dng theo ng truyn tnh mch. i. C ch: Phc hp Digoxin kt hp vi Fab s c o thi qua thn, lm mt tc dng ca Digoxin. Mt ng Fab 40mg trung ha 0,6mg Digoxin.

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ii. Vi ng c mn Digoxin: S ng Fab cn dng = [nng Digoxin mu (ng/ml) cn nng c th (kg)] / 100. iii. Vi ng c cp Digoxin: S ng Fab cn dng = [liu lng Digoxin dng cho bnh nhn (mg) 0,8] / 0,6. 2. Thuc li tiu: a. Thuc li tiu lm tng o thi nc tiu, qua lm gim khi lng nc trong c th, gim khi lng mu lu hnh, lm bt lng mu tr v tim v lm gim th tch cng nh p lc cui tm trng ca tm tht, lm gim tin gnh, to iu kin cho c tim b suy yu hot ng c tt hn. b. Bin chng c th gp khi dng cc thucved tiu li ser l h K+ mu, h Na+ mu, lm gimreth tch v s mt vn kim ha mu. H K+ mu lright m.bin chng quan trng, c th e do All oomng ca bnh tnh .co v. vi Digoxin. Do oe nhn, nht l khi dng lcngyah Fin020@ cn phi theo di khi iu tr bng 08. 2 li tiu, thuc 20 mu. cht ch in giiocity Vic b mui Kali hoc t gh P t phi hprivi li otiu gi Kali l vn lun lun y n. phiCop nh c. Nhm thuc li tiu Thiazide (Chlorothiazide, Hydrochlothiazide, Metolazone, Indapamide): Thng c dng mt cch kh ph bin trong iu tr suy tim nhng bnh nhn m chc nng thn cn bnh thng. V tr tc ng ca thuc l ng ln xa (ring Metolazone cn tc ng trn c ng ln gn), vi c ch lm tng bi tit mui, do s lm tng thi nc. Hydrochlothiazide cn c dng nhiu v gi kh r. Bin chng c th gp khi dng Thiazide l h K+, Na+, Ca++ mu. Thuc cng c th lm tng ur, creatimin mu, c khi gy vim ty, vim mch. Gn y ngi ta cp n tc 361 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

d. Nhm thuc li tiu tc dng ln quai Henle (Furosemid, Bumetanide, Acid Ethacrynic...): V tr tc ng ch yu ca thuc l nhnh ln ca quai Henle. Li tiu nhm ny lm tng thi Natri ln n 25%, ngoi ra chng cn c tc dng lm tng dng mu n thn do lm tng hot ha Prostaglandin PGE c tc dng gin mch thn. V c tc dng li tiu mnh v khng lm gim chc nng thn nn li tiu nhm ny c ch nh bnh nhn suy tim m i hi phi gim th tch ved tun hon nhanh hoc bnh nhn esuy thn. ser r Furosemide ngoi kh nng hts .vn lm gim tin g m i gnh nhanh, khi dng tim rtnho mch n cn ll c . A ahoo. tip. V vy, c tc dng gy ginev y trc o mch inl c @ Furosemide c. bit 20 hiu qu trong iu tr F 0 bnh nhn suy 8 ity2 00 tim nng hoc b ph phi cp. 2 o Li tiu t nhmc ny c th gy h K+, Na+, gh ++ Pot ++ i , Capyr Mg mu. Ngoi ra mt s bnh nhn Co khi c th c biu hin ni ban, vim i mch... e. Nhm thuc li tiu gi Kali (Spironolactone, Triamterene, Amiloride): Li tiu nhm ny tc ng trn on cui ca ng ln xa. Spironolactone tc ng thng qua vng nhy cm aldosterone; Triamterene v Amiloride cng tc ng vng cui ca ng ln xa nhng khng chu s kim sot ca aldosterone. Tc dng li tiu ca cc thuc thuc nhm ny yu nu ch dng mt mnh. Nhng v li ch gi Kali nn chng thng c phi hp vi li tiu Thiazide hoc li tiu quai Henle. Li tiu gi Kali thng tc dng chm v 362 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

ko di. Ni chung vi loi li tiu gi Kali ny, khi dng cng phi theo di Kali mu, c bit ch khi dng cng vi thuc c ch men chuyn, hoc thuc gim vim khng Steroide. Ngoi ra nhm li tiu gi Kali ny cng i khi cng c th gy ra tng ur mu, si thn (vi Triamterene) hoc chng v to nam gii (vi Spironolactone). Bng 18-3. Mt s thuc li tiu dng trong suy tim. Tc Thuc ng Liu TB Bt u dng dng ngy (mg) tc ko di dng Thiazide Chlorothiazide U 250 2h 6 - 12h ved 500 ser e TM 500 15ph hts r 1h vn g m.12h Hydrochlothiazi U 25 100 2hll ri .co -de v. A hoo loe @ya Metolazone U 2,5 - 20,0 20 1h 24 - 48h Fin 8. 2 0t5,00 2h 0 Indapamide U 2,5 i y 24h 2 t oc Li tiu quai gh Pot ri Furosemide Upy 20 80 1h 6 - 8h Co TM, 10 80 5ph 2 - 4h TB Ethacrynic U 25 100 30ph 6 - 8h acide TM 50 5ph 2 - 4h Bumetanide U 0,5 - 2,0 30ph 2h TM, 0,5 - 2,0 5ph 30ph TB Torsenide U 5 - 10 2h 8 - 12h TM 5 - 10 5ph 6 - 8h Nhm gi kali Spironolactone U 50 - 200 1 - 2ng 2 - 3 ng Triamterene U 100 - 200 2 - 4 ng 7 - 9 ng Amiloride U 5 - 10 2h 24h

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OLX: ng ln xa, OLG: ng ln gn, QH: Quai Henle, U: ng ung, TM: tim tnh mch, TB: tim bp, h: gi, ph: pht, ng: ngy.

3. Cc thuc gin mch trong iu tr suy tim: a. Nh chng ta r, c ch b tr bnh nhn suy tim bao gm c s co tht h ng mch v tnh mch. S co tht h ng mch lm tng hu gnh v s co h tnh mch lm tng tin gnh. Hn na trong suy tim, s co tht h mch phi cn l hu qu ca thiu xy mu, hoc s p ng lu di vi vic tng dng mu qua phi (v d khi c Shunt tri phi trong tim) hoc p ng lu di vi vic tng p lc nh tri (V d: Hp hai l, suy tim tri...). b. Cc thuc gin mch c th u tin tc dng gim ved ser hu gnh, tin gnh hoc c hai. ts re n thuc Nhng h lm gin tnh mch nhiu hn rig com.v gim tin s lm ll . gnh v p lc y tht. ahoo cc thuc lm v. A Cn loe gin ng mch s. Fin 20@y hu gnh. V vy, lm gim 0 ni chung cc 2008 ity2 mch s ci thin c thuc gin t toc cung lnghtim, ogim p lc y tim v gim P rigthnh tim. nhng bnh nhn h van y sc ppln Co tim, suy tim nng hoc c tng tr khng mch, hoc suy tim c tng huyt p th dng cc thuc gin ng mch rt c hiu qu. c. Tc dng ph ni chung ca cc thuc gin mch trong iu tr suy tim thng l: H huyt p (nht l h huyt p trong t th ng), tng nh ur mu... Dng thuc gin mch cn ht sc thn trng nhng bnh nhn c hn ch cung lng tim (V d: Hp van ng mch ch, bnh c tim ph i tc nghn) hoc nhng bnh nhn c ri lon chc nng tm trng (Bnh c tim hn ch). d. Thuc c ch men chuyn dng angiotensin:

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Cc thuc thuc nhm ny c tc dng c ch men c nhim v chuyn t Angiotensin I thnh Angiotensin II t c ch s tng hp Angiotensin II, l mt cht gy co mch, ng thi li lm tng Bradykinin, l mt cht gy gin mch. Kt qu chung l cc thuc c ch men chuyn ny s lm gin mch nhiu, lm gim hu gnh, t gp phn ci thin tnh trng suy tim. Trong nhng nm gn y, vai tr ca thuc c ch men chuyn trong iu tr suy tim ngy cng c nhn mnh nht l trong nhng trng hp suy tim tr vi nhng bin php iu tr kinh in. Chng ch nh dng khi: Hp ng dmch e erv thn hai bn, ph n c thai. res Nhng tc dng ph c thggp .vn ho, ni hts l: ri cotng creatinin l . ban, tt huyt p, lon v lgic, m v. A ahoo mu, tng kali mu loe y n 0@ 2 Thn trng khiFidng thuc c ch men . 08 ty20 0 vi loi li tiu gi kali hoc 2 chuyn cng oci t gh Pot bnh nhn c huyt p thp. dngrthuc cho i py Bng 18-4. Mt s thuc c ch men chuyn thng dng. Co Thuc Liu u Trung bnh (mg/ngy) (mg/ngy) Benazepril (Cibace, Cibacen, 5 - 10 10 - 40 Lotensin) Captopril (Capoten, Lopril, 12,5 - 25 12,5 - 100 Lopiril, Captopril) Enalapril (Innovace, Pres, 2,5 - 5 2,5- 40 Renitec, Renivace, Vasotec) Fosinapril (Monopril, Staril) 10 10 - 40 Lisinopril (Prinivil, Zestril) 10 5 - 40 Quinapril (Accupril, Acuitel) 10 5 - 80 Ramipril (Altace, Delix, 1,25 - 2,5 1,25 - 20 Ramace, Triatec, Tritace) 365 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

e. Nhm thuc c ch trc tip th th AT1 ca angiotensin II: Cc thuc nhm ny kh mi v c ch l c ch trc tip th th AT1. Khc vi thuc c ch men chuyn, cc thuc c ch th th AT2 khng lm tng bradykinin nn c th khng gy ra cc triu chng ph nh l ho khan (mt tc dng ph rt ph bin khi dng CMC v l hn ch ng k ca CMC). Cc thuc ny c dng ch yu iu tr bnh nhn THA nhng cc nghin cu mi y cng chng minh vai tr tt trong iu tr suy tim v l thuc thay th cho CMC khi khng dung np c. ved Bng 18-5. Mt s thuc c ch th th ser AT1 ca re ts angiotensin II trong iu tr suy tim. gh m.vn ri co Thuc Liu ban uAll hLiu trung bnh . a oo. ev Candesartan 8-16inlo 0@y mg 2-32 mg 2 . F 20mg 8 Eprosartan 200-400 400-800 mg 00 ity 275-150 mg oc Irbersartan 75-300mg ht Pot rig Losartan 25 mg 25-100 mg py Co Telmisartan 20-40 mg 40 80 mg Valsartan 80 mg 80-320 mg f. Nhm Nitrates: Nhm Nitrat ch yu lm gin h tnh mch, t lm gim tin gnh. Nhm ny cn lm gim bt tnh trng thiu mu c tim do lm gim p lc y tim, ngoi ra chng cn lm gin trc tip ng mch vnh. Bng 18-6. Mt s Nitrat thng dng. Ko di Dng thuc Liu Bt (mg) u (pht) Nitroglycerin (ngm) 0,3 - 0,6 2 - 5 10-30ph Dinitrat Isosorbide (ngm) 2,5 - 10 10- 30 1 - 2 h 366 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Dinitrat Isosorbide (ung) 5 - 20 30- 60 4 - 8 h Mononitrat Isosorbide (ung) 10 - 20 30- 60 6 - 8h Nitroglycerin (cao dn) 5 - 15 > 30 12 - 14h Tc dng ph c th gp ca thuc l: nhc u, h huyt p, ni ban Nitrat c th c dng di dng ung, m bi da, cao dn, ngm di li hoc tim truyn tnh mch. g. Hydralazine: Lm gin h ng mch do tc dng lm gin trc tip c trn ca thnh mch mu, t lm gim hu gnh. V vy, Hydralazine rt c ch trong iu tr suy tim do h van tim. Ch : thuc c th gy tng nhp tim phn ved se x, au u, nn, lm xut hin cn rau tht e sr ngc. Liu dng trung bnh ht .ung 20 g l vn l ri om 100mg, chia thnh 2 - 3. ln trong ngy. Al hoo.c v h. Mt s thuc gin inloe @ya mch dng ng tim 0 . F thng c ch nh cho truyn: Cc thuc8ny 02 00 ity2 2 t suy nhng bnh tnhnoc tim nng hoc bnh nhn Po gh khng th ung c thuc. Khi suy tim ri y m p C dng,o cn bt u bng liu nh v theo di cht din bin v huyt ng. Khi ngng thuc, cn gim liu dn dn trnh cc phn x co mch t ngt. Nitroglycerin: lm gin h thng tnh mch v c tc dng gin trc tip mch vnh. (a) Nitroglycerin c ngh trong iu tr suy tim nhng bnh nhn b nhi mu c tim cp hoc bnh nhn au ngc khng n nh. (b) Thi gian bt u tc dng ca thuc rt nhanh; bn hy thng t 1 - 3 pht. (c) Liu dng ban u thng l 10g/pht (dng bm tim in). Bin chng nguy him c th gp l tt huyt p. 367 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Natri Nitroprusside: gy gin trc tip ng mch lm gim hu gnh, cn tc dng gin h tnh mch thng khng nhiu. (a) Thuc c ch nh nhng bnh nhn suy tim cp, nng do tng huyt p hoc h van tim nng. (b) Liu ban u thng l 10 g/pht (ti a 300 - 400 g/pht). Thi gian bn hy ca thuc l 1-3 pht. (c) Tt huyt p cng l bin chng quan trng cn theo di. V thuc c chuyn ha di dng Cyanide, nn c th gy ng c vi nng Thiocyanate trn 10 ng/dl, do cn thn trng bnh nhn ved suy thn. ser re ts Enalaprilat: gh m.vn l ri ca (a) L dng hot ha mt leste.co Enalapril . A ahoo dng tim tnh loev y Thi gian bt u mch. Fin020@gian bn hy ngn. tc dng nhanh, thi . 08 2 2 ocit thng l 1,25mg tim tnh (b) Liu ban0 u y ht Pot mch cho mi 6 gi. nhng bnh nhn rig py Co c dng km li tiu hoc suy thn nn gim liu (0,025mg tim TM/6gi). 4. Thuc chn bta giao cm: a. Trong nhng nm gn y, vai tr ca thuc chn bta giao cm trong iu tr suy tim ngy cng c nhn mnh. C ch l ngn chn tc dng kch thch thi qu ca h thn kinh giao cm trong suy tim huyt mn tnh. b. Cc thuc chn bta giao cm c ch nh trong iu tr suy tim mn, nng khi dng y cc thuc khc, nhng cng khng nn dng khi suy tim qu nng mt b. c. Hin nay mi ch c 3 loi thuc chn bta giao cm c chng minh l c th dng trong 368 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

iu tr suy tim l: Carvedilol (Dilatrend); Metoprolol (Betaloc) v Bisoprolol (Concor). d. Khi dng thuc chn bta giao cm trong iu tr suy tim nn bt u bng liu rt thp, theo di cht ch v tng dn liu chm. Li ch thc t ca khi dng chn bta giao cm ch xut hin chm v lu di. 5. Cc thuc chn knh canxi: a. Tuy l cc thuc gin mch nhng cc thuc chn knh canxi khng c dng iu tr suy tim v n c th nh hng sc co c tim, nht l cc thuc th h th nht. b. Mt s thuc th h th hai (Amlodipine) khng nh hng n sc co c tim nhng cnged erv khng res ci thin c suy tim. ts n igh khc: rtimom.v 6. Cc thuc lm tng sc co bpAc o.c ll o v. thng c dng a. Cc thuc ging giao nloe @yah cm: i iu tr trong cc 08. F 20hp suy tim nng m cc trng 20 0 thuc thng t thngity 2 c khng c hiu qu. Mt s h Poto g tc dngriph ca thuc c th gp l: lm tng py C thiu omu c tim, nhp tim nhanh, ri lon nhp tht, co mch ngoi bin. Khi iu tr ta cn phi theo di cht ch tnh trng huyt ng v in tim ca bnh nhn. Dopamine: (a) Liu 1- 3 g/kg/pht c tc dng lm gin mch thn v mc treo, thng qua kch thch th th Dopamine, kt qu lm tng dng mu n thn v s lng nc tiu. (b) Liu 2-5g/kg/pht lm tng sc co bp ca c tim do kch thch th th bta. (c) Liu cao hn 5-10 g/mg/pht th thuc s kch thch th th alpha giao cm gy co mch ngoi bin, tng tr khng h mch nh hng xu n cung lng tim. 369 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

(d) Dopamine rt c ngha khi ta dng cho bnh nhn suy tim c h huyt p. Mt nhc im ca thuc l hay lm cho nhp tim nhanh nhiu. Dobutamine: (a) Ch yu kch thch chn lc 1-giao cm, tc dng trn 2 v -giao cm yu hn nhiu. Thuc c tc dng ci thin tnh trng huyt ng, thng qua vic kch thch trc tip tc dng co c tim v lm gin h ng mch phn x, t lm gim hu gnh v tng cng ci thin cung lng tim. Khi dng thuc ny thng huyt p v nhp tim thay i d rve khng qu nhiu. Tuy nhin senhp tim re nhanh vn c th xy ra khi ts .vn liu cao. gh dng l ri m (b) Liu dng ban u,Albngcong truyn . ahoo. tnh mch hng loev y 1-2 g/kg/pht v nh t Finn @ t c hiu qu iu chnh 8. 020 khi cho 2 0 20 o ity huyt ng ccn thit. t t (c) Nhng bnh nhn suy tim nng, mn tnh, igh Po yr p Co c th dng tng t Dobutamine trong 2-4 ngy, gim mt cch ng k cc triu chng ca suy tim. Nhng bnh nhn phi dng Dobutamine ko di, cn theo di cht ch v khng nn vt qu liu 10 g/kg/pht. (d) Dobutamine khng c vai tr tt trong iu tr suy tim nhng bnh nhn c ri lon chc nng tm trng (v d: bnh c tim ph i) hoc bnh nhn suy tim c tng cung lng. b. Cc thuc c ch men Phosphodiesterase: lm tng sc co bp ca c tim v gin mch do lm tng adenosin mono phosphate vng (AMPc). 370 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Hai loi thuc c s dng trong lm sng l Amrinone v Milrinone. Chng c ch nh trong nhng t iu tr ngn ngy bnh nhn suy tim dai dng, kh iu tr. Amrinone c tc dng ci thin huyt ng nh Dobutamin, nhng lm gin mch mnh hn. V vy, h huyt p c th xy ra nhng bnh nhn c dng thuc ny cng vi mt thuc gin mch khc. Liu lng : (a) Amrinone tim tnh mch 750 g/kg trong 2 - 3 pht sau truyn tnh mch vi liu 2,5 - 10,0 g/kg/pht. (b) Milrinone: liu ban u l 50 g/kg, tim ved tnh mch trong 10 pht sau etruyn TM ser r ts vi liu 0,375-0,750 g/kg/pht.n gh m.v l ri c Tc dng ph ca ccAlthuco c ch men . ahoo. phosphodiesterse: c ev y gy lon nhp nh lo th @ Fin020tc mch. hay tht v i8khi gy . 0 ty2 i c. Vesnarinone: 20 omt dn xut ca Quinoline, t l c Po gh dngt lm tng co bp c tim. Khi kt i thuc c rtc opy hp Cvi Digoxin v thuc c ch men chuyn trong iu tr suy tim, thuc c th ci thin c tt hn tnh trng suy tim. Liu trung bnh l 60mg/ngy, dng ko di. Tc dng ph c th gp l gim bch cu ht. 7. Thuc chng ng: a. Trong suy tim, mu thng li cc c quan ngoi bin nn rt d to thnh cc cc mu ng trong h thng tun hon v t gy ra nhng tai bin tc nghn mch mu. V vy, ngi ta phi dng thuc chng ng khng nhng trong nhng trng hp cp tnh nh tc ng mch phi, no, chi... m cn phi iu tr d phng

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trong cc trng hp suy tim c tim to, nht l trong cc trng hp c thm rung nh. b. Bn cnh Heparin c s dng trong cc trng hp tc mch cp, ngi ta cn s dng cc thuc chng ng thuc nhm khng vitamin K. C. iu tr nguyn nhn Ngoi cc bin php iu tr chung (nh trnh by trn), ta cn phi p dng mt s bin php iu tr c bit ty theo tng nguyn nhn: 1. Suy tim do cng gip: Phi iu tr bng khng gip trng tng hp hoc phng php phng x hay phu thut. 2. Suy tim do thiu vitamin B1: cn dng vitamin B1 ved ser liu cao. re ts vn gh m.th phi c 3. Suy tim do ri lon nhp tim ko di l ri o Al oo.c bin php iu tr cc ri lonv.nhphtim mt cch hp e a l: dng thuc, sc in Finlot my to nhp. hay 0@y 2 . 0 08 4. Suy tim do nhi mu ity2tim : ngi ta c th can 20 oc c t thip trc tipgvo Pot tc ca ng mch vnh bng i h ch yr huyt, nong v t Stent ng mch thuc tiup si Co vnh hoc m bc cu ni ch vnh... 5. Suy tim do mt s bnh van tim hoc d tt bm sinh: nu c th, cn xem xt sm ch nh can thip qua da (nong van bng bng) hoc phu thut... D. Mt s bin php iu tr c bit khc 1. Bin php h tr tun hon c bit: c th c p dng nhng bnh nhn suy tim m nhng bin php iu tr khc tht bi hoc t hiu qu. a. t bng trong ng mch ch: Bng phng php thng tim, ngi ta a mt ng thng c gn mt qu bng c bit, t ng mch i, ng thng c y ln ti ng mch ch. Bng s c t v tr trong lng ng mch ch 372 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

di ch phn nhnh ra ng mch di n tri. Bng s c bm cng ra mt cch ng b vo thi k tm trng ca chu chuyn tim. Kt qu l n s lm tng lng mu n ti cho ng mch vnh v lm gim nhu cu xy ca c tim. Thm vo , n lm gim ng k tin gnh v hu gnh, ci thin mt cch r rt cung lng tim cho bnh nhn. b. Thit b h tr tht: L thit b phi m cy ghp gip cc bnh nhn suy tim qu nng ko di thm thi gian ch thay tim. 2. Thay (ghp) tim: a. L bin php hu hiu cui cng cho nhng bnh nhn suy tim giai on cui, khng li evi tt vd ser thng e c cc bin php iu tr ni, ngoi rkhoa ts vn gh m.hp c tn i thng. thng l nhng ltrng l r co . A ahoo. thng c tim rt rng v enng n. ov y inl 20thy k t khi c thuc b. Mt thng k gn y cho @ .F 08 ty20 gim min dch0Cyclosporine, t l sng st sau 2 ci mt nm ight Ptim l 90% v sau 5 nm l 65ghp oto r py 70%. oNi chung th chc nng v cht lng cuc C sng ca bnh nhn c ci thin ng k sau ghp tim. c. Cc thuc thng hay dng nht iu tr gim min dch sau ghp tim l: Glucocorticoids, Cyclosporine v Azathioprine. Mt s loi thuc gim min dch mi khc cn ang trong giai on th nghim. d. Nhng bin chng c th gp sau ghp tim bao gm: thi ghp sm, nhim trng do dng thuc gim min dch. S pht trin ca bnh mch vnh sau m cng l mt nguyn nhn quan trng gy t vong sau nm u tin c ghp tim.

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VI. Suy tim cp v ph phi cp do tim A. Sinh l bnh 1. Ph phi cp xy ra khi p lc ca mao mch phi tng qu ngng gy thot dch ra khi lng mch vo trong khong k v ph nang. T gy ri lon trm trng s trao i kh. 2. Vic tng p lc mao mch phi ny ch yu gy ra l do tnh trng suy tim tri cp v mt s bnh l tc nghn ng ra ca ca tnh mch phi c bit l bnh hp van hai l. B. Chn on 1. Triu chng lm sng: d a. Tnh trng kh th nhiu, i khi d servev t di re ngt, pht trin nhanh chng. ts gh m.vn i b. Km theo bnh nhn lo lng, vt v,o tm ti ll r c . A ahoo. oev c. Mt s ho ra mu hoc lthmych tro bt hng ra in 20@ F ming. 8. 0 00 ity2 d. Khm thy ht 2 onhn kh th nhanh, nng. Nghe bnh toc rig thy ran rt, ran ngy v c bit l phi cyth P p Co ran m to nh ht hai bn ph trng (c th din bin kiu nc thu triu dng t hai y phi). 2. Chp Xquang phi: a. Hnh nh bng tim to, huyt qun phi tng m. b. M hnh cnh bm lan to t hai rn phi. c. i khi thy hnh nh ng Kerley B. d. Tin trin theo tnh trng lm sng. C. iu tr 1. Cc bin php h tr ban u: a. Cung cp xy y . b. t ni kh qun v thng kh nhn to nu cn. c. bnh nhn t th na ngi. 374 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

d. C th tin hnh gar ba chi lun phin hoc chch mu nu khng c iu kin thuc men tt. 2. Dng thuc: a. Morphine sulphate l thuc rt quan trng v lm gim lo lng cho bnh nhn v gin h tnh mch phi, tnh mch h thng. Morphine c dng bng ng tim tnh mch 2-5mg mi ln v nhc li sau 10-25 pht nu cn cho n khi c tc dng. b. Furosemide lm gim gnh nng tun hon v c hiu lc tc thi gin ng mch phi nhanh khi tim tnh mch. Liu ban u t 20-40 mg tim thng tnh mch sau c th tng liu v nhc li sau vi pht cho n khi p ng u r. Liu ved se c th tng n ti a l 2000mg. ts re gh vn c. Nitroglycerin l thuc gin chriyum. tnh mch l .co h l lm gim tin gnh v cev. A ahoo hip ng vi o tc dng inl @y Furosemide. Nn dng ng truyn tnh mch . F 2020 8 vi liu bt u 0 it10 g/pht v tng dn tu 0 l y 2 toc t theo p ng. Po igh yr p d. Nitroprusside rt c hiu qu iu tr ph phi Co cp bnh nhn tng huyt p hoc h van tim cp. Khi dng thuc ny cn theo di cht ch p ng ca bnh nhn da trn cc thng s huyt ng. Liu khi u l 0,25 g/kg/pht. e. Cc thuc tng co bp c tim c ch nh sau khi dng cc bin php ban u trn v bnh nhn b huyt p thp hoc sc tim. 3. Chy thn nhn to cp hoc siu lc mu c ch nh nhng bnh nhn c bnh thn hoc khng p ng vi li tiu. 4. Theo di huyt ng bng ng thng tim phi (Swan-Ganz) c th c ch bnh nhn p ng km vi iu tr. Theo di p lc ng mch phi v mao 375 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

mch phi bt cn gip phn bit c nguyn nhn gy ph phi cp l do tim hay khng phi do tim. 5. Ch v gii quyt cc nguyn nhn nu c th. Cc nguyn nhn gy ph phi cp huyt ng thng gp l: a. Tng huyt p. b. NMCT cp hoc bnh mch vnh cp. c. H van tim cp (do NMCT, vim ni tm mc...) d. Cc bnh vim c tim, bnh c tim e. Cc ri lon nhp tim mi xy ra hoc qu ti th tch (truyn nhiu dch qu) bnh nhn c ri lon chc nng tht tri. Ti liu tham kho ved ser e 1. Bonow RO, Udelson JE. Left ventricular diastolic tdysfunction as a sr gh m.vn cause of congestive heart failure. Ann InternriMed 1992;117:502ll .co 510. v. A ahoo loe 2. Bristow MR, Gilbert EM, Abraham WR y al. for the MOCHA Fin020@ et . 08 Investigators. Carvedilol produces y2 20 ocit dose-related improvements in left ventricular function ght survival in subjects with chronic heart and Pot i r1996; 94:2807-2816. failure. Circulation py Co
3. Cairns JA, Connolly SJ, Roberts RS, Gent M. Canadian Amiodarone Myocardial Infarction Arrhythmia Trial (CAMIAT): rationale and protocol. Am J Cardiol 1993;72:87F-94F. CAST Investigators. Preliminary report: effect of encainide and flecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med 1989;321: 406-412. Chatterjee K. Heart failure therapy in evolution. Circulation 1996;94:2689-2693. CIBIS Investigators and Committees. A randomized trial of beta blockade in heart failure: the Cardiac Insufficiency Bisoprolol Study (CIBIS). Circulation 1994;90:1765-1773.

4.

5. 6.

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7.

8. 9.

10. 11.

12. 13.

14.

15.

16.

17.

Cohen GI, Pietrolungo JF, Thomas JD, Klein AL. A practical guide to the assessment of ventricular diastolic dysfunction using Doppler echocardiography. J Am Coll Cardiol 1996;27:1753-1760. Cohn 'IN. The management of chronic heart failure. N Engl J Med 1996;335:490-498. Doval HC, Nul DR, Grancelli HO, et al., For Gruppo de Estudio de la Insuficiencia Cardiaca en Argentina. Randomized trial of low dose amiodarone in severe congestive heart failure (GESICA). Lancet 1994;344:493-498. Hosenpud JD, Greenberg BR. In: Hosenpud J, ed. Congestive heart failure. New York: Springer-Verlag, 1994. Lenihan DJ5 Gerson MC, Hoit BD, Walsh, RA. Mechanisms, diagnosis, and treatment of diastolic heart failure. Am Heart J 1995;130:153-166. ved Marso SP, Griffin BP, Topol EJ, eds. Manual of Cardiovascular ser re Medicine. Philadelphia: Lippincott-Raven, 2000. hts .vn g m i Moss AJ, Hall AJ, Cannom DS, et al. for the lMulticenter Automatic l r co . A ahoo. Defibrillator Implantation Trial Investigators (MADIT). Improved oev inl 20@y patients with coronary F survival with an implanted defibrillator in 8. 0 00 ity2 arrhythmias. N Engl J Med 2 oc disease at high risk for ventricular t gh Pot 1996;335:1933-1940. i yr Nishimura RA, pTajik AJ, Evaluation of diastolic dysfunction in Co health and disease: Doppler echocardiography is the clinician's Rosetta stone. J Am Coll Cardiol 1997; 30:8-18. Packer M, Bristow MR, Cohn JN, et al. for the U.S. Carvedilol Heart Failure Study Group. The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. N Engl J Med 1996;334:1349-1355. Packer M, Gheorghiade M, Young JB, et al. for the RADIENCE Study. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-converting-enzyme inhibitors. N Engl J Med 1993;329:1-7. Packer M, O'Conner CM, Ghali JK, et al. for the Prospective Randomized Amlodipme Survival Evaluation Study Group (PRAISE). Effect of amlodipine on morbidity and mortality in severe chronic heart failure. N Engl J Med 1996;335: 1107-1114.

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18. Pitt B, Segal H, Martinez FA, et al. Randomized trial of losartan versus captopril in patients over 65 with heart failure (Evaluation of Losartan in the Elderly Study, ELITE). Lancet 1997;349:747-752. 19. Poole-Wilson PA, Massie BM, Yamani MR. In: Poole-Wilson P, ed. Heart failure. New York: Churchill Livingstone, 1997. 20. Siugh SN, Fletcher RD, Gross Fischer S, et al. for the Survival Trial ofAntiarrhythmic Therapy in Congestive Heart Failure. Veterans Mfairs Anti-arrhythmia in Heart Failure Trial. N Engl J Med 1995;333:77-82. 21. SOLVD Investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med 1991;325:293-302. 22. The Antiarrhythmics versus Implantable Defibrillators (AVID) Investigators. A comparison of antiarrhythmic drug therapy with ed implantable defibrillators in patients resuscitated from rv se near-fatal re ts ventricular arrhythmias. N Engl J Med 1997;337:1576-1583. gh m.vn i 23. Uretsky BF, Young JR, Shahidi FE, Yellen LG, o.co ll r Harrison MC, Jolly . A aho MK. Randomized study assessing theoev y of digoxin withdrawal l effect Fin020@ heart failure: results of in patients with mild to moderate congestive . 08 2 20 oc y the PROVED trial. PROVED itInvestigative Group. J Am Coll t ht Cardiol 1993;22:955-962. Po rig py 24. Young JB, Haas GA, Rodkey SR. In: Topol E, ed. Textbook of Co cardiovascular medicine. Philadelphia: Lippincott-Raven, 1997. 25. Young JB. Contemporary management of patients with heart failure. Med Clin North Am 1995;79:1171-1191.

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Bnh c tim gin


Bnh c tim gin khng r nguyn nhn l bnh cha r bnh nguyn gy ra hu qu lm mt dn chc nng co bp ca c tim. Chn on xc nh khi c du hiu suy gim chc nng tm thu v gin bung tht tri m khng tm thy cc nguyn nhn thng thng nh bnh ng mch vnh, bnh tim bm sinh, bnh van tim, tng huyt p hoc bnh mng ngoi tim. Trong mt vi trng hp bnh c tim gin thy c cc yu t thun li trn lm sng nh nghin ru, thai sn hoc tin s gia nh c mc bnh c tim. Tuy nhin ngi ta cha tm ra mt nguyn nhn c mi lin quan chc chn no dn n bnh c ved tim gin. Gii khoa hc vn ang tip tc nghin cu rcc mi se lin quan n bnh c tim gin ca h thng tots re n t min, keo, h rig ha v thn kinh c, cc qu trnh vim, hay chuyn com. nhm gp ll . phn l gii bnh sinh phc tp ca bnhev. A ahoo ny. lo y Fin020@ I. Gii phu bnh . 08 2 20 htty trng hp bnh c tim A. Gii phu bnh cathu toci cc h Po rig nhn t vong u cho thy cc bung gin sau khi bnh py Co tim gin nhiu. Tng nhiu trng lng ton b, khi c, v th tch t bo c tim trong bnh c tim gin, tuy nhin dy ca thnh tht tri khng tng thm ch cn mng v dt xung. B. Huyt khi trong bung tim v huyt khi bm thnh ni mc ca tim thng thy trong hn 50% cc trng hp bnh c tim gin. C. Tn thng vi th trong bnh c tim gin thng thy t bo c tim ph i v kch thc ln, c hnh bu dc rt k l. D. Cu to bn trong ca t bo c tim cng rt bt thng, c th thy bin i gin phn, ng ch T gin, v c cc ht lipid bn trong. Trng hp nhng bnh tim khc thng khng c cc du hiu ny. S tng si ha 379 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

thng xuyn thy trong bnh c tim gin, tuy nhin cc tiu ng mch xuyn thnh v cc mao mch li c cu trc bnh thng trong bnh c tim gin. II. Sinh l bnh A. C ch sinh bnh hng u ca bnh c tim gin l gim kh nng co bp ca t bo c tim. Hu qu l lm gim phn s tng mu v tng th tch cui tm trng tht tri, nh tt c cc nguyn nhn khc dn n hu qu cui cng l suy tim. Tuy nhin do qu trnh ny din ra t t lm bnh nhn thch ng tt, v vy c rt nhiu trng hp tuy chc nng tm thu tht tri gim nhiu nhng bnh nhn vn c rt t triu chng lm sng. B. Thay i ng k nht c nhn thy trong bnh c tim ed gin khng r nguyn nhn l phc hp erv s th th re adrenergic G protein adenylate ca cgtim..vTrong cc hts n i bnh nhn suy tim nng thy c gim 60om 70% th ll r c n . A ahoo. th bta 1 adrenergic v tng th ethy o v bta 1 mRNA. inl 20@ F III. Triu chng lm sng 008. y20 2 cit ht Po A. Triu chng cgnng to i yr 1. Tt c ccp la tui u c th gp bnh c tim gin, Co tuy nhin la tui thng gp nht l tui trung nin. Cc du hiu thng din ra rt t t v bnh nhn thng c mt giai on di t vi thng n vi nm hon ton khng c triu chng. Mt vi trng hp bnh khi pht t ngt nh cc bnh nhn sau mt thi k tng nhu cu hot ng ca tim nh sau phu thut hay nhim trng. i vi cc bnh nhn tr tui nhiu khi b chn on nhm vi cc bnh phi thng thng nh vim phi, vim ph qun... 2. Dn dn sau bnh nhn thng c cc biu hin ca suy tim tri nh kh th khi gng sc, kh th khi nm v kh th v m.

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3. Giai on nng ln ca bnh s thy cc du hiu ca suy tim phi nh ph ngoi bin, nn, cng tc bng do gan to, i tiu m v c chng. Cc du hiu khc c th gp l biu hin ca hi chng cung lng tim thp nh mt mi v suy nhc c th. au ngc cng c th gp mc d h thng ng mch vnh hon ton bnh thng. Cc du hiu ngt v xu thng c ngun gc do ri lon nhp hoc do dng thuc gy h huyt p t th ng. B. Triu chng thc th 1. Khm lm sng thng khng c du hiu c hiu v thng ch lin quan n mc suy tim ca bnh nhn. Huyt p bnh nhn thng bnh thng nhng nu tnh trng ri lon chc nng tht tri etin trin ved sr re c th dn n h huyt p, mch nh v yu. ts gh m.vn i 2. Khm tim thng thy nhp timl nhanh, i khi c l r co . A ahoo. thi tm thu ting nga phi. Thng ngheev y ting lo thy F n0 do ca h van hai l v 8ba i l 20@ gin cc bung tim. . 00 ty2 Ngoi ra cn thy2cccidu hiu bung tim gin vi ht Po o mm tim xung thpt v sang tri (gin tht tri) hay rig py gin v pha mi c ca tht phi. Co 3. Khm phi trong trng hp tr tun hon nhiu c th thy xut hin cc ran m, bnh nhn kh th kiu nhanh nng, th kh kh v thng c trn dch mng phi phi hp. 4. Khm bng nhm pht hin cc du hiu ca suy tim phi vi gan to. Trong cc trng hp nng c th dn n x gan tim vi bng c chng trn lm sng. Phn hi gan tnh mch c dng tnh, nhng a phn cc bnh nhn c tnh mch phi ni t nhin. 5. Khm ngoi bin pht hin ph chi di sau c th dn n ph ton thn. Hay gp du hiu gim ti mu ngoi bin vi chi lnh, ti hay tm. y 381 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

chnh l nhng bng chng th hin mc cung lng tim gim cc bnh nhn bnh c tim gin khng r nguyn nhn. IV. Cc xt nghim chn on Khng c mt xt nghim no c coi l tiu chun vng chn on xc nh bnh c tim gin. Vic chn on cn phi kt hp gia lm sng v cc xt nghim cn lm sng. 1. in tm (T): Khng c du hiu T in hnh cho bnh c tim gin. Chng ta c th thy du hiu nhp xoang nhanh nhng cng c th gp cc ri lon nhp nh v tht phc tp. Ri lon dn truyn trong tht hay gp m in hnh l bloc nhnh, on ed ST v sng T cng rt hay bin i. Mt erv bnh s vi re ts nhn li c sng r nh v Q su cc chuyn o gh m.vn trc tim lm ta d nhm ln vi ll ri otrng hp nhi cc .co v. A aho tri v trc tri mu c tim c. Du hiu ldy y oe tht Fin020@ cung hay gp. . 08 2 20 ocity to, vi ch s tim ngc ln. 2. Chp tim phi:t Bng tim h Pot Ph phi lydu hiu c th thy trn phim do tng p rig p Co h tnh mch phi. Tnh mch ch trn v tnh mch n (azygos) gin do tng p h tnh mch ch. C th gp trn dch mng phi. 3. Siu m tim: L phng php hu hiu nht chn on v theo di tin trin ca bnh c tim gin cng nh loi tr cc nguyn nhn c th dn n gin cc bung tim nh bnh tim bm sinh, bnh van tim, bnh mch vnh... a. Siu m hai chiu: cho thy cc bung tim gin nht ct 4 bung tim t mm v cnh c tri. dy ca vch lin tht v tht tri vn trong gii hn bnh thng, nhng bin di ng ca ton b cc vch tim thuc tht tri u gim. C th thy dch mng ngoi tim trong mt s cc trng 382 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

b. Siu m Doppler: gip nh gi dng h van hai l, ba l v c tnh p lc ng mch phi. 4. Thng tim v chp bung tim: a. Hnh nh chp bung tht tri thy tht tri gin v gim vn ng ton b. b. V mt huyt ng, thy c suy tht tri hay suy c hai tht vi tng p lc cui tm trng ca tht tri trong khi p lc tm thu li gim nhiu. c. H thng ng mch vnh bnh thng hay hp khng ng k (hp di 50%). 5. Sinh thit c tim: xc nh nhng nguyn nhn ed dn n suy tim d nhm vi bnh c timreserv khng gin r nguyn nhn nh vim c tim, .vn hts sarcoidose, rig com ll . hemosiderosis... v. A ahoo loe V. Din bin t nhin v tin lng0@y Fin02 8. 2 1. Din bin t nhin 00 citbnh s dn n suy tim tng 2 ca y o dn v c th ht t tvong trong bnh cnh suy tim b Po rig py nng hayori lon nhp. C 2. T l t vong trong vng 5 nm l 40 n 80%. Trong i a s cc nghin cu cho thy t l t vong trong vng 1 nm l 25% v 2 nm l 35 n 40%. Tuy nhin cc tc gi cng ch ra rng cc bnh nhn sng qu 2 hoc 3 nm u c tin lng lu di tt hn rt nhiu. Tnh trng n nh s gp trong khong 20 n 50% cc trng hp nhng chc nng tht tri tr v bnh thng rt him gp trong thc t. 3. Tin lng da vo cc yu t sau: triu chng ca bnh nhn, phn s tng mu ca tht tri, ch s tim, ri lon dn truyn nh tht, ngoi tm thu tht a , h natri mu v tng yu t ANF (atrial natriuretic factor). Ngoi ra cc yu t khc cng c th nh hng n tin lng nh nghin ru, tin s gia 383 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

nh b bnh c tim, kch thc bung tht tri gin nhiu, p lc nh tri tng, rung nh, tng hm lng norepinephrine mu. Cc yu t sau y khng c lin quan n tin lng l tui, thi gian mc bnh, tin s nhim virus, ngoi tm thu tht n gin. VI. iu tr A. iu tr ni khoa Nhm mc ch n nh tnh trng suy tim. Vic iu tr bao gm ch n hn ch mui v nc, gim hot ng ca tim bng gim tin gnh, hu gnh v nhp tim, tng sc co bp ca c tim. 1. Thuc li tiu khi cho phi cn c vo chc nng thn v th tch dch trong c th. Ch nh ttdtrong ve trng hp tng p MP, tr ti phi veser r ngoi bin hts n r rng. Qu liu li tiu s lm ri ilon in gii v r g com.v ll . ur mu t lm gim cungAlng tim. Li tiu v. ahoo l e quai nh Furosemid, c la chn l cc loi li otiuy Fin020@ . Torsemid hay Bumetanide. Cn Thiazid thng 08 2 20 ocitydo hiu qu km. khng c khuyn dng ht Pot rig 2. Thuc gin mch lm gim gnh cho tim nh c ch py Co dng Angiotensin, Nitrat v Hydralazin men chuyn trong c ch men chuyn dng Angiotensin l thuc nn c la chn hng u. Cn ch tc dng h huyt p t th ca thuc gin mch. 3. Digitalis l thuc c la chn trong cc trng hp rung nh c tn s tht cao. Hn na cc nghin cu cn ch ra rng n c tc dng ci thin phn s tng mu, ci thin kh nng gng sc ca bnh nhn v triu chng lm sng ngay c i vi cc bnh nhn c nhp xoang. Tuy nhin trong nghin cu mi y (nghin cu DIG) Digoxin khng lm thay i t l t vong cc bnh nhn suy tim khi so snh vi gi dc. Do cc trng hp nhp xoang ch nn dng Digitalis khi bnh nhn c tim to, ri lon chc nng tht tri nhiu v khng p ng vi iu tr li 384 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

tiu cng nh thuc c ch men chuyn dng Angiotensin. 4. Thuc khng vitamin K cn c s dng khi bnh nhn c huyt khi trong bung tim, c rung nh hay c tin s tc mch. 5. iu tr ri lon nhp trong bnh c tim gin thng gp nhiu kh khn. Trong s cc loi thuc chng lon nhp th Amiodaron l thuc dng nh c hiu qu v t tc dng ph nht. Ti cc nc pht trin vic s dng my ph rung t ng cho kt qu tng i kh quan i vi cc ri lon nhp phc tp. 6. Thuc chn bta giao cm. Hin ti duy nht ch c Carvedilol l thuc c chp nhn dng iu tr suy tim ti Hoa K. Tuy nhin, cc nghin cu mi ved ser y cng ch ra rng cc thuc khc nhe Bisoprolol sr hay Metoprolol cng c hiu qu right m.vn t l t lm gim ll khi vong cc bnh nhn suy tim.. Liuoo.co u cn rt v A ah thp v ht sc thn trnginloe nng liu iu tr. khi @y 2 . F tim 0 8 B. iu tr phu thut ghpy20 00 it 2 Ch nh trong ght trng hp NYHA 3 hoc 4 khng cc Potoc i p ng vi iuotr rni khoa ( bao gm c chn bta). Tuy py C nhin, phu thut ny tn km v mi ch c thc hin ti mt s trung tm y hc ln. Ti liu tham kho
1. 2. 3. Braunwald E, ed. Heart disease: a textbook of cardiovascular medicine, 5th ed. Philadelphia: WB Saunders, 1997:1077-1104. Fauci AS, ed. Harrison's principles of internal medicine, 14th ed. New York: McGraw-Hill, 1998:785-791. Kopecky SL, Gersh BJ. Dilated cardiomyopathy and myocarditis: natural history, etiology, clinical manifestations, and management. Curr Probl Cardiol 1987;12:573 647. Marso SP, Griffin BP, Topol EJ, eds. Manual of Cardiovascular Medicine. Philadelphia: Lippincott-Raven, 2000. Alexander RW, Schlant RC, Fuster V, eds. Hurst's the heart. New York: McGraw-Hill, 1998:2205-2239.

4. 5.

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6. 7.

Otto C. The practice of clinical echocardiography. Philadelphia: WB Saunders, 1997:389-403. Topol EJ, ed. Textbook of cardiovascular medicine. Philadelphia: Lippincott-Raven Publishers, 1998:607-637.

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r ese sr n t gh .v l ri .com l . A oo oev yah inl @ . F 2020 8 00 y 2 tocit ht Po rig

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Bnh c tim ph i

Bnh c tim ph i l bnh cha r bnh nguyn gy ra hu qu lm ph i c tim m khng c s gin cc bung tim. Chc nng tm thu tht tri thng trong gii hn bnh thng nhng cc thnh tim co bp mnh. y l nguyn nhn hng u gy t t cc bnh nhn tr di 35 tui. I. Nguyn nhn Thng mang tnh cht gia nh, hin ti ngi ta tm thy 6 gen c lin quan n bnh c tim ph i. Trong s gen bta myosin trn nhim sc th 14q1 chim tn sut gp cao nht (35 n 45%). ved ser re II. Gii phu bnh ts gh m.vn ri co Gii phu bnh ca hu ht cc trngAll oobnh c tim ph . hp . oev ah i thy cc du hiu: inl 20@y F 8. 1. Ph i khng ng 0tm 20 tm tht tri vi vch 0 ity ca 2 lin tht ph ihnhiuohn thnh t do ca tht tri. t ot c P g i 2. Bung tht yr nh hoc c kch thc bnh thng. p tri Co 3. X ha thnh ni mc ca tim t vch lin tht trn ng ra tht tri cho n l trc ca van hai l. 4. Van hai l rng v gin ra, c th dy hoc khng dy th pht. 5. Gin bung nh. 6. Bt thng lng ng mch vnh vi s dy ln ca thnh mch v hp lng mch. 7. X ha cc m k v ri lon cu trc ca tht tri. III. Triu chng lm sng A. Triu chng c nng 1. Triu chng suy tim: bao gm kh th khi gng sc hay xut hin v m, mt mi, nguyn nhn thng 387 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

do tng p lc cui tm trng ca tht tri v gim kh nng gin ca tm tht. 2. Thiu mu c tim vi biu hin au ngc: C th gp trong c cc trng hp bnh c tim ph i tc nghn hay khng. C ch chnh xc ca hin tng ny cn cha r nhng ngi ta cho rng cc yu t sau c th nh hng n du hiu au ngc ca bnh nhn: a. H thng mch vnh kch thc nh, gim kh nng gin ra khi nhu cu xy c tim tng. b. Tng p lc ca thnh tim do hu qu ca thi gian gin tm trng tht tri chm v do cn tr ng tng mu ca tim. d c. Gim t l gia h mao mch v m tim.rve se re ts d. Gim p lc ti mu ca ng mch vnh. gh m.vn l ri o 3. Ngt v xu: Nguyn nhn do. gim oti mu no v Al ho .c e a cung lng tim thp hay linvquan vi ri lon nhp nlo y Fi 020@ nhn tr tui khng . tim hoc gng sc. Ngt 2 bnh 08 y 20 ocitlng nguy him cc bnh nht thit l yut t tin h Pot nhn c bnhgc tim ph i. Ngc li tr em v ri py Co thiu nin y l yu t lm tng nguy c t t. 4. t t hay nhng ri lon nhp nng c th gp trong khong 1 n 6% cc trng hp. B. Triu chng thc th i vi cc bnh nhn c chnh p qua ng ra tht tri, khm lm sng c th pht hin thy cc du hiu: 1. Ting thi tm thu pha thp dc theo b tri xng c, cng gim khi bnh nhn ngi xm v nm cht tay, cng tng ln khi bnh nhn lm nghim php Valsalva, ng ln v sau cc ngoi tm thu tht.

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2. Du hiu mch ngoi bin ny mnh vi dng hai pha, pha th nht nhanh mnh v pha th hai ko di nh nc thy triu. 3. Mm tim p hai v tr, thng thy nht bp tin tm thu mnh hn, du hiu ny lin quan n ting th ba nghe c trn lm sng. IV. Cc xt nghim chn on 1. in tm (T): T bt thng trong khong 90 n 95% cc trng hp. Tuy nhin khng c du hiu T c hiu cho bnh c tim ph i. Dy tht tri vi tng bin ca phc b QRS v bin i bt thng on ST, T l cc du hiu thng gp. Cng hay gp bloc phn nhnh tri trc v sng Qdsu e er dy nh cc chuyn o pha sau, sng T o ngc, v res t tri v du hiu gi nhi mu vi gim sbin sng gh .vn l ri .com R cc chuyn o trc tim bnlphi. v. A hoo lo @ a 2. Chp tim phi: Bng timntoeviych s tim ngc ln. Fi 0 Ph phi l du hiu 08. th 02 trn phim do tng p c 2 thy y 0 2 h tnh mch tphi.ocit bung nh tri cng hay h Pot Gin gp. Tuy pyrig bng tim to t c gi tr trong vic nhin Co nh gi s tin trin ca bnh, ngi ta thng s dng siu m Doppler tim nh gi vn ny. 3. Siu m tim: L phng php hu hiu nht chn on v theo di tin trin ca bnh c tim ph i cng nh loi tr cc nguyn nhn khc nh hp van MC, hp trn van MC... a. Siu m hai chiu: nh gi mc ph i ca thnh tim. Thng c s ph i khng ng tm ca thnh tht tri, vi u th vt tri ca vch lin tht so vi thnh sau tht tri. Tht tri thng khng gin v khng c cc bnh l khc c th dn n tng dy ca thnh tim. Thnh tim c th dy khu tr tng phn tuy nhin thng thng c s dy lan ta ca tt c cc thnh tim, 389 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

nht l ca vch lin tht. S di ng ra trc trong th tm thu ca van hai l thng gp c gi tt l du hiu SAM. Du hiu ny lin quan n s cn tr ng ra tht tri v thng i km vi vic ng sm van ng mch ch.

Hnh 20-1. Du hiu SAM (mi tn) trn siu m TM. ved ser re ts gh m.vn i ll r co . A ahoo. oev inl 20@y F 8. 0 00 ity2 2 t oc gh Pot ri py Co Hnh 20-2. Mt ct dc trn siu m 2D c ph i ton b cc thnh tht tri (LV) trong th tm trng (A), tm thu (B). b. Siu m Doppler: cho php nh gi mc chnh p ng ra tht tri, dng h van hai l, ba l v p lc ng mch phi, t nh gi mc tin trin ca bnh. 4. Thng tim: Ch nh trong cc trng hp chun b phu thut, t my to nhp, gy tc nhnh vch th nht ca ng mch lin tht trc hay cc trng hp kh khn cn chn on phn bit. a. Chp bung tht tri s gip nh gi kch thc tht tri v sc co bp ca tht tri. 390 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

b. V mt huyt ng thy c chnh p trong bung tht tri v do c cn tr ng ra tht tri nn c c chnh p gia tht tri v ng mch ch. Nu chnh p ny khng r rng th c th lm cc nghim php lm tng chnh p trong bnh c tim ph i nh nghim php Valsalva, truyn Isoproterenol hay ngi Amyl Nitrite, gy ngoi tm thu tht. c. H thng ng mch vnh thng bnh thng hay hp khng ng k (hp di 50%). Cn ch quan st nhnh vch th nht ca ng mch lin tht trc. d. Khng c ch nh sinh thit mt cch c h thng tt c cc trng hp bnh c tim phed v i. ser mc e 5. Holter in tim: Cn tin hnh nhrgi ts gh m.vn v s xut hin ca cc cn nhprinhanh tht. y ll co chnh l yu t nh gi mcev. Anguy. c t t trong hoo lo ya bnh c tim ph i. Fin020@ . 08 2 V. Din bin t nhin v tinclng 20 o ity ht Pot 1. y l mtytrong nhng bnh tim din bin ht sc rig p Co phc tp. N l mt nguyn nhn hng u dn n t t cc bnh nhn tr tui. Tuy nhin nhiu trng hp bnh nhn vn c th chung sng ha bnh vi bnh m khng cn i hi cc phng php iu tr c bit. 2. t t: c th gp cc bnh nhn tr (t 12 n 35 tui). Cc du hiu suy tim c th din bin tng dn sau tui 35 n 40 tui. Cng c mt nhm bnh nhn hon ton khng c triu chng c nng. Cc bnh nhn ln tui c th c biu hin suy tim nng sau mt giai on hon ton khng c triu chng lm sng. Cn ch t t c th gp c cc bnh nhn bnh c tim ph i c hay khng c tc nghn ng ra tht tri. Mt s t cc bnh nhn tr tui 391 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

3. Rung nh lm mt s co bp hiu qu ca tm nh c th l nguyn nhn ca suy tim nng trn lm sng v tc mch. Vim ni tm mc nhim khun c th gp cc bnh nhn c h hai l. Qu trnh thai sn c th vn c din bin tt, ngay c khi cho bnh nhn thng. VI. Chn on phn bit 1. Ting thi tm thu trn lm sng cn phn bit vi hp van MC, thng lin tht, hay h hai l. Mt vi bnh nhn tr em b bnh c tim ph i c hn ch ng ra tht phi cn c phn bit vi hp van ved ng mch phi. ser e sr 2. au ngc trong bnh c tim ph i ht mth rt in g c .vn i l r hnh nh cn au tht ngc v i lkhi.co . A ahoo ngay trn T ov cng c hnh nh ca NMCT eviy inl 20@ sng Q hoi t. F 8. 0 VII. iu tr 00 ity2 2 t oc gh Pot triu chng: c th khng i A. Bnh nhn khng c yr cn iu tr Cop c hiu nhng cng c th iu tr d thuc phng bng chn bta giao cm hoc Verapamil nhm mc ch gim s tin trin ca bnh. B. Bnh nhn c triu chng kh th v au ngc 1. Cn iu tr bng chn bta giao cm. Thuc chn knh canxi nh Verapamil c th lm gim triu chng v tng kh nng gng sc ca cc bnh nhn khng p ng vi thuc chn bta giao cm. Mt vi trung tm ang th s dng Disopyramid ci thin cc triu chng lm sng. 2. Thuc chng ng cn ch nh trong cc bnh nhn c rung nh hoc c ri lon nhp trn lm sng. Khng sinh dng trong cc trng hp cn d phng vim ni tm mc nhim khun. 392 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

3. Thuc gin mch khng nn s dng m ch nn s dng li tiu nu cn cc bnh nhn c hn ch ng ra tht tri. 4. Digitalis c th lm tng chnh p ng ra tht tri, do chng ch nh dng cc thuc ny cc bnh nhn bnh c tim ph i c hp mg ra tht tri. 5. Cc bnh nhn c nguy c t t cao (tin s ngng tun hon, tin s gia nh c t t, c nhp nhanh tht trn lm sng) cn d phng bng Amiodarone v my ph rung t ng nu c iu kin. C. Phu thut v cc can thip xm ln khc 1. Phu thut Morrow (ct b phn c ph i ca vch lin tht): c ch nh cc bnh nhn c ved se triu chng nng n vi chnh p ngrerar tht tri ts n trn 50mmHg khng p ng vi iuhtr thuc. Phu rig com.v l thut ci thin tt cht lng cucl sng nhng khng . A oo. oev yah bnh (ti pht loi tr hon ton s tin l trin ca in 0@ . bnh) v nguy c t 8tFca2bnh nhn. Trong phu 0 ty20 0 2 i thut nu c h thai l cnng c th thay bng van hai h Poto l c hc. yrig p Co 2. t my to nhp hai bung loi DDD c th ch nh trong cc trng hp nhp chm, bloc nh tht v gip cho ci thin triu chng lm sng v chnh p qua ng ra tht tri. 3. Gy tc nhnh vch th nht ca ng mch lin tht trc bng cch bm cn chn lc vo nhnh ng mch ny. y l phng php c thc hin trong phng thng tim sau khi chp MV. Cc nghin cu gn y thy rng phng php ny cho cc kt qu ht sc ng khch l trong vic lm gim chnh p ng ra cc bnh nhn c bnh c tim ph i.

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Ti liu tham kho


1. Alessandri N, Pannarale G, Del Monte F, et al. Hypertrophic obstructive cardiomy-opathy and infective endocarditis: a report of seven cases and a review of the literature. Eur Heart J 1990;11: 1041-1048. Almendral JM, Ormastre J, Martinez-Abby JD, et al. Treatment of ventricular arrhythmias in patients with hypertrophic cardiomyopathy. Eur Heart J 1993;14:71-72. Braunwald E, ed. Heart disease: a textbook of cardiovascular medicine, 5th ed. Philadelphia: WB Saunders, 1997, 1414-1426. Fananapazir L, Epstein ND. Prevalence of hypertrophic cardiomyopathy and limitations of screening methods. Circulation 1995;92:700-704. Lakkis N, Kiemman N, Killip D, et al. Hypertrophic obstructive cardiomyopathy: alternative therapeutic options. Clin Cardiol 1997;20:417-418. Maron JM, Cerchi F, McKenna WS, et al. Risk factors and stratification for sudden death in patients with hypertrophic cardiomyopathy. Br Heart J 1994;72 (Suppl):S13-Sl8. ed Maron JM, Gardin JM, Flack JM, et al. Prevalence of serv hypertrophic re cardiomyopathy in a general population of young adults. Circulation ts 1995;92:785-789. gh m.vn i Maron JM, Isner JM, et al. Task All r .c3: Hypertrophic Force o . ahoo cardiomyopathy, myocarditis, and other v oe myopericardial diseases and mitral valve prolapse. J Am Coll Cardiol0@y inl 2 1994;24: 880-885 Maron JM, Pelliccia A, Spirito . F Cardiac disease in young trained 8P. 20 athletes: insights methods200 city for distinguishing athlete's heart from t t structural heart disease, with oparticular emphasis on hypertrophic igh Po cardiomyopathy. Circulation 1995;91:15961601. yr p Morten ET. Hypertrophic obstructive cardiomyopathy: problems in Co management. Chest 1997;112:262-264. Posma JL, van de Wall EE, Blauksma P. New diagnostic options in hypertrophic cardiomyopathy. Am Heart J 1996;132:1031~1041. Robbins M. Hypertropic cardiomyopathy. In: Marso SP, Griffin BP, Topol EJ, eds. Manual of Cardiovascular Medicine. Philadelphia: Lippincott-Raven, 2000. Schlant RC, Alexander RW, eds. Hurst's The Heart, 8th ed. New York: McGraw-Hill, 1621-1635. Smolders W, Redemakers F, Conraads V, et al. Apical hypertrophic cardiomyopathy. Acta Cardiol 1993;48: 369-383. Spirito P, Seidman CE, McKenna WS, et al. The management of hypertrophic cardiomyopathy. N Engl J Med 1997;336:775-784. Topol EJ, ed. Textbook of cardiovascular medicine. Philadelphia: Lippincott-Raven, 1998:745-768. Watkins H. Multiple disease genes cause hypertrophic cardiomyopathy. Br Heart J 1994;72:54-59. Wigle D, Rakowski H, Kimball B. Hypertrophic cardiomyopathy: clinical spectrum and treatment. Circulation 1995;92: 1680-1692.

2. 3. 4. 5. 6. 7. 8. 9.

10. 11. 12. 13. 14. 15. 16. 17. 18.

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Bnh c tim Hn ch

Bnh c tim hn ch l bnh c t l gp rt thp nhng l mt nhm bnh quan trng trong suy tim tm trng. N c nh ngha l bnh c tim tin pht hay th pht gy ra ri lon chc nng tm trng tht tri nhng khng phi l vim mng ngoi tim co tht. Cc bung tht khng gin hay ph i, tng p ng v tnh mch phi, p lc cui tm trng tht tri tng. Tuy nhin tm nh c th gin nhiu, i khi rt to a n hnh nh tim to trn phim chp Xquang. Chc nng tm thu tht tri thng bnh thng. I. Nguyn nhn ved ser nhng Mt vi trng hp khng r nguyn nhn (v re ts cn), gh m.vn nhiu trng hp thng do nhim amyloid. Hemochroatosis i ll r co l nguyn nhn hay gp gy bnh c. A hoo. nhng li t tim gin ev a nlo Cc gp hn trong bnh c tim hn ich.0@y nguyn nhn gy .F 2 bnh khc c th l vim c 8tim, 0 ghp tim, sarcoidose, 00 ity2 sau 2 t o Loffler, x ha ni mc, bnh c gh Pot Gaucher tr em ri py II. Triu chng lm sng Co Du hiu ch yu l tr ngoi bin nh gin tnh mch c, huyt phi v gan to, c chng. III. Cc xt nghim chn on 1. in tm (T): Hu nh lun c T bt thng. Bloc nhnh tri v dy nh l cc du hiu hay gp. Trong nhim amyloid hay c du hiu gim bin cc sng ngoi bin i ngc vi hnh nh dy cc thnh tim trn siu m tim. Ri lon nhp tim nht l rung nh rt hay gp, c bit l trong nhim amyloid. 2. Chp tim phi: Bng tim thng khng to tr khi c gin rng hai nh, huyt phi thng nng. 395 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

3. Siu m tim: Tm tht thng c kch thc bnh thng vi chc nng tm thu trong gii hn bnh thng. Trn dch mng tim i khi gp. Khng thy cc bt thng cu trc tim khc, c bit l khng thy cc tn thng van tim. ng knh tht tri tng trong th tin tm trng tuy nhin khng tng ln na trong thi k gia v cui tm trng. Dng chy trong tm tht c trng bi sng E rt u th do ko di thi gian gim tc.

ved ser re ts gh m.vn i ll r co . A ahoo. oev inl 20@y F 8. 0 00 ity2 2 t Hnh 21-1. Ph Dopplertoc dng chy qua van hai l gh Po ca ri ngi mc bnh c otim hn ch do amyloidosis (A) v ngi py C bnh thng (B). T l E/A (A) cao hn (B). 4. Chp ct lp t trng (CT) v cng hng t trng ht nhn (MRI): Cho hnh nh gip phn bit vi bnh vim mng ngoi tim co tht nh du hiu dy mng ngoi tim. 5. Thng tim: Ch nh trong cc trng hp cn chn on phn bit vi vim co tht mng ngoi tim v cng phc v cho mc ch sinh thit c tim chn on nguyn nhn bnh c tim hn ch. ng cong p lc ca tm nh ging ht nh trong bnh vim mng ngoi tim co tht, p lc cui tm trng ca tm tht cng c dng cao nguyn. Tuy nhin nu dng cao nguyn tht tri cao v r rng hn so vi tht phi th lc ny ngh nhiu n bnh c tim hn
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ch hn l vim mng ngoi tim co tht. Phim chp bung tht tri thy tht tri kch thc v sc co bp ca tht tri trong gii hn bnh thng v khng c vng ri lon vn ng khu tr ca thnh tim. 6. Sinh thit ni mc c tim cho php chn on xc nh v c th hng n chn on nguyn nhn. IV. Chn on phn bit: ch yu l phn bit vi vim mng ngoi tim co tht. 1. Nu c tin s lao, chn thng, vim mng ngoi tim cp, bnh h thng, sau chy tia x, sau phu thut... thng ngh n vim co tht mng ngoi tim. Nu c tin s ghp tim, nhim amyloid, hemochromatosis... th thng ngh n bnh c tim ved hn ch. ser e sr 2. Tc dng chy qua van hai l s ght m.vn ht vo tng khi i ll r su bnh nhn vim mng ngoioo.co co tht, cn . A ah tim v trong bnh c tim hn inloe th hin tng ny s ch @y 0 F 8 khng thay i theo h .hp.02 00 ity2 2 oc 3. Chn on xc ht Pobng sinh thit ni mc c tim. g nh t ri py V. iu tr Co A. Khi bnh nhn c tng p cui tm trng tht tri nhiu: c th iu tr bng li tiu. Cc loi thuc tng co bp c tim thng khng c hiu qu. Cc thuc gin mch cn s dng ht sc thn trng. Thuc chn knh Canxi c th tng sc gin n cui tm trng ca tm tht nhng cha c khng nh trn lm sng v hiu qu iu tr. B. iu tr bnh nguyn 1. Nhim amyloid hay gp cc nc khng thuc vng nhit i. C th ch nh hng n tim nhng cng c th c nh hng n cc h thng khc. Hay gp ri lon nhp km theo, tin lng khng tt, hu nh ch c cch iu tr hiu qu l ghp tim. 397 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

2. Trng hp hemochromatosis th hay gp bnh c tim gin hn l bnh c tim hn ch. Ti liu tham kho
Aroney C, Bett N, Radford D. Familial restrictive cardiomyopathy. Aust N Z J Med 1988;18:877-8. 2. Buxbaum J. The amyloidoses. Mt Sinai J Med 1996;63:16-23. 3. Cetta F, OLeary PW, Seward JB, Driscoll DJ. Idiopathic restrictive cardiomyopathy in childhood: diagnostic features and clinical course. Mayo Clin Proc 1995;70:634-40. 4. Goodwin JF. Cardiomyopathies and specific heart muscle diseases: definitions, terminology, classifications and new and old approaches. Postgrad Med J 1992;68:Suppl 1:S3-S6. 5. Hirota Y, Shimizu G, Kita Y, et al. Spectrum of restrictive cardiomyopathy: report of the national survey in Japan. Am Heart J 1990;120:188-94. 6. Katritsis D, Wilmshurst PT, Wendon JA, Davies MJ, Webb-Peploe ed MM. Primary restrictive cardiomyopathy: clinical and erv s pathologic characteristics. J Am Coll Cardiol 1991;18:1230-5. ts re n 7. Kushwaha SS, Fallon JT, Fuster V. Restrictiveigh m.v cardiomyopathy. N l r .co l Engl J Med 1997;336:267-276. . A oo 8. Lewis AB. Clinical profile andev outcome of restrictive o yah l Fin0 J 1992;123:1589-93. cardiomyopathy in children. Am .Heart 20@ 8 9. Pellikka PA, Tajik AJ, Khandheria BK, et al. Carcinoid heart 00 y2 2 tocit disease: clinical and ht o echocardiographic spectrum in 74 patients. P ig Circulation 1993;87:1188-96. yr p o 10. Richardson P,CMcKenna W, Bristow M, et al. Report of the 1995 World Health Organization/International Society and Federation of Cardiology Task Force on the Definition and Classification of Cardiomyopathies. Circulation 1996;93:841-2. 1.

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Vim mng ngoi tim cp

Vim mng ngoi tim l mt tnh trng bnh l c ngun gc do phn ng vim ca mng ngoi tim vi cc triu chng chnh l au ngc, ting c mng ngoi tim v cc bin i in tm . Bnh hay gp nam gii hn so vi n gii. Cc th bnh v nguyn nhn gy bnh ca vim mng ngoi tim cp rt a dng. Nguyn nhn hay gp nht l: vim mng ngoi tim cp v cn, do virus, do vi khun (nht l vi khun lao), tng ur mu, sau nhi mu c tim, ung th v chn thng. I. Vim mng ngoi tim cp khng r cn nguyn ved ser re C kh nhiu cc trng hp vim mng hngoi tim cp ts g tam.vn rng i i khng tm thy nguyn nhn gy bnh, ngi co cho ll r . A dooo. a s cc trng hp ny c ngunoev ah virus. Tuy nhin gc inl 20@y bnh hin cn gp vic phn lp tm ra chnh xc. F virus gy 0 8 nhiu kh khn v mt k 200 ity2 thut. t otoc P A. Triu chng lmhsng rig py Co 1. Triu chng c nng: a. au ngc do vim mng ngoi tim thng au sau xng c, au but, c th mc nng d di nhng cng c th m ko di sut ngy, au thng lan ln c v ra sau lng. Kinh in au thng tng ln khi ho v khi ht vo su. b. Thng km theo st v du hiu au mi c nh cc trng hp nhim virus thng thng. c. Kh th i khi c th gp nhng thng thng xut hin sau giai on au ngc khi vim mng ngoi tim cp din bin thnh trn dch mng ngoi tim. d. Bnh nhn thng cm gic cng thng, bun b v kh chu. 399 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

2. Triu chng thc th: a. Nghe tim l du hiu ch yu chn on. Nghe thy c ting c mng ngoi tim. Ting c thng th, rp, rt, c m cao. N c th thay i theo thi gian v t th bnh nhn hoc khi bnh nhn ht vo su. Kinh in ting c s c ba thi k tng ng vi tm nh co, tm tht co v tin tm trng. Tuy nhin, thng thng chng ta ch nghe thy ting c trong thi k tm nh v tm tht co, thm ch ch nghe thy trong mt thi k nht nh m thi. b. V tr tt nht nghe thy ting c mng ngoi tim l pha thp ca b tri xng c, khi bnh nhn ngi hi ci ra trc v ht su voved nn ri ser th. re ts gh m.vn i B. Cc xt nghim chn on ll r o.co o . A aT s din bin v 1. in tm (T): Kinhoein h inl 20@y rt c gi tr qua 4 giai on. y lFxt nghim . 0 08 chn on xc nh,0chn 2 2 ocity on phn bit v nh gi giai on vim ht Potngoi tim cp. mng rig a. GiaiCon u thng xut hin vi gi sau cn opy au ngc u tin. y l giai on rt kh phn bit vi du hiu ti cc sm hay nhi mu c tim cp trn in tm . Kinh in giai on 1 s gm cc du hiu on ST chnh ln ng hng vi sng T dng cc chuyn o trc tim. b. Giai on th hai xut hin vi ngy sau vi on ST tr v ng ng in, sng T dt xung. c. Giai on ba l giai on sng T m o ngc. d. Sau vi ngy n vi tun sng T s dng tr li, y l giai on cui cng ca bnh. e. Nu vim mng ngoi tim cp c trn dch mng tim, T c th c du hiu in th gim (nht l cc chuyn o ngoi vi) v du hiu lun phin in hc. 400 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

ed Hnh 22-1. Tin trin trn in tim tserv on giai re VMNT cp (trn) chuyn sang giai on ghts cp (di). bn .vn l ri om 2. Chp tim phi: hnh tim to .thng.cch thy trong Al hoo v cc trng hp c trn dchloe @yangoi tim phi hp in mng 0 v y cng khng 08. F 202du hiu c hiu gip phi l 0 ity 2 chn on. t oc gh Pot i 3. Cy mu,pyr m v dch ht d dy c kh nng cy Co on mt s cc trng hp vim mng gip chn ngoi tim phc tp nh do lao (sau 1 tun), nhim khun huyt hay vim ni tm mc nhim khun. 4. Xt nghim mu: thng c tng bch cu, mu lng tng v tng men creatine phosphokinase MB.
5. Siu m tim: a. Siu m tim thng c ch nh trong cc trng hp giai on sau ca bnh (vi tun sau du hiu lm sng u tin xut hin) hay khi c bin i huyt ng tuy nhin cng c th thc hin thng quy trong tt c cc trng hp chn on loi tr. Du hiu c th gp trn siu m l khong trng siu m do dch mng ngoi tim gy ra (8 n 15% cc trng hp vim mng 401 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

ngoi tim cp). Him gp hn c th c du hiu mng ngoi tim dy hn so vi bnh thng. b. Mt khc trong cc trng hp bnh nhn mi phu thut tim hay nghi ng c trn dch mng tim, lc ny siu m tim tr thnh xt nghim kh quan trng, cn thc hin nhiu ln nh gi s tin trin ca bnh. 6. Cc xt nghim khc nh siu m tim qua thc qun, chp ct lp vi tnh, cng hng t ht nhn c th p dng trong mt vi trng hp c bit nghin cu k hn v mng ngoi tim. C. Chn on phn bit 1. au ngc do tch thnh ng mch ch, nhi mu ved phi, vim phi hay nhi mu c tim. ser re ts 2. Bin i T cn phn bit vi cc ibin i do thiu gh m.vn ll r co mu c tim cc b gy ra. DinAbino.ca on ST v . aho oev sng T cho php phn bitntrongy a s cc trng i l 20@ i F 8. 0 hp. Tuy nhin cc0trng hp ST chnh ln lan ta 0 ity2 2 oc cc chuyn o tcnotlm siu m chn on loi gh tim (tm ri lon vn ng vng trn r tr nhi mu ic P py Co siu m tim). D. iu tr 1. Nguyn l chung: i a s cc trng hp vim mng ngoi tim cp khng c bin chng, bnh s t khi v p ng tt vi iu tr ni khoa. a. Thuc iu tr ch yu l thuc khng vim khng steroid. b. iu tr vim mng ngoi tim c bin chng trn dch mng ngoi tim hay vim mng ngoi tim co tht s c bn lun nhng bi sau. 2. iu tr ni khoa:

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a. Ibuprofen 600 n 800mg ung chia 3 ln trong ngy, trong 3 tun hay Indomethacin 25 n 50mg ung chia 3 ln trong ngy, trong 3 tun. b. Trong cc trng hp bnh nhn khng p ng vi khng vim khng steroid hay trong trng hp ti pht vim mng ngoi tim c th s dng prednisone ung trong 3 tun, cng c th dng ng tim tnh mch vi Methylprednisone trong cc trng hp nng. Colchicine 1mg trong ngy cng c mt vi nghin cu ch ra tnh hiu qu trong iu tr vim mng ngoi tim cp. 3. iu tr chc dn lu dch mng ngoi tim qua da (trn dch mng tim c p tim): Ch p dng trong cc trng hp vim mng ngoi tim c trn dch ved ser trng nhiu, c nh hng n huyt ng hay trong re ts hp cn chc d chn on bnhh nguyn. Chc g m.vn l ri o dn lu vi gy t ti ch c thAl hoo.c lu trong cc . t dn ev trng hp dch nhiu, tiinlo 0@ya tc. pht lin F 8. 02 4. Phu thut: 00 ity2 2 oc a. M dn right mng ngoi tim di xng c lu Pot p thng y p dng trong cc trng hp vim Co ch mng ngoi tim do ung th. b. Phu thut ct mng ngoi tim thng p dng trong trn dch ti pht nhiu hay vim co tht mng ngoi tim. II. Vim mng ngoi tim do virus Nguyn nhn ch yu do Coxackie virus nhm B v Echovirus gy ra. Chn on da vo du hiu nhim virus ng h hp, au ngc xut hin sau vi bin i T v cui cng l cc xt nghim huyt thanh chn on. i a s cc trng hp bnh t khi. i khi c th dn n cc bin chng nh vim c tim, ti pht vim mng ngoi tim, trn dch mng tim, p tim v vim mng ngoi tim co

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tht. Du hiu lm sng v iu tr nh trong cc trng hp vim mng ngoi tim khng r nguyn nhn. III. Vim mng ngoi tim do lao A. Triu chng lm sng Tt c cc trng hp vim mng ngoi tim c st lai dai, nht l v chiu th trc ht cn phi ngh n vim mng ngoi tim do lao. 1. Du hiu lm sng in hnh thng n mun, i a s cc bnh nhn ch c biu hin kh th, st, n lnh v ra m hi v chiu ti. 2. Du hiu tr ngoi bin trn lm sng hay gp hn du hiu au ngc v ting c mng ngoi tim. ed B. Nguyn nhn: Vim mng ngoi tim do laoslvnguyn er e nhn hng u dn n vim mng ngois r vn co tht. t tim gh m. ri c Vim mng ngoi tim gp khongll t .1o n 2% cc . A ahoo trng hp lao phi. oev inl 20@y F C. Cc xt nghim chn0on0 8. 0 ity2 2 oc 1. in tm : ht PotST chnh ln kinh in thng g on i khng thyyr p trong vim mng ngoi tim do lao. Co 2. Chp tim phi: thy du hiu ca lao phi mi hoc c trong mt s cc trng hp v du hiu bng tim to ra do c dch mng ngoi tim. 3. Cy tm vi khun lao BK (AFB): l xt nghim c hiu cho chn on. Dch cy c th ly t cc dch tit ca c th (m, dch d dy, dch mng phi...) hay t chnh dch chc ht ca mng ngoi tim. 4. Xt nghim mu: thng tng bch cu a nhn giai on sm v bch cu lympho giai on mun hn, mu lng thng tng trong a s cc trng hp. 5. Siu m tim: Thy du hiu c dch khoang mng tim vi nhiu si fibrin, ng thi c th c du hiu mng ngoi tim dy hn so vi bnh thng. 404 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

D. iu tr 1. Rifampicin 600mg/ngy, Isoniazid 300mg/ngy, Pyridoxine 50mmg/ngy phi hp vi Streptomycin 1g/ngy hoc Ethambutol 15mg/kg/ngy trong 6 n 9 thng. 2. Cn sm phu thut ct mng ngoi tim trong cc trng hp trn dch ti pht gy p tim nhiu ln hay mng ngoi tim dy nhiu dn n vim mng ngoi tim co tht. IV. Vim mng ngoi tim sau nhi mu c tim Do vim mng ngoi tim phi hp vi hoi t c tim nn bnh nhn c nguy c suy tim huyt v t l t vong trong vng mt nm cao. Trong nhm cc bnh nhn nhi d rve sehay nong mu c tim cp c ti ti mu (tiu si huyt re hts vn ng mch vnh), t l vim mng ngoigtim .thp hn i ll r com nhm iu tr bo tn. . A ahoo. oev Vim mng ngoi tim hay ngp @y i l 20 trong cc trng hp F 8. 0 nhi mu c tim thnh trc rng ko di vi gi n vi 00 ity2 2 ngy sau nhi mu. ght Potoc ri p A. Triu chng y Co lm sng Tt c cc trng hp sau nhi mu c tim cp m thy bnh nhn c ti pht au ngc v nghe tim c ting c mng ngoi tim th cn phi ngh n vim mng ngoi tim sau nhi mu c tim. B. Cc xt nghim chn on in tm cho thy sng T c th dng cao hn trong hai ngy hoc sng T o ngc trc tr nn dng. Tuy nhin, cc du hiu T in hnh cho vim mng ngoi tim thng khng thy r. C. iu tr 1. Aspirin l la chn iu tr hng u.

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2. Chng ch nh cc thuc khng vim khng steroid do c th gy co tht ng mch vnh, cn cc thuc steroid th li c th gy thng tim trong vim mng ngoi tim sau nhi mu co tim cp. V. Hi chng Dressler Xut hin vi tun cho n vi thng sau nhi mu c tim vi t l gp khong 1%. Sinh bnh hc cn cha r rng tuy nhin ngi ta ngh nhiu n nguyn nhn do c ch t min. Bnh nhn thng c biu hin st, trn dch mng phi, ting c mng tim, mng phi, xu v au ngc nhiu. iu tr bng Aspirin v thuc chng vim khng steroid, ngh ngi ti ging. Nu dng thuc chng ng c th d gy ra trn mu mng ngoi tim tuy nhin tin lng ca hi chng ny thng rt tt. Hn hu cc etrng d erv hp khng khng ch c phn ng vim miesphi dng r ts steroid iu tr. gh m.vn ri VI. Hi chng sau m mng ngoi tim ll oo.co . A ah ev Hi chng ny cng gn inlo 0@y chng Dressler, ging hi F 2 8. xut hin mt tun sau phu0thut.0T l gp khong 10 n 0 ity2 2 40% cc trng hp. Bnh othng t khi song i khi ko t toc gh bng Aspirin, chng vim khng di vi tun. iuri tr P py Co steroid, Corticoid ch dng trong cc trng hp khng p ng vi iu tr. Bin chng c th gp l p tim v him gp hn l vim mng ngoi tim co tht. VII. Vim mng ngoi tim do tng ur mu A. Triu chng lm sng 1. Hay gp cc bnh nhn va bt u lc mu, rt hay nghe thy ting c mng tim trn lm sng. 2. Thng gp trn dch mng ngoi tim s lng nhiu sau giai on vim cp.

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B. Sinh bnh hc: Cn cha tht r rng c ch sinh bnh hc ca bnh v khng thy mi lin h vi nng ur mu cng nh ng c vi s xut hin ca vim mng ngoi tim. C. iu tr 1. iu tr ni khoa: Hn ch s dng chng vim khng steroid; steroid nhiu khi t hiu qu tt. 2. iu tr dn lu dch mng ngoi tim qua da: Lc mu l la chn hng u cho cc bnh nhn vim mng ngoi tim do tng ur mu nu c triu chng. Nu khng c triu chng ca hi chng ur mu cao th lc mu khng phi l bt buc. Nu trn dch mng tim s lng nhiu vi tng bch cu, st hay c p tim th vic chc dn lu dch mng tim d cn l e thit. erv res 3. iu tr ngoi khoa. M mng ngoi hts .di xng tim vn rig c ch c, ct mng ngoi tim ti thiullcom nh cho A oo. cc trng hp ti pht nhiuev. yhoc khng ht dn o ln ah l lu dch qua da c. 8. Fin020@ 00 y2 VIII. Vim mng ngoi tim2docung th to it t igh Po i a s cc trng hp l do di cn n mng ngoi tim yr op (ung th phi, C th v, Hodgkin v khng Hodgkin, lung x-mi...). Ung th nguyn pht mng ngoi tim him gp c th do sarcome, mesothelioma, teratoma hay fibroma. A. Triu chng lm sng 1. Bnh nhn thng khng c triu chng lm sng g c bit, ngoi cc triu chng ca bnh l ung th. Vim mng ngoi tim thng pht hin kh mun. 2. C th gp du hiu c nng l kh th, trn dch mng phi v i khi bnh nhn n vin v p tim. 3. Cn sm pht hin p tim cc bnh nhn ung th khi t ngt xut hin kh th, mt mi hoc ph. B. Cc xt nghim chn on 1. in tm (T): Cc du hiu T in hnh cho vim mng ngoi tim thng khng thy r. Bin 407 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

i on ST-T khng c hiu, i khi c th thy du hiu lun phin in hc. 2. Xt nghim gii phu bnh vi th: tm t bo ung th trong dch chc ht mng ngoi tim hoc cc dch tit khc ca c th. T l gp t bo c tnh cao trong dch mng ngoi tim cc bnh nhn ung th phi, ung th v nhng t l ny thp cc bnh nhn ung th mu v cc ung th khc. 3. Siu m tim: gip nh gi mc trn dch mng tim, huyt ng v theo di s din bin ca bnh. C. iu tr 1. iu tr dn lu dch mng ngoi tim qua da: a. Chc dn lu dch mng tim: Rt tt nu c s hng dn ca siu m, ch nh cho ccd bnh rve nhn c triu chng lm sng ca trnese mng r dch s ngoi tim m s lng kh nhiu.ght m.vn ri co ll . b. Dng bng nong mng ngoi tim ol k thut nguy v. A aho him hn, ch nn pinloe @y cc bnh nhn ti dng F 020 pht trn dch mng. ngoi tim nhiu ln. 8 00 ty2 2. Phu thut: ct 2 otp dng mt vi th thut sau th oci igh trong nhng rtrngPhp cn thit: y op a. M C mng ngoi tim di xng c. b. Lm cng mng ngoi tim bng Tetracycline vi nc mui sinh l. Bin chng c th gp ca th thut ny l au nhiu trong th thut, ri lon nhp v st. c. Ct mng ngoi tim. Phu thut ny khng l la chn hng u cho cc bnh nhn trn dch mng ngoi tim do ung th. IX. Theo di cc trng hp vim mng ngoi tim Cc bnh nhn vim mng ngoi tim do virus hay khng r nguyn nhn cn c theo di trong vng mt thng k t sau khi ht cc triu chng lm sng khng nh khng c ti pht bnh v khng c vim mng ngoi tim co tht. 408 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Cc bnh nhn c trn dch mng ngoi tim cn phi theo di nh k bng siu m khng nh khng c ti pht hay tng mc dch trong khoang mng tim. X. Bin chng A. Ti pht vim mng ngoi tim Thng gp vi t l 20 n 30% cc trng hp, hay gp trong vim mng ngoi tim khng r nguyn nhn, sau phu thut tim h, chn thng, hi chng Dressler. iu tr nu khng p ng vi khng vim khng steroid c th dng Prednisone 40-60mg/ngy t 1 n 3 tun. Phu thut c ch nh trong cc trng hp ti pht nhiu ln vim mng ngoi tim c au ngc nhiu m khng p ng vi iu tr ni khoa. Phng nga ti ved pht c th s dng Colchicine 1mg/ngy trongermt thi s re gian vi vic gim dn liu trc khigdng n hts .v hn. Tuy i nhin cn cn c thm mt s cc All r o.cocu lm sng nghin m . aho khng nh vn ny. oev inl 20@y F 8. 0 B. p tim: chim khong 15% cc trng hp. 00 ity2 2 c t tim C. Vim mng ngoi Poto co tht: khong 9% cc gh ri trng hp vim mng ngoi tim s b vim dnh mng py Co ngoi tim mc t trung bnh tr ln. Ti liu tham kho 1. Adler Y, Finkelstein Y, Guindo J, et al. Colchicine treatment for
recurrent pen-carditis. Circulation 1998;97:2183-2185.

2. Alexander RW, Schiant H, Fuster V. Hurst's the heart, 9th ed. New
York: McGraw-Hill, 1998.

3. Braunwald E, ed. Heart disease: a textbook of cardiovascular


medicine, 5th ed. Philadelphia: WB Saunders, 1997.

4. Fowler NO. Tuberculous pericarditis. JAMA 1991;266:99-103. 5. Kirkland LL, Taylor RW. Pericardiocentesis. Crit Care Clin
1992;8:669-711. 6. Shabetai R. Diseases 1990;8(4):579-716. of the pericardium. Cardiol Clin

409 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

7. Spodick DH. Pericarditis, pericardial effusion, cardiac tamponade,


and constriction. Crit Care Clin 1989;5:455~75. 8. Topol EJ, ed. Textbook of cardiovascular medicine. Philadelphia Lippincott-Raven Publishers, 1998. 9. Wu J. Acute pericarditis. In: Marso SP, Griffin BP, Topol EJ, eds. Manual of Cardiovascular Medicine. Philadelphia: Lippincott-Raven, 2000.

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Trn dch mng ngoi tim

Trn dch mng ngoi tim l mt tnh trng bnh l kh thng gp trn lm sng. Bnh c th hon ton thm lng, khng c triu chng nhng cng c th nguy kch n tnh mng bnh nhn trong bnh cnh p tim. Biu hin lm sng ty thuc vo s lng dch cng nh bn cht ca dch. I. Trn dch mng ngoi tim khng c du p tim Khoang mng ngoi tim cha ng t 15 n 30 ml dch gip cho hai l thnh v l tng khng c st vo nhau. Kh nng cha ti a ca khoang mng ngoi tim l t 80 n 200ml dch, vi s lng dch ny trn lm sng rhu nh ved se r khng nhn thy cc bin i v huyt ng. Cce bnh nhn ts gh m.vntm tng vim mng ngoi tim cp p lc tnh mch trung l ri o Al c lm gim s tr v ca h tnh mch. do hoo. kh nng cha ev a dch ca khoang mng tim s tnglo 0@y in ln. Vi s tng dn ca . F 02 lng dch nhiu trng hp 8khoang mng tim c th cha 00 ity2 2 o n 2 lt dch m vn ht Pocc bin i huyt ng trn lm g cha t i sng. Chn p huytr ng hay gp trong cc trng hp dch py Co qu nhiu hay tng qu nhanh hoc trong cc trng hp dch c nhiu si fibrin, trn dch mng tim do ung th. A. Triu chng lm sng 1. Triu chng c nng: a. Dch mng tim tng dn khng lm bin i p lc trong bung tim thng khng c biu hin triu chng lm sng. b. i khi bnh nhn c biu hin au m , p nng ngc. c. C th c cc biu hin do dch mng tim p vo cc c quan ln cn. Kh nut do chn p vo thc qun, kh th do chn p phi v xp phi,

411 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

nc do chn p vo dy thn kinh honh, nn v cng bng do chn p cc tng trong bng. 2. Triu chng thc th: a. Dch mng tim s lng t thng kh thy cc du hiu trn khm thc th. b. Dch mng tim s lng nhiu c th thy cc du hiu ting tim m, du hiu ca Edwart (g c, ting thi ca ph qun) v ran phi do chn p th pht. B. Nguyn nhn Cc nguyn nhn hay gp gy trn dch mng ngoi tim nhiu l vim mng ngoi tim khng r nguyn nhn, tng ur mu, hi chng thn h, vim mng ngoi tim ved do ung th hay u nhy, suy tim huyt, x gan,esuy gip, sr re ts sau phu thut tim v do thuc. gh m.vn i l r c Bng 23-1. Cc nguyn nhn gy trnldchomng tim . A ahoo. oev 1. V cn inl 20@y F 8. 0 00 ity2 2. Nhi mu c tim cp c 2 t oto gh Ptn thng c tim-mng tim: hi 3. Cc hi chng sau ri py Co chng Dressler; sau m mng tim 4. Nguyn nhn chuyn ho: hi chng ur mu cao, ph nim, gim albumin mu 5. Do tia x 6. Phnh tch ng mch ch ngc 7. Chn thng: ng dp, do dng c, th thut..) 8. Do virus: Coxsackie cc tp A, B5, B6; Echovirus; Adenovirus, virus cm, quai b, thu u, vim gan B, HIV 9. Do vi khun: t cu, ph cu, lin cu, H. influenzae, no m cu, lu cu, lao, thng hn, vi khun gy st m, st vt, L. hemophilia, vim ni tm mc nhim khun 412 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

10. Do nm su, nm ph tng: Histoplasmosis, Aspergillosis, Blastomycosis, Coccidiodomycosis 11. Cc loi nhim trng khc: amp, Echinococcus, st Lyme, M. pneumonia, Rickettsia 12. U tin pht (mesothelioma, teratoma, fibroma, leiomyofibroma, sarcoma, lipoma, angioma...) v di cn (ung th v, ph qun, l-x-mi, u lympho...) 13. Cc bnh min dch (thp tim, lupus ban h thng, vim ct sng dnh khp, vim khp dng thp, vim mch, vim nt quanh ng mch, x cng b, vim da v c, bnh Whipple, Behcet, Reiter, st a Trung Hi, vim ng mch thi dng, amyloidosis d rve seHeparin, 14. Do thuc: Procainamide, Hydralazine,e r ts Warfarin, Phenytoin, Phenylbutazone, mDantrolene, gh .vn i ll r co Methysergide, Doxorubicin, Penicillin, Minoxidil, . A ahoo. oev Interleukin inl 20@y F 8. 0 C. Cc xt nghim chn0on 0 ity2 2 t oc 1. in tm gh Pot Kinh in s thy du hiu (T): i yr in thCop lan ta. Du hiu lun phin in hc thp hay gp trong cc trng hp dch mng tim nhiu. 2. Phim chp tim phi: bng tim khng thay i khi dch mng tim ch dy 1 n 2mm, tim to thng ch thy trong cc trng hp c trn dch mng ngoi tim s lng nhiu hn 250ml. Tim to vi du hiu gin rng cung ca tnh mch ch trn, tnh mch n (azygous) v gim ti mu phi gi cho chn on trn dch mng ngoi tim. 3. Siu m tim: L phng php hu hiu nht chn on v theo di trn dch mng ngoi tim. Ngoi gi tr chc chn trong chn on, siu m cn gip cho vic t dn lu mng tim v nh gi s lng dch cn li trong khoang mng tim. Tuy nhin siu m t 413 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

c gi tr chn on sinh bnh hc ca cc loi dch mng tim khc nhau. a. Siu m hai bnh din cn tm cc du hiu sau: Khong trng siu m gia l thnh v l tng ca mng ngoi tim.

Hnh 23-1. Khong trng siu m khi c TDMT. Tng vn ng ca cc thnh tim ved serdu hiu Khi dch mng tim nhiu c th s re thy t gh m.vntim. y qu tim lc lc trong khoang mng i ll r o chnh l c ch ca v. A htng lun phin hin oo.c e a in hc thy cnlo 0@y tm . Fi trn in 2 . 08 dch b. Kch c ca lng ty20 mng ngoi tim c th 20 oci xc nh thngPqua khong cch gia hai l ca ht ot rig tim ( dy ca lng dch) v kiu khoangy p mng Co ca dch mng tim. lan ta Lng dch t (di 100ml) tp trung ch yu pha sau v dy thng di 1 cm. Lng dch trung bnh (t 100 ti 500ml). Lng dch thng bc xung quanh tim nhng dy vn di 1 cm hoc ch c t xung quanh cc mch mu ln. Lng dch nhiu (hn 500ml) qu tim b y ra sau vi lng dch bc xung quanh lan ln ti c cc mch mu ln, c bn, mm v pha trc ca tim. dy ca lng dch ln hn 1cm mi v tr. 4. Cc xt nghim khc nh siu m qua thc qun, chp ct lp vi tnh, cng hng t trng ht nhn 414 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

c th p dng trong mt vi trng hp c bit nghin cu k hn v mng ngoi tim. 5. Xt nghim dch mng tim nhng trng hp dch nhiu c chc ht dn lu. Cc xt nghim cn lm l tm trc khun lao, sinh ha, vi khun v t bo hc. a. Xt nghim dch s cho php xc nh mt s cc nguyn nhn gy bnh gip ch rt nhiu cho vic iu tr. Dch mng tim l mu thng gi c chy mu mi vo trong khoang mng tim, tuy nhin nu dch mu mu c th gp trong cc trng hp bnh ung th, nhim khun hay vim nhim. Nu dch c rt nhiu mu, cn gi mu mu lm xt nghim kh mu. Nu c dy c e mu cc r rng th rt c th chc vodmch erv rs mu hay bung tim. Dch m nguyn enhn l do hts n vi khun nhim trng. Dch dng m.v thng rig co chp ll do tn thng hay tc ng v. A hoo. ngc. a loe b. Cy dch c ch nh trongycc trng hp nghi Fin020@ . ng c ngun 2008 igy bnh l do nhim trng, gc ty2 t ot c bao gm chnhimo virus v nhim nm. P rig py D. iu tr Co 1. Nguyn l chung: iu tr bao gm iu tr bnh nguyn, iu tr cc bin ng v huyt ng do dch mng tim gy ra. 2. iu tr chc dn lu dch mng ngoi tim qua da: a. Ch nh trong cc trng hp ung th, nhim khun vi khun, nm. b. Trong cc trng hp trn dch mng ngoi tim s lng dch nhiu, d triu chng lm sng khng in hnh cng vn c th ch nh chc dn lu mng ngoi tim. c. Chc dch mng ngoi tim khng nn ch nh cc trng hp dch mng tim t. 415 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

3. iu tr thuc chng ng: cn hn ch s dng thuc chng ng trong tuyt i a s cc trng hp trn dch mng ngoi tim. II. Trn dch mng ngoi tim c du hiu p tim Khi dch mng tim s lng nhiu s dn n hin tng tng p lc trong khoang mng ngoi tim v t s dn n hn ch tm trng ca tim, qu trnh p tim bt u xy ra. Bnh cnh p tim c xc nh bng cc triu chng ca tng p lc trong cc bung tim, hn ch s gin ra ca tm tht trong thi k tm trng v lm gim cung lng tim. A. Triu chng lm sng 1. Triu chng c nng: ved ser lng Biu hin trn lm sng l bnh cnh care cung hts n tim thp: bn chn, lo lng hocl rig om.v kch thch, l m l c ng g, c th xu i; gimev. A ahoo. nc tiu; c th tch o y nl @ bit l biu hin kh th; icm0gic chn p ngc; suy . F 202 sp, chn n v gy08 ty trong cc trng hp trn 0 st 2 i dch mng ngoit tim toc tnh. h Po mn rig py 2. Triu chng thc th: Co a. Tng p lc ca tnh mch trung tm, th nhanh; nhp tim nhanh; ting c mng ngoi tim; ting tim m. b. Cc triu chng ging nh suy tim phi: gan to, tnh mch c ni, c th c trn dch mng phi phi hp... c. Tt huyt p v du hiu mch o c xc nh l huyt p gim thp hn 10mmHg khi bnh nhn ht vo su. C ch ca hin tng ny l khi ht vo su s lm tng lng mu tnh mch tr v tht phi, do xung quanh tim l dch p khng cho tim n ra nn tht phi phi n v pha tht tri lm gim s y ca tht tri, hu qu cui cng l gim s tng mu ngoi bin gy 416 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

gim huyt p. Mch o khng c hiu trong p tim, n c th gp trong bnh phi tc nghn, nhi mu tht phi, nhi mu phi hoc hen ph qun. S khng thy c mch o trn bnh nhn c p tim nhng chc nng tht tri gim nhiu v c tng p lc tm trng hoc trong thng lin nh, h ch hay p tng vng tim. B. Cc xt nghim chn on 1. Siu m tim qua thnh ngc: l phng php bt buc phi thc hin khi nghi ng c p tim trn lm sng. N s gip khng nh chn on khi thy c nhiu dch trong khoang mng tim. a. Siu m hai bnh din cn phn bit cc trng d hp c tng p lc tnh mch trung serve v h tm e sr huyt p nh nhi mu c tim thttphi, vim co gh m.vn i tht mng ngoi tim. ll r co . A ahoo. b. Cc du hiu ca p timloev y bao gm: Fin020@mng ngoi tim (biu C dch trong. khoang 08 2 20 khong hin bng cc ocity trng v siu m tim). t t Du righ po nh phi th tm trng thng hiu P y p bt u t cui tm trng v thy r nht Co mt ct cnh c tri trc ngang, di sn v 4 bung t mm. y l du hiu c nhy cao tuy nhin c hiu ch l 82% vi gi tr d bo dng tnh l 50%.

A B Hnh 23-2. Du hiu p tht phi (A) v p nh phi (B). 417 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Du hiu p tht phi thng quan st thy ti thnh trc tht phi v vng phu trong t th nm nga. Trc ngang v trc dc cnh c tri l hai mt ct thun li nht quan st du hiu ny. Cn s dng siu m TM khng nh du hiu ny. Du hiu p tht phi n c trn siu m c th c trc biu hin p tim trn lm sng. Du hiu p nh tri. Tng kch thc tht phi v gim kch thc tht tri mt cch bt thng khi bnh nhn ht vo su. Thay i theo nhp th ca cc dng chy qua van nh tht, tng bt thng dng chy qua van ba l v gim bt thng dng chy qua ed van hai l khi bnh nhn ht vo ssu. Bnh erv e thng khi ht vo dng chyhts r n ba l qua van .v g chy qua van khng tng qu 7%, cn ldng om l ri c A h Nu khi ht vo, .10%.oo. hai l khng gim qu a oev sng E qua van Finl l @y hn 25% th rt hai 20 gim . gi c biu 08 typ tim trn siu m. hin 20 20 oci ht Pot rig py Co

Hnh 23-3. Thay i theo h hp th ht vo (INSP) v th ra (EXP) ca ph Doppler xung dng chy qua van hai l (pha trn) v van ba l (pha di) bnh nhn TDMT p tim. 418 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Gin tnh mch ch di. Tnh mch ch di gin hn 50% khi bnh nhn ht vo su l du hiu rt nhy (97%) nhng c hiu ch l 40% trong chn on p tim. Tht tri gi ph i. 2. Thng tim phi: quan trng cho chn on v ra hng iu tr. N khng nh chn on p tim, nh gi s cn tr huyt ng v xc nh cung lng tim, theo di s tin trin ca huyt ng sau khi c chc dn lu dch mng ngoi tim. a. Cc du hiu huyt ng cn xc nh l p lc nh phi, p lc mao mch phi bt, p lc tm trng ca ng mch phi, p lc gia tm ved ser t 10 trng ca tht phi, vi ch s bnhsthng re t n 30mmHg. Trong khi th rarigh lc.vmao mch p m n o ll phi bt tng nh so vi . p hoo.c trong khoang v A a lc loe mng tim do hot ng n y ca tht tri. Khi Fin020@ ra . bnh nhn ht 2008 ity2 mao mch phi bt s vo p lc c ht Poto tng dn in chnh p rt thp, thm ch l m rg giaChy op thng tnh mch phi v tht tri. b. Khi chc ht dn lu mng ngoi tim cn xc nh s gim ca hu ht cc p lc trong thng tim (nh phi, tht phi tm trng, khoang mng tim, p lc mao mch phi bt v p lc cui tm trng ca tht tri). C. iu tr 1. Nguyn l chung. Khi c chn on p tim th u tin hng u l cn phi ht dn lu dch mng ngoi tim. Phng php c th thc hin l chc ht qua da vi gy t ti ch, phu thut dn lu (m khoang mng tim di xng c, m ca s mng tim v ct mng tim gn ton b), nong mng ngoi tim qua da bng bng. Trong cc trng hp trn 419 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

dch mng ngoi tim sau m, phu thut dn lu mng ngoi tim hay c ch nh; cc trng hp khc vic chc ht qua da l phng php u tin c la chn vi bc s c kinh nghim, theo di huyt ng lin tc v c siu m kim tra. Soi lng ngc di mn tng sng s gip hn ch ti a cc bin chng ca th thut. 2. iu tr ni khoa: Bao gm bi ph dch, thuc nng huyt p nu c tt p nh Norepinephrine, Dobutamine, trnh dng cc thuc gin mch nh Nitroglycerine, Nitroprusside... 3. iu tr chc dn lu qua da: C th thc hin ed nhanh chng trong iu kin cp cu, t xm vln hn ser b ti re cc phng php khc v ch cn stschun gh m.vn v cc i thiu. Bin chng c th gp l chc vo tim ll r co . A ahoo.ng cng ph mch mu ln, chc vo phi, phn oev inltc @y v... C th t dn lu .lin 20 nhng nn trnh trong F 0 8 cc trng hp b 200 city2 t hn 1cm, dch khu tr dy dch t o hay c nhiurisi fibrin dnh cht. gh Pot py Co 4. Nong mng ngoi tim bng bng qua da: Ch nn p dng khi c nhiu kinh nghim v cc bnh nhn ung th gy trn dch mng ngoi tim. Bng nong c th s dng l bng ngoi bin nh Mansfield kch c t 18 n 30mm hay bng Inoue. Sau khi nong c th t dn lu mt thi gian hon ton ht dch trong khoang mng ngoi tim. 5. Phu thut: Trong cc trng hp trn dch phc tp, sau m hay ti pht dch th c th ch nh phu thut dn lu dch mng ngoi tim. a. M dn lu mng ngoi tim di xng c. C th thc hin bng gy t ti ch. K thut thc hin bng cch m mt ng rch nh di 420 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

xng c nhn thy mng ngoi tim trc tip, sau s a ng dn lu vo khoang mng tim. b. M ca s mng ngoi tim. Nhm mc ch to ra s thng thng gia khoang mng tim v mng phi tri. Kt qu ngay lp tc l lm gim bt p lc trong khoang mng tim, hn na do lm tng din tip xc nn s lm tng s hp thu dch, t trnh c hin tng ti pht trn dch mng tim. ng rch thng v tr ca ngc tri. c. Ct mng ngoi tim ton b hay gn ton b. Phu tch mng ngoi tim v tr st tnh mch ch di gn c honh cho n cc mch mu ed erv ln. Phu thut ny c la chnestrong cc r ts trng hp trn dch khu tr hayhtrnvn g m. dch phi l ri o Al hp vi co tht mng ngoi.tim.hoo.c oev a inl 20@y F 8. 0 00 ity2 2 Ti liu tham kho t oc gh Pot ri 1. Chetcuti S. Pericardial effusion. In: Marso SP, Griffin BP, Topol EJ, py Co
2. 3. eds. Manual of Cardiovascular Medicine. Philadelphia: LippincottRaven, 2000. Feigenbaum H. Pericardial disease. In:Feigenbaum H, ed. Echocardiography, 5th ed. Baltimore: Williams & Wilkins, 1994. Lorell BH, Grossman W. Profiles in constrictive pericarditis, restrictive cardiomyopathy and cardiac tamponade in cardiac catheterization. In: Bairn DS, Grossman W, eds. Angiography and intervention, 5th ed. Baltimore: Williams & Wilkins, 1996:801-822. Lorell BH. Pericardial diseases. In: Braunwald E, ed. Heart disease: a textbook of cardiovascular medicine. 5th ed. Philadelphia: WB Saunders, 1997:1478-1534. Pericardial heart disease. Curr Probl Cardiol 1988 (Aug);22.

4.

5.

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6.

7.

Riem A, Scalia G. The pericardium, restrictive cardiomyopathy, and diastolic flinction. In: Topol EJ, ed. Textbook of cardiovascular medicine. Philadenphia: LippincottRaven Publishers, 1998:639-707. SanFillpo AJ, Weyman AE. Pericardial disease. In: Weyman AE, ed. Principles and practice ofechocardiography, 2nd ed. Philadelphia: Lea & Febiger, 1994:1102-1134.

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r ese sr n t gh .v l ri .com l . A oo oev yah inl @ . F 2020 8 00 y 2 tocit ht Po rig

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vim mng ngoi tim co tht

Vim mng ngoi tim co tht l hu qu ca qu trnh x ho lm dy ln v dnh ca mng ngoi tim, l hu qu th pht ca qu trnh vim mn tnh do nhiu nguyn nhn gy ra. Lc ny qu tim c mt mng ngoi tim c nh cng nhc bao bc, lm hn ch tim gin ra trong th tm trng, tng cc p lc trong bung tim v lm mt tng ng gia p lc trong cc bung tim v p lc ca lng ngc. S tng p lc trong bung tim v gim s gin th tm trng ca tim lm hn ch s v ca mu tnh mch ch v phi, gy ra du hiu ca suy tim huyt ca c tim bn phi v bn tri. Rt nhiu cc trng hp ved b b st chn on vim mng ngoi tim co tht v khng c ser e ngh n nn dn ti hu qu nng n cho bnh ts r vn nhn. gh m. i ll r co I. Nguyn nhn . A ahoo. oev Cc nguyn nhn hay gp gy vim 0@y ngoi tim co tht inl 2mng .F c lit k bng di y:08 ty20 0 i 2 t oc 1. Khng r nguyn nhn (idiopathy). gh Pot i yr 2. Nhim Cop trng: lao, vi khun, virus, nm v k sinh trng. Trong s lao vn l nguyn nhn hng u dn n vim mng ngoi tim co tht. 3. Chn thng (bao gm c phu thut tim) trong cc trng hp phu thut tim c trn mu mng tim l yu t thun li dn n vim mng ngoi tim co tht sau ny. 4. Sau chy tia x iu tr. y l bin chng mun ca x tr liu dn n vim co tht mng ngoi tim, nhiu khi vi nm sau. 5. Vim nhim/ri lon min dch: thp tim, lupus ban , sarcoidose. 6. Bnh ung th: v, phi, hch lympho, u sc t, u trung biu m. 423 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

II. Triu chng lm sng A. Triu chng c nng 1. Cc du hiu sm ca vim mng ngoi tim co tht thng rt khng c hiu nh xu, mt, v gim kh nng gng sc. 2. Dn dn sau bnh nhn thng c cc biu hin ca suy tim tri nh kh th khi gng sc v kh th v m. 3. Giai on nng ln ca bnh s thy cc du hiu ging nh ca suy tim phi nh ph ngoi bin, cng tc bng v c chng. B. Triu chng thc th ved 1. Tnh mch c ni, phn hi gan tnh mch ec dng sr re ts Rt tnh gp gn nh tt c cc bnh nhn.vn nhiu gh m. i cc trng hp c du hiu mchl oco Kussmaul l r ca . A ahoo. ca tnh mch (ht su vo li lm gim vcng to oe inl 2 @y c). Du hiu ny c Fnhy0cao nhng c hiu 8. 0 00 ty2 thp do n c th 2gpcitrong cc trng hp ph i t o tht phi v righ mu c tim tht phi. Nguyn nhn nhi Pot y ca tt cop hin tng ny l do s gin nhanh ca C cc tm tht trong thi k u tm trng. 2. Khm tim: thng thy ting tim m do mng ngoi tim dy. Ting ng van hai l v ba l gn nh xut hin cui th tm trng, gy ra ting T1 rt nh. i khi c th nghe ting g ca mng ngoi tim ngay u tm trng (60 n 120 ms sau ting T2). Ting ny c ngun gc do s gin ra t ngt ca tm tht sau mt giai on b mng tim cng hn ch gin. Cn phn bit ting ny vi cc ting tm trng sm khc nh ting T3, ting m van hai l. Thng thng ting g mng ngoi tim c m sc cao hn v n sm hn ting T3 v ting m van hai l lun lun i km vi ting rung tm trng. 424 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

3. Khm phi thng thy gim r ro ph nang hai y phi, nguyn nhn l do xung huyt phi hay trn dch nh y mng phi hai bn. Trong trng hp tr nhiu, c th thy ph phi vi cc ran m xut hin. 4. Khm bng nhm pht hin cc du hiu ging nh suy tim phi vi gan to. Trong cc trng hp nng c th dn n x gan tim vi bng c chng r. 5. Khm ngoi bin pht hin ph hai chi di, sau c th dn n ph ton thn. III. Cc xt nghim chn on khng nh chn on vim mng ngoi tim co tht th vn khng c mt xt nghim no c coi l tiued v chun ser cc xt vng c. V vy, cn phi kt hp gia lm snge v r ts nghim cn lm sng. gh m.vn i ll r co 1. in tm : Kinh in thy. A hoo. hiu in th c du ev a thp lan ta. Sng T thnglodt, y th thy du hiu in 20@ c .F dy nh tri v cng 008 tgp rung nh phi hp. hay y20 2 oci 2. Chp tim phi:t Pot gh i yr a. Mngopngoi tim canxi ho l du hiu hay gp C trn lm sng. du hiu ny thng thy trn phim chp nghing v hay thy v tr ca tht phi v rnh nh tht. b. Trn dch mng phi cng l du hiu hay gp. c. Gin nh phi v nh tri c th thy r rng trn phim chp Xquang. d. Ph phi l du hiu him thy trn phim. 3. Siu m tim: L phng php hu hiu nht chn on v theo di trn dch mng ngoi tim. Ngoi gi tr chc chn trong chn on, siu m cn gip cho vic t dn lu mng tim v nh gi s lng dch cn li trong khoang mng tim. Tuy nhin siu m

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tim t c gi tr chn on nguyn nhn ca cc loi dch mng tim khc nhau. a. Siu m TM cn tm cc du hiu sau: Thnh t do tht tri dt. dy ca mng ngoi tim thng tng ln v c th thy c du hiu vi ho ca mng ngoi tim (mng ngoi tim dy v sng hn so vi bnh thng). Tuy nhin vic o b dy mng ngoi tim mt cch tht chnh xc bng siu m TM nhiu khi cng gp kh khn. Lc ny cc phng php chn on hnh nh khc c nhiu u im hn nh CT Scanner, MRI, siu m thc qun. Van ng mch phi m sm. Do tnged lc v p sern nh cui tm trng ca tht phi dn re ts hng ti p lc ng mchrphi. .vn gh m i Vn ng nghch thngll cacovch lin nh . A ahoo. v trong th tm thu. inloe @y 0 .F b. Siu m 2D: cn8c 202 thy thm mt s du 00 ity th hiu khc nh: 2 otoc t gh P rilin tht ny ln trong th tm trng: Vch py Co mt ct 4 bung tim t mm. thy Gin tnh mch ch di. Gim gc hp gia nh tri v tht tri. Gc ny b nhn hn so vi bnh thng do s vn ng bt thng ca tm tht v tm nh. c. Siu m Doppler: Siu m TM v 2D cho php gi vim mng ngoi tim co tht. Tuy nhin cc du hiu va nu ch c nhy v c hiu thp. Trong khi siu m Doppler l phng php cho php nh gi tt nht chc nng tm trng ca tm tht. C th l: S thay i theo h hp ca dng chy qua van hai l v van ba l. Khi bnh nhn ht vo su, p lc trong lng ngc gim, p lc ny 426 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

ko theo p lc trong tnh mch phi gim nhng khng lm thay i p lc tht tri. Chnh do nguyn nhn ny nn trong giai on ht vo, tc dng chy qua van hai l tng ln cn tc dng chy qua van ba l gim i: Tc sng E qua van hai l tng ln khong 33%, cn tc qua van ba l li gim i. Dng chy trong tnh mch phi gim trong giai on th ra. C s thay i theo h hp ca dng chy trong tnh mch gan.

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r ese sr n t gh .v l ri .com l . A oo oev yah inl @ . F 2020 8 00 y 2 tocit ht APo rig

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Hnh 24-1. Thay i theo h hp ca dng chy qua van hai l (A), qua van ba l (B), trong tnh mch phi (C), trong tnh mch trn gan (D): lc ngng th (trn), khi ht vo (gia) v khi th ra (di), ngi bnh thng (1), bnh nhn VMNT co tht (2) v bnh c tim hn ch (3).

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4. Thng tim: y l phng php quan trng chn on phn bit vim co tht mng ngoi tim v bnh c tim hn ch. a. p lc tm nh: sng nh s c dng ch W, do sng a chim u th. b. p lc tm tht: p lc tht c biu hin b nho-cao nguyn (dip-plateau), l mt du hiu kinh in ca vim mng ngoi tim co tht.

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r ese sr n t gh .v l ri .com l . A oo oev yah inl @ . F 2020 8 00 y 2 tocit ht Po rig

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Hnh 24-2. Du hiu b nho cao nguyn biu hin r hn sau mt nht bp ngoi tm thu. p lc cui tm trng ca hai tm tht khng ch tng cao m cn cn bng gia tht tri v tht phi, chnh p cui tm trng gia hai tht nh hn 5mmHg vi p lc cui tm trng tht phi ln hn 1/3 p lc tm 428 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

thu ca tht phi. y chnh l du hiu kinh in chn on phn bit gia vim mng ngoi tim co tht v bnh c tim hn ch. IV. iu tr A. iu tr ni khoa Cc bnh nhn giai on u vi mc kh th NYHA 1 c th iu tr ni khoa bo tn bng li tiu v ch n hn ch mui. Ngoi ra iu tr ni khoa cng c ch nh cc bnh nhn qu nng khng cn ch nh m hay khng chp nhn nguy c ca cuc m. B. iu tr phu thut 1. Phu thut ct mng ngoi tim l phu thut c la chn. Hn 90% c ci thin triu chngrved k ng e res sau phu thut. hts n rig com.vi cao (5 2. T l t vong trong v ngay sau m tng ll . v A ah o n 20%) l mt yu t cn . thno trng cn nhc. loe y Cng chnh v nguyn .nhn 20@ cc phu thut vin Fin0 ny 8 thng quyt nh200 city2 cho cc bnh nhn ch m sm o khng i n ht Pot trng bnh nhn b suy sp khi th rig do bnhCopy bin ko di. din Ti liu tham kho
1. 2. 3. Brockington GM, Zebede J, Pandian NG. Constrictive pericarditis. In: Shabetaj R, ed. Diseases of the pericardium. Cardiol Clin 1990;8(4):6454561. Fewler N. Constrictive pericarditis: its history and current status. Clin Cardiol 1995;18:841-B50. Klein AL, et at. Differentiation of constrictive pericarditis from restrictive cardiomyopathy by Doppler transesophageal echocardiographic measurements of respiratory variations in pulmonary venous flows. J Am Coll Cardiol 1993;22:1935-1943. Klein AL, Cohen GI. Doppler echocardiographic assessment of constrictive pericarditis, cardiac amyloidosis, and cardiac tamponade. Cleveland Clin J Med 1992;59:27&290. Oh J, et at. Diagnostic role of Doppler echocardiography in constrictive pericarditis. J Am Coll Cardiol 1994;23:154-162.

4. 5.

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6.

Braunwald E, Lorell BH. Pericardial diseases. In: Braunwald E, ed. Heart disease: a textbook of cardiovascular medicine, 5th ed. Philadelphia: WBSaunders, 1997:1496-1505. 7. Feigenbaum H. Pericardial disease-constrictive pericarditis. In: Feigenbaum H, ed. Echocardiography. Baltimore: Williams & Wilkins, 1994:577-583. 8. Grossman W, Lorell BH. Profiles in constrictive pericarditis, restrictive cardiomyopathy, and cardiac tamponade. In: Balm DS, Grossman W, eds. Cardiac catheterization, angiography, and intervention. Baltimore: Williams & Wilkins, 1996:801-821. 9. Topol EJ, Klein AL, Scalia GM. Diseases of the pericardium, restrictive cardiomyopathy, and diastolic dysfunction. In: Topol EJ, ed. Comprehensive cardiovascular medicine. Philadelphia: Lippincott-Raven Publishers, 1998:669-733. 10. Reginelli JP, Grady TA. Constrictive pericarditis. In: Marso SP, Griffin BP, Topol EJ, eds. Manual of Cardiovascular Medicine. Philadelphia: Lippincott-Raven, 2000.

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Tm ph mn
Tm ph mn (chronic cor pulmonale) l mt thut ng m t cc nh hng ca ri lon chc nng phi ln tim phi. Tng p ng mch phi (TAMP) l cu ni gia ri lon chc nng phi v tim phi trong tm ph mn (TPM). Do cc ri lon chc nng phi dn n TAMP nn TPM l mt dng bnh tim th pht, nh l mt biu hin mun ca nhiu bnh phi v trong tng trng hp bnh c th th tng hu gnh tht phi l biu hin chung nht. Tu theo mc v thi gian b m TAMP s dn n gin tht phi v c hoc khng c ph i tht phi. Suy tim phi khng phi l yu t cn thit chn on TPM, nhng suy tim phi l biu hin ph bin ca bnh. d Cc du hiu lm sng ca TPM thay i theo cung serve tim, lng re cn bng nc in gii v trong hu ht cc trng n ts hp l s gh m.v i thay i trao i kh phi. ll r co . A ahoo. Ri lon chc nng tim phi th lphty suy tim tri, cc oev sau in 20@ F bnh l van tim, bnh tim bm sinh 20 khng nm trong nh 8. u 00 ib nghn hp l mt nguyn 2 ngha ca TPM. Tnh mch phic ty ht P to gmchophi tc nghn thng c xem nhn ca TPM. Bnh tnh ri py l nm trong bnh cnh TAMP nguyn pht. Co I. Nguyn nhn Gin ph nang v vim ph qun mn tnh l nguyn nhn ca hn 50% cc trng hp tm ph mn Hoa K. Tn xut ca TPM rt kh xc nh v TPM khng phi xy ra tt c cc trng hp b bnh phi mn tnh. Hn na, cc thm khm thc th v xt nghim thng qui th thng kh xc nh c TAMP. Tn xut bnh phi tc nghn mn tnh Hoa K khong 15 triu ngi, l nguyn nhn trc tip ca 70.000 ca t vong mi nm v gp phn gy t vong 160.000 trng hp khc. TPM chim t 5-10% bnh tim thc tn. Trong mt nghin cu ngi ta thy TPM l nguyn nhn ca 20 n 30% cc trng hp nhp vin.

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TPM thng gp nht nhng ngi n ng ht thuc l, tuy nhin t l ny ph n cng ang tng ln, do ph n ht thuc ngy cng nhiu. Bng 25-1. Cc nguyn nhn ca TPM phn loi theo c ch tng p ng mch phi. 1. Co mch do gim xy mu: a. Vim ph qun mn v kh ph thng, x nang phi. b. Gim thng kh phi mn. Bo ph. Kh th khi ng. Bnh thn kinh c. Ri lon chc nng thnh ngc. c. Bnh m yu mn tnh vng ni (bnh Monge). 2. Tc nghn h thng mch mu phi: ed erv strng, a. Thuyn tc ng mch phi, nhim trng k sinh re ts tc nghn mch mu phi do u. gh m.vn ri o b. Tng p ng mch phi nguyn pht.All hoo.c . a v c. Bnh tc tnh mch phi / Gin inloe0mch phi. mao @y F d. Bnh hng cu hnh lim / 08. y202 tu. 0 Tc nghn t 2 e. Vim trung tht x ho, u otoci tht. t trung ghdo P i f. Vim mch mupphi bnh h thng: yr Co mch. Bnh collagen Bnh phi do thuc. Vim hoi t v nt ng mch. 3. Bnh nhu m phi c mt din tch ti mu: a. Trn kh hnh bng, bnh thiu anpha1 antiproteinase. b. Gin ph qun lan to, x nang phi. c. Bnh m k lan to. Bnh bi phi. Sarcoid, bnh x phi t pht, chng m bo huyt X. Lao phi, nhim trng nm mn tnh. Hi chng suy gim h hp ngi ln. Bnh collagen mch mu (bnh phi t min). Vim phi qu mn cm.

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T nm 1950 - 1964 ti khoa ni bnh vin Bch Mai c 200 trng hp tm ph mn (ng Vn Chung). Bnh TPM chim 7% bnh phi ti khoa h hp bnh vin Bch Mai (Chu Vn - 1986). A. Bnh phi tc nghn mn tnh (COPD) 1. Cc bnh phi tc nghn mn tnh (BPTNMT) gy ra TPM qua mt vi c ch c tc ng qua li bao gm: gim thng kh phi, gim xy mu do t l thng kh/ti mu (V/Q) khng tng ng nhau, v gim din tch b mt c ti mu. a. Bnh nhn vi gim xy mu v gim thng kh ph nang l chnh thng c chng a hng cu, ph, v sm c biu hin TPM, TPM xanh. ed b. Bnh nhn vi triu chng chnh l kh vth khi ser re gng sc thng c gim thnghts .vn hn v kh t g m i o gim xy mu lc ngh t hn rv.cvy thng c ll . A ahoo e biu hin TPM mun hn,vTPM hng. nlo 0 y FiTPM@ 2 xanh v TPM hng c 2. Mt vi s khc bit 08. 20 gia 20 ocity th lin quan n cch thc thng kh phi. Bnh ht ot nhn c thng kh P phi thp c v thch ng vi loi rig py Co trong khi loi TPM hng vn gi c pH TPM xanh, v nng kh mu ng mch bnh thng. Mt gi thit khc l nhng ngi b TPM xanh thng do vim ph qun v nhm TPM hng thng do gin ph nang n thun hn. 3. Khm thc th tt c cc th BPTNMT u thy tng ng knh lng ngc, c honh h thp, g vang, r ro ph nang gim vi m th kh kh th th ra, ting tim nghe m, tnh mch c ni trong th th ra v gan to. Gan to v ph chn l du hiu ng dch v suy tim phi. 4. Xquang lng ngc c th thy cc c im ca kh ph thng nh hai trng phi sng, tng ng knh trc sau ca lng ngc v cc c honh nm phng 433 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

5. Thm d chc nng phi cho thy tng th tch cn (RV) v dung tch phi ton phn (TLC); gim mnh dung tch sng (VC) v kh gim cc t l lu lng th ra (FEV1, FEF). 6. Xt nghim v kh mu ng mch thng l bnh thng nhng trng hp bnh nh v i vi nhng trng hp nng th PaO2 gim, PaCO2 tng v pH gim. Cc bnh nhn TPM thng c PaO2 thp di 55 mmHg. T l V/Q khng tng xng v gim thng kh ph nang, c hai gp phn lm gim xy mu. PaO2 lc ngh khong 45 mmHgerved t chng res gim thng kh ph nang r. ts n ighom.v rhim khi dn n 7. Hen l mt dng BPTNMT nhng .c ll v. A ahoobnh tc nghn TPM, c l do hen thng e ch l lo y ng h hp tng lc. . Fin020@ 8 2 00 8. TPM trong BPTNMTocy 2 t cit lin quan n mc nng t igh Po ca ri lon rchc nng phi v TAMP l biu hin y p Co ca bnh. Hn ch kh nng gng sc trong BPTNMT thng do hn ch kh nng thng kh phi m khng lin quan n d tr tim mc d cc bnh nhn ngi nhiu l t th lm gim kh nng gng sc. Khng c mt thm d n c no v phi nh o cc dung tch v th tch chc nng ca phi, kh nng khuych tn CO (DL CO), cc nng kh mu hay Xquang phi l c gi tr d bo nhiu v TPM v nhng bt thng nh gim din tch b mt trao i kh v co mch do gim xy t chc xy ra c lp vi p lc ng mch phi. B. Bnh m k phi lan to 1. Bnh nhn thng kh th, th nhanh, khng c kh nng gng sc v i khi c ngn tay, chn hnh di 434 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

2.

3.

4.

5.

trng. Nghe phi thng c ran m, ran n v c th nghe thy c trong th ht vo. Phim Xquang phi thng c cc tn thng nh mng ph huyt qun m, tn thng dng li-nt hoc x ho lan to. Cc du hiu ny khng phi lc no cng c m s xut hin lin quan cht ch vi cc tn thng sinh l phi. Trong mt s bnh nh vim phi k bc vy, chng ta c th thy hnh ph nang y cng vi hnh ph qun y kh. Sinh thit phi l cn thit xc nh nguyn nhn chnh xc ca bnh, nhng khng phi lc no sinh thit cng em li kt qu ng. Sinh thit phi qua ph qun c th chn on c mt s bnh m k phi nh bnh sacoide v ra ph qun phrved c e nang res th a ra chn on trong nhiu trng shp. ht n rig om.v Cc xt nghim chc nng phillchocthy tnh trng . A o. tc nghn phi vi gim dungvtch ho oe ya phi, gim n l Fin0 khuych tn kh cc hi phi v gim kh . nng20@ 8 ng th khng tc 0 city2 Dung tch sng gim, v 20 nghn. o t l th tchight raotti a trong mt giy vi dung th P yr pti a thng di 80%. Lc u, PaO2 tch sngo C gim khi gng sc nhng vn gi c mc bnh thng lc ngh bng cch tng thng kh. Khi bnh tin trin nng hn, PaO2 s thp trong c lc ngh. Tin trin v tin lng bnh m k phi ph thuc vo cn nguyn bnh v nhiu yu t khc ca bnh. Biu hin ca TPM trong cc bnh m k phi thng l cc ri lon chc nng phi mc nng hn, c l c lin quan n mch mu (nh lupus ban h thng) v TPM cng c th khng xy ra ngay c khi bnh giai on cui.

435 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

C. Cc hi chng gim thng kh 1. Mt s d tt (nh g vo ct sng) c th lm suy gim v hn ch thng kh phi dn n gim thng kh chung ca ph nang v gim xy ph nang. 2. Bo ph nhiu c th c thng kh phi km, tm, a hng cu v bun ng (khng c s tht nght phi) thng c gi l Hi chng Pickwick. Bnh nhn bun ng ngy, au u vo bui sng, ri lon v nhn cch c nhn v c nhng giai on kh th trong khi ng kt hp vi mt ng, ngy to, gim xy mu v tng CO2 mu do tc nghn ng h hp trn (do li, a-mi-an to hoc sp thnh kh qun). 3. Mt s bt thng v no nh bt thng Arnold d Chiari cng c th lm suy gim trung tmsh ehp v erv re gim thng kh phi nguyn pht. Cchbnhn ts thn kinh g m.v c nh hi chng sau vim tu rixm, hi chng ll o.co v. A ahon TPM v suy Guillain-Barre mn tnh cloe dn th y Fin020@ tim phi. . 08 y2 20 ocitkh c xc nh qua phn 4. Chn on gim thng ht Pot tch kh mu,ig ng thng kh gim sau th nghim yr p p ht CO2,Co thm d v gim thng kh phi hoc cc cc thm d v gic ng. Ri lon thng kh trong khi ng l mt biu hin kh thng gp nhiu hi chng gim thng kh. 5. Trong tt c cc trng hp gim thng kh, nguyn nhn chnh lm tng p lc ng mch phi l co mch do gim xy t chc, mt p ng ca cc tiu ng mch phi i vi gim xy ph nang. Tnh trng toan h hp, i km vi gim thng kh, c th lm tng p ng co mch i vi gim xy t chc. D. Cc bnh mch mu phi 1. Tm ph mn l hu qu ca mt vi bnh mch mu phi. Tng p ng mch phi tin pht v thuyn tc ng mch phi l nhng bnh cnh hay gp. 436 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

2. Bnh t bo hnh lim, do c hemoglobin SS hoc SC, c th gy ra tm ph mn sau mt thi gian di b nhi mu phi nh, khu tr v thuyn tc ng mch phi do m hay huyt khi. 3. Tc tnh mch phi l bnh him gp, thng c tng p ng mch phi v thm nhim phi nhiu ni, p ng tt vi iu tr bng thuc gim min dch. 4. X gan thng c km vi gin cc mch mu phi. 5. Nhim HIV cng l nguyn nhn gy bnh mch mu phi, ging vi TAMP tin pht. 6. Bnh collagen mch mu c th dn n TPM do vim mch tin pht cng nh do x ho t chc k lan to. Bnh x cng b, lupus ban h thng v vim khp dng thp l cc bnh collagen mch mu thng gy ra vim tiu ng mch phi nht. Bnh nhn b lupus ban h thng hoc b vimd khp ve dng thp thng c bnh phi k tin pht. er res hts n II. Sinh l bnh rig com.v ll . A ahoo. ng mch phi c lu lng cao,vpylc dng chy thp, loe sc cn mch mu thp vi chc nngncung cp mu cho trao i Fi 020@ . kh v c 3 c im: (1) thnh 08 ity2vi trng lc c lc ngh 20 mng t c thp, (2) ngi ln, lc hnghotoc s iu chnh nh vn mch rigkinhPt ng, (3) c nhiu tiu ng phi nh h thng opy thn C ph nang khng tham gia vn chuyn mu mch v mao mch lc ngh v c th hot ng li khi cn thit m rng mng li mao mch phi v nh vy lm gim sc cn mch mu phi. Bnh thng, p lc ng mch phi trung bnh khong 12 - 17 mmHg, khi p lc ng mch phi lc ngh ln hn 20 mmHg th cn phi ngh ti c tng p ng mch phi. Sc cn ca h mch mu phi tng v TAMP l nhng c ch bnh sinh chnh trong tt c cc trng hp TPM. A. C ch tng p ng mch phi 1. Suy h hp tng phn gy thiu xy mu, thiu xy t chc, lm co tht cc tiu ng mch phi v t dn n tng p lc ng mch phi. Nguyn nhn quan trng nht gy co cc tiu ng mch phi l thiu xy cc ph nang. C ch co mch do thiu xy t chc cn cha c r. Ngi ta cho l c th 437 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

2. Mc co mch do gim xy t chc ph thuc ch yu vo PaO2 ph nang v khi PaO2 ph nang < 55 mmHg th p lc ng mch phi tng rt nhanh. Khi p lc ng mch phi ln hn 40 mmHg th bo ho xy ng mch c th thp hn 75%. 3. Suy h hp ton b s lm tr CO2 v gy toan h hp. Toan mu lm co tht cc tnh mch phi v phi hp vi co tht tiu ng mch phi do thiu xy t chc s lm tng p lc ng mch phi.

ved ser re ts v ghtng n i Suy h hp om. phn Suy h hp tng phn ll r c . A ahoo. oev inl 20@y F 8. 0 00 ity2 Thiu xy mu Tng CO2 2 t oc gh Pot ri py Co
Suy h hp Thiu xy t chc Toan mu

Co tht tiu ng mch phi

Co tht tiu tnh mch phi

Tng p ng mch phi

Ph i tht phi Suy tim phi

Hnh 25-1. S v c ch tng p lc ng mch phi v suy tim phi trong TPM. 438 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

4. Mt s c ch khc lm tng p lc ng mch phi nh tng lu lng tim do tng chuyn ho, hot ng gng sc, nhim khun phi cp tnh...; Tng qunh ca mu: a hng cu th pht; Nhp tim nhanh do thiu xy hoc do suy tim... B. C ch gy suy tim: Tng p lc ng mch phi l tr lc chnh lm tng cng ca tim phi. Tnh trng thiu xy, tng th tch, tng cung lng tim cng gp phn lm tng cng ca tim. Tng cng ca tim ko di lm ph i tht phi, sau gin tht phi v cui cng l suy tim phi. III. Triu chng lm sng A. Triu chng c nng ved ser b che 1. Biu hin lm sng ca tm ph mn thng re ts v gh thcnth c du bi cc triu chng ca bnh phi m. i ll r co sn. Cn phi xc nh loi bnh v omc nng ca . A ah o. oev cc bnh phi sau mi lxem y bnh nhn c b in 20@ xt F tm ph mn khng.008. y20 2 cit ht c 2. Bnh nhn cgth Potonhng t ph chn, au ngc ri p khng iny Co hnh, kh th khi gng sc, tm ngoi vi lin quan n gng sc. a. au ngc c th do lng ngc b cng phng (au c xng) hoc c th lin quan n thiu mu c tim tht phi. b. Ho v cm gic d b mt mi l cc triu chng ph bin. c. Mt s bnh nhn c biu hin gim thng kh ban m, kh th khi ng v c th c thay i nhn cch c nhn, tng huyt p nh v au u. d. Th ngn l triu chng lun c cc bnh nhn tm ph mn. Cn phi xem xt mc hot ng no lm cho bnh nhn kh th v bnh nhn thng gim hot ng trnh kh th. 439 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

e. i khi c au tc vng bng do mu gan. B. Triu chng thc th 1. Hai phi cng phng c tnh cht mn tnh nn lng ngc thng bin dng hnh thng v g vng ngc hai bn u thy rt vang. Ting tim thng hi m do hin tng gin ph nang ca phi. 2. Cc du hiu sm nht l cc du hiu c lin quan n tng p lc ng mch phi ko di. a. Du hiu nhy nht ca tng p ng mch phi l thnh phn phi ca ting T2 vang mnh, c th nghe c v tr van ng mch phi v vng tht phi trn xng c. b. Khi p lc ng mch phi tng rt cao, ced c th v ser ting thi tm trng van ng mch phi v e sr ting thi tm thu van ba l ido th.vn v h gh m phi lr van ba l, ng thi cng c ltho.co thy ting . A aho nghe oev tng mu tm thu v ting nga phi T3 tht phi. inl 20@y F 0 8 3. Khi c suy tim phi. bnh nhn thng c tim to, 00 ity2 2 tnh mch c ni, ganc to v ph ngoi bin. Du t o gh Pot ri hiu tnh omch c ni c trong th ht vo v th ra l py C ch im chc chn c suy tim phi. Trong du hiu cc trng hp suy tim phi nng, bnh nhn c th c ph ton thn v trn dch c mng phi, mng tim, c chng 4. Cc u chi c th m do gin mch ngoi bin v tng CO2 mu; hoc cng c th tm do lu lng mu thp hoc gim xy mu. 5. Nhng bnh nhn c TPM lu c th b tm en nh ngi en, mt li v do tng sinh ca cc mch mu mng tip hp trng nh mt ch v thng c ngn tay, ngn chn di trng. IV. Cc xt nghim chn on A. in tm 440 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

1. in tm ca bnh nhn TPM b nh hng bi nhiu yu t nh p lc ng mch phi, s quay v thay i v tr ca tim do hai phi cng phng, thay i kh mu ng mch, thiu mu c tim v cc ri lon chuyn ho. V vy gi tr ca in tm trong chn on bnh tm ph mn cn ph thuc vo bnh phi nn v cc bin chng ca n. 2. Hnh thi ph i tht phi thng gp nhng trng hp c tc hp h mch mu phi. Hai phn ba bnh nhn b bnh phi tc nghn mn tnh c ph i tht phi khi m t thi nhng trn in tm li khng c hnh nh ca tht phi ph i. Khi khng c hnh nh ph i tht phi in hnh th vic chn on phi da vo mt lot cc du hiu inved tm ser P cao nh rS V5, V6; qR aVR; v P ph.re Sng s nhn DII v aVF chng t dy nhight m.Bloc nhnh phi. vn r phi gp 15% bnh nhn TPM. ll oo.co . A ah oev inl 20@y F 8. 0 00 ity2 2 t oc gh Pot ri py Co

Hnh 25-2. in tm ca mt bnh nhn b TPM. 3. Ri lon nhp khng phi lun c bnh nhn TPM khng bin chng, nhng khi c ri lon nhp th hu 441 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

nh l ri lon nhp trn tht v chng t c bt thng v kh mu, h kali mu hoc dng qu liu cc thuc nh Digitalis, Theophyllin v cc thuc kch thch giao cm. Cn tim nhanh nh a thng gp bnh nhn b bnh phi tc nghn mn tnh v iu tr tt nht l kim sot bnh phi nn hn l dng cc thuc chng lon nhp. Bnh nhn TPM khi ri lon nhp tht thng c tin lng xu v t l t vong cao. B. Xquang tim phi 1. Phn ln cc bnh gy ra TPM u c hnh nh hai trng phi sng hn bnh thng trn phim Xquang lng ngc v v vy vic chn on tng p ng mch phi trn phim s gp kh khn hn. erved res 2. Tht phi gin c th kh xc nh csvinbng tim ht .v ig trn phim thng nm thng ng rdocom ph thng ll o. kh v A o v so snh vi cc phim c oc. thhgip ch cho vic l e @ya n chn on. Hu ht bnh inhn TPM u c tht phi . F 2 20 08 tto, 0 0 v ng mch phi2gini y nhng tng p ng mch oc ht Potgin tht phi. phi thng rig trc c py 3. Mt chCo im v tng p ng mch phi l o ng knh ca ng mch phi phi v tri. ng mch phi phi gin khi c ng knh ngang > 16mm v i vi ng mch phi tri l > 18mm. Du hiu ny gp 43 - 46% bnh nhn bit c tng p ng mch phi, nhng nhy v c hiu tht s ca php o ny vn cha c xc nh. C. Siu m tim: rt hu ch bnh nhn b TPM. 1. Siu m tim kiu TM cho php xc nh tht phi gin v cng c th xc nh c tng p ng mch phi qua hnh thi vn ng ca van ng mch phi (mt sng a). 2. Siu m tim 2 bnh din c th nhn thy c ton b bung tht phi, o c dy thnh tht cng 442 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

nh xc nh c nhng thay i ca vch lin tht do ph i tht phi. V tht phi c hnh dng khng i xng nn vic o th tch tht phi rt kh. Tng gnh p lc tht phi thng c xc nh bng ph i thnh trc tht phi v bung tht phi gin. Trng hp TPM nng c th thy ph i vch lin tht v di ng nghch thng ca vch vo tht tri. Tng gnh th tch tht phi thng lm gin bung tht v c vch lin tht di ng nghch thng. 3. Siu m Doppler tim: l phng php thm d huyt ng khng chy mu tin dng xc nh tng p ng mch phi v cung lng tim. Phng php ny kh chun xc khi p lc ng mch phi > 30mmHg v km chun xc hn i vi p lc ng ved ser cng mch phi thp hn mc ny. Siu m Doppler re hts vn hu ch theo di hiu qu lu digca .mt tr liu i ll r com bng thuc. . A ahoo. oev inl 20@y D. Thng tim phi F 8. 20 00 cygi tr xc nh p lc 1. Thng tim phi ch cit 2 o t gh P lc ng mch phi, pot ng mch phi bt v cung i yr lng tim.pBnh nhn TPM c p lc ng mch phi Co trung bnh cao hn nhiu so vi p lc ng mch phi bt, khng ging vi suy tim tri hay hp van hai l ch c s chnh lch nh gia p lc ng mch phi trung bnh v p lc phi bt. 2. p lc ng mch phi trung bnh rt cao trong cc trng hp bnh mch mu phi tc nghn nhng ch tng nh cc bnh m phi k. Trong giai on u ca bnh TPM, p lc ng mch phi ch t 25 30mmHg v khi c suy tim phi thng tng trn 40mmHg. E. Kh mu ng mch 1. Giai on u: suy h hp tng phn, p sut xy mu ng mch (PaO2) thng gim, nht l khi 443 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

2. Giai on suy h hp ton b: PaO2 gim nhiu < 70mmHg; PaCO2 tng cao 50 - 80mmHg; SaO2 gim <75%; pH gim di 7,2. F. Cng thc mu: thng thy biu hin ca a hng cu v tng hematocrit. V. Chn on A. Chn on xc nh TPM da vo: 1. Tin s mc bnh phi mn tnh hoc bnh ca h ved thng c xng lng ngc. ser re ts 2. Hi chng suy tim phi. gh m.vn ri 3. in tm : P ph, dy tht. All oo.co phi, tng gnh tht oev ah phi. inl 20@y .F 4. Phim Xquang lng008 ty20 ngc: bng tim to, cung ng 2 i mch phi ni, ht Potoc mch phi phi, tri gin. g cc ng ri 5. Thm dopy C huyt ng (siu m tim hoc thng tim phi): p lc ng mch phi tng. B. Chn on phn bit 1. Suy tim ton b do bnh van tim mc phi (hp van hai l), bnh tim bm sinh, bnh c tim. 2. Suy tim do suy vnh, nhi mu c tim : cn au tht ngc in hnh, bin i on ST -T v cc men tim tng. 3. Hi chng Pick: Vim mng ngoi tim co tht. 4. Tim ngi gi: ngi ln tui, khng c tin s b bnh phi mn tnh.

444 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

C. Chn on giai on 1. Giai on sm: Ch c bnh phi mn tnh vi nhng t suy h hp kch pht, cha c tng p ng mch phi, cn pht hin sm phng. 2. Giai on tng p ng mch phi: Thng lm sng khng th pht hin c, thm d bng thng tim phi hoc siu m Doppler tim th c tng p ng mch phi, c th iu tr tt v tr v n nh. 3. Giai on suy tim phi cn hi phc: c biu hin tng p ng mch phi v suy tim phi, iu tr c kt qu. 4. Giai on suy tim phi khng hi phc: iu tr khng c kt qu. ved ser re VI. Tin trin v tin lng ts gh m.vn i Bnh phi mn tnh tin trin t t, chm.cchp, dn lm ll r o . A ahoo n suy gim v tn thng n chc nng h hp caoephi dn inl 20@y nng phi ton b F chc nng phi tng phn, ri suy. gim chc 8 20 00 iphi, ri suy tim phi. v cui cng l tng p ng mch ty 2 t otoc gh ph thuc vo ngi bnh c c S tin trin caybnh P ri p pht hin bnh sm,oc iu tr v theo di thng xuyn hay C khng. Nhn chung, nhng bnh phi mn tnh gy suy tim phi c tin trin nhanh nu nhng t kch pht xy ra nhiu ln. Ngc li, khi bnh nhn c theo di v iu tr tt th c th n nh c t 5 n 20 nm v hn na. Tin lng bnh ph thuc ch yu vo vic kim sot bnh phi nn hn l iu tr tng p ng mch phi. Trong nhm bnh phi tc nghn, vim ph qun mn tnh tin trin nhanh hn, bnh hen ph qun tin trin chm hn nht l th hen d ng. Trong nhm bnh phi hn ch c bit l cc bnh c lin quan n tnh cht c hc ca h hp nh g vo, d dng lng ngc nu khng b bi nhim phi th c th sng lu m khng c biu hin TPM. Bnh tc mch mu phi tin lng xu hn. 445 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

VII. iu tr A. xy liu php 1. Rt quan trng, c th cho th xy bng ng thng qua mi, bng xy, th xy trong vng kn. xy nn dn qua bnh nc lm m, khng cho th xy 100% trong trng hp suy h hp ton b c tng CO2 v nh vy d c ch trung tm h hp. S tng p lc xy trong mu ci thin tnh trng thiu xy t chc s lm gim p lc ng mch phi. 2. Cc nghin cu ln ti Anh v Hoa K u cho thy dng xy liu php liu thp (1 -2 lt/pht), ko di (12 - 24 gi/ngy, trong vi thng n nhiu nm) lm ci thin r t l sng cn bnh nhn tm ph ed mn. c bit dng xy liu php lin tceservth lm c r ts gim t l t vong r hn dng xy hliuvn g m. php ngt i qung vo ban m. ll r co . A ahoo. v 3. xy liu php cng lm ciloe @y chc nng tm thn in thin 0 F 8. v kinh ca bnh nhn TPM 202s ci thin ny thng 00 ity 2 o c c sau mttthng cdng xy. gh Pot i 4. V sao xy r py liu php lm ci thin tnh trng sng Co cn ca bnh nhn TPM n nay vn cha c r. C hai gi thit chnh: (1) xy lm gim tnh trng co mch phi, gim sc cn mch mu phi v vy chc nng tht phi c ci thin v th tch tng mu tht phi tng; (2) xy liu php lm ci thin nng xy mu ng mch nn cung cp tt xy cho cc c quan sng cn nh no, tim, gan, thn... 5. Liu php xy ko di c khuyn co cc bnh nhn TPM c PaO2 lc ngh di 55mmHg v c iu tr n nh trong 3 tun vi cc thuc nh thuc gin ph qun, khng sinh, li tiu... Bnh nhn c PaO2 lc ngh ln hn 55mmHg th cn phi xem xt cn nhc khi dng xy liu php ko di v ch dng khi bnh nhn c a hng cu hoc c cc du 446 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

6. xy liu php ko di ban m c vai tr quan trng cc bnh nhn c ri lon bo ho xy mu khi ng. Bnh nhn gim bo ho xy khi gng sc ch cn cung cp b sung xy khi gng sc v hiu qu ca liu php xy ko di cha c chng minh trong trng hp ny. B. Thuc li tiu v tr tim 1. Thuc li tiu loi c ch men anhydrase carbonic nh Diamox, hoc li tiu nh Aldacton t ra d ch c e bnh nhn TPM, liu 10 mg/kg cn nngerv tng cho res t 3-4 ngy. Khng nn dng thuc hts .tiu khi pH li vn ig mu < 7,30. ll r o.com v. A ho 2. Thuc tr tim nhm Digitalis:ya loe @ Tc dng ca cc in . F 20 thuc ny ln chc nng tht phi rt phc tp. Cc 08 ty20 0 2 ci thuc Digitalis lm tng kh nng co bp ca c tim ht Poto ig phi nhng rng thi cng lm tng co tht mch py Co mu phi, lm gim s tr v ca mu tnh mch ngoi bin do lm tng th tch d tr ca tnh mch v v vy c th nh hng n cung lng tim. a. Ch nn dng tr tim nhm Digitalis bnh nhn TPM khi c suy tim tri ng thi. Mathur v cng s theo di tc dng ca Digoxin liu 0,25mg/ ngy cc bnh nhn TPM trong 8 tun th nhn thy Digoxin khng lm ci thin phn s tng mu tht phi khi phn s tng mu tht tri bnh thng; ch cc bnh nhn c phn s tng mu tht tri gim t u th Digoxin c lm ci thin phn s tng mu tht phi. S dng thuc tr tim phi rt thn trng, Digitalis c th gy ri lon nhp tim, ch nn s dng khi suy tim cn b tr v liu nh. 447 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

b. Khng dng khi suy tim mt b. Thuc li tiu v Digitalis trong trng hp ny khng quan trng bng cc bin php ci thin thng kh ph nang nh xy liu php. Mc d cc thuc tr tim nhm Digitalis khng phi l thuc iu tr thng thng ca bnh tm ph mn, nhng mt nghin cu cho thy dng Digoxin ng tnh mch trong nhng t suy h hp cp bnh nhn TPM c th lm tng sc cng ca c honh v tng cung lng tim. 3. Cc thuc gin ph qun: a. Theophylline: y l thuc c tc dng lm gin ph qun c s dng nhiu nht. Tuy nhin, Theophylline c tc dng lm gim khrved ch th e yu nhng bnh nhn b bnh ng th tc res hts nghn. Aminophylline dng ng m.vn mch c rig co tnh ll . th lm gim nhanh p lcAng mch phi v v. ahoo e lm tng phn s tng lo 0@yca c tht phi v Fin0mu 2 . tht tri. Ung Theophylline ko di bnh nhn 08 2 20 ocity TPM cng hc tc dng tt ln chc nng tht t ot P g ringhin cu cho thy bnh nhn dng phi. oC py C Theophylline trong 4 thng lm ci thin r phn s tng mu tht phi. Phn s tng mu tht tri cng tng ln r. Cc nghin cu in vivo cho thy Theophylline v Aminophylline u lm gim hu gnh (do lm gim sc cn mch mu phi v mch mu h thng) v lm tng sc co c tim, v vy, mt tr liu Theophylline ko di c th lm tng r chc nng bm mu ca hai tht. Tuy nhin, Theophylline khng lm gim hin tng co mch mu phi do thiu xy t chc. b. Cc thuc kch thch th th -adrenergic nh Salbutamol, Terbutaline, Pirbuterol c s dng nh thuc lm gin ph qun v c tc dng tt 448 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

4. Cc thuc gin mch: a. Rt kh khn khi nh gi tc dng ca cc thuc gin mch trong iu tr TPM v nhng rthay i ed ev sMc ch huyt ng trong iu tr rt phc tp. re ts gh m.vn ca vic dng cc thuc gin mch l lm gim l ri o p lc ng mch phi v. Al hoo.c cao bnh ang tng l e ya nhn TPM. Gin mcho lm gim sc cn ca Fin020@ 8. 2 mch mu nhng0b li l cung lng tim tng v 20 ocity cui cng lt p olc ng mch phi khng thay h Pt rig gin mch l tc dng c li (v lm i. Cyth op tngCs vn chuyn xy) mc d tng p ng mch phi khng h bt. Cc thuc lm gim s tr v ca mu tnh mch (nhm Nitrate) hoc cc thuc lm gim chc nng tht phi (Nifedipine) c th lm gim bt tng p ng mch phi do lm gim cung lng tim. Cc nghin cu theo di ko di cho thy cn thit phi nh gi cc p ng v mt huyt ng khi dng cc thuc gin mch v cn nh gi tc dng ln t l sng cn ca tng loi thuc khc nhau. b. Dng cc thuc gin mch c th c tc dng ph nh h huyt p v gim bo ho xy mu ng mch. Phn ln cc thuc gin mch c tc 449 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

dng mnh ln mch mu h thng hn l mch mu phi. cc bnh nhn c tng p ng mch phi nhiu v cung lng tim bn phi gim th co mch h thng nh l mt c ch bo v chnh duy tr huyt p ng mch h thng. cc bnh nhn ny, gin mch mu h thng chn lc c th lm gim huyt p v khi u cho vng xon bnh l ca suy tht phi (do gim lu lng mch vnh phi) v tru mch. Cc thuc gin mch cng c th lm gim xy mu ng mch do trng lc mch mu phi b ph v lm mt cn bng thng kh - ti mu ca phi. c. Kt qu nghin cu iu tr TPM vi cc thuc gin mch ny u khng c kt lun r rng v ved khng c mt thuc no trong ccrethuc trn ser c khuyn co s dng thng hts .vtrong thc quy n rig co l v .cm dng tt hnh lm sng. Cc nitrate. c oo tc Al oev yahvai tr r rng v nhng thc cht u khng c l @ Fin mu lm gim nng . xy020 ng mch v lm 08 2 gim c ch s 20tocity tim. t igh Po d. iu tr rTPM vi cc thuc gin mch cn phi y op xemCxt v cn nhc k v ch dng khi cc iu tr thng quy v xy liu php khng lm ci thin tnh trng suy tim phi v tng p ng mch phi. V cc thuc ny c nhiu tc dng ph nn hiu qu ca chng v mt huyt ng v vn chuyn xy cn c nh gi cn thn, thng sau 4 - 5 thng iu tr v tt nht l nh gi qua thng tim phi. 5. Khng sinh: Vai tr khng sinh trong iu tr t bi nhim rt quan trng. Thuc khng sinh nn dng loi c ph khng khun rng, dng ko di v liu lng cao trong 2-3 tun (tim, ung, kh dung). Nhiu tc gi ch trng dng khng sinh ngoi t bi nhim phng nht l cho ung khng sinh 450 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

vo nhng thng ma lnh (mi t ung 10 ngy trong 3 thng). 6. Corticoid: C hiu qu trong iu tr t cp: dng Prednisolon ung, Hydrocortison kh dung, Depersolon hay Solu-Medron tim tnh mch. Corticoid va c tc dng chng vim, chng d ng v lm gim tit dch. 7. Chch mu: t dng, ch nh khi hematocrit ln hn 65%. Ly khong 300ml mu mi ln. Sau chch mu, p lc ng mch phi trung bnh v sc cn mch mu phi thng gim, cung lng tim thay i khng ng k, s vn chuyn xy gim nhiu v s tiu th xy lc ngh c th tng nh hoc khng thay i. Chch mu c tc dng r rt irved kh e vi res nghin nng gng sc ca bnh nhn TPM. tNhiu hs n cu cho thy kh nng gng sc, lthi om.v gng sc rig c gian Al tng v mc tiu th xy ti a. u oo. ln ng k oev yah sau khi chch mu ccFbnh0nhn TPM c a huyt inl @ . 202 cu. Chch mu 008 tgim hematocrit cn khong 2 lmi y 50% c tc dng Potoc mt huyt ng trong thi ht tt v ig gian ngn, yr p nht l khi c gng sc. Tuy nhin, tc Co dng lu di ca vic chch mu lp li nhiu ln vn cha c xc nh. 8. Ch d n ung v ngh ngi: Nhng ngi b bnh phi mn tnh khi xut hin kh th th nn lm vic nh, khng phi gng sc. Khi c du hiu suy tim phi th phi ngh vic hon ton. n t mui. 9. Khng dng cc thuc sau: Morphin, gardenal v cc thuc an thn khc khng c dng cho cc bnh nhn TPM v s gy suy trung tm h hp. 10. Tp th: Rt quan trng, lm tng gin n ca phi v lng ngc, tng thng kh ph nang, nht l tp th bng c honh. 11. Loi b cc yu t kch thch: Thuc lo, thuc l... 451 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

C. iu tr tm ph mn mt s th c bit 1. Tm ph mn bnh nhn hen ph qun: cho Hemisucinat Hydrocortison, Depersolon tim tnh mch. 2. Bnh nhn x phi thng khng c tr CO2, nn ch cn cho th xy rng ri v cho corticoid. 3. Ngi bo bu: cho n ch lm gim cn. 4. Ngi g vo ct sng d dng lng ngc: tp th, chng bi nhim phi l rt quan trng, c th cho iu tr chnh hnh t sm. 5. Do tc mch phi: ngh ngi tuyt i, n ch khng mui, dng thuc chng ng, tr tim digitalis, th xy. Phu thut ly cc mu rng tc ved se ng mch phi ln. re ts gh m.vn i Ti liu tham kho ll r co . A ahoo.of Cardiovascular 1. Marso SP, Griffin BP, Topol EJ, eds. vManual loe y Medicine. Philadelphia: Lippincott-Raven, 2000. Fin020@ . 2. Topol E, ed. Textbook of 008 y2 cardiovascular medicine. Philadelphia: 2 ocit Lippincott-Raven, 1997.t t igh Po 3. Rubin LJ, Rich S, eds. Primary pulmonary hypertension. New York: yr p Marcel Dekker;o1997. C
4. 5. 6. 7. 8. 9. Jaffe CC, Weltin G. Echocardiography of the right side of the heart. Cardiol Clin 1992; 10:4157. Shure D. Chronic thromboembolic pulmonary hypertension: Diagnosis and treatment. Semin Respir Crit Care Med 1996; 17:7. Braunwald E. Heart disease: a textbook of cardiovascular medicine, 5th ed. Philadelphia: WB Saunders; 1997. Feigenbaum H. Echocardiography, 5th ed. 1994. Baltimore: Williams & WilkinB. Reynolds T. The echocardiographer's pocket reference. Arizona Heart Institution Foundation, 1993. Weyman AE. Principles and practice of echocardiography, 2nd ad. Philadelphia: l,ea & Febiger, 1994.

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Nhi mu phi

Tc ng mch phi hay thng gi l nhi mu phi (NMP) l mt bnh l ht sc nng n, thng dn n t vong nu khng c pht hin v x tr kp thi. Mc d c nhiu bin php iu tr kh tch cc hin nay, nhng t l t vong chung (ti Hoa k) bnh nhn NMP vn khong 20-30%. Tc mch phi l mt bnh l kh thng gp, bnh cnh lm sng d a dng, d b b st hoc chn on nhm, t vong thng do rve secoi huyt ri lon huyt ng khi tc mch phi din rng. ts re Nn n h khi tnh mch su v tc mch phi l cng lmt quvtrnh bnh rig com. l l. Tin lng sm ty vo cc loi riev. A ahoo. ng. Chn lon huyt o y on v x tr tc mch phi i theo lhai@ hng khc nhau ty in . F 020 08 ty2sng. Chp ct lp vi tnh theo s n nh huyt ng trn lm 20 i xon c, thuc tiu sight Potov can thip qua ng ng huyt c i thng... l nhng bin yr tin tin c th lm thay i hn din p php Co bin v tin lng khi x tr tc ng mch phi. I. Sinh l bnh Vic tc t ngt mt mch ca phi dn n tng t ngt tr khng ca mt vng h mao mch phi, tng gnh cho tim phi, tht phi gin v suy cp, lm gim cung lng tim v h huyt p ng mch. Thm vo c hin tng gim xy mu ng mch v s mt tng xng gia thng kh v ti mu cng lm bnh thm trm trng. Tc mch phi biu hin lm sng rt a dng, c th khng h c triu chng lm sng nhng cng c th c suy huyt ng nhanh chng dn n t vong. Hai biu hin bnh l chnh khi tc mch phi l ri lon chc nng tht phi v ri lon trao i kh. Tc mch phi lm 453 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

tng sc cn mch phi, tng hu gnh tht phi, tng p lc v sc p ln thnh tim ca bung tht phi, tng nhu cu xy c tim... a n thiu mu c tim v ri lon chc nng tht phi, gim th tch tng mu tht phi. Tht phi gin gy y vch lin tht sang tri lm gim y v tin gnh tht tri (cn do gim th tch tng mu tht phi), t cung lng tim, huyt p ng mch ch, p lc ti mu mch vnh u gim. Nhp tim nhanh, nhu cu xy tng, bung tim qu gin, ti mu vnh gim... l nhng yu t lm nng thm ri lon chc nng tht phi v to vng xon bnh l dn n cung lng tim gim sc tim. Ri lon trao i kh bnh nhn tc mch phi rt phc tp, lin quan n kch thc v tnh cht ca cc nghn, mc lan rng, thi gian tc cng nh tnh trng bnh tim phi trc . Gim xy mu thng do tng khong cht phdnang, e er lung thng t phi sang tri, bt tng hp gia thngvkh vi res ti mu (V/Q) v bo ha xy mch trn (MvO2hts .vn(ch yu ) thp rig do lthpcom ti phn b l hai c ch cui). T l thng kh/ti mul o. v. A ho dng mu phi (gim lng mu novngatc mch, tng qu l e @y in mc lng mu n vng phi lnh) v 0 xp phi khng hi . F 2 do 08 ty20 phc sau khi ly gii cc tc. 20 ophi cn do mt lp surfactant, Xp ci t Pt ghtnh otrng gim CO2 ph nang, do co xut huyt ph nang hoc i yr tht ph qun, tt cop c s tham gia ca cc yu t th dch C u do tiu cu trong li cc huyt khi gy ra. PaO2 c th gim hn na sau dng thuc vn mch do tng lung thng sinh l khi tng dng mu qua vng phi c t l V/Q thp. Cc hin tng khc cng c nhc n nh: ph phi sau tc mch phi do p lc nh phi tng v hu qu ca lung thng t phi sang tri qua l bu dc hoc l thng lin nh gy tc mch nghch thng hoc gy gim nng PaO2. Tc mch phi nh khi din tc mch 20% hoc p lc mch phi (ALMP) trung bnh < 20 mmHg. Tc mch phi din rng c nh ngha khi din tc mch 50% hoc tc 2 ng mch ca hai thy phi.

454 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

II. Chn on Chn on nhi mu phi va d b st va d chn on nhm. Rt d b st chn on bnh nhn c bnh tim phi t trc, ngi gi, hoc khi ch c duy nht triu chng kh th. 10% trng hp t vong ti vin l do tc mch phi cp, a s ch c chn on khi m t thi. Mt khc, cng d chn on nhm. Ngay c cc nc tin tin, chn on xc nh bng chp ng mch phi ch chim xp x mt phn ba s bnh nhn nghi ng. A. Triu chng lm sng Bng 26-1. c lng kh nng tc mch phi - Kh th t ngt, th nhanh (> 20 ln/pht) hoc Cao > 85% au ngc (kiu mng phi hoc sau xng c) ekhng d er gii thch c, km theo t nht 2 trongessv nhng r ts biu hin sau: gh m.vn i - C yu t nguy c (khng vn ng,o o tun hon, ll r c tr . A aho . tin s vim tc tnh mch, loev m xng khp hoc sau y @ Fin02khi u c tnh, suy tim, tiu khung, sau chn thng, 0 . 08 ty2 0 dng thuc trnhtthai...).i 2 toc h duohiu tng gnh tht phi mi c - Thu km theo P rig py o trn inCtim. - Triu chng vim tc tnh mch su (sng, nng, , au mt chn). - Phim Xquang c du hiu nhi mu phi, bu vng rn phi hoc vng gim ti mu. Trung C cc biu hin nm gia hai nhm thp v cao. bnh Thp - Khng c kh th t ngt, th nhanh (> 20 < 15% ln/pht) hoc au ngc. - Kh th t ngt, th nhanh hoc au ngc nhng do l do khc. - Khng c yu t nguy c. - Bt thng trn phim Xquang do nguyn nhn khc. - INR > 2 hoc aPTT > 1.5 ln chng trong vng 1 tun trc . 455 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Hu ht bnh nhn c biu hin m h vi rt nhiu mc khc nhau, nn rt cn c cc thm d thm loi tr hay khng nh chn on. Nhiu nghin cu cho thy phi hp cc triu chng lm sng, yu t nguy c, vi thm d n gin cho php phn loi kh tin cy kh nng tc mch phi, t s la chn nhanh chng, chnh xc, t tn km cc bin php chn on khc. Xc nh kh nng tc mch phi trn lm sng c bit c ch khi phi hp nh gi kt qu x hnh phi-mt phng tin chn on c in. Ngoi tr bnh l tng ALMP do thuyn tc mn tnh, tc mch phi c th chia thnh ba loi chnh: 1. Tc MP nh, cp tnh: Nu din tc nghn mch t hn 50% mch phi, th thng khng c triu chng. Triu chng cd nng rve hay gp nht l kh th ngay c khi gng sc rnh. Mt s ese t khc xut hin biu hin ca nhi mu phis (NMP) ngay gh m.vn l ri bnh): au chi t u (khi tc nhnh MP c .trungoo.co Al oev yahmu. T l NMP ngc, c th km ho khan hoc ho ra l @ 0 Fin0 nhn khng c bnh tim ch chim khong 10% s8.bnh 2 00 ity2 phi t trc, trong tkhi tcl ny c th n 30% nu c 2 o gh ot bnh tim tri ri hoc P ng h hp. Triu chng thc py Co th ch c khi NMP: kh th nhanh, nng do au ngc song cha tm, hi chng ng c ln vi trn dch mng phi, c th c c mng phi. Thng st nh v nhp tim nhanh (do au+st). p lc MP t khi > 25 mmHg, cung lng tim khng gim, khng tt huyt p, ting tim v p lc tnh mch hon ton bnh thng. 2. Tc MP din rng cp tnh: Nu tc cp tnh trn 50% din mch phi th biu hin ch yu l hi chng tm ph cp kt hp vi try mch, tt huyt p. Thng gp nht l du hiu kh th t ngt, nhp tim nhanh (> 100 chu k/pht) v triu chng suy tht phi (TM c ni cng, tht phi p mnh, nhp nga phi b tri xng c, T2 tch i rng hoc mnh ln, thi tm thu do h van ba l, gan to). 456 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Nng hn na l biu hin try mch: mch nhanh nh, trng ngc, tt huyt p, v m hi, u chi lnh, tm ti, ngt/thu hoc l ln... Gn 22% s bnh nhn tc mch phi din rng c au ngc tri ging NMCT. Tht phi gin cng, p lc tht phi v ALMP tm thu tng, song t khi >55 mmHg; p lc nh phi v cui tm trng tht phi tng (15-20mmHg), ch s tim v huyt p ng mch gim, sc cn ngoi vi tng. Mt s trng hp p lc mao mch phi bt bnh thng, nht l khi th tch bung tht tri nh (do mt tng quan gia p lc v th tch tht tri khi vch lin tht b y sang tri). Triu chng s y nu biu hin 24 gi k t khi khi pht, song t khi y nu xut hin sau 24 gi. ved ser Try mch, tt huyt p (sc) khi huytep tm thu sr ng mch 90 mmHg v/hoc phiight .vthuc vn dng n ll r c m mch. Sc bnh nhn tc mch phi cpotnh (mt cn . A ahoo. v bng gia cc c ch b tr duyoe @huyt p v/hoc ti tr inl 20 y . mu m ca c th) l hu Fqu ca tc mch phi din 08 20 20 octy s bnh phi tc nghn rng bnh nhn khngt ci tin ht Po mn tnh (COPD)ghoc tc din nh hn bnh nhn c ri py Co tin s COPD. T l t vong tng thm 3 n 7 ln nu c sc tim (22-40%), a phn t vong ngay trong gi u. Tuy nhin a s (97%) trng hp tc mch phi din rng li khng c sc trn lm sng. Nu khng c sc th t l t vong tng ng gia tc mch phi din rng v din nh hn (0-8%). Cc ri lon huyt ng khc bao gm tt huyt p khng cn dng vn mch; thu/ngt (do phi hp gia gim xy mu v tt huyt p, chim ti 13%), ri lon nhp v dn truyn, ngng tim (ch yu do phn ly in c) hoc t vong. Cc ri lon ny chim khong 10% (thm ch cao hn) tng s trng hp tc mch phi ni chung, trong khi t l ny tng cao nhm nng c suy tim phi cp hoc tng p lc ng mch phi: t l ngng tim chim ti 18-29%, 457 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

sc phi dng vn mch l 10% (theo cc nghin cu UPET, UPSET, ICOPER, PIOPED, MAPPET). 3. Tc MP din rng bn cp: Thng do nhiu cc tc kch thc nh hoc trung bnh din ra trong vi tun, do c qu trnh thch nghi ca tht phi. Triu chng ch yu l kh th tng ln v gim dung np vi gng sc, thng km theo ho khan, c th c tm kiu trung ng. Mc kh th khng tng xng vi cc triu chng thc th. Mch v huyt p vn trong gii hn bnh thng. Khm thng thy tnh mch c ni, ting T3 phn di mi c tng ln khi ht vo, thnh phn phi ca ting T2 mnh. Tin s c nhiu t NMP xen k, cui cng tin trin nng dn d dn n suy tim phi v gim cung lng tim ging bnh rve sethu MP e cnh cp tnh. p lc tht phi v p lc ttm sr n gh m.vso vi tc cao hn trong khi p lc nh phi thp hn i ll r co MP din rng cp tnh. . A ahoo. oev inl 20@y B. Cc xt nghim chn on0 F 8. 00 ity2 bnh tim phi t trc, 1. in tm : D 2 oc c t khng gh Potch gp trong 6% tc mch phi in tim bnhi thng yr ln cp Cop v 23% tc mch phi bn cp. Nu tc tnh mch phi nh, huyt ng n nh thng ch gp nhp nhanh xoang. Cc ri lon nhp nh bloc nh tht cc cp hoc ri lon nhp tht rt t gp, t l rung/cung nh ch chim 0-5%. Du hiu thng gp nht ( 50%) l thay i khng c hiu on ST v T, thng thong qua, cc thay i giai on kh cc tr li bnh thng sm hn so vi ti cc, mc thoi trin sng T lin quan cht vi hiu qu iu tr ca thuc tiu si huyt. Hnh nh tm ph cp (trc QRS quay phi, bloc nhnh phi, P ph, SIQIIITIII-S su rng DI, Q su DIII, T m o chiu DIII) ch chim khong mt phn ba cc trng hp tc mch phi din rng. in tm ch yu loi tr cc chn on khc nh NMCT hoc vim mng 458 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Tc mch phi thng nng hn nu: xut hin sm ( 24 gi) o ngc sng T V1-V4, ri lon dn truyn v ti cc ca tht phi, dng SISIISIII. Tuy nhin biu hin trn in tim vn c th tn ti nhiu ngy sau khi bnh thoi trin. 2. Xquang tim phi: Hnh nh phim chp Xquang phi bnh thng c th gp trong tt c cc dng tc mch phi (16-34%) nn khng th dng bin php ny xc nh hoc loi tr tc mch phi ln. D khng c hiu, chp Xquang phi cng gip chn on tc mch phi ln nh loi tr cc bnh ging tc mch phi (vim phi, trn kh mng phi, suy ved ser phi tim tri, u, gy xng sn, trn dch re ts mng n gh m.tn thng nhiu, xp phi thy), xc nh l nhng v ri co l nghi ng cn thm d tip v vcho php c lng . A oo. oe yah c phim chp nng ca bnh ng thi lcng cn in @ . F 20 Xquang nh gi0yty20 08 phim chp x hnh phi. 2 ci Hnh nh t xp to gh Po phi, trn dch mng phi s ri lng t, opyhonh nng cao l nhng du hiu c C c nhy thp. Du bu ca Hamptons (nt m ngoi vi hnh ch V hoc bn nguyt, nm dc cnh mng phi, hng v rn phi, hay gc sn honh), du Westermark (vng phi b gim ti mu khu tr) hoc phng on gn MP hay gp bnh nhn tc mch phi din rng. 3. Cc xt nghim mu: Men LDH tng, bilirubin gin tip tng v SGOT bnh thng l b ba xt nghim gp trong trng hp tc mch phi, tuy khng nhy song kh c hiu, thng gp nht l tng LDH. Bch cu tng nh (12.000-13.000/ml) trong khi hematocrit gim nh (30-35%). Tiu cu cng gim nh 459 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

(100.000-200.000/ml) c khi khng c bin chng do dng heparin. Sn phm lin kt cho thoi ging ca fibrin c cha D-dimer (c trng cho qu trnh tiu hy fibrin ni sinh) tng > 500 ng/ml trong > 90% bnh nhn tc mch phi. Tuy D-dimer tng c khi c huyt khi tnh mch, ng mu ni qun ri rc (DIC), sau chn thng, phu thut hay c khi u c tnh... song c nhy cao (nht l khi nh lng bng k thut ELISA) nn c th dng lm xt nghim sng lc loi tr tc mch phi, c bit l nhm c biu hin trn lm sng v/hoc hnh nh c nguy c thp-va. 4. Kh mu ng mch: Bin i c trngrved PaO2 l e gim v PaCO2 bnh thng hoc gim doetng thng rs ts kh. PaCO2 gim v kim chuyn rha m.vnxy ra igho vn l c bnh nhn c ng CO2 trc l.o.Tc mch phi v. A aho e din rng c th gy c Finlo h y (do tng khong toan 0@ hp 2 cht sinh l VD/VT v 8. y20 h hp) v toan chuyn 00 mt c 2muitm khi sc). 14-38% nhng ha (do gim ti otoc ht P rig trng hpytc mch phi vn c kt qu kh mu p Co bnh thng (PaO2 80 mmHg, PaCO2 35 mmHg, chnh lch gia phn p xy ph nang v ng mch phi P(A-a)O2 bnh thng). PaO2 khng bao gi bnh thng bnh nhn tc mch phi ln nhng vn bnh thng nu tc mch nh do tng thng kh, khi P(A-a)O2 > 20 mmHg l du hiu nhy hn. Song PaO2 gim v P(A-a)O2 tng thng do nhiu nguyn nhn, nn kt qu kh mu ng mch khng mnh loi tr hoc xc nh tc ng mch phi. McIntyre v Sasahara ghi nhn tng quan tuyn tnh gia mc nng ca tc mch phi (o bng ch s tc mch khi chp mch, p lc MP trung bnh, ch s tim) v gi tr PaO2 bnh nhn 460 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

khng c tin s COPD. Ngoi ra cc tc gi ny cn thy tng quan cht gia P(A-a)O2 vi ALMP trung bnh v s thng tn trn phim chp mch. Thng kh khong cht sinh l (VD/VT) tng (o gin tip qua th tch v p lc ring phn ca CO2 ton phn hoc cui k th ra ETCO2) l mt ch s rt nhy v c hiu chn on tc mch phi, lin quan cht vi mc tc v tin trin bnh. 5. Siu m tim: Siu m tim (qua thnh ngc hoc thc qun) dng nh gi tnh trng tng gnh tht phi, tm huyt khi bung tim v loi tr nhng bnh l khc (phnh tch ng mch ch, bnh mng ngoi tim, sc gim th tch, ri lon chc nng/nhi d mu c tim, h van tim - trong 2 bnhvl cui r e setc mch chim gn mt na s bnh nhn nghi s re ng t n gh chvnn coi l phi c lm siu m). Siu m tim m. i ll r co phng tin ph tr hn l phngo.tin chn on . A aho ev chnh, xc nh tc mch inlo 0@y phi. . F 02 Nhng du hiu8 ity2 tng gnh tht phi do 00 ca 2 c ht siu tc mch phigtrn Poto m gm: gin/gim vn ng ri tht phi opy TP hay gp nht: 50-100%), tng t l C (gin ng knh TP/TT, di ng nghch thng vch lin tht, h van ba l... Nhng du hiu ny t khi gp nu tc mch phi din nh. Gin tht phi cn c th gp trong cc nguyn nhn khc: NMCT tht phi, bnh c tim, tm ph mn hay TALMP, song c th ngh n tc mch phi cp nu c km cc du hiu nh: tht phi khng ph i ( dy 57mm) km khng xp TMC di khi ht su, di ng vch lin tht nghch thng, vn tc ti a dng chy ca h van ba l mc trung bnh (>2,5-2,8 m/s v <3,5-3,7m/s), hoc ri lon vn ng vng c bit ca tht phi (mt vn ng vng gia thnh t do, vn ng bnh thng vng mm: do tng co bp b ca tht tri). 461 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Siu m tim qua ng thc qun c th thy huyt khi thn hoc on gn ch chia ng mch phi (chim 50-90% cc trng hp gin tht phi) vi chnh xc cao ( nhy: 80-96,7%, c hiu: 84-100%), tuy nhin nhy gim vi nhng huyt khi nhnh nh ca MP, hoc on gia v xa ca MP tri. Siu m tim cho php xc nh tnh trng huyt khi ang di chuyn (emboli-intransit) tim phi, chim ti 17% s bnh nhn tc mch phi cp, vi hai tp A v B khc nhau v hnh thi v tin lng (theo phn loi ca European Cooperative Study). Tp A (gp trong 18% tc mch phi ln c sc) l cc huyt khi di (2-10cm), rt di ng, ngun gc t h tnh mch su ngoi vi, thng ved thy nh phi (84%) th vo tht phi, nguy c cao ser re (mt phn ba cht trong vng 24 gi, hts l n vong g tm.v t i 40% k c khi dng tiu si huyt), v oy thng l ll r c . A ahoo. nhng trng hp c ch nh tuyt i m cp cu oev inl 20@y 15-25%). Tp B l ly huyt khi (t l t. F 0 cn vong 08 2 20 o nh cc huyt khi thngcity hn, hnh trn/van, t di ht Pot ng, nm trong tht phi, lin quan n cc ri lon rig y tng ngptrong tht phi (suy tim huyt, in cc Co to nhp vnh vin, d vt...), thng tin lng tt (d gy tc mch phi trong 40% cc trng hp). Tuy nhin Kinney v Wright li khng thy s khc bit r v t l t vong gia cc loi huyt khi. Siu m cng xc nh nhm bnh nhn c nguy c cao nh: cn l bu dc (tng t l t vong, tc mch no v cc bin chng gn khc). Ri lon chc nng tht phi l yu t nguy c ng ch khc: d bo tin lng xu, c bit bnh nhn huyt ng khng n nh. 10% bnh nhn huyt ng n nh c ri lon chc nng tht phi s tin trin thnh sc tim, vi t l t vong vt qu 50% do tc mch phi ti pht, nht l bnh nhn tui cao, mi sau phu thut xng hoc chn thng, huyt 462 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

p thp. Tuy cn phi nghin cu thm na, song dng nh thuc tiu si huyt gp phn lm gim t l t vong nhm tc mch phi huyt ng n nh c ri lon chc nng tht phi (MAPPET). 6. X hnh phi (scintigraphy): X hnh phi l phng tin chn on gin tip v khng th pht hin c bn thn huyt khi m ch pht hin hu qu l cc vng khuyt v ti mu. Hnh nh x hnh ti mu phi bnh thng cho php loi tr chn on tc mch phi. Kh nng chn on tc mch phi ca hnh nh vng khuyt ti mu c th chia thnh 3 loi: cao, trung bnh v thp. Hnh nh c kh nng cao cho php chn on ng ti 85%. Tuy nhin phn ln (60%) bnh nhn nghi tcdmch rve phi trn lm sng ch c nhng hnh rnh c kh ese ts l nng chn on thp hoc trung bnhhnht n bnh rig com.v l nhn c tin s COPD, m trongl . tc mch phi v. A oo oed yah hp vi kh nng thc s ch chim 25%. Mc @ kt inl 0 chn on tc mch 08. F 202 vo lm sng s nng phi da 0 ity c cao chnh xc2 song cng ch chn on ng ht Poto g khong mtriphn ba s bnh nhn. Ngc li, d py C hnh nho x c kh nng thp cng khng loi tr c chn on v c ti 40% l tc mch phi nu kh nng tc mch trn lm sng cao. D vy, x hnh phi vn rt c ch quyt nh hng x tr: hnh nh x hnh ph hp vi lm sng c kh nng thp cho php loi tr tc mch phi, hnh nh x hnh ph hp vi lm sng c kh nng ng cao ng ngha vi vic phi iu tr. Nhng phng tin khc nh siu m tm huyt khi tnh mch su, chp ng mch phi hay phim CT s dng la chn phng php iu tr cho hai nhm trn cng nh gip cho chn on khi khng ph hp kh nng chn on gia lm sng v nh x hnh phi, ch khng nn ch da vo lm sng... 463 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

7. Chp ct lp t trng vi tnh (CT thng, CT xon c, CT chm in t): Chp CT xon c c dng thuc cn quang hoc chp CT chm in t (electron beam CT) l bin php chn on khng xm ln c nhiu u th, b sung hoc thay th cho ghi hnh phng x phi kinh in. CT xon c c nhiu ni coi l bin php u tay chn on do k thut chp nhanh (ch trong mt ln nn th), phc tp v t ph thuc hn, pht hin c gin tht phi so vi phng php chp mch phi truyn thng; hnh nh r nt v y hn (c nhu m v mch mu) so vi ghi hnh phng x. Biu hin ca tc mch phi trn phim CT r rng trong a s (90%) trng hp: cc hnh ekhuyt vd serhay du mt phn hay hon ton trong lng mch, re hts .v hiu ng ray (dng chy giaighuyt nkhi bp l r com bnh trong lng mch v thnh lmch). i vi tc . A ahoo. ov thn MP, tc MP ti thyehoc phn thy phi th inl 20@y F 8. 0 chp CT c chnh0xc 85% ( nhy v c hiu 0 ity2 2 100% nhm bnh nhn nng u 94%, thm chtoc t gh Po r hoc c tngi gnh tht phi). Hnh nh dng tnh py Co do hch rn phi to gy xp phi, m trung gi c th tht, ph quanh mch (suy tim huyt), bm thuc cn quang chm... Hnh nh m tnh gi c th gp khi nh gi cc ng mch nh ca h phn thy phi, hoc nhng vng MP xut pht khng theo chiu dc, hoc khi c tc TMC trn, c lung thng trong tim, trong phi gy gim cn quang cc MP. chnh xc ca chp CT ch gim nhm bnh nhn tc mch phi nh (di h phn thy), l nhm chim t l t (6% cc trng hp tc mch phi) v tin trin vn tt d khng dng thuc chng ng. Sau khi chp CT phi c bm thuc, lng cn quang trong h tnh mch vn nh gi tip huyt khi trong tnh mch su vng chn, vng bng, khung chu v TMC di m khng tn thm thi 464 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

gian (5 pht), rt cn nu bnh nhn c ch nh t dng c lc trong TMC di. 8. Chp cng hng t ht nhn (MRI): Chp cng hng t ht nhn cng l mt bin php chn on khng xm ln, cho php nh gi v hnh thi gii phu-chc nng ca ti mu phi cng nh chc nng tht phi. So vi chp CT hay chp mch phi, MRI cn c cc u im nh: trnh ng c thn do thuc cn quang, chp h tnh mch ngay trong mt th, nhy v c hiu rt cao pht hin huyt khi tnh mch su v huyt khi MP. Tuy nhin thi gian chp ko di (15-30 pht) gy nhiu bt li nht l nhm bnh nhn c huyt ng khng n nh. Do , MRI cng t c ng dng trong chn ved ser on tc mach phi. re ts vn gh m.ng mch 9. Chp ng mch phi: Chp chn lc i ll r co phi c th coi l tiu chunev. A h. chn on xc vng oo o ya nh hoc loi tr tc mch lphi. Nn ch nh khi Fin020@ . 2 c tt huyt p, try8mch hoc khng chn on 0 20 ocity c bng phngPtin khc. Tuy nhin khng phi ht ot rigthc hin c v lun c nguy c t ch no cng py Co vong d nh (< 0,3%) khi chp, nht l nhm nng c p lc cui tm trng tht tri cao hoc tng p ng mch phi. Chng ch nh tng i bnh nhn c thai, nguy c chy mu cao, suy thn v c huyt khi trong tim phi. C th chp bng ng thng i qua tnh mch i (khng th nu bnh nhn t li lc TMC di, c nguy c lm bong huyt khi vng chu i hoc TMC di v d chy mu nu dng thuc tiu si huyt), ng TM cnh tay (kh li ng thng, d co tht TM nht l khi sc hoc dng thuc vn mch liu cao) hoc TM cnh trong v TM di n (chng ch nh nu dng chng ng liu). Trc khi chp nn thng tim nh gi cung lng tim, shunt, mc ri lon 465 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

huyt ng v nguy him phng nga, chn loi v lng thuc cn quang... Nhng thay i huyt ng ty vo mc tc (bn nh lng trn phim chp) bao gm: tng p ng mch phi (th pht do tc mch ln), p lc nh phi v cui tm trng tht phi tng, p lc cui tm trng tht tri v cung lng tim gim. Huyt khi th hin qua hnh nh ct ct hoc khuyt trn trong lng mch km theo gim ti mu vng phi chi phi. Nhiu tc gi t du hi v s cn thit phi chp ng mch phi trc khi can thip tch cc nh dng thuc tiu si huyt thm ch phu thut ly huyt khi do nguy c chy mu, bin chng v lm chm tr chn on trong khi ced v nhng ser nhin, bin php khng xm ln chnh xc khc. eTuy sr chp ng mch phi s l bt bucight mpndng cc nu .v lr o bin php ly huyt khi hoc. nongohuyt khi theo Al ho .c oev a ng ng thng. inl 20@y F 8. 0 10. Pht hin huyt khitytnh mch su: a phn 00 i 2 2 t ot c huyt khi tnhhmch ochi di (HKTMCD) khng c P g i triu chng r rng m vic pht hin phi da vo: pyr o siu mCDoppler mu mch mu, MRI hay chp cn quang h tnh mch. Chp cn quang h tnh mch hin rt t c s dng, MRI li qu phc tp, nn siu m Doppler mu mch mu l phng tin l tng pht hin huyt khi tnh mch su, cho d t tin cy nhm khng biu hin triu chng hoc khi nh gi huyt khi TMC di. 40% bnh nhn huyt khi TM su c tc mch phi khi lm x hnh d khng c triu chng lm sng. Cho d cc bin php trn khng th chn on xc nh tc mch phi, song vic pht hin huyt khi TM su rt quan trng quyt nh hng x tr. Bn thn vic tn ti huyt khi TM on gn c ch nh iu tr thuc chng ng d lm sng khng biu hin tc 466 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

mch phi, ngc li nu khng c huyt khi TM gc chi, bn, chu..., khng cn nguy c tc mch thm th d c tc mch phi nh vn c th b qua thuc chng ng. Tt nhin phi rt thn trng khi kt lun nhm bnh nhn c chc nng tim phi hn ch, t hot ng hoc huyt khi hnh thnh t ni khc (nh phi, TMC...). Mt khc siu m mch c th lm li nhiu ln nu vn nghi ng. C. Chn on phn bit 1. Nhi mu c tim cp. 2. Vim phi thu. 3. Suy tim tri cp. 4. Tng p ng mch phi tin pht. ved ser re 5. Cn hen ph qun. ts gh m.vn i ll r co 6. Vim mng ngoi tim. . A ahoo. oev 7. Trn kh mng phi. inl 20@y .F 0 8. Gy xng sn. 2008 ity2 t o oc P 9. Vim khp snhsn.t rig py 10. au c,Co thn kinh lin sn. au III. iu tr Bnh nhn tc ng mch phi c nguy c t vong, huyt khi ti pht hoc bin chng mn tnh. T l t vong c th ln ti 30% nu khng iu tr. Ngay khi nghi ng tc mch phi nn tim trc tip tnh mch ngay 5.000-10.000 n v Heparin nu khng c chng ch nh, ri tip tc chn on xc nh. Nu loi tr tc mch phi th dng Heparin, nu c chn on xc nh th la chn iu tr ph thuc vo tnh trng huyt ng ca bnh nhn. Khi huyt ng suy sp nng gy tt huyt p hoc sc, cn nhanh chng m thng ch tc mch phi bng thuc tiu huyt khi v/hoc th thut can thip iu tr huyt khi. Nu tht bi hoc chng ch nh, nn tin hnh phu thut cp cu ly huyt khi. 467 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Nu thnh cng, tip tc duy tr bng Heparin v thuc khng vitamin K. Bnh nhn tc mch nh hoc thm ch tc mch din rng nhng huyt ng n nh c iu tr bng Heparin gi vi thuc chng ng ng ung. Tc mch phi ti pht hoc chng ch nh dng khng vitamin K, th nn xem xt t dng c lc (filter) tnh mch ch di phng huyt khi. A. Cc bin php hi sc cho NMP din rng 1. Bnh nhn nghi ng tc mch phi din rng thng phi hi sc tch cc n nh huyt ng ngay c trong lc chn on. 2. Nu au ngc nhiu c th dng thuc gim au. 3. Nu xy mu gim nng, t p ng vi th xy qua mt n p vo mi, cn t ng ni kh qun vd thng ve kh nhn to. t ni kh qun v thng khernhn to s re hts vn c th lm nng thm tnh trng suygsp .huyt ng ri m do: (1) thuc gy ng dng khi All oo.co ni kh qun . t ng hoc th my s gy gin v @yah ng thi lm loe mch Fin020 gim/tr tc dng ca. catecholamine, (2) th my 08 2 lm gim lng t 20tTMytr v v tng sc cn mch mu ocit igh Po phi. Do rcn cn nhc thn trng gia li ch v y op nguy cCca bn thn vic t ni kh qun, k thut tin hnh v cc thuc h tr. Etomidate l thuc gim au gy ng l tng v t nh hng n huyt ng. Th my p lc dng lm ci thin tt xy mu do tc mch phi hay c xp phi. 4. Thng thng, truyn 1-2 lt dch mui s nng c huyt p bnh nhn sc khng r nguyn nhn. Cung lng tim s tng ln bnh nhn tc mch phi din rng khi cha tt huyt p nu truyn 500ml Dextran. Tuy nhin, bnh nhn tt huyt p c ri lon chc nng tht phi nng, th tch v p lc bung tht phi cao lm tng sc p ln thnh tim v/hoc gy thiu mu tht phi, y lch vch lin tht qu mc sang tri gy ri lon kh nng gin v/hoc y tht tri. Khi truyn dch qu mc 468 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

cng lm nng thm tnh trng trn cng nh ri lon chc nng tht phi nhiu hn, v th nu p lc bung tim phi cao hoc c biu hin suy tim phi th vic truyn dch cn phi rt thn trng v nn dng thuc vn mch sm. 5. T l sng ca bnh nhn tc mch phi din rng ph thuc vo vic duy tr p lc ng mch ch cp mu mch vnh nui dng cho tht phi ang suy. Noradrenaline thng qua th th (gy co ng mch-tng p lc ti mu mch vnh v gy co tnh mch-tng lng mu tnh mch tr v tim) ng thi thng qua th th 1 (tng co bp c tim hn na) cho php ci thin r rt chc nng tht phi. Dobutamine tuy tng cung lng tim v kh nng vn ved ser chuyn xy song li thay i t l thng kh/ti mu e sr (V/Q) v lm gim PaO2 bnh nhnht m.vn g tc mch phi ri din rng c sc, hn na thucAll oo.co mch ngoi . gy gin h v vi thng qua th th 2. inloe th a V @y nu tc mch phi 0 F din rng, nn chn 08. 202 Dobutamine nu h huyt p t0 ity 2 c va v Noradrenaline onu sc nng, tuy nhin khi t gh Pot ni sinh t n mc rt ri nng catecholamine opy Cp ng vi cc thuc vn mch s km, c cao nn khi khng c tc dng m cn gy ri lon nhp. B. Heparin Bng 26-2. Liu Heparin trong HKTMCD v NMP Chn on Liu heparin HKTMCD - Tim thng TM 5000 v tip theo truyn TM khng km 1000 v/gi, kim tra thi gian throboplastin bn theo NMP phn (aPTT) iu chnh liu Heparin sao cho hoc NMP aPTT trong khong 1,5 - 2,5 ln thi gian chng. nh - C th thay bng dng Heparin trng lng phn t thp liu 1 mg/kg tim di da x 2 ln/ngy. - Dng khng vitamin K, gi t ngy th 3-4, ngng Heparin sau 7-10 ngy. 469 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

NMP ln - 7000 -10 000 v tim thng TM, sau truyn (din rng) tc 1000 - 2000 v/gi, kim tra thi gian aPTT iu chnh liu Heparin sao cho aPTT trong khong 1,5 - 2,5 ln thi gian chng. - Dng khng vitamin K, gi t ngy th 3-4, ngng heparin sau 7-10 ngy (khi n nh). Cc thuc khng vitamin K (Warfarin, Cumadin...) cn c dng gi vo t ngy th 3-4 sau khi dng Heparin v thi gian c tc dng ca cc thuc ny mun. Cn iu chnh liu sao cho INR trong khong 2,0 n 3,0. Warfarin nn dng bt u bng liu 5 mg/ngy. Thi gian dng thuc ny t 3-6 thng sau khi bnh nhn ra vin. Nu bnh nhn cn c nhng tnh trng tng ng ( ni trn) th vn nn tip tc ko di. ved C. Thuc tiu huyt khi ser re ts 1. Tc dng nhanh chng lm tan ccgh m.vnkhi gy huyt i ll r o nghn MP, gim ti v hi phc hoo.c trng suy tim . A a tnh ev phi cp. Thuc tiu huytlo 0@yso vi Heparin lm in khi F gim ng k t l 0t8.vong 2 30 ngy (4,7 so vi 0 ty20 sau 2 i 11,1%), gim nguy otocti pht nghn mch phi (7,7 t c gh P ri so vi 18,7%) v gim nguy c pht trin bnh l py Co mch phi do thuyn tc mn tnh. tng p ng 2. iu tr tiu huyt khi c ch nh cho bnh nhn suy sp huyt ng: tt huyt p, thiu niu, gim xy mu nng. Mt s tc gi cn ch nh cho nhng trng hp ri lon chc nng tht phi trn siu m. 3. Cc thuc tiu si huyt dng nh u c hiu qu v an ton nh nhau nu s dng vi liu tng ng (Bng 26-3). Nu dng Streptokinase hoc APSAC (Anistreplase hay Antisoylated Plasminogen Streptokinase Activator Complex) th nn phi hp 100 mg Hydrocortisone gim cc tc dng ph. 4. Chng ch nh bao gm: cc bnh l ni s, ni ty, chy mu trong, mi phu thut ln hoc chn 470 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

thng nng (< 10 ngy), tng huyt p khng kim sot c, tin s d ng hoc mi dng thuc (ring vi Streptokinase hoc APSAC). Ngc vi NMCT, tiu huyt khi vn c tc dng iu tr trong vng 10-14 ngy cho cc bnh nhn nhi mu phi k t khi khi pht. Hiu qu l tng ng d dng ng tnh mch ngoi vi hay trc tip qua ng thng vo MP. Ngng Heparin trc v sau khi dng thuc tiu si huyt, o aPTT v fibrinogen mu quyt nh thi im dng tip Heparin. Nu aPTT vn gp i chng hoc fibrinogen < 1g/l th lm xt nghim ny 4gi/ln cho ti khi c th dng li an ton Heparin, sau gi vi khng vitamin K t nht trong nm ngy. Bin chng chnh khi dng dthuc e erv tiu si huyt l chy mu nng (12%, tng ng res gia cc thuc tiu si huyt), tronghts .vn huyt g xut l ri .com ni s khong 0,5-2,1%. Streptokinase hoc APSAC l . A oo c th gy d ng nh nng vbng, ni ban, st (5oe yah inl @ 7%), p ng tt vi corticoid0v khng histamine d . F 202 8 00 sc phn v rt him khity ra (<0,5%). 2 toci xy t o gh Bng 26-3. LiurithucPtiu si huyt cho NMP. y p Co Streptokinase Liu np 250.000-500.000 n v/15 pht, duy tr 100.000 n v/gi 24 gi Urokinase Liu np 4.400 n v/kg/10 pht, duy tr 4.400 n v/kg/gi 12 gi rt-PA Liu np 10mg, sau truyn lin tc 90 mg/2 gi APSAC 30mg/5 pht Reteplase 2 mi tim trc tip 10 n v cch nhau 30 pht D. Can thip qua da v phu thut 1. t dng c lc tnh mch ch di xuyn qua da ngn nga nguy c tc thm MP khi bnh nhn c biu hin ca HKTMCD. Ngy nay ngi ta thng dng loi lc (Green Field) t ngay tnh mch ch di, di ch vo ca hai tnh mch 471 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

thn. C th i bng ng tnh mch i bn khng b tc hoc i t ng tnh mch nn. Hin nay ngi ta ang th nghim dng dng c c bit (Angio - Jet) ht cc mu ng qua ng thng tim (catheter), phng php ny bc u t ra c trin vng. 2. Phu thut ly cc mu ng trong ng mch phi l phu thut nng vi t l t vong rt cao, kh thc hin cc trung tm y t nh. Phu thut ch c ch nh khi bnh nhn c tnh trng rt nng vi suy tht phi nhiu, huyt p tt v chp mch phi hoc cng hng t chng minh c cc tc mch ln (thn ng mch phi hoc nhnh ln). E. Ngn nga nguy c v iu tr HKTMCD V HKTMCD l mt trong nhng nguynd nhn e hng u gy NMP, nn vic ngn nga v iu tr kp erv res thi HKTMCD cng l ngn nga NMP. hts n .v g 1. Yu t nguy c ca HKTMCD: ll ri .com v. A hoo a. Tnh trng bnh l hoetnh amch, tn thng l @y n mch, hoc tnh trng itng0ng th pht: . F 202 08 tnng (c bit l cc phu Cc phu thuti y 0 2 c thut vng chiodi, tiu khung). ht Pot g Chnrithng (c bit l gy xng i, chn py Co thng s no, v tu sng). Suy tim huyt, gim cung lng tim. Cc bnh c tnh. Ph n c thai. Dng thuc trnh thai ko di. Bo ph. Gin tnh mch chi di. Bnh vim i trc trng. Tui gi. Hi chng thn h. Nhim trng. b. Tnh trng tng ng tin pht: Thiu ht yu t Antithrombin III. Thiu ht Protein C. Thiu ht Protein S. Ri lon Plasminogen v s hot ho. Bnh i ra hemoglobin kch pht v m. 472 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Bnh gim tiu cu gy ra bi Heparin. Khng th khng lupus (anticoagulant hoc anticardiolipin). Ri lon tng sinh tu xng. Bnh a hng cu. 2. Chn on HKTMCD a. Lm sng thng l xut hin sng, au, cng mt chi. Mt s trng hp triu chng lm sng khng r rng m ch n khi xut hin NMP mi pht hin ra c HKTMCD. b. Chn on xc nh da vo chp h tnh mch, tuy nhin y l thm d chy mu v gy kh chu cho bnh nhn. c. Siu m Doppler tnh mch l xt nghim rt hu ch, cho php chn on tt. 3. iu tr HKTMCD ved ser a. Heparin tim TM 5.000 n v sau t etruyn TM sr n gh7m.10 ngy. tc 1.000 v / gi lin tc trong o - v l ri Al hoo c b. Heparin trng lng phnv.t thp. (LMWH) hin e a c coi l thuc tt lo 0@ytr thay cho Heparin iu Fin02 khi tnh mch chi thng trong iu8.tr 2 huyt 0 2 oci c di. Cc thuc 0nyty nhiu u im hn l tc t ot dng koigh khng phi theo di bng cc xt r di, P p nghimy dng, ngoi tc dng chng yu t Xa Co khi cn c tc dng chng yu t II tiu cu. Bng 26-3. Heparin trng lng phn t thp trong iu tr huyt khi tnh mch. LMWH Xa/IIa iu tr D phng Adreparin 1.9 130 U/kg/12h 50 U/kg/12h (Normiflo) Certoparin 8000 U/12h 3.000 U/24h (MonoEmbolex) Dalteparin 2.7 120 U/kg/12h 2.500200 U/kg/24h 5.000 U/24h (Fragmin) Enoxaparin 3.8 100 U/kg/12h 2.000-4.000 U/24h (Lovenox) Nadroparin 3.6 <55kg:4.000 U/12h 3.100 U/24h 55-80kg:6.000 U/12h 40-60U/kg/24h (Fraxiparin) 473 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

>80kg: 8.000 U/12h

Reviparin 3.5 <60kg: 4.200 U/12h 1750 U/24h >60kg:6.300 U/12h (Clivarin) Tinzaparin 1.9 175 U/kg/24h 3.500 U/24h 50 U/kg/24h (Innohep) c. Dng gi t ngy th 3-4 mt loi khng vitamin K (Warfarin, Sintrom) v ko di vi thng. d. Hin nay mt s tc gi a dng cc thuc tiu si huyt (Streptokinase, Urokinase, rt-TPA...), tuy nhin kt qu cha vt tri hn phng thc iu tr thng thng v rt t tin. e. Can thip t dng c lc (phin lc) tnh mch ch di ngn nga cc mu ng bn ln ng mch phi gy NMP. ved ser re Ti liu tham kho ts gh m.vn 1. ACCP Consensus Commitee on pulmonary rembolism. Opinions l i o Al hoo.c .of venous thromboembolic regarding the diagnosis and management ev a disease. Chest, 1996;109:233-7. inlo 0@y F 2. Britist Thoracic Society, Standards202 Care Commitee. Suspected 8. of 00 ita practical approach. Thorax, 2 acute pulmonary embolism:c y t o 1997;52(suppl 4):S1-24. Pot gh ri 3. Fitzmaurice D, py Hobbs FDR, McManus R. Thromboembolism. Co
Clinical Evidence, 2001;5:158-68. Geerts WH, Heit JA, Clagett GP, et al. Prevention of venous thromboembolism. Chest, 2001;119:132S-175S. 5. Goldhaber SZ. Pulmonary embolism. N Eng J Med, 1998;339:93104. 6. Hyers TM, Agnelli G, Hull RD, et al. Antithrombotic therapy for venous thrombo-embolic disease. Chest, 2001;119:176S193S. 7. Layish DT, Tapson VF. Pharmacologic hemodynamic support in massive pulmonaryembolism. Chest, 1997;111:218-24. 8. Mercat A, Diehl JL, Meyer G, et al. Hemodynamic effects of fluid loading in acute massive pulmonary embolism. Crit Care Med, 1999; 27:540-4. 9. Riedel M. Emergency diagnosis of pulmonary embolism. Heart, 2001;85:607-9. 10. Riedel M. Venous thromboembolic disease. Acute pulmonary embolism 1: pathophysiology, clinical presentation, and diagnosis. Heart, 2001;85:229-40. 4.

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11. Riedel M. Venous thromboembolic disease. Acute pulmonary embolism 2: treatment. Heart, 2001;85:351-60. 12. Wood KE. Major pulmonary embolism: Review of a pathophysiologic approach to the golden hour of hemodynamically significant pulmonary embolism. Chest, 2002;121:877-905.

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Thng lin nh

Thng lin nh (TLN) chim khong t 5% n 10% cc trng hp tim bm sinh. Cng vi bnh van ng mch ch hai l van v sa van hai l, TLN l bnh tim bm sinh cn hay gp nht ngi ln. Bnh ch yu gp n gii: t l gp n so vi nam l 2 so vi 1. i a s cc bnh nhn TLN khng c triu chng c nng m ch c cc triu chng lm sng rt kn o do thng b b st chn on cho n tui trng thnh. i vi cc trng hp TLN khng c iu tr trit , cc bnh nhn s dn dn c cc triu chng lm sng. ved di Lu ser bung cc bnh nhn s biu hin cc du hiu ca s qu ti e sr tim phi nh ri lon nhp nh (tng dn nguyight m.vn tui ca c theo r bnh nhn), tng p ng mch phi v tngll oo.co mch phi, sc . A ah cn v cui cng hu qu tt yu l dn n loe @y xung huyt. Vic in suy tim 0 F tn ti l thng lin nh cng l 08. yu t thun li dn n tc mt 02 0 ity2 2 mch nghch thng. t oc gh Pot ri I. Gii phu bnh:yc bn dng thng lin nh thng thng: p Co TLN kiu l th hai, TLN kiu l th nht, TLN kiu xoang tnh mch v TLN th xoang vnh. A. TLN kiu l th hai hay TLN th pht (l bu dc) l tn thng hay gp nht chim khong t 60% n 70% cc trng hp. L thng nm v tr gn l oval, trung tm vch lin nh (VLN). C th gp phi hp vi sa van hai l, c bit ph n (t l 2:1 so snh gia n v nam gii). B. TLN kiu l th nht hay TLN tin pht chim 15% n 20% cc trng hp. L thng nm thp, gc hp bi vch lin nh v mt phng ca vch ngn nh tht (mt phng van nh tht). Chnh v v tr thp nn loi ny hay i km vi khuyt tt ca van nh tht v vch lin tht. Khi c TLN l th nht th rt thng gp 475 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

h van hai l i km do c k h ca l trc van hai l. Lc , bnh l ny c phn loi trong nhm c bit gi l thng sn nh tht (ng nh tht chung), c c ch sinh l bnh, din bin lm sng v phng hng iu tr khc. C. TLN th xoang tnh mch l loi TLN t gp, chim khong t 5% n 10% cc trng hp. L thng nm cao v ra sau ca VLN, n nm ngay st vi tnh mch (TM) ch trn do vy rt hay gp hin tng tnh mch phi (TMP) qua l thng vo nh phi (TMP lc ch). Ngoi ra c th gp cc th rt him ca TLN nh: TLN nm rt thp pha di st vi TM ch di (pha sau v di ca VLN). v thng D. TLN th xoang vnh l th him gp nht,erled res dng nm ngay st pha trn xoang TM vnh, do hts .vn rig ctrc'' ny. Tn shunt t nh tri s trc tip vo l''cu om l . thng ny hay phi hp vi cc. A ahoo bm sinh khc v d tt oe y inl 20ch nh ng nh tht chung, tnhFmch @ trn lc ch. . 08 20 20 ocity ht Pot rig py Co

Hnh 27-1. V tr gii phu ca cc dng TLN. II. Sinh l bnh A. TLN thng dn n dng shunt t nh tri sang nh phi, lu lng shunt ph thuc vo ng knh l thng v ph thuc gin tip vo gin n ca tht tri v tht 476 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

phi. Lung thng c th ngay lp tc (di 1 nm) hoc dn dn (nhiu nm) dn n s tng gnh ca bung tim phi lm ph i tht phi, tng ti mu phi v cui cng s dn n tng p lc ng mch phi (MP). cc bnh nhn ngi ln hoc do p lc bung tim phi tng ln hoc/v kh nng co bp ca tim tri gim xung (c tim b nh hng do tng cng hay do bnh ng mch vnh, tng huyt p... phi hp), lc ny dng shunt thng s gim xung dn dn v c th dn n shunt hai chiu hay o chiu dng shunt (him gp). B. Nguy c chnh ca vic khng ng l thng lin nh l s gy suy tim th pht do tng gnh mn tnh, tng p MP, ri lon nhp nh v tc mch. ved III. Triu chng lm sng ser re A. Triu chng c nng: thng kn o,tsinkhi bnh gh m.v l ri nhn n khm v kh th khi gng lsc,.co . A ahoo vim ph qun oev s phi nhiu ln hoc chm ln. lMt y t cc trng hp in 20@ vi l TLN ln c th dn8. F 20 0 n shunt tri sang phi nhiu 20 ocitrt sm khong t 6 n 12 v tr c du hiu c nng y ht ot thng, cn li i g s cc trng hp bnh thng pht ri a P py hin mun Co thm khm thng k. Cc trng hp nh bnh din bin lu di c th c cc biu hin ca ri lon nhp nh rung nh hay cung nh, tng p ng mch phi nng v suy tim xung huyt. B. Khm lm sng: Nghe tim c ting thi tm thu cng nh van MP do tng lu lng mu qua van MP. Ngoi ra cn nghe thy ting T2 tch i do s ng mun ca ba l van MP; ting T1 mnh v rung tm trng do tng lu lng van ba l c th gp trong cc trng hp dng shunt ln lm tng nhiu s y v tht phi. IV. Cc xt nghim chn on A. in tm (T) 477 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

1. TLN l th hai: in tm thng c dng: a. RSR hay rSR V1. b. QRS ln hn 0,11 giy. c. Trc phi. d. i khi c th km theo PR ko di (khong 20% cc trng hp, hay gp cc bnh nhn TLN mang tnh cht gia nh). e. Dy nh phi trong khong 50% cc trng hp. 2. TLN l th nht: in tm c dng a. RSR V1. b. Trc tri. c. Bloc nh tht cp I. d. C th thy dy c 2 tht. ved ser e sr B. Chp Xquang tim phi: Tim to vahtphin vi gin g m.v cung MP. i khi thy du hiu gin ibodi phi ca ll r o.c . A amu phi hay gp. tim do gin bung nh phi. Tngev y ho lo ti Fin020@ . C. Siu m tim: y l phng2php ch yu v chnh xc 08 20 ocitynh. i vi cc bnh nhn nht chn on ht ot lin thng rig cnPdng siu m qua thnh ngc cn nh tui c thych op i vi cc C bnh nhn ln tui, thnh ngc dy, i khi cn lm siu m qua thc qun. 1. Siu m qua thnh ngc: Mt ct siu m in hnh quan st l TLN l trc ngn cnh c tri, bn bung t mm v nht l mt ct di sn. a. Hnh nh gin tip s thy du hiu gin bung tht phi v nh phi. Mc gin bung tim phi ph thuc vo mc dng shunt tri phi hay kch thc l TLN. b. Thy hnh nh trc tip ca l TLN trn siu m 2D: bn bung t mm, 4 bung di mi c, hay trc ngn cnh c tri. Hnh nh TLN th xoang tnh mch kh thy hn, c bit ngi ln tui. 478 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

c. Tm kim s bt thng ca TM phi v TM ch: TM ch trn tri vo nh phi khng c thn TM v danh; TM phi lc ch vo TM ch trn, TM v danh, TM ch di hay nh phi... l cc bt thng bm sinh c th gp phi hp vi TLN. Cn quan st bng siu m 2D v c bit l siu m Doppler mu. d. nh gi mc ca dng shunt: gin tip thng qua kch thc tht phi so vi tht tri. Nu thy t l kch thc tht phi/tht tri t 1/2 n 2/3: TLN l nh. Nu t l ny t 2/3 n 1: TLN l trung bnh. Nu t l ny trn 1: TLN l rng. e. Nn tin hnh o cung lng phi, so snh vi ved ser nhiu: cung lng ch. Nu tng cung lngre phi s TLN c dng shunt tri phi rln.t m.vn gh l i co f. nh gi p lc MP: bng ldng chy qua van . A ahoo. ev ba l v dng chy qualo 0@y in van MP (trong TLN p .F 2 lc MP thng0tngytng i mun). 08 t 20 2 i t oc gh Pot ri py Co

Hnh 27-2. Hnh nh thng lin nh trn siu m 2D. 2. Siu m qua thc qun: c p dng vi cc trng hp thng lin nh m siu m qua thnh ngc cn cha r. Siu m qua thc qun rt hu ch trong vic o chnh xc kch thc l thng lin nh cng nh kch thc cc ra pha trn v pha di ca l thng chun b bt cc l thng bng dng c. Siu m qua thc qun cng cn c p dng i 479 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

vi cc th TLN him gp c bit l TLN th xoang tnh mch vi bt thng s v ca tnh mch phi. 3. Siu m cn m: Siu m vi tim cht cn m c bit rt hu ch cho vic chn on xc nh v loi tr cc bt thng bm sinh phi hp khc.

ved serphi. Hnh 27-3. Hnh nh ra bt cn m trong re nh ts gh m.vn i D. Thng tim ll r co . A ahoo. 1. Mc ch ca thng tim: loev y in 20@ . a. Chn on xc nhF TLN ch yu da vo siu 08 ty20 20 2D, m tim (siu mtoci Doppler, siu m cn m, ht Po ig siu m rqua thc qun). Thng tim c th gip py Co ch cho vic nh gi mc shunt, ngoi ra cn xc nh chnh xc p lc ng mch phi, o cung lng ng mch phi, cung lng ng mch ch... b. Vit nam do c rt nhiu cc trng hp n mun nn vic thng tim xc nh chnh xc mc shunt, p lc MP, t l cung lng QP/QS v c bit l sc cn mch phi c vai tr quyt nh xem bnh nhn c cn ch nh phu thut hay khng. Vi cc bin php th xy, thuc gin MP lm gim p MP s l nhng nghim php cui cng quyt nh chn on bnh nhn c tng p lc ng mch phi c nh (hi chng Eisenmenger) hay khng ?
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c. Ngoi ra trong nhng nm gn y, thng tim cn nhm mc ch ng l TLN bng dng c qua da (Amplatzer, CardioSeal...). 2. Chp bung tim: a. Nu l thng thy r trn siu m, c th khng cn thc hin chp bung tim. b. Khi c du hiu ca TM phi lc ch, c th chp MP cho hnh nh r rng v xc nh lung thng ( th thuc ''chm'' khi mu v TM phi). L thng lin nh s thy r gc chp nghing tri 20 n 450 nghing u 250, ng thng bm thuc cn quang nm tnh mch phi phi. c. Chp bung tht tri c th thc hin erved gi nh es co bp tht tri v mc h van rhai l. Nu s n ht v nghi ng thng lin tht v h ig com. nh tht l r cc van l . phi hp th cn chp oev. A ahtht tri t th bung oo y i l thng mt v nghingntri @ 70o, chch u . F 2020 60 8 khong 250. 200 ity toc d. Cui cnggtcco bnh nhn c tui (nam hn 40, i h P yr cn chp MV mt cch h thng p n hn 45), Co xc nh c bnh ng mch vnh phi hp hay khng. V. Ch nh iu tr v tin trin A. ng l TLN c th thc hin bng phu thut tim h vi tun hon ngoi c th (ng m dc xng c, di sn hoc sau bn lng). y l phng php iu tr kinh in c p dng t lu. Hin nay ngi ta c th ng qua da cc l TLN th pht m cn c g xung quanh l thng bng cc loi dng c c bit. B. Ch nh iu tr 1. i vi cc l thng b: ting thi nh, ting T2 tch i, ng knh tht phi/ tht tri nh hn 2/3 th cn theo di nh k thng xuyn. 481 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

2. Vi cc l thng kch thc trung bnh: khng c du hiu c nng, bloc nhnh phi khng hon ton, t l ng knh tht phi/tht tri t 2/3 n 1, c tng ti mu phi trn phim chp Xquang: nu l n gii th nn phu thut khong nm 15 tui (phu thut ng ngang di v); nu l nam gii th nn phu thut lc 5 tui. Nu c kh nng ng qua da bng dng c (Amplatzer, CardioSeal...) th nn thc hin ngay khi c th cc l thng loi ny. 3. Vi cc l thng ln: ting T1 mnh, rung tm trng do tng lu lng, t l ng knh tht phi/tht tri ln hn: nu c tng p MP cn ng l thng ny cng sm cng tt. Nu khng tng p MP, ng l thng mt cch h thng lc tr 5 tui. ved r ese 4. TLN nghi ng c tng p MP c tnh: cn lm sr n h thng tim chn on. Ch phu thutig om.v c tng l r khi cha l c . A phi p MP c nh, lu lng mch hoo. vn tng hn oev ya lu lng i tun hon Finl 2cn shunt tri phi l (vn @ . 20 0 08 typhi vn cn trong gii hn ch yu) v sc cn 0 2 mch i t thnh cho php (chahtr Potoc phc hp Eisenmenger). g ri 5. Tin trinpy TLN thng dung np tt v vy i Co ca khi pht hin bnh rt mun tui trng thnh. Tng p MP c nh (khng cn ch nh phu thut) c th gp tui 20 n 30. Suy tim v ri lon nhp tim c th bt u xy ra tui 30 n 40. Nu l thng lin nh c ng kn (bng phu thut hay bng dng c qua da) th c th coi nh bnh nhn c cha khi hon ton. Ri lon nhp cc bnh nhn ny l hn hu.

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C. Phu thut ng TLN vi tun hon ngoi c th t rt lu tr thnh mt phu thut kinh in. Ty theo kch thc v v tr ca l TLN m phu thut vin c th khu trc tip hoc lm ming v bng mng ngoi tim ng kn hon ton l TLN. 1. Nguy c phu thut lin quan n c a bnh nhn nh tui, rung nh, p lc ng mch phi v sc cn mch phi tng cao. 2. Sau m, bnh nhn cn c th b nguy c mc hi chng sau m mng ngoi tim (hay gp hn cc phu thut tim bm sinh khc). Ri lon nhp nh c th vn ko di mt thi gian sau cho n khi kch thc ca nh v tht phi tr v kch thc bnh d thng. Ti mt vi trung tm, thuc chn ebta giao rve s phng re cm c s dng t 3 n 6 thng sausm t gh m.vn i nga cc ri lon nhp nh. ll r co . A ahoo. oev inl 20@y F 8. 0 00 ity2 2 t oc gh Pot ri py Co

Hnh 27-4. Trc (A) v sau (E) ng l TLN bng Amplatzer. D. ng l TLN qua da bng dng c l th thut ngy cng c p dng nhiu nc trn th gii. Ti Vit Nam phng php ny hin nay c tin hnh thng quy ti Vin Tim mch Vit Nam. Tt c cc trng hp TLN l th hai c kch thc khng qu ln v g xung quanh l ln (hn 5mm) u c kh nng ng bng dng c qua da di mn tng sng. Phng 483 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

php ny ngy cng chng minh c tnh hiu qu nh thi gian nm vin ngn, t au, khng c so m, t bin chng ngay c nhm bnh nhn c nguy c cao. Ti liu tham kho
1. Brecker S,ID. Atrial septal defect. In: Redington A, Shore D, Oldershaw P, eds. Congenital heart disease in adults: a practical guide. London: WB Saunders, 1994:103-110. 2. Connelly MS, Webb GD, Sommerville J, et al. Canadian Consensus Conference on Adult Congenital Heart Disease 1996. Can J Cardiol l998;14:395-452. 3. Gatzoulis MA, Redington AN, Somerville J, Shore DF. Should atrial septal defects in adults be closed? Ann Thorac Surg 1996;61:657659. 4. Latson LA. Per-catheter ASD Closure. Pediatr Cardiol 1998;19:86d 93. rve seatrial and 5. Mahoney LT. Acyanotic congenital heart disease: re t ventricular septal defects, atrioventricular canal,s patent ductus gh m.vn i arteriosus, pulmonic stenosis. Cardiol Clin 1993;11:603-616. ll r o.co o . ALong-term follow-up ef 6. Mandelik J, Moodie DS, Sterba R, etev ah o al. children after repair of atrial septalndefects. Cleveland Clin J Med i l 20@y F 8. 20 1994;61:29-33. y 00 septal defect. In: Marso SP, Griffin 7. Moore JD, Moodie DS.t Atrial cit 2 to h Manual of Cardiovascular Medicine. o BP, Topol EJ, rig eds. P py Philadelphia: LippincottRaven, 2000. Co 8. Perloff JK. Survival patterns without cardiac surgery or interventional catheterization: a narrowing base. In: Perloff JK, Child JS, eds. Congenital heart disease in Adults, 2nd ed. Philadelphia: WB Saunders, 1998:15-53. 9. Snider AR, Serwer GA, Ritter SB. Defects in cardiac septation. In: Snider AR, Serwer GA, Ritter SB, eds. Echocardiography in pediatric heart disease, 2nd ed. St. Louis: Mosby, 1997:235-246. 10. Vick GW. Defects of the atrial septum including atrioventricular septal defects. In: Garson A, Bricker JT, Fisher DJ, Neish SR, eds. The science and practice of pediatric cardiology, 2nd ed. Baltimore: Williams & Wilkins, 1998:1141-1179.

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Thng lin tht

Ngoi tr bnh van ng mch ch (MC) ch c hai l van th thng lin tht (TLT) l bnh tim bm sinh hay gp nht, n chim khong 25% cc bnh tim bm sinh. Do cc triu chng lm sng c hiu (ting thi tm thu to vng gia tim) v cc bin chng sm ca n nn thng lin tht hay c chn on sm t khi bnh nhn cn nh. Chn on TLT t khi cn trong thai nhi c th thc hin c bng siu m tim bi cc bc s c kinh nghim. TLT l nh rt hay gp v thng dung np rt tt. Do n c th gp ngi trng thnh v c kh nng t ng. T ved ser ln n l t ng li ca cc trng hp TLT l nh trrem e ts 75%. Ngc li TLT l ln s nh hng nhanhhnvn hp v g m. h ri co p lc ng mch phi (MP) c th tng All oocch c nh rt . mt . h oev sm t 6 n 9 thng. i vi cc trng hpa sc cn mch phi inl 20@y F 8. tng c nh (hi chng Eisenmenger)0bnh nhn him khi sng 00 ity2 2 oc c qu tui 40. Cc bin chng hay gp nhm bnh nhn t gh Pot tm mc, p xe no, ri lon r ny l chy mu phi,i vim ni py Co chng ca a hng cu. Tin lng s rt nhp tht v cc bin km cc bnh nhn c cc biu hin ngt, suy tim xung huyt v ho ra mu. Ngi ta nhn thy ngoi nguyn nhn do m b cm trong ba thng u, TLT hay gp trong cc hi chng bnh l, c bit l hi chng c ba nhim sc th 21, hi chng do m nghin ru khi mang thai... I. Gii phu bnh A. Phn loi: C rt nhiu cch phn loi gii phu bnh v TLT khc nhau c t ra nhng nhn chung li c 4 loi TLT chnh v gii phu bnh l: TLT phn quanh mng, TLT phn c, TLT phn bung nhn v TLT phn phu (TLT pha trn ca ca Wolff). 485 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

1. TLT phn quanh mng l loi TLT hay gp nht, chim khong 70-80% cc trng hp, nm cao thuc phn mng ca vch lin tht (VLT), ch ni gia van 3 l v van MC. Tuy nhin n c th dch chuyn ra sau, ra trc hay xung di mt cht ty tng trng hp. Tn thng thng phi hp to thnh mt ti nh di van 3 l hay xung quanh b van (thng cng c gi l ti phnh phn mng vch lin tht). N c th gy h van MC v hp phn thp ca ng ra tht phi. y l loi TLT c kh nng t ng cao. 2. TLT phn c hay TLT gn mm tim. N c th bt c v tr no ca phn thp VLT cho n mm tim. Th bnh ny chim khong 5 n 20% cc ved ser cao tr trng hp TLT v cng c kh nng t ng e sr cc trng hp c nhiu l TLT. right m.vn ll .co v. A ahoo loe y Fin020@ . Hnh 28-1. V tr 08 2 20 ocity t gii phu cc loi ht Po rig thng lin tht. py Co

3. TLT phn bung nhn hay TLT kiu ng nh tht chung chim khong t 5 n 8% cc trng hp. TLT loi ny thng v tr cao ca VLT, rng, t kh nng t ng v hay i km tn thng ca cc van nh tht. Hay gp phnh vch lin tht v tr ny. 486 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

4. TLT phn phu hay TLT di van MC hoc di van MP: him gp hn (5 n 7%), l loi TLT m l thng nm phn rt cao ca vch lin tht ni c tip gip vi van MC v van MP (nn cn c gi l thng lin tht kiu ''di cc i ng mch''). im c bit quan trng ca loi TLT ny l l thng thng phi hp vi tn thng l van MC v c h ch i km (hi chng Laubry-Pezzy). B. Cc tn thng khc phi hp c th gp: hp van MP, hp trn van MP, h 3 l, thng trc tip t tht tri sang nh phi, mng ngn di MC II. Sinh l bnh A. Lung thng ca shunt c lu lng ph thuc vo kch ved thc l TLT v sc cn h MP cng nhrepr lc tht se phi. Lung shunt s gy ra qu ti ights .vn tri v phi, nh ll r o.com tht tri. . A ho oev y gy lMP a suy tim phi v B. Din bin xu dn s l tngFp 0@ in 2 . v sau s chuyn thnh 008 chng Eisenmenger (tng sc hi ty20 i 2 bnh cn ca mch phi tdoPotoc l MP tc nghn c nh gh i lm gim dng rshunt tri phi, lm tng dng shunt py Co phi tri). III. Triu chng lm sng A. Triu chng c nng: hay gp nht bnh nhn ln tui l kh th, mt kh nng gng sc. Cc triu chng thng lin quan n mc ca lung thng tri phi, p lc v sc cn ca ng mch phi. B. Triu chng thc th: Nghe tim l du hiu ch yu chn on. Thng nghe thy c ting thi ton tm thu, cng mnh cnh c tri, tng i thp v lan ra tt c xung quanh. Ting thi ny c th nh hn nhng c m sc cao hn trong cc trng hp l thng nh phn c v c th ch lan ra mm hay sang tri nu l TLT mm tim. Nu l TLT qu ln, c th nghe thy 487 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

C. Chn on phn bit trn lm sng vi h van ba l, t chng Fallot khng tm (Fallot trng), hp di van ng mch phi n thun v bnh c tim ph i. IV. Cc xt nghim chn on A. in tm (T): thy hnh nh tng gnh bung tim tri vi dy tht tri, dy nh tri. Trc tri hay gp trong cc trng hp TLT phn bung nhn hoc ng nh ed erv tht chung. Dy tht phi v trc phi gpestrong cc r trng hp tng gnh bung tim phi vits .vn p ng tng gh m i ll r co mch phi. . A ahoo. ev B. Chp Xquang tim phi Finlo 0@y 8. 02 00 h mch phi bnh thng hay 1. Hnh tim khng to2v city2 ht Poto thy cc trng hp TLT l nh khng gy tng p rig p ng mchy Co phi. 2. Tim to va phi vi gin cung di tri. i khi thy du hiu gin cung MP. Tng ti mu phi hay gp cc bnh nhn c lung thng tri phi ln. 3. Bng tim khng to nhng c du hiu huyt phi nhiu thng gp trong cc trng hp TLT l rng c tng sc cn mch phi c nh (hi chng Eisenmenger). C. Siu m tim 1. Hnh nh gin tip: Kch thc bung tim tri v thn MP u gin. 2. Hnh nh trc tip ca l TLT trn siu m 2D: mt ct trc di cnh c tri (TLT phn phu); mt ct qua cc gc ng mch (TLT quanh mng, phu); 488 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

mt ct di c, bn bung t mm (TLT phn c, quanh mng v bung nhn).

Hnh 28-2. TLT phn quanh mng: mt ct cnh c trc ngn (hnh tri) v mt ct 5 bung tim t mm (hnh phi). 3. nh gi mc ca dng shunt: dng shunt tri ed phi ln khi gin bung nh tri, tht trierv MP. s v re t o chnh p qua l TLT nh gi sp n MP gh m.v lc i (nu khng c cn tr ng raAll r o.co v mc tht phi) . aho ev bnh. Nu chnh p cn lnlochng t l thng nh v in 20@y F khng c qu ti tim phi.2Cn nh o huyt p ng 8. 0 00 Doppler tim. mch khi lm siu 2 ocity t m gh Pot r 4. Trong trngi hp p lc MP tng c nh: thnh py Cody, dng chy qua l TLT yu hoc hai tht phi chiu, p lc MP tng nhiu gn bng hay vt p lc i tun hon. 5. Siu m Doppler tim cn cn phi loi tr cc tn thng phi hp nh thng lin nh, cn ng ng mch, h ch, cn tr ng ra tht phi v tht tri. D. Thng tim 1. Ch nh: a. Cc trng hp TLT vi cc du hiu qu ti ca tht tri (tim to, thi tm trng mm tim, suy tim huyt) hoc tng p MP m cn phi c cc bng chng khng nh mc lung shunt,

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b. Cc trng hp TLT vi nghi ng c cc tn thng khc phi hp nh h ch, hp ng ra tht phi, hp di van MC... cng l cc trng hp c th ch nh thng tim. c. Thng tim ng l TLT bng dng c (Amplatzer, Coil, Buttoned device...). 2. Chp bung tim: a. Chp bung tht tri s gip xc nh chnh xc v tr, kch thc ca l thng lin tht v c bit gip cho chn on thng lin tht c nhiu l. T th chp hay dng nht l nghing tri 45 e 700, nghing u 250. Tuy nhin ty loi rl d e v thng res mng: c th thay i cht t. TLT kiuts n quanh v 0 igh r TLT phn c, ra thy r nghing tri 60-45ll. com. . . A ho 0 pha trc chp nghingvtria45o. TLT kiu di loe @y cc gc ng mch. ln chp t th nghing 900 Fin 20 08 ty20 v nghing phi.0 i 2 oc t xc b. Chp MCh Pot nh c h ch phi hp hay g ri p khng?y Co c bit trong cc th TLT kiu di cc gc ng mch, hi chng Laubry - Pezzy. c. Chp bung tht phi xc nh xem c hp ng ra tht phi khng, c h van ba l khng v xem c phi ch vo ca dng shunt trc tip vo tht phi hay khng. V. Ch nh iu tr v tin trin A. iu tr ni khoa 1. TLT vi tng p MP nhiu tr nh cn c iu tr bng li tiu, tr tim v gim tin gnh trc khi phu thut. 2. Sau phu thut v cc trng hp cha phu thut (hoc khng cn phu thut) cn phng bin chng 490 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

vim ni tm mc nhim khun (rt d xy ra vi cc trng hp TLT). B. ng l thng qua da bng dng c Hin nay c th ch nh cc trng hp TLT l nh phn c, mm hoc sau NMCT c bin chng. Tng lai nhiu loi dng c ang c nghin cu ng TLT phn quanh mng-bnh bm sinh c tn sut gp cao nht. C. iu tr ngoi khoa ng l TLT c th thc hin bng phu thut tim h vi tun hon ngoi c th (ng m dc xng c). Cn lu c mt t l kh ln l TLT c th t ng rved li. e res 1. i vi cc l thng b, shunt nh, p ts vMP bnh lc gh m. n rixuyn hng nm, thng cn theo di nh k thng o.co ll o v. Anhim khun. Nguy phng chng vim ni tmloe @yah mc in 0 c gp nhm ny l 8. F 202 ch (TLT phn phu) 0 Osler, h 20 c ty v hp phn phu MP i(TLT phn quanh mng). ht Poto rig py 2. Khi l thng lin tht ln s nh hng r n ton Co trng tr di 6 thng: iu tr ni khoa vi li tiu, tr tim, c ch men chuyn. Nu khng p ng vi iu tr ni th cn ng l TLT. 3. Khi l TLT ln, nh hng r n ton trng tr trn 6 thng th cn phu thut ng l TLT. 4. Khi l thng ln, c tng p MP trn 50mmHg tr hn 6 thng: phu thut ng l TLT. 5. Khi l TLT phi hp vi h van MC va hoc hp ng k ng ra tht phi th cn phu thut ng l TLT.

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6. Nu TLT c nhiu l, c nh hng n ton trng th cn lm phu thut nh ai (banding) MP cc tr nh di 6 thng v sau phu thut sa cha ton b. Tin trin ca TLT nu c ng kn (bng phu thut hay ng l thng qua da) c th coi nh bnh nhn c cha khi hon ton. Ri lon nhp cc bnh nhn ny l hn hu nh bloc nh tht sau phu thut. 7. Cc trng hp TLT nghi ng c tng p MP c nh: cn thng tim vi nghim php th xy v thuc gin mch, chp mao mch phi, o sc cn ed erv sphi. Nu mch phi v cui cng c th sinh thite r hts n gnh.vth c th sc cn mch phi khng tng ci om ll r o.c . Atho l mt chng phu thut, nu tng c nh ah ev nlo 0@ trng hp nghi ng iTrong y ch nh ca phu thut. F 8. 202 00 iai MP v lm li cc thm c th phu thut nh ty 2 oc t gh Pot vi cc trng hp khng cn d sau viinm. i r opy Cm na th thng din bin c th nng ln ch nh bng cc du hiu suy tim phi, hn ch gng sc, a hng cu vi biu hin tm nhiu da v nim mc. Cc bin chng c th gp l chy mu phi, pxe no v t t. Gii php iu tr ch ng duy nht trong trng hp ny l phu thut ghp c tim v phi cho ngi bnh. Ti liu tham kho
1. Brecker SJD. Ventricular septal defect. In: Redington A, Shore D, Oldershaw P, eds. Congenital heart disease in adults: a practical guide. London: WB Saunders, 1994:111-117.

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2.

Bridges ND, Perry SB, Keane JF, et at. Preoperative transcatheter closure ofcongenital muscular ventricular septal defects. N Engl J Med 1991;324:1312-1317.

3.

Connelly MS, Webb GD, Sommerville J, et at. Canadian Consensus Conference on Adult Congenital Heart Disease 1996. Can J Cardiol 1998;14:395-452.

4.

Ellis JH, Moodie DS, Sterba R, Gill CC. Ventricular septal defect in the adult: natural and unnatural history. Am Heart J 1987;114:115120.

5.

Folkert M, Szatmari A, Utens E, et at. Long-term follow-up after surgical closure of ventricular septal defect in infancy and childhood. J Am Coll Cardiol 1994;24:1358-1364.

6.

re g m. ri co pediatric cardiology; 2nd ed. Baltimore: llWilliams & Wilkins, . A ahoo. oev 1998:1119-1140. inl 20@y F 7. Lock JE, Block PC, McKay08. y20 at. Transcatheter closure of 0 RG, et 2 ocit t ventricular septal defects.Circulation 1985;78:361-368. gh Pot ri py 8. Mahoney LT. oAcyanotic congenital heart disease: a trial and C
Bricker JT, Fisher DJ, Neish SR, eds. The science sandn ht v practice of ventricular septal defects, atrioventricular canal, patent ductus arteriosus, pulmonic stenosis. Cardiol Clin 1993;11:603-616. 9. Moore JD, Moodie DS. Ventricular septal defect. In: Marso SP, Griffin BP, Topol EJ, eds. Manual of Cardiovascular Medicine. Philadelphia: LippincottRaven, 2000.

v Gumbiner CH, Takao A. Ventricular septal defect. In: eGarson A, sr

ed

10. O'Fallon MW, Weidman WH, eds. Long-term follow-up of congenital aortic stenosis, pulmonary stenosis, and ventricular septal defect. Report from the Second Joint Study on the Natural History of Congenital Heart Defects (NHS-2). Circulation 1993;87[Suppl II]:II1-II-126. 11. O'Laughlin MP, Mullins CE. Transcatheter closure of ventricular septal defect. Catheter Cardiovasc Diagn 1989;17:175-179.

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12. Perloff

JK.

Survival

patterns

without

cardiac

surgery

or

interventional catheterization: a narrowing base. In: Perloff JK, Child JS, eds. Congenital heart disease in adults, 2nd ed. Philadelphia: WB Saunders, 1998:15-53. 13. Snider AR, Serwer GA, Ritter SB. Defects in cardiac septation. In: Snider AR, Serwer GA, Ritter SB, eds. Echocardiography in pediatric heart disease, 2nd ed. St. Louis:Mosby, 1997:246-265. 14. Somerville J. How to manage the Elsenmenger syndrome. Int J Cardiol 1995;63:1-8.

Co

py

r ese sr n t gh .v l ri .com l . A oo oev yah inl @ . F 2020 8 00 y 2 tocit ht Po rig

ved

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Cn ng ng mch

Cn ng ng mch (COM) (TBS) chim khong 10% cc bnh tim bm sinh (1 trong 2000 n 5000 tr s sinh). Dng shunt thng nh v t triu chng lm sng, tr khi c bin chng. Din bin t nhin ca bnh ph thuc vo kch thc ca ng ng mch v mc dng shunt triphi. Nu khng c iu tr c th dn n suy tim huyt do qu ti bung tim tri. Trong thc t rt t gp ng ng mch t ng sau khi tr ra i (tr cc trng hp rt sm) m thng phi ng ng bng phu thut hay ng qua da bng dng c. Nu ngd ng e erv mch qu mun m cha c can thip nh ngi trng res s hoc rung thnh th c th gp cc ri lon nhp nh cung tnhvn igh m. rcnomch phi c ll nh, vim ni tm mc nhim khun, tng sc o.c v. A aho nh (hi chng Eisenmenger). loe y Fin020@ . I. Gii phu bnh 08 2 20 ocity t o A. Thng thng nghngt mch s t ng t gi th 15 P rig n gi thCopy sau khi sinh. Cc yu t thc y vic 16 ng ng ng mch l p lc ring phn ca xy trong mao mch phi tng, gim nng prostaglandine lu hnh trong mu do tng chuyn ha tun hon phi v do cc hiu ng nhau thai gy ra. Cc yu t ny c th ko di tc dng n ngy th 21 sau khi sinh nhng nu cn thy tn ti ng ng mch sau 3 thng tui th gn nh chc chn ng ng mch khng th t ng, tr mt s rt him cc trng hp t ng ng ng mch do phnh ng bnh nhn c tui v thng sau vim ni tm mc nhim khun. B. V gii phu, ng ng mch nm quai MC ngay ch chia ra ca ng mch di n tri v c vo thn hoc MP tri. ng ng mch thng c chiu di thay i v c th phi hp vi gin MC khi MC quay 495 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

phi, ng ng mch c th xut pht t pha trc ni hnh nh soi gng ca thn ng mch khng tn tri hoc t pha sau ng mch di n tri bt thng hoc him gp hn l t quai MC bn tri. II. Sinh l bnh A. Lung thng ca ng ng mch thng nh, nhng i khi lung thng ln c th gy qu ti phi v tng gnh nh tri, tht tri. Cui cng c th dn n huyt phi v suy tim huyt, tng p MP, hi chng Eisenmenger. B. Rt hay gp hin tng huyt phi, d dn n vim phi v c th gy Osler bt k loi ng ng mch no. N cn lm gim p lc tm trng ca ngdmch e erv ch do hiu ng ca dng pht ngc tm trng. res ts n C. Tn thng phi hp hay gp l: Hp ighom.vbm sinh, r MC ll c hp eo MC. Nu c TLT phi hp: coo. che lp ting v. A ah th e tm trng ca ting thi linlotc y thi tm thu ca Fin020@ do . TLT qu to. Khi hp eo08 ty2 phi hp hp MP: hi MC 20 oci chng Rubella. ght Pot ri py III. Triu chng lm sng Co A. Triu chng c nng: Cng nh cc bnh tim bm sinh khng tm khc, ng ng mch rt t cc triu chng c nng c hiu. Cc du hiu c th gp l gim kh nng gng sc, kh th... B. Triu chng thc th 1. Nghe tim l du hiu ch yu chn on: a. Nghe thy c ting thi lin tc cng ln di xng n bn tri. Ting thi ny c th ch c trong th tm thu, hi ko di ra trong th tm trng trong cc trng hp ng ln v c tng p MP nhiu. Ngoi ra c th nghe thy ting thi nh trong cc trng hp ng nh. 496 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

tr s sinh, ting thi thng v tr thp v thng ch c th tm thu. b. C th nghe thy ting rung tm trng do tng lu lng mu qua van hai l. c. Nu lung shunt ln gy tng p MP th c th thy ting thi nh i, khng ko di v c ting th hai mnh ln. 2. Mch ngoi bin ny mnh v chm su, hay gp du hiu ny khi dng shunt tri phi ln. 3. Mm tim xung thp v sang tri do gin bung tim tri. Nu bnh nhn c tng p MP, tht phi s gin vi mm tim sang phi. C. Chn on phn bit: vi d ng-tnh mchd phi, e ev d ng mch vnh vo cc bung tim bn phi,rd ng res hts n tnh mch h thng, v ti phnh xoanggValsalva, thng ri com.v ll lin tht vi h van ng mch ch phi . hp, tun hon v. A ahoo lin tht vi oe y bng h ch-phi cc bnh lnhn thng Fin020@ thiu sn van ng mch08. 2 phi... 20 ocity t IV. Cc xt nghim chnon t igh Po yr A. in tm Cop (T): thng khng c hiu, c th thy hnh nh tng gnh bung tim tri vi trc tri v dy tht tri. Ph i tht phi c th thy giai on mun vi tng p MP nhiu. B. Chp Xquang tim phi: tim to va phi vi gin cung di tri. i khi thy du hiu gin cung MP. C th thy gin nh tri vi hnh nh hai b. Hnh nh tng ti mu phi cng hay gp. Phim Xquang c th cho ta thy s b mc nh hng n huyt ng ca bnh. C. Siu m Doppler tim 1. Hnh nh trc tip ca ng ng mch trn siu m 2D thy c mt ct trn c v qua cc gc ng mch ln. o ng knh v nh gi hnh thi ca ng. Siu m Doppler mu xc nh chnh xc v tr 497 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

vo MP ca ng ng mch. nh gi chnh p qua ng ng mch bng siu m Doppler, t xc nh mt cch gin tip p lc ng mch phi (cn o huyt p ng mch khi lm siu m tim). Quan st quai MC tm cc tn thng phi hp. 2. Hnh nh gin tip: Gin bung tim tri v MP c th gp trng hp ng ng mch c shunt ln.

ved ser Hnh 29-1. Hnh nh ng ng mch: mtre n cnh c ct hts trc ngn (hnh tri) v mt ct hm trn c (hnh com.v rig phi). ll . v. A ahoo loe y Fin020@ . 08 2 20 ocity Hnh 29-2. Dng t gh Pot chy qua ng ng ri py mch trn siu m Co Doppler mu.

3. nh gi mc ca dng shunt: dng shunt tri phi ln khi thy gin bung nh tri, tht tri v thn MP. Cn nh gi p lc MP tng c nh cha, dy ca thnh tht phi, dng chy qua ng ng mch yu hoc hai chiu, p lc MP tng nhiu gn bng hay vt p lc i tun hon.

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D. Thng tim 1. Ch nh thng tim: Khi khng thy ng ng mch trn siu m tim mt bnh nhn c ting thi lin tc hoc cn ng ng mch nhng p lc MP tng nhiu trn siu m Doppler tim. Ngoi ra thng tim cn ng ng ng mch qua da bng dng c (Coil, Amplatzer...). 2. Cc bc tin hnh thng tim: a. Thng tim phi theo cc phng php kinh in (nh trong thng lin nh): ng thng ln MP thng d dng qua ng ng mch xung MC xung (nu thng tim theo ng TM di n phi s thy hnh ch kinh in). Nu gp kh ed khn c th dng dy dn iu khin. vKhi ly ser re mu mu cn phi ly on xa hca cc nhnh ts g m.vn nn ri c MP do dng shunt thngllchyo lch, . A ahoo. MP khng bo ho xy thn v on gn ca oev y inl 2xy c nh ca MP. phn nh ng bo F 0 0@ ho 8. Nu c tng p 00 city2 MP nhiu c th s dng cch 2 o ng ngight Pmch tm thi bng bng v theo ng ot yr di pplc MP trong khi bm bng, nu p lc Co h xung tt th c th ch nh ng ng ng mch. b. Thm d huyt ng: Thy c bc nhy xy MP. o QP/QS vi bo ho xy on xa ca MP. a s cc trng hp ALMP thng bnh thng, i khi ng ng mch ln c th dn n tng ALMP. Trng hp p lc qu cao c th lm nghim php ng ng tm thi bng bng c l bn (ng thng u c gn bng, on gn u c l bn theo di p lc). Trong hi chng Eisenmenger c s o chiu dng shunt t phi tri, bo ho 499 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

xy MC xung s thp hn MC ln, lc ny khng cn ch nh ng ng. c. Chp bung tim: bng cch bm trc tip thuc cn quang vo ng ng mch t th ngang 900. Nu nghi ng hp eo MC cng chp MC t th ny. ng ng ng mch cng dng t th ny nhng bm thuc t MC sang MP. V. Ch nh iu tr 1. Ch nh ng ng ng mch l bt buc nu cn dng shunt tri phi. 2. ng bng thuc: s dng prostaglandine trong cc trng hp tr s sinh (bit dc l Indocid 0,2mg/kg ved serl thuc r c th tim nhc li sau 8 gi). Cn che ts gh m.vn cng c th gy suy thn hoc hoi ri rut. ll t co . A ahoo. 3. ng qua da bng dngnloev @y th dng coil hay c: C Fi mi0 khc nh: Amplatzer, . cc loi dng c th 8h 202 0 20 ocity Buttoned Device, CardioSeal... Coil thng c ch t t igh Po nh trongpyr trng hp ng ng mch kch thc cc Co b trn phim chp (di 4mm). Cn cc dng c khc dc bit l Amplatzer th rt tt cho cc trng hp ng ln, ngn.

Hnh 29-3. ng ng ng mch bng Amplatzer. 4. ng ng ng mch bng phu thut theo ng bn sau ca lng ngc. Hin nay ti Vit Nam vn l phng php iu tr ch yu nhng trong tng lai 500 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

gn y th ch l phng php c la chn th hai sau khi khng ng c ng qua da hoc khi c cc d tt bm sinh khc phi hp cn phu thut. 5. Phng vim ni tm mc nhim khun cn ko di 6 thng sau khi ng ng bng phu thut hay bng dng c qua ng ng thng. Ti liu tham kho
1. Burke RP, Wernovaky G, van der Velde M, et al. Video-assisted thoracoscopy surgery for congenital heart disease. J Thorac Cardiovasc Surg 1995;109:499-505. 2. Connelly MS, Webb GD, Sommerville J, et al. Canadian Consensus 1998;14:395-452.

ese sr n t gh .v 3. Fisher RG, Moodie DS, Sterba R, Gill CC. ll ri .com Patent ductus arteriosus v. A hoo in adults: long-term follow-up-nonsurgical versus surgical loe @ya Fin 20 management. J Am Coll Cardiol.1986;8:280284. 08 ty20 0 i c 4. Harrison DA, Benson LN,2Lazzam C, et al. Percutaneous catheter ht Poto rig patent ductus arteilosus in the adult. Am J closure of the persistently py Co Cardiol 1996;77:1084-1097.
5. Ing FF, Mullins CE, Rose M, et al. Transcatheter closure of the patent ductus arteriosus in adults using the Gianturco coil. Clin Cardiol 1996;19:875-879. 6. Mahoney LT. Acyanotic congenital heart disease: atrial and ventricular septal defeczs, atrioventricular canal, patent ductus arteriosus, pulmonic stenosis. Cardiol Clin 1993;11:603-616. 7. Moore JD, Moodie DS. Patent ductus arteriosus. In: Marso SP, Griffin BP, Topol EJ, eds. Manual of Cardiovascular Medicine. Philadelphia: Lippincott-Raven, 2000. 8. Mullins CE, Pagotto L. Patent ductus arteriosus. In: Garson A, Bricker JT, Fisher DJ, Neish SR, eds. The science and practice of

Conference on Adult Congenital Heart Disease 1996. CanrveCardiol Jd

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pediatric cardiology, 2nd ed. Baltimore: Williams & Wilkins, 1998:1181-1197. 9. Perloff JK. Survival patterns without cardiac surgery or interventional catheterization: a narrowing base. In: Perloff JK, Child JS, eds. Congenital heart disease in adults, 2nd ed. Philadelphia: WB Saunders, 1998:15-53. 10. Schenk MH, 0 Laughlin MP, Rokey R, et at. Transcatheter occlusion of patent ductus arteriosus in adult patients. Am J Cardiol 1993;72:591-595.

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Bnh van ng mch phi

Van ng mch phi l van t chim ngn cch ng mch phi vi tht phi. Ri lon hot ng van ng mch phi s gy tc ng c hi ln chc nng ca tht phi. Bnh thng, t l h van ng mch phi pht hin bng siu m Doppler tim ngi bnh thng kh cao, song ch c mt s t bnh l van ng mch phi (h hoc hp) thc s gy nh hng n tnh trng huyt ng ca tim phi v gy ri lon chc nng tht phi. I. Hp van ng mch phi n thun (HP) A. Triu chng lm sng ved ser re 1. Cc triu chng suy tim phi v kh thskhi gng sc t gh m.vn i thng xut hin tui 30-40 nu rbnh khng c ll co . A ahoo. pht hin v iu tr t trc. ev y o inl 20 Fting @ tm thu tng mu . 2. Triu chng in hnh8l 20 thi 0 203-4ty khoang lin sn toci tri, gim cng khi ht ht Po vo (do gimg chnh p qua van ng mch phi) ri py C ng thio gim cng hoc mt hn ting T2. 3. Triu chng suy tim phi biu hin giai on mun. B. in tm 1. Hnh nh in tim bnh thng nu HP nh. 2. Trc phi, dy tht phi khi HP mc t va-nng. Mc dy tht phi trn in tim c lin quan kh cht vi mc nng ca HP. Trng hp hp kht van MP, c th gp hnh nh dy nh phi. C. Chp tim phi: bng tim khng to, cung ng mch phi phng r (gin MP sau hp), mu ln phi t. Bng tim s to khi c suy tim. D. Nguyn nhn 503 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

1. Hp van ng mch phi bm sinh l dng bnh l hay gp nht (chim t l 10% trong s cc bnh tim bm sinh). 2. Di chng thp tim: dnh mp van gy hp van. Cn lu rng van ng mch phi l van t b nh hng nht do bnh thp tim. 3. Hp th pht do hi chng u carcinoid gy thm nhim l van MP. 4. Gi hp van ng mch phi trong trng hp tc nghn ng tng mu tht phi do u trong tim hoc ti phnh xoang Valsalva. E. Chn on: 1. Siu m Doppler tim rt c gi tr chn on xc ved ser phi. nh v lng gi mc hp van ngts re mch gh m.vn ct trc a. Van ng mch phi thy r ll ri co mt nht . ngn cnh c tri hoc di sn. Nu hnh nh v. A ahoo oe y l qua thnh ngc c .cht 20@ km, c th dng Fin0 lng 8 siu m tim qua 00 ity2 thc qun. 2 toc t b. Siu m Dopplero tim cho php nh gi tnh trng igh P yr mch phi (van dy, vi, hn ch vn van Cop ng ng ngi ln; l van khng vi, m dng vm tr con) v tht phi (bnh thng hoc ph i ph thuc vo mc hp van ng mch phi v thi gian b bnh). 2. Mc hp van ng mch phi c phn loi da trn chnh p ti a nh-nh qua van ng mch phi o bng ph Doppler lin tc (tnh theo cng thc ca Bernoulli). Hin ti, siu m Doppler tim c xem nh mt phng php chun nh gi mc hp van (tng quan rt cht so vi tiu chun vng l thng tim). Hp van MP chia thnh cc mc nh sau: a. Hp nh: khi chnh p ti a qua van MP < 40 mmHg 504 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

b. Hp va: khi chnh p ti a t 40 n 80 mmHg c. Hp kht (nng): khi chnh p ti a 80 mmHg. F. iu tr 1. Hp van ng mch phi mc t nh n va c tin lng rt tt v rt t khi cn can thip. 2. Hp van ng mch phi nng hoc suy tim phi th pht thng biu hin sau tui 40 hoc 50 d c nhiu dng bnh biu hin ngay t nh. Phng php iu tr chnh l nong van ng mch phi bng bng qua da, c kt qu kh quan, ni chung gim c 75% chnh p qua van. Tin lng lu di v t l sng cn sau can thip hon ton ph thuc vo tnh trng chc nng tht phi khi nong van. ved ser chng 3. Hp van ng mch phi th pht dorehi s carcinoid c tin lng rt xu (thihtgiannsng st rig com.v l . trung bnh sau khi chn onAlbnh ch c 1,6 v. ahoo e nm), hu nh khng plongyvi nong van bng Fin020@ . bng nn ni chung phi thay van. 08 2 20 ocity II. H van ng mch ht Pot(HoP) phi rig py A. Triu chng lm sng Co 1. Thng c biu hin kh th khi gng sc v triu chng ca suy tim phi. 2. Nghe tim: a. Thi tm trng m sc thp, nghe r nht khoang lin sn 3-4 tri km T2 tch i, tng ln khi ht vo v nu c tng p ng mch phi th T2 mnh. b. Ting thi ca Graham Steell l ting thi tm trng gim dn v cng , c m sc cao, xut hin ngay sau ting T2, l ting thi in hnh khi p lc ng mch phi vt qu 70 mmHg ng thi c h van MP. 505 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

3. Ngoi ra c th pht hin c cc triu chng ca suy tim phi. B. Nguyn nhn 1. Khc vi hp van, h van ng mch phi rt t khi do nguyn nhn bm sinh nh khng c l van, thiu sn hay thng l van MP. 2. Thng gp l cc bnh tim mc phi gy h van ng mch phi: hng u l hp van hai l, u nhy nh tri gy tng p lc ng mch phi, sau l do vim ni tm mc nhim khun. U carcinoid hoc thp tim cng c th gy HoP song thng gy hp van nhiu hn. Cn gp HoP th pht trong hi chng Marfan do gin ng mch phi. ved ser re ts C. Chn on: ch yu bng siu m Doppler tim. gh m.vn l ri o Al hoo.c 1. Van ng mch phi nhn thy. r nht mt ct trc oev a ngn cnh c tri hoc di sn. a s ngi bnh inl 20@y .F thng u c mt 008 ty20 ngc nh do h van dng pht 2 oci ng mch phit rt onh. Dng HoP ny ch c coi gh P t ri l ng Copy pht su vo tht phi 1-2 cm v ko k khi di 75% thi k tm trng. Doppler xung cng c th dng thm d dng pht ngc trong thi k tm trng. 2. Khng gim vn tc dng h trong thi k tm trng l du hiu gi tng p lc ng mch phi gy ra h van. Biu hin khc ca tng p lc ng mch phi trn siu m tim l hin tng mt sng a v s ng nh van MP gia tm thu trn siu m TM cng nh trn ph Doppler dng chy qua van. 3. p lc MP tm thu c th c tnh da trn ph Doppler ca dng h van ba l. p lc MP cui tm trng (ALMPCTTr) c th tnh c khi ghi c ph ca h van ng mch phi, da theo cng thc: 506 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

ALMPCTTr = 4(VPR-E)2 + ALTP Trong ALTP l p lc tht phi v thng = 10 mmHg; VPR-E l vn tc dng HoP cui tm trng. Tng t nh vy, ta cng c th tnh c p lc trung bnh ca MP (ALMPTB) cn c vo vn tc u tm trng ca dng h phi da theo cng thc sau: ALMPTB = 4(VPR-P)2 + ALTP Trong ALTP l p lc tht phi v thng = 10 mmHg; VPR-P l vn tc dng HoP u tm trng. 4. Hin tng gim vn tc dng h phi k tm trng thng gi c d dng ca van MP. ved ser D. iu tr re ts v gh tin n 1. H van ng mch phi tin phtri om. lng rt l c Al ho c .ra suyo.tht phi. tt, t khi cn x tr tr phi gy a oev inl 20@y 2. H van MP th pht: 20 lng hon ton ph . F tin 08 0caty 2 thuc vo din bin toci bnh chnh nh hp van hai t o gh tm mc nhim khun, u carcinoid, l kht, vimrini P opy tng p Clc ng mch phi... iu tr ngoi khoa bng thay van hoc sa vng van ng mch phi ch c p dng trong mt s trng hp rt hn hu. III. Ti liu tham kho
1. 2. Braunwald E. Heart disease: a textbook of cardiovascular medicine, 5th ed. Philadelphia: WB Saunders; 1997. Cheitlin MD, MacGregor JS. Acquired tricuspid and pulmonary valve disease. In: Topol EJ, ad. Textbook of cardiovascular medicine. Philadelphia: Lippincott-Raven Publishers, 1998:557-578. Feigenbaum H. Echocardiography, 5th ed. 1994. Baltimore: Williams & WilkinB. Reynolds T. The echocardiographer's pocket reference. Arizona Heart Institution Foundation, 1993:23-29.

3. 4.

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5. 6.

Topol EJ, ad. Textbook of cardiovascular medicine. Philadelphia: Lippincott-Raven, 1998. Weyman AE. Principles and practice of echocardiography, 2nd ad. Philadelphia: l,ea & Febiger, 1994:chapter 26, 824-862.

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T chng Fallot

T chng Fallot l bnh tim bm sinh c tm hay gp nht, chim khong 10% cc bnh tim bm sinh. C th chn on c bnh ny t trc khi sinh bng siu m tim thai. Din bin t nhin ca bnh thng l tm ngy cng tng, i khi c cn mt xu. Chn on lm sng hay da vo cc du hiu tm da, ting thi cao ca hp ng mch phi, phi sng v tng gnh tht phi. Siu m tim thng gip khng nh chn on. Phu thut sa ton b c kt qu tt tr t 6 n 9 thng. Phu thut sa ton b hoc lm cu ni cp cudtrong rve trng hp c cn xu, ngt do thiu oxy. T l t vonge khi phu res hts n thut thp, tin lng tt. rig com.v ll T chng Fallot l bnh tim bm ev. A hay. i km vi cc sinh hoo a lo tn thng ngoi tim. C th c lin iquan@y hi chng nhim F n020 n: . c ru bo thai, hi chng Goldenhar, hi chng Cardiofacial, 08 2 20 ocity hi chng c 3 nhim sc tth o21 (thng i cng vi ng nh h Pt rig cht gia nh. tht chung) v c thopy tnh c C I. Gii phu bnh A. T chng Fallot gm 4 chng Hp ng ra ca ng mch phi (MP). Thng lin tht (TLT). ng mch ch (MC) lch sang phi v ci nga ngay trn l thng lin tht. Ph i tht phi. 1. Trong s cc chng ny th 2 "chng" quan trng nht l hp ng ra ca MP v TLT. Hp ng ra MP c rt nhiu th nhng bao gi cng c hp phn phu MP. Hp c th di hay ngn, cao hoc thp, kht hoc va. Ngoi ra c th hp ng ra MP phi hp vi hp van MP, hp trn van v cc 509 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

nhnh MP. C th hp va hoc hoc rt kht, thm ch thiu sn nhnh MP. L TLT trong Fallot 4 thng rt rng, b ca c, ngay pha di ca ca Wolf (loi quanh mng chim khong 80% cc trng hp). 2. Chnh do 2 thng tn hp MP v TLT ny s dn n ph i tht phi, dng shunt t phi tri s c xu hng ko ng mch ch lch sang phi v dn dn "ci nga" trn l TLT. Mc lch phi ca MC ph thuc vo 2 yu t: kch thc ca MC v kch thc ca l thng lin tht (t l thun vi 2 thng s ny). B. Cc thng tn phi hp ved 1. MC quay phi (25% cc trng hp). ser re 2. Hp MP (10 - 20%). ts gh m.vn ri co 3. Thiu sn MP vi nhiu tunll hon bng h (5. A ahoo. 10%). oev inl 20@y 4. TLT phn c phi hp8(5 - 10%). .F 0 00 i- y2 (5- 10%). 5. Tun hon bng h2ch t phi t toc 6. Bt thng rMVPo - 2%) trong hay gp l (1 igh y MVLTTp bt u t MV phi. y c th l mt Co kh khn cho phu thut t chng Fallot. II. Sinh l bnh A. Hp MP ngn cn dng mu ln MP v gy ra ting thi tm thu van MP. Tng gnh bung tim phi do hp MP, tuy nhin tn thng ny c dung np tt nh c l thng lin tht rng do mu s c "thot" sang i tun hon (do p lc tm thu bung tim phi cn bng vi p lc i tun hon). B. Lung thng qua l TLT s lin quan n mc hp MP v sc cn ca h mch i tun hon. Khi tc nghn ca ng ra tht phi tng ln (theo thi gian s pht trin ca c vng ph i tng) v sc cn ca h mch i tun hon gim (v d khi gng sc) dng shunt 510 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

III. Triu chng lm sng A. Bnh s: mc tm nhiu hay t thng ph thuc vo mc hp ng mch phi. Tm thng i km vi gim vn ng. Tm c c im l khng hng nh, tng ln khi gng sc hoc khi lnh. Cn tm kch pht km ngng th v ngt, c th dn n t vong, co git v li triu chng thn kinh, nhng thng hi phc. Du hiu ngi xm v du hiu ngn tay di trng cng thng gp trn lm sng. B. Khm lm sng ved ser mch 1. Ting thi tm thu tng mu (do hp re ng ts gh m.vn thy phi): cng t 3 n 5/6, thng nghe l ri co khoang lin sn II - IV st b Al hoxng c. C th . tri o. ev a nghe c ting clc tngnlo 0@MC, ting T2 mnh i mu y F 2 duy nht. Nu T2 tch8.i, 0loi tr chn on teo tt 00 ity2 2 van MP. i ht ctoc nghe c thi lin tc di khi o th P g ri xng ny(do cn ng ng mch), hoc vng p Co lng (do tun hon bng h ch - phi). 2. Tm nhiu da v nim mc; ngn tay di trng rt thng gp. 3. th khng tm: thi tm thu do TLT v hp phu, c th nghe c dc b tri xng c v bnh nhn khng tm (du hiu lm sng ca Fallot 4 khng tm ging vi TLT shunt nh). IV. Cc xt nghim chn on A. Xquang ngc 1. Bng tim bnh thng vi mm tim ln cao, cung gia tri lm, ph trng sng. 2. 20% quai MC bn phi kh qun. 511 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

B. in tm : ph i tht phi n thun, ph i 2 tht c th gp th khng tm.

ved ser re Hnh 31-1. Hnh phim Xquang tim phi thng. n ts gh m.v i C. Siu m Doppler tim ll r co . A ahoo. v 1. TLT rng, cao, thng l inloe quanh mng. phn @y 0 F 8. 02 2. MC gin rng c hnh tnh ci nga ln VLT. 00 i y2 2 t ot c 3. Hp MP: hphphu, ovan MP (phi o c ng P g i yr knh vngpphu, vng van v 2 nhnh MP). Siu m o DopplerC khng nh mc hp ng mch phi bng cch o chnh p qua phu v van MP (p lc MP thng bnh thng).

Hnh 31-2. Mt ct trc dc vi hnh nh thng lin tht cao (mi tn) v MC ci nga r. 512 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

4. Cn phi thm d trn siu m xem c hay khng cc tn thng sau: hp cc nhnh MP, thng lin tht nhiu l, thng lin nh, dng chy lin tc trong MP chng t cn ng ng mch hoc tun hon bng h ch phi. 5. Xc nh cc tn thng phi hp nh thng lin nh, thng lin tht phn c... D. Thng tim 1. Ch nh: Trc phu thut tt c bnh nhn t chng Fallot nn c thng tim xc nh s tc nghn ca ng ra tht phi, c hp MP on gn hay cc nhnh ca n hay khng, v loi tr cc bt thng v v tr xut pht v ng i bt thng (nu ved c) ca ng mch vnh. ser re ts 2. Cc thng s huyt ng: gh m.vn l ri o a. o bo ho xy c th lthyc dng shunt 2 . A ahoo. ev chiu qua l TLT viinlo 0@nhy xy tht phi bc y .F 2 v gim bo ho0xy y20 tri cng nh MC. 08 t tht 2 i t o oc b. p lc ththphi, ttht tri v MC bng nhau do P g i l thng r py lin tht rng. Co c. Hp ng mch phi thng mc va, vi p lc MP t mc thp n bnh thng. 3. Chp bung tim: a. Chp bung tht phi t th nghing phi 30o, quay ln u 25 v t th nghing tri 60o n 70o, chch u 250. T th nghing phi s thy ng ra tht phi v MP, t th nghing tri s thy l thng lin tht. Nu cha r, c th chp t th nghing tri nh 30o v chch u 25o, t th ny thy r MP v ch phn i. b. Chp bung tim tri (nghing phi v/hoc nghing tri 60-75o chch u 25o) nh gi chc nng tht tri v xc nh cc dng ca l TLT. 513 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

c. Chp MC t th nghing phi, nghing tri v chp MV chn lc l cn thit v t l bt thng ca n kh thng gp bnh nhn Fallot 4 (ch ng mch lin tht trc). d. Nu c nghi ng shunt t MC - MP cn chp MC xc nh cu trc ny (nh chp chn on cn ng ng mch). V. Tin trin t nhin A. Tm ngy cng tng vi cc hu qu: 1. a hng cu, nguy c gy TBMN, nht l nhng trng hp hng cu nh, s lng hng cu ln hn 7 triu/mm3. Tng hng cu lm thay i cc xt nghim v ng mu v gim tc mu lng.ed erv 2. Thng c ngn tay di trng. res hts .vn rig comn tnh. 3. Hn ch hot ng th lc do thiu xy m ll . Aa . vhu hoo ca shunt phi 4. Bnh nhn rt d b p xe no, y qu loe Fin020@ sang tri. . 08 y2 20 ocitmch phi. 5. Thay i tun hon mao t gh Pot rith pht c th c sau nhiu nm tin 6. Bnh c opy tim C trin (10 - 20 nm). 7. Bnh nhn rt d b lao phi do gim tun hon phi. B. Cn thiu xy: thng xut hin vo bui sng khi ng dy hoc sau gng sc: khc, cu gin, kch thch au, st... Cn thiu xy thng c lp vi mc tm v c th dn n t vong hoc b TBMN. Cn thiu xy thng bt u bng pha "cng" vi kch thch, khc, tm tng ln v nhp tim nhanh. Sau l pha c ch": da xm v nht, th nhanh v su do toan chuyn ho, nhp tim nhanh vi gim hoc mt ting thi do hp ng mch phi, gim trng lc c. Nu cn qua i, tr s ng v bnh tnh li.

514 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

VI. iu tr t chng Fallot A. iu tr d phng: pht hin v iu tr thiu mu thiu st tng i, phng thiu mu hng cu nh ca ph n mang thai. B. iu tr cn thiu xy 1. a tr ln vai hoc cho tr ngi u gi vo ngc. 2. Morphin sulfat 0,1 - 0,2 mg/kg tim di da hay tim bp c ch trung tm h hp, ct cn kh th nhanh, khng nn c gng tim tnh mch m nn s dng ng tim di da. 3. iu tr nhim toan bng natri bicarbonate 1 mEq/kg tnh mch, nhm lm gim kch thch trung tm h hp do toan chuyn ho. ved serc gim 4. Th xy cn hn ch v trong bnh l ny re ts dng mu ln phi ch khng phi dohthiuncung cp g m.v i ll r co xy t ngoi vo. . A ahoo. v 5. Nu khng p ng vi ccloe @y php trn, c th in phng 0 F dng Ketamin 1-3 mg/kg 2tim TM chm thng c 8. 02 y 00 icn i tun hon, an thn). kt qu (gy tng 2scc t t to gh Thuc co rimchPo nh Phenylephrine. (Neo py synephrine) 0,02 mg/, Propranolol: 0,01 - 0,25 mg/kg Co tim TM chm thng lm gim tn s tim v c th iu tr cn thiu xy. 6. Ung Propranolol 2-4mg/kg/ngy c th dng phng cn thiu xy v tr hon thi gian m sa cha ton b. Hot tnh c li ca Propranolol l lm n nh phn ng ca mch ngoi vi. C. Phng vim ni tm mc nhim khun: Nh trong cc bnh tim bm sinh c tm khc. D. iu tr ngoi khoa 1. Phu thut tm thi: c ch nh tng dng mu ln phi tr tm nng v khng kim sot c cn thiu xy nhng bnh nhn m phu thut sa ton b kh thc hin an ton v tr nh hay phu thut sa ton b gp kh khn v mt k thut. 515 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

a. Cu ni Blalock Taussig (ni gia ng mch di n v mt nhnh MP) c th thc hin tr nh. b. Cu ni Gore - Tex: ng Gore - Tex gia ng mch di n v mt nhnh MP. c. Phng php Waterston: ni gia MC ln v MP phi nhng phng php ny khng cn thng dng na do c nhiu bin chng. d. Phu thut Potts: ni gia MC xung v MP cng him khi c s dng. Tt c cc phu thut to cu ni ch phi u c m ngc theo ng bn, thi gian nm vin t 8 - 10 ngy; t l t vong rt thp, bin chng c th gp l trn kh, trn dch v dng chp mng phi; xon vn nhnh ca MP l bin chng lu di c th gp. ed erv sTLT bng re 2. Phu thut sa ton b: bao gm ng l ts vn gh bng vic ct ming v, m rng ng ra tht phi m. l ri o t chc c phn phu, thng v. Almt .c t hoo ming patch lm rng ng ra ca inloe phi. C th m rng tht @ya 0 F 0patch nu cn thit. Phu vng van MP bng 08. 2 2 ming 0 khity nhnh MP v h lu pha 2 thut c thc hin toci 2 t gh bt o xa tt, khngic P thng MV. r py Co thut c thc hin vi tun hon ngoi Phu c th v ng m dc gia xng c. Thi gian nm vin trung bnh t 12 - 15 ngy v t l t vong 1 - 5%. Bin chng c th gp l bloc nh tht cp III, l TLT tn lu, nht l cn hp ng mch phi. 3. Nong van MP: ch p dng trong trng hp hp van ng mch phi, c nguy c gy cn thiu xy nng. Ch ginh k thut ny cho nhng trng hp c chng ch nh phu thut. E. Ch nh iu tr 1. T chng Fallot thng thng (MP tt, MV bnh thng, 1 l TLT) c tm nhiu v hng cu hn 6 triu/mm3: phu thut sa ton b bt k tui no. 2. T chng Fallot thng thng (MP tt, MV bnh thng, 1 l TLT) vi cn thiu xy: phu thut tm 516 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

thi vi cu ni Blalock-Taussig hoc sa ton b ty theo kh nng ca tng bnh vin. 3. T chng Fallot thng thng: phu thut sa ton b c thc hin mt cch h thng khi tr c t 6 9 thng tui. 4. T chng Fallot c bit (hp nhnh MP, TLT nhiu l), bt thng MV v d tt khc): Nu trc 2 tui th c th lm phu thut tm thi (cu ni Blalock). Nu sau 2 tui th ty tng trng hp v kh nng ca bnh vin m quyt nh phng php iu tr thch hp cho tng ngi bnh. F. Sau khi phu thut 1. Nu kt qu phu thut tt thng a bnh nhn tr v cuc sng bnh thng. Khi c hn ch kh nng ed erv gng sc th khng nn luyn tp th thao.sC th c re ts h van ng mch phi do m rng hphungy tng g m.v l ri co gnh tm trng tht phi. Theo ldio.hng nm bng A . aho th thy s tin ev siu m tim v Holter in ltim y c n o hoc xut hin cc ri iphi0@ F trin ca hp ng mch 02 8. lon nhp: ngoi 200 city2 hoc nhp nhanh tht... tm thu Thng xut ight Poto ri lon nhp nhng trng hin cc r hp cn hp MP. py Co 2. Trong mt s trng hp, nht l nhng trng hp MP m qu rng, suy tht phi do tng gnh tm trng nhiu v trong vi trng hp do h van ng mch phi nhiu. 3. Cc bc s tim mch s ngy cng gp nhiu cc bnh nhn b Fallot 4 m, nhng vn cn tn ti hp MP, cn l TLT, hoc h MP nng gy gin bung tht phi, ri lon chc nng tht phi v h van ba l (c nng hay thc th). Thng tim c th c ch nh nu cc bt thng cn nng n c ch nh m li. Ri lon nhp tht cng nh hng nhiu n tin lng xa do cng c th c ch nh thm d in sinh l cc bnh nhn Fallot 4 m sa cha ton b. 517 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

Ti liu tham kho


1. Connelly MS, Webb GD, Somerville J, et at. Canadian Consensus Conference on Adult Congenital Heart Disease 1996. Can J Cardiol 1998;14:395-452. 2. Cullen S, Celermajer DS, Franklin RCG, et at. Prognostic significance of ventricular arrhythmia after repair of tetralogy of Fallot: a 12-year prospective study. J Am Coll Cardiol 1994;23: 1151-1155. 3. Harrison DA, Harris L, Siu SC, et at. Sustained ventricular tachycardia in adult patients late after repair of tetralogy of Fallot. J Am Coll Cardiol 1997;30:1368-1373. 4. Murphy JG, Gersh BJ, Mair DD, et at. Long-term outcome in patients undergoing surgical repair of tetralogy of Fallot. N Engl J Med 1993;329:593-599. 5. Nollert G, Fischlein T, Bouterwek 5, et at. Long-term survival in patients with repair of tetralogy of Fallot: 36-year follow-up of 490 survivors of the first year after surgical repair. J Am Coll Cardiol ved 1997;30:1374-1383. ser re 6. Yemets IM, Williams WG, Webb GD, et at. Pulmonary valve ts n ghAnnvThorac Surg replacement late after repair of tetralogy of Fallot. m. i ll r co 1997;64:526-530. . A ahoo. oev y 7. Neches WH, Park S, Ettedgni JA. Tetralogy of Fallot and Tetralogy @ inl Garson A, Bricker JT, Fisher of Fallot with pulmonary atresia.FIn:020 . 08and 2 DJ, Neish SR, eds. The science ity practice of pediatric cardiology, 0 2 c 2nd ed. Baltimore: Wmiams otoWilkins, 1998:1383-1411. ht P & rig 8. Perloff JK. Survival patterns without cardiac surgery or py o interventional Ccatheterization: a narrowing base. In: Perloff JK, Child JS, eds. Congenital heart disease in adults, 2nd ed. Philadelphia: WB Saunders, 1998:15-53. 9. Redington A, Shore D, Oldershaw P. In: Tetralogy of Fallot. Redingion A, Shore D, Oldershaw P, eds. Congenital heart disease in adults: a practical guide. London: Mm Saunders, 1994:57-67. 10. Snider AR, Serwer GA, Ritter SB. Defects in cardiac septation. In: Snider AR, Serwer GA, Ritter SB, eds. Echocardiography in pediatric heart disease, 2nd ed. St. Louis: Mosby, 1997:235-246. 11. Moore JD, Moodie DS. Tetralogy of Fallot. In: Marso SP, Griffin BP, Topol EJ, eds. Manual of Cardiovascular Medicine. Philadelphia: Lippincott-Raven, 2000.

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Hp eo ng mch ch

L bnh tim bm sinh (TBS) cng thng gp, chim khong 8% cc bnh TBS. Cn pht hin sm tr s sinh hay tr nh v l bnh nguy him c th dn n t vong. Chn on lm sng thng da vo du hiu khng c hay yu ca mch bn so vi mch cnh tay, ting thi tm thu thng kh in hnh. Hp eo MC rt hay i km vi cc bnh TBS phc tp khc m c bit hay gp trong hi chng Turner (20%), hi chng Noonan. Cc bin chng mun ca bnh c th gp l phnh mch ti ch hp, tch thnh ng mch ch ln, gin phnh v ev cc vd mch mu no, tng huyt p ng mch. Tng huyt ep c th sr re cn tn ti ngay c sau khi phu thut sa chaghts .b c bit ton vn i ll r com cc bnh nhn can thip mun. . A ahoo. oev I. Gii phu bnh inl 20@y F 8. 0 00 ity eo A. i a s cc trng hp hp 2 MC nm ngay trc 2 oc t ng mch ngha l gn st vi v tr xut pht cahng ot P g ri py ch bt uCca MC xung. Thng gp c s ph i, o co tht thnh sau ca MC gy hp lng mch MC v tr ny. Cng c th gp s thiu sn ca eo MC vi cc mc khc nhau. Bnh c th t ngt hoc t t dn n suy tim huyt tr nh. ng mch di n tri thng xut pht ngay gn ch hp ca eo MC. Trong mt s him cc trng hp, v tr hp nm MC ngc hay MC bng. B. Tun hon bng h thng gp bnh nhn ln tui. in hnh nht l xut pht t ng mch di n, ng mch v trong, gian sn, ng mch gip trng xung, ng mch ch xung sau ch hp eo ng mch ch. C. Cc tn thng phi hp: a s l cc bt thng ca bung tim tri; van MC c 2 l van chim khong 519 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

50% cc trng hp, hp di van MC, bt thng hnh dng van 2 l (hi chng Shone), TLT, ng nh tht chung, tm tht duy nht, bt thng ch xut pht ca ng mch di n phi. II. Sinh l bnh Hp eo MC dn n tng huyt p vi s chnh lch huyt p tm thu tay v chn. Tng hu gnh do dn n ph i tht tri v cui cng dn n gin bung tim tri v suy tim tri dn n suy tim ton b vi tng p MP. Hp eo MC mn tnh s dn n hin tng pht trin tun hon bng h t MC ln sang MC xung. III. Triu chng lm sng A. Du hiu c nng: Hp eo ng mch ch pht hin ved ser p, au c ngi ln thng bi du hiu tng s re huyt t n ghccvbnh nhn u hay l du hiu au cch hi. i ri m. vi o l tr tui hay phi nhp vin v cc v. Alsuyotim huyt. t ho .c loe ya B. Triu chng thc th . Fin020@ 08 2 1. Mch chi trn ny 0 ocity hn nhiu so vi mch chi 2 mnh t gh P t di. Nhngritrng ohp hp nng c th khng thy y p mch bn. Tuy nhin mt s trng hp m ng Co mch di n tri xut pht t ngay ch hp ca eo MC th mch quay tri cng khng c hoc yu nh ng mch bn. Cn trng hp ng mch di n phi qut ngc thc qun, mch cnh tay phi cng nh v M cnh phi p rt mnh. 2. Huyt p chi trn thng tng t l thun vi mc hp eo MC. Cn phi o huyt p tay bn phi, thng thch ng tt khi huyt p tm thu cha vt qu 150mmHg. 3. Ting thi tm thu thng nghe thy vng di n bn tri, c th lan ra lng v tr cnh ct sng. Ngoi ra c th nghe thy cc ting thi lin tc do tun hon bng h gy ra. Trong cc trng hp phi 520 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

hp vi van ng mch ch c hai l van chng ta c th nghe thy ting thi tm trng, thi tm thu do h, hp van MC gy nn. IV. Cc xt nghim chn on A. in tm : Thng c du hiu tng gnh tht tri. Nu c du hiu tng gnh tht phi nhng bnh nhn hn 2 tui th cn tm cc tn thng phi hp. B. Xquang ngc: C th bnh thng hay bin i nh vi cung di tri gin. Kinh in c th thy du hiu 3 cung ng mch ch, quan st thy t th thng mt. Sau vi tui c th thy cc du hiu c hiu hn nh: du n xng sn, ch s tim ngc tng r rt. ved ser re ts gh m.vn i ll r co . A ahoo. oev inl 20@y F 8. 0 00 ity2 2 t oc gh Pot ri py Co Hnh 32-1. Du n sn trn phim tim phi thng. C. Nghim php gng sc: C th thy du hiu tng huyt p tm thu cc bnh nhn hp eo MC. D. Siu m Doppler tim: L xt nghim quyt nh chn on tr nh, tuy nhin c th gp kh khn cc bnh nhn ln tui. 1. Siu m TM xc nh dy ca cc vch tim, sc co bp ca tm tht tri. 2. Siu m Doppler mu v siu m 2D cho php xc nh v tr v hnh thi ca ch hp eo MC, c bit 521 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

l tr nh. Siu m Doppler khng nh chn on v o mc chnh p qua eo MC. 3. Siu m cn gip loi tr hay pht hin ra cc tn thng phi hp. c bit cn pht hin mt s bt thng nh van ng mch ch c hai l van, hp van hai l, tc nghn ng ra tht tri v thng lin tht phi hp. 4. Cn ch quan st trn siu m pht hin cc tn thng ca ng mch ch bng, cung ng mch ch v cc mch mu vng u v c. Siu m cng c th pht hin s tn ti ca ng ng mch cng nh cc tun hon bng h nu c. E. CT Scanner xon c, 3 chiu v cng hng t ed trng ht nhn (MRI) l nhng thm d ertrv se hu ch sr cho vic xc nh hnh thi ca ch hp eo tMC, cc tn gh m.vn ri o thng phi hp, dng hp eo MCllvi.ccc nhnh ca . A ahootun hon bng ng mch di n, c hay khng c oev inl 20@y cn c th quan st h. Vi cc th h my mi F 0 ta 8. chng 2 00cng hng t, y l cc hnh hnh nh quay phim trn ocity 2 t t nh rt hu ch cho vico chn on v ra phng php igh P yr p iu tr. Co

Hnh 32-2. Hp eo MC trn phim MRI v chp mch. F. Thng tim v cc bc tin hnh thng tim 1. Thng tim v chp bung tim c ch nh khi: 522 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

a. Nghi ng c tn thng phi hp. b. Cc thm d khng chy mu cha xc nh r rng hoc khng thng nht v kt qu. c. Xc nh mc tun hon bng h chun b phu thut. d. Can thip bng bng v Stent qua da. 2. K thut thng tim a. Thng tim phi nu c tn thng phi hp ti tim. b. Thng tim tri qua ng ng mch i c th gp kh khn khi qua ch hp eo nhng vi dy dn mm thng vn c th thc hin c i a s cc trng hp. Cn o chnh p qua eo ved MC v chp MC. ser re c. Nu khng th qua ch hp cahts .vn g eo MC theo ri m ng ng mch i th .cllth .co A hoo thng tim theo ev ng ng mch cnh otay ya chp ch hp eo inl 20@ .F 0 MC v tun hon8bng h. 00 ity2 2 oc d. bo ho txyotv cung lng tim cn c o P gh thut. trc khiri py phu Co 3. Cc thng s huyt ng: a. Hp eo MC c chn on khi c chnh p ln hn hay bng 10mmHg gia MC ln v MC xung. b. Chnh p qua eo MC khng phi lun lun c mi tng quan trc tip vi mc hp eo MC, do c rt nhiu tun hon bng h pht trin lm thay i thng s ny. 4. Chp ng mch: a. ng thng ''ui ln'' c a n gn st ch hp (pha trn). Chp t th nghing phi v nghing tri. b. Tun hon bng h cng hay thy c cc t th ny. 523 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

c. Cc phim chp bung tim c th thc hin nu nghi ng c bt thng bm sinh khc phi hp. V. Tin trin t nhin A. Suy tht tri c bit nhng trng hp hp nhiu c th dn n din bin lm sng nng n ngay nhng tun u tin ca tr (sau khi ng ng mch ng). Trn lm sng thy du hiu suy tim tri vi ting nga phi tri, ran phi; T, Xquang v siu m tim khng nh du hiu qu ti bung tim tri. Din bin lm sng tip theo thng rt nng n vi t l t vong cao. Vic iu tr tch cc suy tim c th gip tr thot khi suy tim cp nhng thng li hu qu trn tht tri v tng huyt p ng mch (cnh tay) nng n. i vi cc trng hp ved nhiu tui hn, suy tim tri thng din bin thm lng ser vi kh nng thch ng tt, do vic b tste chn on sr gh khivn c tht i c th gp v bnh nhn thng nhplvin om. l r c . A ahoo. tri gin nhiu. oev inl 20@y F B. Tng huyt p ng mch: Thng xut hin sau 15 8. 0 00 ity2 p tm thu vn di 2 ngy tui. Thng thngc huyt t oto gh Pp tm thu t 150 n 200mmHg 150mmHg. Nuri y huyt th s c dy ptht tri nhiu trn T, Xquang v siu Co m tim. Nu huyt p tm thu trn 200mmHg, c th thy du hiu m mt. Khi t tui 15 tr ln, tng huyt p ng mch thng s tr nn c nh, khng gim xung c sau khi iu tr nguyn nhn. C. Bin chng khc c th gp l Osler. Phnh ng mch ch ch xut hin sau mt thi gian di tin trin bnh. VI. iu tr A. iu tr ni khoa l iu tr triu chng nhm bo tn bnh nhn chun b can thip. iu tr suy tim tri l vn quan trng nht. i vi tr s sinh, Prostaglandine E1 gip m ng ng mch s ci thin nhanh chng triu chng lm sng. Thuc li tiu, Digoxin v thng kh nhn to l cc bin php phi hp 524 Copyright 2008. Finloev. All rights reserved Potocity2020@yahoo.com.vn

B. Ch nh phu thut: trong cc trng hp: 1. Tr s sinh m iu tr ni khoa t kt qu. 2. Tr nh nhi v tr nh: c du hiu suy tim tri trn lm sng v cn lm sng. 3. Tr c huyt p ng mch tm thu ln hn 150mmHg. 4. i vi cc trng hp hp eo MC khc th phu e thut mt cch h thng khi tr t 6 n 9 thngdtui. erv res in khi s n 5. Vi ngi ln th ch nh can thiphtkinh .v rig c30mmHg. Tuy chnh p qua eo MC ln hn 20 ln. om l o v A h nhin cn phi hp vi cc du. hiu okhc nh suy tim loe @ya xung huyt, ph i tht. tri, 20 huyt p kh khng Fin tng 08 ty20 0 ch... 2 toci ht Peo ng mch ch sau khi can 6. Trng hp rig hp o ti opy thip thCc nhiu trung tm ch nh nong bng bng qua da c hay khng km vic t gi (Stent). Cc nghin cu ngn hn ch ra kt qu kh tt, t bin chng, tuy nhin vn cn phi c cc nghin cu lu di hn khng nh vn ny. C. Theo di Tt c cc bnh nhn hp eo MC cn c theo di lu di. Theo di bng lm sng (tnh trng suy tim tri, tng huyt p, mch bn) v cn lm sng (S, T) mi nm mt ln. Ti liu tham kho
1. Breelver SJD. Coarctation of the aorta. In: Redingion A, Shore D, Oldershaw P, eds. Congenital heart disease in adults: a practical guide. London: WB Saunders, 1994:119-125.

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2. 3. 4. 5. 6. 7. 8.

9.

Connelly MS, Webb GD, Sommerville J, et al. Canadian Consensus Conference on Adult Congenital Heart Disease 1996. Can J Cardiol 1998;14:395-452. Ebeid MR, Prieto LR, Latson LA. Use of balloon expandable stents for coarctation of the aorta: initial results and intermediate-term follow-up. J Am Coll Cardiol 1997; 80:1847-1852. Kaplan S. Natural history and postoperative history across age groups. Cardiol Clin 1993;11:543-556. Mathew P, Moodie D, Blechman C, Gill CC. Long-term follow-up of aortic coarctation in infants, children and adults. Cardiol Young 1993;3:20-26. Mendelsoha AM. Balloon angioplasty for native coarctation of the aorta. J Intervent Cardiol 1995;8:487-508. Moore JD, Moodie DS. Coarctation of the aorta. In: Marso SP, Griffin BP, Topol EJ, eds. Manual of Cardiovascular Medicine. Philadelphia: LippincottRaven, 2000. Morriss MJH, McNamara DG. Coarctation of the aorta and interrupted aortic arch. In: Carson A, Bricker JT, Fisher DJ, Neish ved ser SR, eds. The science and practice ofpediatric cardiology, 2nd ed. re Baltimore: Williams & Wilkins, 1998:1317-1346. hts .vn g m Ovaett C, Benson LN, Nykanen, Freedomri RM. Transcatheter ll co . A ahoo. treatment of coarctation of the aorta: voverview. Pediatr Cardiol oe 1998;19:27-44. inl 0@y

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