Hi ngh Tim mch min Trung- Ty nguyn ln VI Bun Ma Thut 08-2011.

nhp nhanh vng vo li ti nt nh tht: nhng quan im mi

Ths. Trn song giang Vin tim mch vit nam

Nhip nhanh nh- (At)

Nnkptt do vng vo li n-t (AVRT)

Nnkptt do vng vo li ti nt n-t (avnrt) n-

Trong c n: gi sng r, s

- NNKPTT l RLNT th-ng gp, bao gm: . NNVVLNNT ( AVNRT). . NNVLNT ( AVRT). . Nhp nhanh nh (AT). - AVNRT l loi th-ng gp nht trong cn NNKPTT ng-i ln ( TG: 52-60%. Vin TM: 50%). 52-Gp nhiu n ( VTM: 71,3%), tui trung nin ( Vin TM n >40 tui:77,4%). - t gp hn tr s sinh v tr em.

C ch hnh thnh cn NNVLNNT: h

Josephson M. Clinical Cardiac Electrophysiology Techniques and Interpretation ed 2001

CHN ON
- Lm sng: cn khi pht, kt thc t ngt. - in tm : 12 C, Holter. C - Thm d SL tim. Th

Thm d in sinh l tim

Chun b bnh nhn  Ngng cc thuc tim mch tr-c: t nht 5 ln thi gian bn hu  Gii thch v mc ch, li ch, nguy c.  K giy ng lm th thut Tin hnh th thut t in cc  Gy t v tr chc bng Novocain  in cc vng cao nh phi, His, mm TP: qua TM bn  C xoang vnh: TM d-i n tri  -ng M: theo M i
CNP His Abl XV

TP

ph-ng php td sl tim

Ghi in trong bung tim v KT tim c ch-ng trnh: trnh:
- o cc khong in c bn. bn.

- o tPHNX, tPHNX. tPHNX. - im Wenckebach chiu xui, ng-c, TK tr nt N-T chiu xui, ng-c, TK tr -ng chm, nhanh, bng chng -ng kp xui, ng-c( b-c nhy AH). AH). - Thi k tr c nh, tht. tht. - Gy cn NNTT v phn tch hnh nh in . . - Tin hnh mt s nghim php KT tim maneuvers). maneuvers). ( Pacing

-ng kp nt n-t chiu xui

KT nh mc sm dn: khi A1-A2 gim 10ms th c b-c nhy A2H2 ( >50ms)

Bng chng -ng kp nt nh-tht

12%
Nhm 1: C - ng kp Nhm 2: khng c - ng kp

88%

C bng chng -ng kp nt NT: Huang: 82%. SA Chen: 75,7%.

Bng chng ca -ng kp :

- Kch thch nh tn s tng dn: AH di > 10ms khi dn: 10ms KT nh cng chiu di xung KT hoc khi A1A1 gim mi 10ms. 10ms. response). - p ng kp tht khi KT nh ( Double response).

p ng tht kp: 1 nh-2 tht

Bng chng c -ng chm : - Kch thch nh tn s tng dn: dn: + Khong PR > PP (khi vn cn DT nh tht 1/1). - KT nh mc sm dn. dn. + Khong A2H2 >200ms. 200ms.

Khong pr>PP

T trong bung tim ca nnvlnnt

T nh DT ng-c ng tm- T nh sm nht His Khong R-A (HRA) <90ms

iu tr bng sng rf

t -ng nhanh hay chm?

Limb A Limb B

Fogoros: Electrophysiologic Testing. 3rd ed. Blackwell Scientific 1999; 108.

v tr -ng dt kp nt nt

Morady F. N Engl J of Med. 1999;340:534-544.

t -ng nhanh: 82- Hiu qu: 82-95%. - Bin chng blc nh tht: 5-8% - Ti pht: 5-14% 5t -ng chm - Hiu qu: 95-98%. 95- Bin chng blc nh tht: <1%. - Ti pht: 5%.

Kay GN. Am J Med. 1996;100:344-356. Morady F. N Engl J Med. 1999;340:534-544.

Ph-ng php t -ng chm Ph-ng php da vo hnh nh gii phu h Ph-ng php da vo T trong bung tim

Da vo giI phu: tam gic koch

Da hnh nh giI phu

RA CS HIS RA CS HIS

ABL

ABL

LAO

RAO

da vo t trong bung tim

- in ti in cc Mapping: t l A/V: 1/10 ti 1/3. Mapping: A/V:
- Sng nh nhiu thnh phn. C in th -ng chm. phn. chm.

Anterior approach ???

Posterior approach

- t trong lc nhp xoang. - -a /c t n b His xung d-i, y nh vo tht ko dn ra v quay v pha vch ( clockwise) in : A nh, V ln.

v tr t -ng chm
.8%

3.5% P M A 7 .7%

Vin Tim mch TW

nh gi kt qu iu tr : thnh cng khi - Trit b hon ton -ng chm ( Elimination) . Khng gy li cn AVNRT. AVNRT. . Khng cn -ng chm. chm.

Kt qu sau t -ng chm

18,9%
Khng cn ng chm Cn ng chm -

81,8%

nh gi kt qu : thnh cng khi - Bin ci -ng chm ( Modification). Modification). . Khng gy li cn AVNRT. AVNRT. . Cn -ng chm vi 1 nht echo nt N-T. . im Wenckebach nt NT thay i, SP-ERP di SPra, hiu s (FP-ERP v SP-ERP) gim, khong A2H2 (FPSPmax ngn li. li.

nh gi kt qu : chp nhn -c v ngng th thut khi - Khong PR di ra. ra. - Blc nh tht thong qua. qua.

kt qu iu tr rf -ng chm : - T l thnh cng: 98% cng: 98% - T l tI pht: 1%. pht: - T l bin chng: 1,5%. ( Hematoma, trn mu, trn chng: kh MP, nhim trng, trn mu mng tim, blc NT )

Kt lun
- NNVVLNNT l loi NNTT th-ng gp. - Hay gp ph n, tui trung nin. n - iu tr bng sng RF: trit , t l thnh cng cao, t l bin chng thp.

xin trn trng cm n

Phn loi nnvvlnnt Th in hnh: chm-nhanh h chm84- L th hay gp nht ( TG: 84-90%, VTM: 95%) Cc th khng in hnh h - Th chm-chm (TG: 11%, VTM 3%) chm- Th nhanh-chm (TG: 8%, VTM: 2%) nhanh- Th bn trI (1,5%). (1,5%).