DEMA-CVN.

COM
GI I THI U

CC TI BO CO T I H I NGH TIM M CH MI N TRUNG- TY NGUYN M R NG L N TH VI T I BUN MA THU T THNG 8 N M 2011

NHN M T TR NG H P GHP TIM TRN NG I THNH CNG T I B NH VI N TRUNG NG HU

A. M
 

Barnard v CS thnh cng ca ghp tim ng i u tin, 1967 Chu n ho tiu chu n ng i nh n tim 1970 + K thu t sinh thi t c tim 1973 + cyclosporine A 1980 thc y pht tri n ghp tim Vi t nam: Qu c h i ban hnh lu t v ch n on ch t no (theo i u 27 c a lu t s 75/2006/QH11) v B Y T ban hnh quy nh "Tiu chu n lm sng, c n lm sng v cc tr ng h p khng p d ng tiu chu n lm sng xc nh ch t no" . Ngy 25/12/2008 B nh vi n trnh H i ng T v n xt ch n nhi m v KH&CN ti Nghin c u tri n khai ghp tim trn ng i l y t ng i cho ch t no. Thng 1/2010 B nh vi n tham gia v c tuy n ch n ph i h p th c hi n ti c p nh n c do H c vi n Qun Y 103 lm ch nhi m ti . Thng 6/2010, B Y t thnh l p H i ng th m nh v ngy 20/7/2010 B Y t ra Quy t nh cng nh n BVTW Hu c tiu chu n ti n hnh ghp tim t ng i cho ch t no 17/6/2010 H c vi n Qun Y 103 v i s tr gip Trung tm Tim m ch Cheng Hsin- i loan th c hi n ca ghp tim trn ng i.(TAIPEI, Taiwan A medical team from Taipei's Cheng Hsin General Hospital was part of the team that performed
the first successful heart transplant in Vietnam last month. The 9 member Taiwanese medical team, which included an anaesthetist and a cardiovascular surgeon, was led by Dr. Wei Jeng, director of Cheng Hsin's Heart Centre, according to a press release issued Tuesday by the hospital).

Ngy 1/3/2011 B nh vi n Trung ghp tim trn ng i

ng Hu

c l p th c hi n thnh cng tr

ng h p

B.TNH HNH GHP TIM TRN TH GI I

NUMBER OF HEART TRANSPLANTS REPORTED BY YEAR
4500 4000

Number of Transplants

3500 3000 2500 2000 1500 1000 500 0

Other Europe North America

ISHLT

2010

J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

NOTE: This figure includes only the heart transplants that are reported to the ISHLT Transplant Registry. As such, the presented data may not mirror the changes in the number of heart transplants performed worldwide

GHP TIM

CHU (1998-2002)
      

? nature and mix of CCF population ie IDC>> IHD low HTx numbers variable servicing rates cultural and religious issues other options for CCF population Australia 350 HTx in 5 yrs.

C. CC PH NG PHP NGO I KHOA I U TR SUY TIM



Ph u thu t quy c - Ti t i mu c tim: b t c u m ch vnh, ti t o m ch b ng laser - S a van v thay van tim - T o hnh c tim Cc ph ng ti n d ng c h tr tu n hon - Bng i xung MC, Implantable Counterpulsation Pump (ICP) - ECMO - D ng c h tr tm th t: heartmate, heartware, ventrassist Ghp tim v Tim nhn t o

C U N I VNH

Laser Revascularization(TMR)

T O HNH VAN V THAY VAN

TI C U TRC TM TH T(D OR)

N p vt c tim Myocor, Maple Grove, MN

BATISTA OPERATION

ACORN ACORN CARDIOVASCULAR

T O HNH C

TIM

BNG (IABP)

I XUNG

MC

C-Pulse Implantable Counterpulsation Pump (ICP)

VPA ECMO

Peripheral Cannulation for CPS

Heartware

THORATEC HEARTMATE LVAD

Ventrassist

Heartmate II

TIM NHN T O SYNCARDIA TAH-T

GHP TIM

D. GHP TIM T I BVTW HU

I.TIU CHU N C A NG
1. B nh tim giai o n cu i

I NH N TIM

(S tiu th oxy t i aMVO2<10cc/kg/phut, Khng p ng i u tr n i khoaFE<20%,S l n n m vi n do suy tim m t b)

2.Th tr ng, sinh l cn ch p nh n c 3.Khng c r i lo n ch c n ng th n v gan 4.Khng c nhi m trng c p tnh 5.Khng c nhi m trng ph i ti pht 6.Tm l n nh 7.Khng nghi n r u, thu c l hay l m d ng thu c

1.2 Ch

nh ghp tim

-B nh c tim thi u mu v b nh c tim dn n v c n chi m a s (90%) -B nh tim b m sinh chi m t l th p (< 2%) -Cc nguyn nhn khc hi m h n nh :B nh c ngu n g c t b nh van tim,Vim c tim virus,Nhi m c c tim do ha tr li u tu i trong gi i h n ghp tim < 55 tu i, ngy ny l < 65 tu i,

1.2 Ch ng ch

nh ghp tim

a.Ch ng ch nh c lin quan do i u tr thu c c ch mi n d ch -Nhi m trng ang ti n tri n ch a c ki m sot c ng l 1 ch ng ch nh t m th i v c nguy c nhi m trng c h i n ng n khi i u tr c ch mi n d ch -B nh ung th km theo - i tho ng bi n ch ng ph c t p v khng th ki m sot c -B nh l ng m ch ngo i vi n ng (c nguy c n ng khi i u tr cyclosporine)

1.2 Ch ng ch

nh ghp tim

b.Ch ng ch nh do b i c nh tm l v x h i -Cc b nh nhn nghi n r u m n, nghi n thu c phi n ph i c cai nghi n m t cch hon ton tr c -Khng c kh n ng ti p thu li u trnh i u tr c ch mi n d ch v cc i u ki n s ng t ng i c.T ng p ng m ch ph i l m t ch ng ch nh c hi u c a ghp tim -S c c n m ch mu ph i t ng cao s l nguy c lm r i lo n c p tnh ch c n ng tm th t ph i c a m nh tim ghp. -S c c n m ch mu ph i > 4 n v wood th c n nh gi cc test h i ph c t ng p ph i v i NO ho c v i Dobutamine, n u s c c n RVP h xu ng < 4 n v wood th c th ti n hnh ghp tim. V trong tr ng h p ny th ng ch n m nh ghp c a ng i cho c cn n ng > cn n ng c a ng i nhn.

1.3 K t qu
Tu i gi i cn n ng

i u tr cho 15 BN ch ghp tim

Tu i trung bnh (n m) 36,7 35,8 36,3 Cn n ng trung bnh (Kg) 49,2 47,2 48,5

Nam (60%) N (40%) Chung

Phn b theo ch n on
Ch n on B nh c tim gin B nh tim b m sinh B nh van tim S b nh nhn 13 01 01 T l (%) 86,87 06,67 06,67

Phn b nhm mu ABO

Nhm mu A B O AB S b nh nhn 05 03 04 03 T l (%) 33,33 20,00 26,67 20,00

M c
Phn

suy tim theo NYHA:

suy tim NYHA NYHA I NYHA II NYHA III NYHA IV S b nh nhn 00 03 08 04 T l (%) 00,00 20,00 53,33 26,67

Phn su t t ng mu th t tri trn siu m tim:

SD Phn su t t ng mu (%) Nam N Chung 26,00 29,50 27,40
c nam v n

13,50 11,02 12,49

u th p < 30%

Nh n xt: phn su t t ng mu trung bnh

Phn

tnh tr ng c p c u cc b nh nhn ch ghp tim

S b nh nhn 05 03 07 T l (%) 33,33 20,00 46,67

Tnh tr ng c p c u N mc pc u N m vi n n i tr Theo di ngo i tr

K t qu
Ph N i khoa

i u tr b nh nhn suy tim ch ghp tim

ng php i u tr S b nh nhn 12 02 01 T l (%) 80,00 13,33 06,67

N i khoa + my t o nh p N i khoa + Ngo i khoa

K t qu
K t qu H i ph c

i u tr b nh nhn ch ghp tim

i u tr S b nh nhn 01 03 05 05 T l (%) 06,67 20,00 33,33 33,33

C p ng, c m ch ng Khng p ng, n ng ln T vong

II.TIU CHU N NG

I CHO TIM CH T NO

1.Ch t no c kh ng nh 2.Tu i < 55 (tr tr ng h p c bi t) 3.Khng c b nh tim t tr c 4.Khng c cc y u t nguy c m c b nh 5.Khng c b nh nhi m trng c p 6.Khng c b nh l c tnh h th ng 7.Khng c ch n th ng tim 8. i n tm bnh th ng 9.HIV v huy t thanh vim gan (-)

ng m ch vnh

Quy nh "Tiu chu n lm sng, c n lm sng v cc tr ng h p khng p d ng tiu chu n lm sng xc nh ch t no" (Ban hnh km theo quy t nh s 32/2007/Q -BYT ngy 15 thng 8 n m 2007 c a B tr ng B Y t ) c qui nh t i i u 28, 29 trang 24, 25 c a lu t v Qui nh c aB Yt .

Ti n trnh ch n on ch t no
 

nh gi cc tiu chu n LS v CLS 6h/m t l n Th c hi n t nh t 3 l n (ko di t nh t 12gi )

Tiu chu n vng GCS < 12 GCS = 3 T VONG

tiu chu n LS ch t no

0h

6h

12h

CH N ON CH T NO H I S C CH T NO

2.1 K T QU
c i m MSD Tu i

I U TR 15 BN CH T NO
Gi i tnh 12 /3 Cn n ng 53,076,47 Nhm mu O 40% A 27% B 20% AB 13% Ch n on CTSN93%

31,81,15

Ch n on ch t no theo tiu chu n B Y t

L n1 Tiu chu n LS v CLS Hn m su ( i m Glasgow) ng t >4mm ng t m t p/x AS M t p/x gic m c M t p/x m t bp b M t p/x kch thch PQ Nghi m php ng ng th (+) Siu m Doppler xuyn s m t dng tm tr i n no ng i n ng 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% L n2 L n3

K t qu h i s c tu n hon:
Gi tr chu n Thng s huy t Huy t p M trung bnh p l c TM trung tm p l c M ph i (SA tim) Ch c n ng th t tri Nh p xoang L ul ng n c ti u Hemoglobin ng 60-80 mmHg 5-12 cmH20 < 40 mmHg T t 60-100 l n/pht 1-2ml/kg/h 7-9 g/dl 658 4-10 253 FE> 60% 70-106 1-2ml/kg/h 102,3 G tr b nh nhn

K t qu h i s c h h p:
Gi tr chu n Thng s h h p pH PaCO2 (mmHg) PEEP (cmH20) VT (ml/kg) FiO2 7,38-7,42 35-40 <7 6-8 40% 7,31-7,46 30-42 0 6-8 40-50% Gi tr b nh nhn

K t qu

i u tr r i lo n ng mu:
Ch s BT K t qu 60-402 BT BT 9612 2,30,9 388

Tn xt nghi m Ti u c u t p trung Co c c mu sau 4h T Prothrombin Fibrinogen aPTT 150-400 (x109 /L) BT BT 70-140% 2-4 g/L Ch ng 32-42 giy

K t qu b o t n ch c n ng tim b nh nhn h i s c ch t no
Ch s bnh (%) Thng s siu m tim FS (D%)- % co c th t tri EF- t ng mu th t tri % 31.9 5.8 59.6 8.3 30,5 4,6 57,8 6,8 K t qu (%)

K t qu th i gian ko di h i s c ch t no
Th i gian (m c cng) 12- 24 gi 24- 36gi 36-48gi 48-60gi 60-72gi thnh S ca (t l ) 01 03 02 05 04

l y t ng
Ghi ch Ng Ng i nh xin v i nh xin v Ng ng tim Ng ng tim Ng ng tim

2.2 CC THNG S

NG

I CH T NO

C TUY N CH N

- Bn nam 29 tu i, Ch t no / xu t huy t ngoi mng c ng l ng l n / CTSN do TNGT - PT l y mu t gi th 17 , sau PT 05 ngy th r i vo tnh tr ng ch t no - Th i gian i u tr cho n khi c kh ng nh ch n on ch t no 09 ngy - Th i gian t khi c kh ng nh ch t no (l n 3) n khi PT l y t ng hi n 12 gi - T ng th i gian h i s c: 10 ngy; Th i gian h i s c sau khi c ch n on ch t no 38h - LS khi ti n hnh PT l y t ng: huy t ng 50/30 70/45, Adrenaline 0,2mcg/kg/pht Tiu chu n LS v CLS Hn m su ( i m Glasgow) ng t >4mm ng t m t p/x AS M t p/x gic m c M t p/x m t bp b M t p/x kch thch PQ Nghi m php ng ng th (+) Siu m Doppler xuyn s i n no L n1 3 >4 +
M t dng tm tr ng

L n2 3 >4 +
M t dng tm tr ng

L n3 3 >4 +
M t dng tm tr ng

ng i n

ng i n

ng i n

NGHI M PHP NG NG TH PCO2/ Kh mu M (Nghi m php ng ng th ) L n1 L n2 L n3

Tr

c nghi m php (mmHg)

33-37 50-55 >12

35-38 50-70 >10

35-40 50-70 >15

Sau nghi m php (mmHg) thay i pCO2(mmHg)

I N NO

DOPPLER XUYN S M T LIN T C SNG M CH MU NO

III. H TH NG T CH C GHP TIM T I B NH VI N TRUNG NG HU

Thng tin ng i cho Thng tin ch p nh n t ng Ch tich h i ng ng ghp tim Thng tin ng i nh n

-T ch n on -T HS ch t no -Kp l y tim

07 t chuyn mn thu c H i

- T chu n b bn - T GMHS - Kp ghp tim

PT l y tim (phng m t ng 5, ODA)

Cc kp h tr (HH c, Mi n d ch, Ho sinh, Vi sinh) TRI N KHAI PT GHP TIM

PT ghp tim (phng m t ng 5, TTTM)

i u tr v qu n l sau ghp tim

IV. CC CH TIU TUY N CH N NG I NH N V NG I CHO TIM

1. Ph n hnh chnh
STT Cc ch s Ng i nh n Ng i cho

1 2 3 4 5 6 7

H v tn Tu i Gi i Ngh nghi p a ch i n tho i Ch n on

Tr n M u . 27 tu i Nam nh, m t s c Hu # B nh c tim gin NYHA.IV

Nam 29 Nam # # # Ch t no / ch n th ng s no

2. T ng qut
8 9 10 11 Chi u cao Cn n ng Di n tch c th ASA 167 cm 58 BMI=20,79 IV 1m65 70 kg BMI=21,03 V

3. Tim m ch
12 13 14 NYHA Huy t p ng m ch III-IV 100/60mmHg Khng II 110/55 Khng

Ti n s ph u thu t tim

i n tim (ngy6/2/2011)
15 16 17 Nh p tim T ns R i lo n nh p Nh p xoang, bloc cnh tri khng hon ton 90 Nh p xoang 60 l n / pht

Siu m tim (ngy01/03/2011)

18 19 20 21 22 23 24 Vch lin th t Thnh sau th t tri K th t tri cu i tm tr K th t tri cu i tm thu Phn su t t ng mu th t tri p l c ph i tm thu Cc van tim ng gi m Gi m ng ng Co bp t t Bnh th 48 mm 31 mm 62% 30 mmHg im<1/4 ng

Dn l n 82mm 75mm 17% PAPS=50mmHg IM=3,5/4; IT=2/4

Thng tim v k t qu cc nghi m php g ng s c (ngy31/05/2010)

25 26 27 28 29 30 31 32 33 34 Nh ph i Th t ph i p l c ng m ch ph i S c c n m ch mu ph i p l c ng m ch ch a:10, v:6, m:5 SP:69,EDP:33,BDP:69 SP:71, DP:34, MP:46 3 n v wood # # # # # # # # # #

SP:109, DP:69, MP:82 0,9 lit/phuts/m2 1,53 lt/pht MVO2 max = 8ml/kg Nh y c m + #

Ch s tim L ul ng tim

Tiu th oxy g ng s c Test dobutamine, prostine Ch p ng m ch vnh

Doppler
35 36 37 38 39 40 41 Cc thn trn Cc MC ng m ch ch b ng ng m ch th n i ng m ch cc chi d Nhm mu Ti n s truy n mu Nhm HLA

ng m ch (ngy8/9/2010)
Khng b t th Khng b t th Bnh th Bnh th ng ng ng ng

4. Mi n d ch v huy t thanh h c
Nhm mu O; Rh+ Khng
HLA A: A* A*11 HLA-B: B* B*13 HLA-DR: DRB1*15, DRB5*, DRB3* HLA-A: A* A*11 HLA-B: B* B*40 HLA-DR: DRB1*12, DRB1*12 DRB3* DRB3*

DRB1*03

42 43

Ph n ng

cho

m tnh m tnh

Khng th khng HLA

5. Bilan virus, vi khu n, k sinh trng

44 45 46 47 48 49 50 51 52 53 54 HBsAg Anticorps anti-HBs Anticorps anti-HBc HBeAg HCV Anti-HCV HCV-DNA EBV IgG, IgM HIV 1-2 HTLV 1-2 HIV Ag P.24 m tnh m tnh m tnh 0,42 d m tnh m tnh m tnh IgG d ng tnh 12,3 EBV-IgM m tnh 7,2 m tnh m tnh m tnh HIVCOM 0,401 m tnh ng tnh m tnh 0,227 m tnh 0,415 m tnh 72,25 d ng tnh IgM m tnh

55 56 59 61

CMV Toxoplasmosis Candida Giang mai, VDRL, RPR Rubella

IgG d ng tnh > 250,0 CMV IgM m tnh 0,46 Toxo IgM m tnh 0,34 Toxo IgG m tnh 0.8 m tnh RPR m tnh TPHA m tnh IgM m tnh 0.00 IgG m tnh 1.6 PCR m tnh

CMV IgM 0,181 m tnh

63

Tim ch ng lao

6. Cc c quan khc bnh th 7. Bilan sinh h c chu n

84 85 86 87 Cng th c mu Ch c n ng ng mu T c l ng mu, CRP i n gi i Hc4.5, Bc7.0, Tc246 Hct38%, Hb12,5 T Prothrombin =100% Bnh th Na 139 Kali 3,4 Ca 2,4 4,0 HBA1C 6,1 5,6 Bnh th Bnh th 111 Bnh th ng ng ng ng

ng
Hc3.9, Bc9,0, Tc:154,Hb:11,2 Tp:88% Na 124,6 K: 4,40 Ca: 1,09 7 7,2 93

88 89 90 91 92 93 94

ng mu Dung n p glucose Ur mu Creatinine mu BUN ur huy t thanh Creatinine ni u Bilan lipid

95 96 97 98 99 100 101

Men tim Men gan Bilirubin Protid mu i n di protein -Feto protein PSA Pro-BNP

Troponin bnh th SGOT=31 SGPT=34 Ton ph n: 13,0 tt: 2,4, gt: 10,6 75 A/G=1,5 m tnh O,274 bnh th 852,8 t ng cao c ti u Bnh th ng ng

ng

CKMB 33,99 Troponine0,019

Bnh th

ng

102

Thng s n

V. QUY TRNH PH U THU T GHP TIM

5.1 CHU N B NG


I NH N TR

CM

GHP TIM

14h 01/03/2011 t i b nh phng ch ghp tim:

Th m khm h s v bilan tr c ghp tim Ki m tra th t c hnh chnh v n b n php lu t Chu n b h s v cc xt nghi m c n lm trong ghp Gi i thch cho gia nh bn v cu c ph u thu t, gi y cam oan Cc kp khm xt tr c m , cc ch s sinh h c v i chi u cc ch tiu tuy n ch n (B ng k t qu )

 

14h30 Bilan mu chu n (xem b ng k t qu ): 15h00 Bilan truy n mu chu n: chuyn khoa t ng h p mi n d ch

1500 h ng c u ng nhm c CMV(-), l c b ch c u 1500 ml huy t t ng t i ng l nh 03 n v ti u c u kh i ng nhm 06 n v t a l nh ng nhm Ch ph m ng mu PPSB 10 l Cell - Saver

5.1 CHU N B NG
 

I NH N TR

CM

GHP TIM

18h30 01/03/2011 chuy n b nh nhn vo phng m : Ki m tra l i tr c ghp

Xc nh nhm mu O Panel Reactive Antibody (PRA): m tnh Ti n s : s l n truy n mu, ti n s ph u thu t: khng Ch p l i phim ph i th ng: r n ph i m, bng tim l n Rct#80%

V sinh b nh nhn (t m thay o qu n v kh n m v khu n), st khu n v b ng v khu n vng m . o chi u cao 167cm, cn n ng 65kg, di n tch c th 1,73m2, T0 370C

5.1 CHU N B NG


I NH N TR cm

CM

GHP TIM

19h00 i u tr chu n b tr

t ng truy n t nh m ch catheter s 18G c g n dy 3 nhnh, nh n n u ng 18h00 tr c ph u thu t n u c th Thu c c ch mi n d ch:

o

Solumedrol, 250mg ho long trong 100ml Glusose 5% tuy n t nh m ch trong 30 pht Cellcept 1g u ng

Thu c ti n m

Atarax 75mg u ng Ceftazidime 2g (t nh m ch) Zantac 50mg (t nh m ch) Zovirax 200mg x 1 vin u ng Mycostatin 5ml

5.2 PH U THU T L Y TIM



20h00 chuy n b nh nhn ch t no vo phng m t ng 5, ta nh ODA

  

Methylprednisolone 1000mg t nh m ch Ceftazidime 2g (t nh m ch) Dextrose 50%, 50ml tim t nh m ch

20h30 b t u PT l y tim t ng i cho ch t no v ti n hnh r a b o qu n tim ngoi c th l n th 1 22h45 v n chuy n tim n phng m ghp

Ph u thu t l y tim

5.3 PH U THU T GHP TIM



22h00 ti n hnh m ng c, ph u tch b c l tim b nh l 22h30 ti n hnh tu n hon ngoi c th 22h30 li u php c ch mi n d ch l n th 1: Solumedrol 1500mg trong dung d ch priming 22h35 C p ng m ch ch , th c hi n ph u thu t c t b tim b nh l theo ng qui trnh v theo nh h ng ghp tim ki u hai t nh m ch ch

5.3 PH U THU T GHP TIM

 

22h30 ti n hnh THNCT + li u php mi n d ch l n th 1 22h45 ti n hnh r a, b o v c tim l n th 2 ngoi c th t i phng m ghp tim v chu n b tim ghp 22h50 ti n hnh mi ng n i tm nh tri, mi ng n i 23h10 ti n hnh mi ng n i t nh m ch ch d 23h30 ti n hnh mi ng n i t nh m ch ch trn 23h40 ti n hnh mi ng n i ng m ch ch ng m ch ph i 23h45 ti n hnh k thu t b o v c tim mu nng l n th 3 23h50 ti n hnh mi ng n i cu i cng, mi ng n i i u tin 23h05 ti n hnh k thu t b o v c tim mu nng l n th 1 23h25 ti n hnh k thu t b o v c tim mu nng l n th 2

       

-K thu t ghp tim

ng v tr theo Lower v Shumway (k thu t hai nh )

K thu t ghp tim

ng v tr v i 2 mi ng n i t nh m ch ch

5.3 PH U THU T GHP TIM



0h10 t i mu m nh ghp v s tim p l i



i m b nh nhn chu n b cho

Isuprel 0,1mcg/kg/pht

 

0h30 ti n hnh u i b t kh trong cc bu ng tim v cho tim ghp p 0h30 ti n hnh ng th i li u php c ch mi n d ch l n th 2:
 

Solumedrol 750mg ngay sau m c p ng m ch ch RATG (Rabbit AntiThymoGlobulin) 1,25mg/kg trong 8h

1h15 t ch c cai tu n hon ngoi c th

TH I GIAN PH U THU T GHP TIM

Thng s Th i gian ph u thu t Th i gian c p ng m ch ch Gi tr 270 pht 120 pht 180 pht 80 pht 85 pht 165 pht 30 pht

Th i gian tu n hon ngoi c th Th i gian thi u mu l nh Th i gian li t tim trong PT ghp T ng th i gian thi u mu Th i gian v n chuy n tim ghp

Ph u thu t ghp tim

VI. K T QU

PH U THU T GHP TIM

ng sau m
ng 90, nh p xoang 70 7 12 11 72 4,7 2,7 1100 124 Gi tr l n/pht mmHg mmHg mmHg mmHg % lt/pht lt/pht/m2 dyne.sec.cm-5 dyne.sec.cm-5

Thng s huy t
Thng s huy t Nh p tim, t n s tim Huy t p p l c p l c L ul

ng m ch trung bnh ng m ch ph i trung bnh ng m ch ph i bt

p l c nh ph i

bo ha oxy mu t nh m ch tr n ng tim Ch s tim Khng l c m ch mu h th ng Khng l c m ch mu ph i

CH C N NG TIM
Thng s Ch c n ng tim K th t tri cu i tm tr Phn su t t ng mu Bu ng tim ph i ng m ch ph i p l c ng Gi tr bnh th T t <45mm T t T t T t ng B nh nhn Co bp t t, 40mm 65% Khng gin Khng gin 25mmHg ng ng thu c Milrinone ng d ng

ng m ch ph i tm thu 10 30mmHg #

Thu c i u tr t ng p ph i

LI U PHP 1. Tr cm :

C CH MI N D CH

Solumedrol, 250mg ho trong 100ml Glusose 5% tuy n TM trong 30 pht (li u n p lc 3h tr c m ) Cellcept 1g u ng (3h tr cm )

2. Trong m :

Solumedrol
1500mg trong dung d ch priming THNCT bn nh n ghp tim 750mg ngay sau khi m c p ng m ch ch bn nh n ghp tim 1000mg t nh m ch khi b t u PT l y tim bn ch t no cho tim

RATG b t u ngay sau khi m c p MC 1,25 mg/kg truy n TM trong 08h (Rabit AntiThymoGlobulin)

LI U PHP 3. Sau m :
 

C CH MI N D CH

 

RATG ti p t c li u 1,25 mg/kg v i u ch nh li u thu c theo n ng CD3 (50100/mm3) trong 5 ngy u sau m . Corticoid: Solumedrol: 120 mg TM m i 8 gi x 3 li u trong ngy u sau m .Sau , chuy n qua prednisolone 5 mg u ng 4 vin/ngy, gi m 1 vin sau 1-2 tu n Cellcept (Mycophenolate Mofetil), b t u ngy 2 sau m . 2000mg/ngy chia 2 l n Neoral (Cyclosporin), b t u ngy 3 sau m Li u kh i u Neoral 350 mg/ ngy chia 2 l n

THEO DI N NG
Ngy C0 C2 19/3 C0 C2 283 1173 21/3 199 5/3 280 6/3 209 7/3 185

CYCLOSPORIN
8/3 205 9/3 240 10/3 226 1241 28/3 298 2/4 263 7/4 294 9/4 218 12/3 208 755 19/4 230 720 15/3 17/3 308 1393 28/4 223

1262 25/3 245

NG

IU TRI

C CH MIEN DICH

ygiai o n u l li u php ph i h p (RATG + Cell Cept + Corticoid); ysau chuy n sang li u php mi n d ch lu di v i (Neoral + Cell Cept + Corticoid).
Gi tr bnh th Thng s RATG (globulin c ch CD3 # 50-100 /mm3 mi n d ch t bo c ngu n g c t th ) Cell Cept Corticoid Neoral # # Co # 200-300 ng /ml thng u tin 70 /mm3 ng B nh nhn

Khng ng k T ng b ch c u v i li u d n corticoid Hi u qu t t

I U TR D

PHNG NHI M TRNG

 

 

Bactrim 480 mg / ngy trong 3-6 thng Acyclovir 400 mg x 2/ ngy, ngy 19/3 chuy n qua Valcyte 450 mg x 2/ ngy trong 3 thng PCR CMV: 2500copies/ml (8/3) IgM:(-) 1030 copies/ml (18/3); 617copies/ml(31/3): p ng t t Nystatin vin 500.000 UI 2 vin x4/ngy trong 4 tu n Khng sinh sau m : Vancomycin 0,5g X 3/ngy trong 3 ngy u Ceftazidime 1g x 3/ ngy n ngy th 14 sau m Meropenem 1gx 3/ngy n ngy th 14 sau m

K T QU
Nguy c Nhi m khu n Nhi m virus

I U TR D

PHNG
B nh nhn

D phng

Ceftazidime x 14j C y mu v b nh ph m khng m c Meropenem x 14j Valcyte Bactrim Nystatin # 08 huy t thanh IgM (-) C y mu v b nh ph m m tnh Khng c Gi m d n v bnh th J5 ng vo ngy

Nhi m n m, k sinh trng Cc tri u ch ng nhi m trng Bi n thin n ng CRP

B NH NHN SAU GHP TIM

10h sng 01/03/2011

VII. K T LU N


th c hi n thnh cng ca m ghp tim trn ng i l y t ng i cho ch t no b i chnh i ng cn b BVTW Hu Ph i k t h p cc chuyn khoa lin quan tri n khai quy trnh ghp tim trn ng i l y t ng i cho ch t no m t cch hon ch nh,theo m hnh ghp tim hi n i- m hnh a trung tm Lm ch k thu t ghp tim, ki u 2 t nh m ch ch tuy ph c t p nh ng ch t l ng tim ghp hon h o

TRN TR NG C M

N!