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B GIO DC V O TO I HC HU TRNG I HC Y DC

PHAN NG BO LINH

CHUYN 1

PHNG PHP NH GI TN THNG NG MCH VNH QUA K THUT CHP MCH VNH CHN LC

CHUYN NGNH: NI TIM MCH M s : 62.72.20.25

HU - 2010

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B GIO DC V O TO I HC HU TRNG I HC Y DC

PHAN NG BO LINH
CHUYN 1

PHNG PHP NH GI TN THNG NG MCH VNH QUA K THUT CHP MCH VNH CHN LC
TN LUN N

NGHIN CU C IM TN THNG MCH VNH V CNG NG MCH BNH NHN TNG HUYT P NGUYN PHT C BNH NG MCH VNH
CHUYN NGNH: NI TIM MCH M s : 62.72.20.25 NGI HNG DN KHOA HC PGS.TS. NGUYN ANH V TS NGUYN CU LI HU - 2010

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MC LC
Trang CC CH VIT TT DANH MC HNH NH DANH MC BNG BIU M U NI DUNG 1. Cc phng php chn on bnh ng mch vnh 1.1. Da vo lm sng chn on 1.2. in tm lc ngh 1.3. in tm gng sc 1.4. Holter in tim 1.5. Siu m tim 1.6. Siu m tim gng sc 1.7. Chp ng mch vnh (Coronary Angiography) 1.8. Chp ct lp vi tnh 1.9. Chp cng hng t 1.10. Chp phng x ht nhn 2. K thut chp ng mch vnh 2.1. Lch s chp ng mch vnh 2.2. Gii phu ng mch vnh 2.3. Trang thit b chp MV 2.4. Chp MV chn lc 2.5. Ch nh chp MV
2.6. Chng ch nh chp ng mch vnh 22

1 4 4 4 6 6 7 7 7 7 8 9 10 11 11 12 15 16 21 23 24 25 26 26 27 29 31 32 33 33

2.7. Bin

chng v x tr bin chng 2.8. Mt s nhm ln, cm by trong chp vnh 2.9. Tin b mi trong k thut chp vnh 3. Phng php nh gi tn thng h MV 3.1. nh gi on mch hp theo ng knh 3.2. Phn loi tn thng MV theo AHA/ACC 1998 3.3. Phn loi tn thng MV theo Hi Can thip Tim Mch Hoa K 3.4. Phn loi tn thng MV theo TIMI dng chy 3.5. Phn nng ca tn thng MV theo im s GENSINI 3.6. S lng mch mu b tn thng 3.7. Xc nh v tr tn thng trn cc nhnh MV chnh

3.8. nh gi d tr lu lng vnh

3.9. Chp vnh nh lng 3.10. Siu m ni mch KT LUN TI LIU THAM KHO

33
34 38 40

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CC CH VIT TT

ACC/AHA: Hip Hi Tim Mch Hoa K CCS: CS: CT: DE-MRI: MV: MLTT: MM: TN: EEM: FFR: IVUS: L(R)AO: MSCT: MRI: NMCT: QCA: PET: SCAI: SPECT: TIMI: Hi tim mch Canada Cng s Chp ct lp in ton (Computerised Tomography) Chp MRI tng bt thuc nhm (Delayed-enhancement-MRI) ng mch vnh ng mch lin tht trc ng mch m au tht ngc Mng n hi ngoi (the external elastic membrane) D tr lu lng vnh (phn on) (fractional flow reserve) Siu m ni mch (IntraVascular Ultrasound system) Chch trc tri (phi) (left (right) anterior oblique) Chp ct lp a lt (MultiSlide - CT) Chp cng hng t (Magnetic Resonance Imaging) Nhi mu c tim Chp vnh nh lng (Quantitative coronary angiography) Chp ct lp x po-si-tron (positron emission tomography) Hi Can thip Tim Mch Hoa K Chp ct lp x hnh n photon (single photon PET) Thrombolysis in Myocardial Infarction

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DANH MC HNH NH
Trang Hnh 1 Hnh 2 Hnh 3 Hnh 4 Hnh 5 Hnh 6 Hnh 7 Hnh 8 Hnh 9 Hnh 10 Hnh 11 Hnh 12 Hnh 13 Hnh 14 Hnh 15 Hnh 16 Hnh 17 Hnh 18 Hnh 19 Hnh 20 Hnh 21 Hnh 22 Hnh 23 Hnh 24 Bnh ng mch vnh X hnh SPECT c tim Gii phu ng mch vnh Tri Gii phu ng mch vnh Phi Cc loi ng thng vnh thng dng Kha a cng dng trong chp vnh ng t lng mch (sheath) V tr chc ng mch i S chc mch theo Seldinger Lun Catheter vo l vnh tri(a-d), phi(e-g) Biu din p lc bnh thng (A-D), bt thng (B-C) Qu o quay ca u chp Minh ha gc nhn hp mch v ng knh v din tch Kiu tn thng MV S cho im, h s ca Gensini Cc p lc ni vnh Lng gi tn thng ng mch vnh Mc hp tn thng u d siu m trong lng mch Ct ngang mch mu bnh thng bi IVUS Ct dc mch mu th hin bi IVUS Ct ngang mch mu c mng x va Cc dng ti cu trc thn mch A dng, B m Tn thng nt v mng va tri, canxi ha thnh mch phi 36 37 38 39 39 32 33 35 35 36 25 26 28 18 20 15 16 17 18 4 10 12 13 15

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DANH MC BNG BIU

Trang Bng 1 Bng 2 Bng 3 Biu 1 Biu 2 Biu 3 nh gi mc TN (n nh) theo CCS nhy cm v c hiu trong chn on bnh MV Phn TIMI dng chy mch vnh T l thnh cng ca cc kiu tn thng vnh ABC Bin chng xy ra theo phn kiu tn thng ABC T l can thip thnh cng theo h SCAI 29 30 5 9 32

28

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M U Bnh ng mch vnh (coronary artery disease) hay l bnh tim do ng mch vnh (coronary heart disease) hoc l bnh thiu mu cc b c tim (ischemic myocardial disease) thng gp v l nguyn nhn bnh l gy t vong hng u trn th gii. Mi nm t chc y t th gii c tnh c 3,8 triu n ng v 3,4 triu ph n cht v bnh ng mch vnh. T l cht v bnh ny gim Bc M v Ty u, nhng ang tng nhanh cc nc ang pht trin. Ngi ta tnh ton rng khong 82% t l cht v bnh ng mch vnh trong tng lai s xy ra cc nc ang pht trin [53]. Vit Nam tnh hnh bnh ng mch vnh cng ngy ang tng cao. Theo thng k ca Vin Tim mch Vit Nam vo nm 1991 t l mc bnh mch vnh ch chim 3% th n nm 1996 t l ny l 6,1% v n nm 1999 ln n 9,5% [2]. Chnh v tnh trng bnh ng mch vnh ph bin v l gnh nng kinh t x hi khng ngng tng ln nn trn th gii cng nh chnh nc ta nn c nhiu cng trnh nghin cu v bnh ny cng b, cn ang tip tc c nghin cu v s chun b c nghin cu... Bnh tim mch ni chung v bnh ng mch vnh ni ring lun chu nhiu yu t chi phi lm thun li cho bnh xut hin v pht trin nng ln. Cc nghin cu bnh ng mch vnh do tc ng ca cc yu t nguy c nh i tho ng, ri lon lipid mu, ht thuc l, bo ph... c nghin cu nhiu cc nc cng nh nc ta. Bnh c nhiu yu t nguy c chi phi tuy nhin cho n nay d kim sot tt cc yu t nguy c cng cha th hon ton ngn c bnh tin trin, iu chng t bnh cn chu chi phi bi nhiu yu t nguy c khc na m cn phi c pht hin v ngn nga. Bn cnh bnh ng mch vnh l mt bnh hu nh khng c s thoi trin mt khi n hnh thnh v pht trin v vy vic pht hin sm cc i

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tng c nguy c mc bnh ng mch vnh nhm ch ng ngn nga t trc l mt iu cn thit. Thm vo mt vn c quan tm trong vi nm gn y l hi chng chuyn ho. Ty theo cc nh ngha khc nhau nhng u bao gm cc tiu ch sau: bo ph dng nam, ri lon lipid mu, ri lon dung np ng mu v tng huyt p. Tp hp cc yu t ny gy nn hai i dch ln l bnh tim mch v i tho ng th 2. Cc nghin cu dch t cho thy ngi hi chng chuyn ho c nguy c mc bnh tim mch do x va tng gp 2-3 ln v nguy c mc bnh i tho ng cao gp 5 ln. Thng k cng cho thy M hi chng chuyn ho chim 25% tui trn 20 v gia tng ln 45% tui trn 50 [46]. V vy bn cnh s pht trin ca cc bin php iu tr th cc cng c chn on cng khng ngng ci tin v hon thin hn. Chp ng mch vnh c xem l tiu chun vng cho chn on bnh ng mch vnh ti nc ta cng ngy c s dng rng ri khng ring g cc trung tm ln. Chp ng mch vnh chn on (cn gi chp vnh mch chn lc) hin l phn ch yu nht ca thng tim chn on, vi mt c tnh khong 2.000.000 ca (khong 800 mi 100.000 dn) thc hin mi nm ti Hoa K [25],[60]. Mc ch l kim tra ton b cy ng mch. Cng tc ny thng c thc hin trong 30 pht hoc t hn, gy t ti ch, trn c s ngoi tr, vi t l bin chng (t vong, t qu, nhi mu c tim..) rt thp < 0,1%. Bng cch bm thuc cn quang vo ni mch vnh trong thc chn la cn thn bng cch s dng cc gc hnh nh x-quang c phn gii cao, c th xc nh tt c cc phn ca lu thng ng mch vnh t thn chnh xung n cc mch nh mc 0,3 mm. Hin ti cha c k thut hnh nh khc cho mt ci nhn chi tit vic lu thng mch vnh ny, mc d k thut khng xm ln nh chp mch cng hng t v chp ct lp vi tnh a din, chp ct lp tia in t (electron-beam CT) ci thin phn gii ca

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mnh v ni ln nh l c hiu qu sng lc xt nghim bnh ng mch vnh. Nhng i vi bnh nhn thiu mu cc b c triu chng, chp mch vnh xem xt tin hnh nh l mt quy trnh chun nhanh chng chuyn sang liu php dt khot can thip mch vnh. Mc d vy, chp vnh b gii hn ch xem lng mch vnh m khng xem c b mt ni m, bn cht mng bm, thnh mch hay dng chy sinh l ng mch vnh. Cc thiu st ca chp mch vnh c th c b sung bng siu m ni mch, chp ct lp vi tnh quang hc, ni soi mch hoc o d tr lu lng, p lc ni mch vnh. Mc d c nhng hn ch, chp vnh chn lc vn cn l tiu chun vng nh gi lm sng gii phu mch vnh. Vic thc hin chp vnh cht lng cao mt cch an ton xc nh mch vnh hp bng gc nhn ti u l mt bin php quan trng ca cc nh can thip mch vnh v l nn tng c kh nng thc hin thnh cng s can thip mch vnh. Trn c s chng ti xin cp chuyn Phng php nh gi tn thng ng mch vnh qua k thut chp mch vnh chn lc.

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NI DUNG 1. Cc phng php chn on bnh ng mch vnh 1.1. Da vo lm sng chn on Chn on thiu mu c tim da vo vic khai thc triu chng au ngc ca bnh nhn. Nhng du hiu gi tnh trng thiu mu c tim khng r rng hay yn lng l nhng ch im khin cho bc s phi i tm thm v nguyn nhn v bin php pht hin ra tnh trng thiu mu c tim. 1.1.1 Cn au tht ngc in hnh - V tr v hng lan: sau xng c, lan xung mt trong cnh tay tri, cng c khi lan ln vai, ra sau lng, ln xng hm, rng, c - Hon cnh xut hin: khi pht sau gng sc hay lnh - Tnh cht: au m h nh b chn, b p ngc - Thi gian: ngn, ko di khng qu vi pht - Gim khi ngh ngi hoc dng thuc gin vnh [1],[7],[9] 1.1.2. Cc th lm sang au tht ngc au tht ngc n nh Cn au tht ngc xy ra sau mt hot ng nht nh m nhu cu oxy c tim vt qu mc kh nng cung cp ca mch vnh do hp bi mng va x ng mch vnh [1],[6],[9],[14],[38]. au tht ngc khng n nh Lm sng c mt trong ba c im sau - Khi pht cn TN nng < 2 thng v hoc 3 cn / ngy - au khi ngh ngi hoc hot ng nh nhng - Gn y hay xy ra hn, ko di hn, vi gng sc nh hn
Hnh 1 Bnh ng mch vnh [19]

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in tim: ST chnh xung v/hoc T o chiu trong cn au v ht khi khng cn cn au; Men tim khng tng [16],[17],[33],[39],[ 43], [65]. Bng 1. nh gi mc TN (n nh) theo CCS [6],[9],[19]. I c im Nhng hot ng th lc bnh Hn ch nh hot ng th lc II thng thng Hn ch ng k hot ng th lc thng thng Cc hot ng th lc thng thng u gy au tht ngc Ch thch au tht ngc ch xut hin khi au tht ngc xut hin khi leo cao >1 tng gc thng thng bng cu thang hoc i b di hn 2 dy nh III au tht ngc khi i b di t 1-2 dy nh hoc leo cao 1 tng gc au tht ngc khi lm vic nh, khi gng sc nh

thng khng gy au tht ngc hot ng th lc rt mnh

IV

Cn au tht ngc Prinzmetal - Do co tht vnh - C th xy ra trn mch vnh bnh thng - Xy ra khi ngh ngi - Lm sng ging cn TN in hnh nhng trm trng hn - ST chnh ln rt cao trn ECG [7],[9],[10],[16],[22] Thiu mu cc b c tim yn lng - C bnh mch vnh nhng khng triu chng - Pht hin bi ECG Holter hay gng sc vi bin i ST T [8],[10],[22] Nhi mu c tim - Xy ra khi tc mt hay nhiu nhnh ca ng mch vnh - L s hoi t thiu mu nng v h thng c tim vi din tch 2 cm2 - Cn TN nng hn v ko di > 30 pht, t gim sau ngh ngi v dng Nitroglycerin.

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+ Chn on xc nh: c 2 trong 3 du hiu sau: (1) cn TN bin i, (2) thay i ECG theo tin trin bnh v (3) s gia tng men tim.[1],[9],[12], [13],[16],[26],[69]. 1.2. in tm lc ngh - L mt thm d sng lc bnh mch vnh. - C ln hn 60% bnh nhn TN n nh c ECG bnh thng. - Mt s c sng Q (NMCT c), ST chnh xung, cng, thng un. C th pht hin tn thng khc nh Block nhnh, ph i tht, tin kch thch.. - Trong cn au c th thy thay i ST v T (ST chnh xung, T m) - ECG bnh thng khng loi tr chn on bnh mch vnh. - Lu l c nhng tnh trng bnh l khc cng c th cho nhng du hiu in tm ging thiu mu c tim [9],[11],[26],[35]. 1.3. in tm gng sc Bnh nhn p xe hay chy trn thm c iu chnh tc Ch nh: - Chn on cn au tht ngc - Bilan ngi tr c nhiu nguy c - nh gi hiu qu iu tr thiu mu c tim - nh gi kt qu phu thut mch vnh hay sau nong vnh - nh gi chc nng ca suy tim cn b Nguy c cao b bnh mch vnh (chn on cn au tht ngc): - ST chnh xung > 2mm - ST chnh xung > 3 pht sau khi ngng gng sc - ST chnh xung kiu dc xung -Thiu mu c tim xut hin khi nhp tim < 120 l/p - Huyt p khng tng hoc gim - Trong vng 3 pht dng tnh

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- Xut hin nhp nhanh tht khi nhp tim < 120 l/p nhy: 68%, c hiu: 77%, dng tnh gi cao ph n v m tnh gi cao ngi gi Nhc im: - ECG gng sc t c gi tr khi c cc bt thng nh dy tht tri, block nhnh tri, ri lon dn truyn - ECG gng sc khng dnh gi c mc hp cng nh nh v chnh xc vng c tim thiu mu. - Khng thc hin c khi bnh nhn khng th gng sc [8],[36],[37]. 1.4. Holter in tim - Chn on bnh mch vnh yn lng (khng c au tht ngc) - Chn on v theo di cn TN Prinzmetal [10],[22]. 1.5. Siu m tim - Tm nhng ri lon vn ng vng nu c: gim co bp, khng co bp, ri lon co bp khu tr ... - nh gi chc nng tim - Cc bnh tim km theo (van tim, mng tim, c tim) [18],[31]. 1.6. Siu m tim gng sc - C th lm vi gng sc th lc (xe p nm) hoc dung thuc (Dobutamin Arbutamin, Adenosin, Dipyridamol). - C th cho php d on vng c tim thiu mu v v tr ng mch vnh b tn thng. - Siu m tim gng sc c nhy > 90% vi hnh nh ri lon vn ng thnh tim. [18],[31]. 1.7. Chp ng mch vnh (Coronary Angiography) c xem l tiu chun vng chn on bnh ng mch vnh s c trnh by r phn tip theo.

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1.8. Chp ct lp vi tnh (CT- scan) Hin nay, my chp ct lp v tnh a dy u d hin i, c nhiu phn mm cho php to nh nhanh, rt a dng, cho php chn on mt s bnh l c bit m cc phng php chp ct lp trc y hn ch. Cho hnh nh r nt, phn gii cao gip pht hin v chn on chnh xc cc thng tn nh trong c th. Thi gian chp nhanh, bao ph rng, cho php chp tt tt c cc mch mu trong c th k c ng mch vnh m lun lun chuyn ng nhanh theo nhp p ca qu tim. Km theo my chp ct lp cn c mt trm x l nh (workstation) a nng cho php ti to hnh nh trong khng gian ba chiu, ni soi o cc b phn trong c th v gi lp cc bnh l trong c th. Chp ct lp in ton a din MSCT hay MDCT: - y l k thut vi nhiu tin b nht trong nhng nm qua. Vi MSCT 64 lt ct, nhng bnh nhn au ngc khi nghi ng bnh mch vnh c th xc nh bnh nhanh chng trong vng 1- 2 gi vi phng php chn on ny. - MSCT 64 lt ct cho hnh nh rt nt h thng ng mch vnh v c th gi bnh nhn no cn can thip mch vnh. - MSCT 64 lt ct c nhiu tnh nng ni bt: + nh gi gn nh hon chnh v h thng ng mch vnh, pht hin vi ha v hp ng mch vnh c chng trnh can thip ph hp. + Kho st tnh trng cu ni ng mch vnh sau phu thut mt thi gian. + Kim tra Stent sau khi t mt thi gian. + Kho st ng mch ch, ng mch cnh, ng mch no, ng mch thn, cc mch mu quan trng khc + Pht hin d dng bm sinh v mc h mu. [19], [21], [32].

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1.9. Chp cng hng t (MRI) Trong thc hnh lm sng thng qui, MRI tng bt thuc nhum (Delayed-enhancement-MRI: (DE-MRI)) v MRI ti mu gng sc bng adenosine l k thut thng s dng nht nh gi thiu mu c tim. Kho st MRI tim mang li nhy l 89%, c hiu 87% v chnh xc chn on l 88% trong vic pht hin bnh mch vnh. MRI ti mu gng sc hin nay l mt phng php ni bt, chnh xc pht hin thiu mu c tim. So vi cc k thut y hc ht nhn (SPECT v PET) MRI ti mu gng sc c cc u im: + S ci thin ng k v phn gii khng gian, + Cho php pht hin thiu mu di ni mc, + Bnh nhn khng phi chu bc x ion, + Thi gian kho st ngn hn. Test s dng gng sc bng thuc adenosine hoc dipyridamole to hnh nh ti mu khc nhau gia vng c tim bnh thng v vng thiu mu. Adenosine thng c dng hn v thi gian bn hy cc ngn (~10 giy). [58],[71]. Nghin cu so snh gia SPECT v MRI ti mu gng sc, kt qu nhy ca MRI l 94% so vi SPECT l 82% v MRI c u th hn trong chn on thiu mu cc bnh nhn khng c nhi mu trc . [5] nhy cm v c hiu trong chn on bnh mch vnh ca cc k thut khng xm nhp [20]. Bng 2 nhy cm v c hiu trong chn on bnh mch vnh [20] K thut MRI EBCT MSCT nhy 50-90% 74-92% 80-90% c hiu 82-97% 71-94% 80-90%

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Cc bnh nhn c MRI ti mu gng sc dng tnh s c nguy c bin c tim mch tip theo cao hn, ngc li nu MRI ti mu gng sc bnh thng th t l bin c tim mch rt thp trong vng 2-3 nm. MRI tng bt thuc nhum vi phn gii khng gian cao, c kh nng nh lng chnh xc vng c tim cn sng v vng b nhi mu. Do c phn gii khng gian cao, MRI tng bt thuc nhum pht hin c nhng vng nhi mu khng thy c trn phng php PET v SPECT, MRI tng bt thuc nhum c th pht hin 55% s nhi mu di ni mc nht l mt s vng d nghi ng c tn thng m b b st trn SPECT nh l thnh sau hoc thnh di tht tri, nh vy s tt hn khi dng MRI tng bt thuc nhum nh gi MSCT EBCT MRI [5],[58],[71]. 1.10. Chp phng x ht nhn X hnh hin i gm cc k thut sau [28],[66],[70]. - X hnh SPECT (chp ct lp bng bc x n nguyn t: Single Photon Emission Computed Tomography) - X hnh PET (Chp ct lp bng bc x positron: Positron Emission Tomography) nhy v c hiu ca x hnh SPECT ti mu c tim trong chn on bnh ng mch vnh l 96,4% v 66,6%. Trong 3 nhnh chnh ng mch vnh, ng mch lin tht trc c pht hin vi
Hnh 2 X hnh SPECT c tim [70]

nhy cao nht (90%) v c hiu cao nht (74%). nhy, c hiu ca in tim gng sc trong chn on bnh ng mch vnh thp hn so vi x hnh SPECT ti mu c tim (75% so vi 96,4% v 62, 8% so vi 66,6%). X hnh SPECT ti mu c tim vi Tc99m l phng php chn on

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khng xm nhp c nhy, c hiu cao hn siu m tim gng sc [3],[70]. 2. K thut chp ng mch vnh 2.1. Lch s chp ng mch vnh - Nm 1945 Bodener chp ng mch vnh nh a thuc cn quang vo ng mch ch. - Nm 1950- 1960 Seldinger chp ng mch vnh nh c ng thng. - Nm 1958 Mason Sones ngi u tin trn th gii chp MV bng bc l cnh tay m ra mt k nguyn mi v chn on tn thng MV bng hnh nh. i c vo ng mch vnh Sones s dng k thut Seldinger i vo ng mch nn cnh tay phi, t y ng thng vo ng mch di n phi y xung quai ng mch ch, li ng thng theo di qua mn tng sng chp chn lc tng ng mch vnh. - Sau Bellman to c ng thng catheter chuyn dng chp ng mch vnh vo nm 1959, ng thng c a t ng mch i v ng mch cnh tay. - Nm 1967 Melvin Judkins ci tin k thut, to nhiu loi ng thng c kch thc, chp MV theo ng ng mch i. Judkins ng dng k thut Seldinger a ng thng vo ng mch i ( thng l ng mch i phi) y ng thng ngc dng ln ng mch ch bng, ln quai ng mch ch; s dng ng thng ring bit chp ng mch vnh phi v tri, chp nhiu t th pht hin cc tn thng ng mch vnh. Cho n nay hu ht cc phng thng tim u s dng k thut ca Judkins. K thut ca Judkins khng p dng c khi bnh nhn hp ng mch chu hai bn, ng mch ch, lc ny ta mi s dng k thut ca Sones [9],[15],[24], [29],[59]. - Ti Vit Nam, Vin Tim Mch Quc Gia (Bnh vin Bch Mai) tin hnh chp MV chn lc u tin t thng 8/1995 v ti Hu k thut ny

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tin hnh t nm 1998. n nay, k thut chp v can thip MV c thc hin kh thng quy ti cc trung tm tim mch ln ti H Ni, Hu v Thnh ph H Ch Minh [9]. 2.2. Gii phu ng mch vnh Mu nui dng tim c cung cp ch yu qua ng mch vnh tri v MV phi. Hai ng mch ny xut pht t xoang vnh. ng mch vnh tri c chia thnh 3 phn Thn chung ca MV tri xut pht t xoang vnh n ch xut pht ca ng mch lin tht trc v ng mch m, ng knh t 3 -6mm v di t 0-10mm, on ny nhn r nht khi chp t th nghing tri 500- chn 300. ng mch lin tht trc i trong rnh lin tht trc ti mm tim, gm cc nhnh chnh l cc nhnh vch v nhnh cho. Nhnh ng mch lin tht trc c th ni vi nhnh vch xut pht t ng mch lin tht sau ca MV phi to thnh h thng tun hon bng h kh phong ph. Nhnh cho ca ng mch lin tht trc chy pha mt trc bn ca tim v c th c mt hoc nhiu nhnh cho. ng mch lin tht trc nhn r cc t th chp: nghing phi 200- chn 300; nghing phi 100- u 400; nghing tri 300- u 300; nghing tri 500-chn 300. Hnh 3 Gii phu ng mch vnh Tri [63]

T th chp chch trc P 30o 1. Thn chung ng mch vnh T 2. Nhnh lin tht trc on gn

T th chp ngang 7. Nhnh cho th 1 8. Nhnh cho th 2

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3. Nhnh lin tht trc on gia 9. Nhnh vch th 1 4. Nhnh lin tht trc on xa 10. Cc nhnh vch 5. Nhnh ng mch vnh m 11.Nhnh tm nh 6. Nhnh ng mch b T 12. Nhnh ng mch b th 2 ng mch m bt ngun t ch phn nhnh ca thn chung MV tri i xung theo rnh nh tht tri, thng c t 1 ti 3 nhnh b. ng mch m nhn r cc th chp: nghing phi 200; nghing phi 200- chn 300; nghing tri 100- u 400. [4],[7],[9],[27],[55],[59]. MV phi t xoang vnh i vo rnh lin nh phi ti mm. MV phi c cc nhnh chnh: ng mch nn, ng mch nt xoang nh, ng mch lin tht sau. MV phi nhn r cc t th: nghing tri 300; nghing phi 300; chch trc tri 600- u 250. Hinh 4 Gii phu ng mch vnh Phi [63]

T th chch trc T 45o T th chch trc P 45o 1. on u (nm ngang) ca MV phi 7. ng mch nt xoang 2. on 2 (nm dc) ca MV phi 8. ng mch b P 3. on 3 (nm ngang) ca MV phi 9. ng mch tht P 4. ng mch lin tht sau 10. ng mch nt nh tht 5. ng mch qut ngc tht 11. ng mch c honh 6. ng mch chp 12. Cc nhnh vch di Cc vng phn phi mu trn 90% mu vo ng mch vnh th tm trng, ch c 10% mu vo ng mch vnh th tm thu. Nh phi v tri do nhnh m v nhnh nh ca hai MV, him khi t nhnh ring ca ng mch ch.

- 20 -

Vch lin tht mt trc ch yu do nhnh xung ca MV tri cung cp mt sau do ng mch lin tht sau l nhnh MV phi cung cp nui dng. Thut ng u th hay u nng ti mu l dng ch nhnh MV no s nui vng sau c tim. 80% l MV phi u th, cn li l cn bng hay MV tri u th. Thnh t do ca tht phi 90% do MV phi cung cp. Thnh t do ca tht tri do cc nhnh ca MV tri, mt honh ca tht tri do nhnh MV phi v nhnh ca ng mch m cung cp mu. Nh c pha trc do ng mch tri, pha sau phi hp nhnh ng mch phi v tri. Giao lu mu gia MV tri v phi, gia cc nhnh giao lu to nn mng li phong ph trong thnh c tim. Do vy c kh nng cung cp mu b trong cc trng hp b ph i tht, bnh MV hay bnh thiu mu cc b c tim [4],[7],[9],[24],[27],[59]. 2.3. Trang thit b chp MV 2.3.1. My chp mch My chp mch xo nn hoc my chp mch C-arm thng. Cc trang thit b theo di v cp cu bao gm my ghi p lc bung tim v mch mu, my o huyt p, in tim v oxy... 2.3.2. Cc ng thng chp ng mch vnh - ng thng Judkins (Judkins catheter): l loi ng thng chp MV thng dng nht. Hnh dng thit k ca n gip cho ngi chp mch d dng a ng thng vo l MV (hnh 5 Tri). ng thng Judkins c 2 loi : ng Judkins tri (JL) dng chp MV tri v ng thng Judkins phi (JR) chp MV phi. ng thng Judkins c nhiu loi: JR3; JR3,5; JR4; JR5; c 4F v 6F cho chp MV phi, cn JL3; JL3,5; JL4; JL5; c 4F v 6F cho chp MV tri. Loi cng ln th chiu di t ng cong th nht ti ng

- 21 -

cong th hai cng ln. ng knh ng thng cng thay i t 4F- 8F (French) mi French = 0,33mm ng knh. Tuy nhin ng thng c 5 F hay c s dng nht. Vic la chn hnh dng v kch c ca ng thng Judki ns ty thuc vo chp MV phi hay tri, tm vc bnh nhn, kch thc gc ng mch ch l khu quan trng gp phn quyt nh thnh cng ca th thut [9], [24], [59]. - ng thng Amplatz (Amplatz catheter): Mc d t c s dng hn nhng ng thng Amplatz (hnh 5 gia) l s thay th tuyt vi trong nhng trng hp ng thng kh Judkins a hoc

khng a c vo l vnh [9], [24], [59]. - ng thng

Hnh 5 Cc loi ng thng vnh thng dng [29].

hnh

ui

ln

(Pigtail catheter): l loi ng thng hay c s dng chp bung tht (hnh 5 phi) do hnh dng thit k c bit ca loi ng thng ny hn ch c s tn thng ni mch, s xut hin ca ngoi tm thu [24]. 2.3.3. H thng kha a cng (manifold) ng thng chp MV c ni vi mt h thng kha (Manifold), h thng ny cho php ngi
Hnh 6 Kha a cng dng trong chp vnh [29].

chp mch c th ng

thi thc hin vic o p lc ng mch, bm nc mui sinh l ra v bm thuc cn quang (hnh 6). Tt c c thc hin qua mt h thng kn,

- 22 -

bo m nhanh chng v v khun [24]. 2.3.4. ng t lng mch c van cm mu (sheath) ng thng chp MV thng c a vo lng ng mch qua mt ng t lng mch c van cm mu.
Hnh 7 ng t lng mch (sheath) [59].

y l mt ng thng lm bng teflon c mt van cm mu u tn, mt cnh tay bn v mt nng ng (hnh 7). Qua n ngi chp mch c th va thao tc chp va o c p lc ng mch [9], [15], [24], [59]. 2.3.5. Dy dn (Guidewire) Dy dn chun chp MV di 180 cm, ng knh 0,038 hay 0,035 inch. Dy dn c bc teflon, 3 mm cui ca dy dn c hnh ch J gip cho n d dng i qua ng mch chu v ng mch cnh tay [24], [59]. 2.3.6. Thuc cn quang Chng ti thng dng loi Ultravist 370 ca hng Shering (thuc cn quang khng ion ha) t c cho thn, nht l ngi ln tui. i khi cn dng loi Telebrix 350 l loi cn quang dn xut iod ion ha c tng phn cao v cho hnh nh nt hn nhiu nhng c hn [15], [24], [59]. 2.4. Chp MV chn lc Chp ng mch vnh l phng php thm d chy mu nhm a thuc cn quang vo ng mch vnh chn on mt s bnh l ca ng mch vnh gip cho ngi thy thuc c phng n iu tr cho bnh nhn. Chng ti tin hnh chp MV chn lc theo khuyn co ca Hi Tim Mch Hoa K [15],[22], [30]. 2.4.1. Chun b bnh nhn - Khi c ch nh chp MV, bnh nhn c kim tra li tnh trng

- 23 -

lm sng v cc xt nghim cn thit mt ln na. - Bnh nhn v gia nh c gii thch v th thut, cn phi c s ng ca bnh hoc ngi thn c trch nhim k vo giy cam oan tin hnh th thut. - Hng dn bnh nhn nhn n v i v sinh trc khi lm th thut. 2.4.2. Tin hnh - Bnh nhn nm nga thoi mi trn bn chp mch, theo di in tim lin tc. Vng ng mch c la chn lm ng vo (thng l ng mch i phi) c lm sch, st trng (c hai bn) v tri khn v khun c cha l ti ch chc. - Ngi chp MV mc o ch, ra tay, mc o m v mang gng v khun, ging nh mt cuc phu thut. 2.4.2.1. Chp ng mch vnh qua ng mch i - Chng ti tin hnh chp MV chn lc theo phng php Judkins, qua ng ng mch i, s dng k thut chc mch qua da ca Seldinger. V tr chc ng mch i - Vic xc nh v tr chc ng mch i ht sc quan trng. Vi cc bnh nhn bnh thng, im chc mch thng l 1-2cm di cung i, ni ng mch p r. - Nu chc cao qu c nguy c gy
Hnh 8 V tr chc ng mch i [9]

chy mu vo khoang ngoi phc mc v kh khn khi p cm mu (Hnh 8). Ngc li nu chc thp qu c th c bin chng gi phnh mch hoc gy d ng - tnh mch [9], [15], [24], [29], [59]. Chc ng mch i theo phng php Seldinger - Sau khi xc nh v tr chc ng mch i, chng ti dng kim nh (s

- 24 -

25- 27 G) gy t ti ch bng 3 -5ml Xylocain 2%, sau dng kim ln (18 22G) ng mch i (c rch 1mm da) ti v tr xc nh trn theo s di (hnh 9) . A: kim chc to thnh mt gc 30- 40 so vi ng mch i v chc vo lng ng mch; B: Mt dy dn ngn c y qua kim vo lng ng mch v t t kim c rt ra qua dy dn trong khi p pha trn ch chc; C: ng t lng c c nng c y vo theo dy dn n st gc ri rt nng v dy dn ra ngoi; D: ng t lng mch c van c nm li trong lng ng mch i [9], [15], [24],[59].

Hnh 9 S chc mch theo Seldinger [24]. Lun ng thng chp vo l vnh . Thng thng dy dn c lun trong ng thng Judkins tri (hoc phi) s 5F (JL5) ri y qua ng t lng mch c van cm mu (sheath) vo ng
Hnh 10 Lun Catheter vo l vnh tri(a-d), phi(e-g) [59].

mch i. Sau ng

thng c y theo dy dn di mn hunh quang ti ng mch ch ln. Ti y dy dn c rt ra cn ng thng c ni vi h thng manifold bm ra v theo di p lc ngay (Hnh 10). i vi l MV tri dng loi ng thng JL u cong 3; 3,5 hay 4; c 4 - 6F cng dy dn mm t th soi tim u tin chch trc phi (RAO) 30 0.

- 25 -

Khi lun vo l MV tri, y ng thng ti st van t chim, sau ko nh ng thng ra cho n khi c cm gic t vo l MV tri (hnh 10 A-D). Trong khi di chuyn ng thng c th bm nh thuc cn quang d tm l MV. Nhng trng hp kh nh MV lc ch, rng ca MV khng ph hp vi ng thng th ta phi thay i loi ng thng JL cc c khc nhau hoc ng thng Amplaz...v phi rt kin nhn khi thc hin th thut. i vi l MV phi dng loi ng thng JR u cong 3; 3,5 hay 4; c 4 - 6F t th soi tim u tin chch trc tri (LAO) 450. y ng thng n mc l MV tri, ng thi ko nh v xoay t t theo chiu kim ng h sao cho cm thy u ng thng nm ng l MV phi (hnh 10 E-G). Trong qu trnh di chuyn ng thng c th bm nh thuc cn quang tm l MV. Nhng trng hp kh nh ng mch vnh lc ch, rng ca ng mch vnh khng ph hp vi ng thng th phi thay i loi ng thng JR cc c khc nhau hoc Amplaz... v phi rt kin nhn khi thc hin th thut [9], [15], [24], [29], [59]. Trong khi li ng thng cn theo di st p lc u catheter phi biu hin bnh thng (hnh 11A), phng hai tnh hung c th xy ra l ng p lc b tt (damping) (hnh 11C) hoc hin tng tht ha. Hin tng damping c th do u ng thng b t vo thnh MV, cn hin tng tht ha l do y ng thng vo qu su (c 2 l MV) hoc n ch hp kht ca thn chung MV tri lm ng thng bt lun MV (hnh 11B). Khi xy ra hin tng ny cn rt ngay ng thng v gc ng mch ch ng p lc s v bnh thng (hnh 11D), c th chp li on phim khng chn lc t xoang Valsalva, gc ng mch ch nh gi s b MV tri (phi), sau thay th bng mt ng thng c nh hn hoc s dng ng thng c l bn. Tuyt i trnh khng c bm thuc chp nu thy hai hin tng trn v c th gy hu qu nghim trng (bc tch thn chung MV tri, rung tht...) [9], [12], [55].

- 26 -

Hnh 11 ng biu din p lc bnh thng (A-D), bt thng (B-C) [24]. Chp ng mch vnh tri phi chn lc Khi tin hnh chp MV, vic bm thuc cn quang rt quan trng. Cn phi bm u tay vi sc y lin tc v mnh m bo cn quang tt h MV. Khi bm cn quang, u bm tim phi hi chc xung bt kh ni ln trn, khng lt vo MV, bm bng tay, mi ln 3-5 ml, thi gian ko di cho n khi xut hin r ht cc nhnh MV, thng 2 -3 giy. T th chp MV tri: chch tri u, chch tri chn, chch phi u, chch phi chn v t th chp ngang. Chp MV phi: nghing tri, nghing phi, chch tri u [4], [9], [15], [24], [29], [55], [59]. Kt qu c lu li trn my tng sng, in trn bng video v my tnh, sau c nh gi t nht 2 bc s c kinh nghim v chp MV. Rt ng thng, p cm mu kt thc chp Sau khi chp xong, ta rt u ng thng ra khi l MV, va rt ng thng va cho dy dn vo v rt c hai ra ngoi (khng ng t lng chy theo), tip rt ng t lng v p cm mu khong 7 pht. Bng p cm mu v tr chc ng mch, kt thc qu trnh chp. Bnh nhn c theo di sau chp ti phng cp cu tim mch [9],[15],[24],[29], [49], [59]. 2.4.2.2. Chp mch vnh chn lc i t ng mch cnh tay hoc quay Thng dng catheter 100cm, 4F. Ni chc kim l ng mch cnh tay hoc ng mch quay ri chnh catheter ln ng mch vnh phi, ng mch vnh tri v vo tht tri. Phng php ny kh lm hn phng php Judkin nhng c dng khi ng mch i, ng mch chu, ng mch ch bng

- 27 -

b va x. Ch cn dng mt catheter nn r tin hn, t b tn thng ng mch hn [9],[15],[24],[29],[49],[59]. 2.5. Ch nh chp MV Nhng bnh nhn khng triu chng Ch nh tuyt i: + C bng chng nguy c cao trn thm d khng xm nhp. + Cc ngh nghip c nguy c cao (phi cng my bay, li xe) + Sau khi hi sc thnh cng bnh nhn ngng tim. Nhng bnh nhn c triu chng + Khng p ng vi iu tr bng thuc. + Cn au tht ngc khng n nh + Cn au Printzmetal hoc bin i. + Cn au tht ngc I hay II theo phn loi Hi Tim Mch Canada v: - Nghim php gng sc dng tnh. - Tin s NMCT hay tng huyt p c in tim thay i. - Tc dng ph ca iu tr bng thuc. - Ngh nghip hay li sng c nguy c cao - Ph phi cp tng lc. + Trc khi i phu mch mu nu c biu hin au tht ngc hay kt qu dng tnh cc thm d khng xm nhp. + Sau hi sc thnh cng bnh nhn ngng tim. au ngc khng in hnh hay khng r ngun gc + Khi trc nghim gng sc pht hin nguy c cao bnh mch vnh. + Nghi ng c bnh ng mch vnh. + Cng vi cc triu chng hay du hiu ca bt thng chc nng hay suy tht tri.

- 28 -

Nhi mu c tim cp NMCT cp, tin trin: - Ch nh tuyt i: khng - Ch nh tng i: + L ng c vin cho iu tr ti to mch mu trong 6 gi u. + Sau liu php tiu si huyt tnh mch khi d nh can thip mch vnh. NMCT hnh thnh (sau 6 gi v trc khi cho ra vin) - Ch nh tuyt i: + au tht ngc ti pht tng k. + Nghi ng c v vch hay pht ngc van hai l cp cng vi suy tim. + Nghi ng phnh tht tri. NMCT hi phc (trc khi ra vin cho ti tun th 8 ) + au tht ngc khi ngh ngi hay khi hot ng th lc ti thiu. + Suy tim, thiu mu ti pht, hay cc ri lon nhp tht. + Thm d khng chy mu dng tnh. + NMCT khng c sng Q [9],[15],[24],[29],[49],[59]. 2.6. Chng ch nh chp ng mch vnh Chng ch nh tng i Suy thn cp. Suy thn mn do i tho ng. Chy mu d dy- rut cp. Bt thng v cm mu. St cha r nguyn nhn, c kh nng do nhim trng. Nhim trng cp cha iu tr. Tai bin mch mu no cp. Van ng mch ch thc vt. Thiu mu nng.

- 29 -

Tng huyt p nng khng khng ch c. Mt cn bng nc v in gii nng c triu chng. D ng thuc cn quang nghim trng. Khng c s hp tc ca bnh nhn. Bnh l ngoi tim lm bnh nhn khng ham mun sng. Ng c Digitalis. Suy tim mt b hay ph phi cp. Khng kim sot c nhp nhanh kch pht. Bnh ng mch nng hn ch kh nng xm nhp mch mu. Bnh vim ni tm mc bn cp van ng mch ch. Bnh t chi can thip mch mu [9],[15],[24],[29],[49],[59]. 2.7. Bin chng v x tr bin chng Chp ng mch vnh c mt s bin chng: t vong, nhi mu c tim, sc, tc mch ngoi vi - Trn h thn kinh trung ng: sc, nghn mch v tc mch gy lit na ngi hoc bi lit, yu c quan vn ng, m tm thi, i khi do nghn tc kh, sau t gi s hi phc - phi cho thuc chng ng. - Nhi mu c tim: do nghn tc kh, thuc cn quang, ng thng ch ng mch vnh hp, gy ra sc tim, bloc tim. X tr nh nhi mu c tim, tt nht nn tm ch tc x l. - Rung tht: sc in, bp tim ngoi lng ngc, th oxy, Lidocaine, cho n khi hi phc. - Bloc tim hon ton hoc v tm thu: cn to nhp tim bng a ngay catheter xung tht tri hoc dng catheter khc theo ng tnh mch di n vo tht phi, kt hp Epinephrine kt hp vi huyt thanh tnh mch. - Cn cng ph giao cm: gy hu qu nhp tim chm ti 20 ln/ pht, huyt p h nhanh v mnh, Atropine c th dng liu cao ti 2 - 3mg.

- 30 -

- St phn ng: rt lnh, run l hu qu khi a cht l vo c th. Cho thuc khng Histaminen v h nhit. - Phn ng d ng vi thuc cn quang: cho cc thuc khng Histamine, nu c h huyt p cho thuc Epinephrine. - Nghn ng mch v mu t: khi c au, mt cm gic, yu c, phi iu tr phu thut. Mt nghin cu a trung tm trn 59792 bnh nhn cho thy: T vong: 0,11%; nhi mu c tim 0,05%; tai bin mch no 0,07%; ri lon nhp 0,38%; cc bin chng mch mu 0,43%; phn ng vi cht cn quang 0,37%; cc bin chng v huyt ng 0,26%. [9],[24],[59], [64]. 2.8. Mt s nhm ln, cm by trong chp vnh C mt s nhm ln trong chp ng mch vnh nn trnh. Thn chung vnh tri ngn hoc l i Khi thn chung qu ngn hoc l i, vic chp chn lc ng mch vnh tri s tr thnh chp chn lc hoc ng mch lin tht trc hoc ng mch m v vy s to ra tnh trng m khng r hay khng c mch m hay ng mch lin tht trc theo th t ngc li. Hp l ng mch vnh L ca hai ng mch vnh phi v tri cn c nhn thy trn phng tip tuyn ca xoang vnh. Mt lng thuc cn quang chy ngc ra khi bm cho ta thy c l hp hay khng hp. L hp c th gy m hnh nh mch do khng a lng thuc cn quang cn thit vo mch vnh khi chp. Nu khng c thuc cn quang pht ngc ra v s gim st p lc vnh bnh thng cng nh s tht ha p lc ng mch vnh l ch im ca hp l ng mch vnh i hi chng ta phi rt sond chp ra khi l vnh ngay trnh gy nhi mu c tim.

- 31 -

Cu c ng mch vnh Lm hp ng mch vnh trong k tm thu nhng hu nh bnh thng trong k tm trng. Co tht ng mch vnh Co tht ng mch vnh c th gy nhm ln vi mt tn thng hp ng mch vnh. Khi c nghi ng chng ta cn tim Nitroglycerin ni vnh loi tr Nghn vnh ton b Nghn vnh ton b c th c tun hon bng h phn xa ca mch vnh hay bn i din vi p lc gim st l cho kch thc ngm thuc nh hn kch thc tht. ng mch vnh lc ch hay bt thng xc nh iu ny chng ta ht sc cn thn v kin nhn tm kim, nu cn c th chp khng chn lc xc nh [9], [24],[49],[59]. 2.9. Tin b mi trong k thut chp vnh My chp vnh th h mi vi u quay t ng theo h trc kp cho php quay ng lc theo hai phng khc nhau c th t chch tri chn l n chch phi uvi gc quay m ln n 180 (hnh 12). Mi vng quay ch mt 7 giy v ch cn mt ln bm thuc cho mi ng mch vnh v hnh nh thu c di nhiu gc v s c dng li hnh mch vnh khng gian 3 chiu cho phn tch kt qu vi s h tr phn mm nh lng QCA. Nghin cu cho thy k thut mi ny gim lng thuc cn quang 51%, lng tia pht gim 35% v gim thi gian tin hnh th thut 18%,
Hnh 12 Qu o quay ca u chp [40]

[34],[40], [47],[50], [57],[62].

- 32 -

3. nh gi tn thng h MV 3.1. nh gi on mch hp theo ng knh Mc hp MV c tnh Mc hp (%) = [(Dn- Ds)/ Dn] x 100%. Trong : Dn l ng knh on mch bnh thng trc ; Ds l ng knh on mch hp nht [24].
50%
Hp 10%

Hp ng knh 75% 88%

Hp 75%

Hp thit din ct ngang

Hnh 13 Minh ha gc nhn hp mch v ng knh v din tch [24] nh gi hp theo t l phn trm gim ng knh ca tn thng vnh trong chp mch c s dng kh rng ri trong chp mch vnh cng nh can thip mch. Vic nh gi ny ch da vo hnh nh nhn ct ngang ca mch m thi. Song a phn tn thng l lch tm khng ng tm v thm ch vi hnh dng khng gian rt a dng v phc tp v th cc gc nhn (view) khc nhau c th cho thy hp khc nhau (hnh13). V vy chng ta cn phi xem xt tn thng mch di nhiu gc nhn khc nhau tm sot xem xt ht sc cn thn mc tn thng nng nht thc s nu c ca tn thng cn xem. Vi cng mt tn thng th v nguyn tc gc nhn no cho thy hp cao nht c chn nh gi. Bn cnh mc hp v ng knh khng din t ht ngha v mt huyt ng hc ca tn thng m ta mun bit. Thc ra mc hp trn din tch ct ngang mi thc s phn nh ht phn no v s hp v mt huyt ng hay dng chy ca

- 33 -

mu nhng kt qu chp vnh thun ty khng cho php chng ta nh gi c iu trn gc nhn ct ngang ca mch da ch yu vo s khc bit tng phn ca m mm xung quanh vi lng mch m thi [24],[29], [49],[59]. Trn c s nh gi hp v ng knh ngi ta phn ra cc hp nh sau d dng cho d liu can thip mch tip sau . S phn ny da vo 2 yu t: Phn : 0: Khng hp. 1: Thnh mch khng ng u, nhng khng hp khu knh. 2: Hp khng c ngha khi hp khu knh < 50%. 3: Hp c ngha khi hp khu knh t 50 - 75%. 4: Hp kht khi hp khu knh t 75 - 95%. 5: Hp rt kht khi gn nh ton b khu knh t 95 - 100% km ng thuc cn quang trc ch hp. 6: Tc hon ton c tun hon bng h. 7: Tc hon ton khng c tun hon bng h [9],[12]. 3.2. Phn loi tn thng MV theo Hip Hi Tim Mch Hoa K ACC/AHA (1998) phn chia thnh 3 kiu A, B, C Bn cnh nh gi mc hp ng knh th vic nh gi v mt hnh thi ca tn thng hp l cn thit nn Hip Hi Tim Mch Hoa K ACC/AHA (1998) phn chia tn thng hp thnh 3 kiu A,B,C (sau c b sung thm kiu B1 v B2) c tc dng tin lng kh nng thnh cng ca qu trnh can thip ti thng vnh v mt lm sng cng nh v mt k thut + Thnh mch bin dng; + hp ng knh

- 34 -

v nguy c bin chng (Hnh14). Kiu A: (Thnh cng cao > 85%, nguy c thp) Hp ng tm, ngn < 10mm, khng nm trn on phn nhnh, lng mch trn nhn, khng b canxi ho, t gp tc hon ton, khng hp l, khng c huyt khi. Kiu B: (Thnh cng trung bnh 60-85%, nguy c trung bnh) Hp lch tm, di 10-20mm, lng mch khng ng u, g gh, on gn ngon ngho, hp nm on gc phn nhnh > 450; < 900 du hiu canxi ho va, hp l vnh, huyt khi lng mch.
Hnh 14 Kiu tn thng MV [24]

Kiu C: (Thnh cng thp <60%, nguy c cao) Hp lan ta >20mm, on gn rt ngon ngoo, canxi ho, gp gc >900, tun hon bng h, tn thng nhiu nhnh [4],[9],[15],[24],[29],[59].

Biu 1 T l can thip thnh cng ca cc kiu tn thng vnh ABC [51] Biu trn cho ta thy t l can thip thnh cng ca kiu A l 97,2 % v kiu C thp nht 84,1% [51]

- 35 -

Bin chng chnh

Cht

Bt cu ni

Biu 2 Bin chng xy ra theo phn kiu tn thng ABC [51] 3.3. Phn loi tn thng MV theo Hi Can thip Tim Mch Hoa K (SCAI) nm 2000 Khi bc vo k nguyn stent, s liu tp hp c y hn ngi ta nhn thy t l can thip thnh cng v bin chng ch yu ph thuc vo hai yu t tn thng cn thng hay nghn hon ton v tn thng c s hin din ca kiu C hay khng nn nm 2000 Hi Can thip Tim Mch Hoa K (SCAI) ti c cu li h phn loi n gin vi bn nhm sau [51], [52]. Tn thng nhm I: (T l thnh cng cao nht v bin chng thp nht) - Khng c c im tn thng nhm C - Lng ng mch cn thng thng Tn thng nhm II: - C mt trong cc c im tn thng nhm C (tn thng lan to trn 20 mm; xon vn nhiu on gn; on mch gp gc trn 900; khng c kh nng bo v nhnh bn ln; tn thng mnh ghp tnh mch b thoi ho v mn) - Lng ng mch cn thng thng

- 36 -

Tn thng nhm III: - Khng c c im tn thng nhm C - Lng ng mch b tc hon ton Tn thng nhm IV : - C mt trong cc c im tn thng nhm C (tn thng lan to trn 20 mm; xon vn nhiu on gn; on mch gp gc trn 900; khng c kh nng bo v nhnh bn ln; tn thng mnh ghp tnh mch b thoi ho v mn) - Lng ng mch b tc hon ton - Hoc tc hon ton trn 3 thng n c [52]

Biu 3 T l can thip thnh cng theo h SCAI [52] Biu trn cho ta thy t l can thip thnh cng theo SCAI 96,8% nhm I v 75,0% nhm VI [52]. Mt khc phn nhm SCAI tp hp 75% bnh nhn vo nhm nguy c thp trong khi phn nhm ABC ch c 31% bnh nhn phn nhm A. [52]

- 37 -

3.4. Phn loi tn thng MV theo TIMI dng chy Tn thng mch vnh qua chp mch cho thy s hn ch trong nh gi mc tn thng thc s ca mch vnh v ch gii hn trn mt mt ct nhn ngang vi s tng phn lng mch m thi. Phn dng chy ca tn thng vnh TIMI phn no cho ta hnh dung c nh hng huyt ng ca tn thng vnh. Bng 3 Phn TIMI dng chy mch vnh [9],[24],[29],[49],[59]. PHN TIMI 0 TIMI I TNH CHT Khng h c dng mu ngang qua ch b tc C cht cn quang ngang ch hp nhng khng ngm thuc hon ton vng h lu Cht cn quang i qua c ch hp, ngm thuc hon ton h lu, tc tho lu thuc chm Cht cn quang qua ch hp tt, ngm thuc hon ton h lu, tc tho lu thuc khng b chm

TIMI II

TIMI III

H chm im dng chy TIMI mang ngha rt ch quan. Gibson v cng s to ra cch tnh khch quan hn bng cch chnh my chp ghi hnh vi tc 30 hnh / giy, vi tc ny khi thuc ri khi catheter t l vnh t n im xa nht nhnh tn ca ng mch lin tht trc i vi ng mch vnh tri v nhnh lin tht sau i vi ng mch vnh phi thng 20 hnh ghi c cho ng mch vnh phi v 36 hnh ghi c cho ng mch vnh tri. Vi TIMI 2 tng ng vi s lng nhiu gp i s hnh ghi c thuc ngm n nhng v tr xa . Tuy nhin iu ny t c dng trong thc t, ch c tnh nghin cu m thi [42] H thng im TIMI rt c ngha v mt lm sng, n cung cp phn

- 38 -

tng nguy c c lp bnh nhn bnh ng mch vnh. Qua nghin cu cho thy t l t vong bnh nhn TIMI 0/1 l 4,5%, TIMI 2 l 2,9% v TIMI 3 l 0,7%. iu ny cho thy t l t vong nhm TIMI 0/1 gp gn 8 ln nhm TIMI 3[23]. 3.5. Phn nng ca tn thng MV theo im s GENSINI + Cho im theo mc gim khu knh Gim: 25% 1 im. 75% 4 im. 99% 16 im 50% 2 90% 8 im. im.

100% 32 im.

+ V tr tn thng MV tnh theo h s -Thn chung: h s 5 - MLTT: on gn: h s 2,5; on gia: h s 1,5; Vng mm: h s 1; Nhnh cho1: h s 1; Nhnh cho2: h s 0,5 - ng mch m Hnh 15 S cho im, h s ca Gensini [9][14][15][54]. on gn: h s 2,5 Nhnh b: h s 1; on xa: Nhnh sau di: h s 1 h s 1; Nhnh sau bn: h s 0,5

- ng mch vnh phi: h s 1 nng tn thng = s im tn thng x h s im Gensini ca bnh nhn l tng s im Gensini ca cc on hp trn mch [9],[14],[15], [41], [54].

- 39 -

3.6. S lng mch mu b tn thng Mch vnh c mt thn chung ca ng mch vnh tri v ba nhnh chnh ca ng mch vnh bao gm ng mch lin tht trc, ng mch m v ng mch vnh phi. Khi tn thng hp xy ra trn thn chnh ca cc ng mch ny thng gy nh hng huyt ng hn l trn cc nhnh ph ca n. Khi mc x va mch t th thng ch gp tn thng mt trong cc s nhnh chnh trn ca ng mch vnh m thi, khi tnh trng x va nng n th tnh trng x va c th gp trn hai hay thm ch c ba thn chnh ng mch vnh. V vy s lng nhnh chnh ng mch vnh 1, 2 hay 3 nhnh b tn thng cng c xem nh mt ch s ni ln mc nng ca bnh cng nh c nh hng n k hoch iu tr v tin lng cho bnh nhn v sau. [15], [30]. 3.7. Xc nh v tr tn thng trn cc nhnh MV chnh Cc on I, II v III ca MLTT l tng ng vi cc on gn, gia v on mm theo s cho im ca Gensini. on I, II v III ca MV phi cng tng t l on gn, gia v on xa. on gn v xa ca MM cng nh th. Thng ngi ta nhn thy cc tn thng x va hay nm nhng khc gp, ch chia nhnh ca h mch vnh. iu ny c th lin quan n huyt ng ca dng chy mu trong ng mch vnh [24], [41]. 3.8. nh gi d tr lu lng vnh (pressure-derived myocardial fractional flow reserve (FFR)) Thng dng cho nh gi chc nng cc tn thng ng mch vnh trung bnh (hp 40-70%) xem cn thit cho can thip mch vnh hay khng. FFR = Pd / Pa Hnh 16 Cc p lc ni vnh [44]

- 40 -

Trong Pa p lc ng mch ch trung bnh, Pd p lc vnh trung bnh sau ch hp (hnh 16). V mt l thuyt iu c th din gii nh sau FFR = Dng c tim ti a trong mch hp (Qh)/Dng ti a mch thng (Qn). FFR = Qh/ Qn Trong mch vnh bnh thng Qn = (Pa Pv)/ R vi Pv p lc tnh mch ch v R tr khng ging vnh. Mch vnh hp Qh = (Pd Pv)/ R. FFR = (Pd - Pv)/ (Pa - Pv) Pd/ Pa Trong Pv thng thp nn c th xem bng khng. Pa c o bng mt ng thng vo mch vnh thng. Pd o bng ng thng c u nhn cm p lc lung qua tn thng hp vnh sau khi dng thuc dn vnh Trong ng vnh bnh thng FFR c bit l bng 1. Trong mch vnh tn thng FFR nh hn 0.75 c xem l tn thng ngha cn c can thip nong vnh. Vi cng c nay thc s gip cho chng ta hiu c bn cht thc s ca mt tn thng hp vnh m hu nh vi chp vnh thun ty khng th no sng t c. Di s hng dn ca FFR chng ta c th quyt nh ngay l mt tn thng vnh c tht s gy ra tnh trng thiu mu c tim hay khng v cn phi can thip hay khng. T cho ta bit rng bnh nhn tht s c li t can thip hay l chu thit thi do lm dng trong ch nh can thip [44],[49],[68]. 3.9. Chp vnh nh lng (Quantitative coronary angiography-QCA) Vic lng gi tn thng hp vnh u tin ch c thc hin bng mt v da vo k nng ca chnh ngi chp mch. V th cng vic ny hon ton mang ngha ch quan khng khc quan nn t n bc l im thiu st t nhin ca n trong kt lun tn thng. Mt khc tn thng mch l ht sc a dng v th vic s ha trong vic lng gi tn thng

- 41 -

vnh khng phi l vn n gin. Tuy nhin do nhu cu khoa hc vn ny cng c gii quyt dn nh vo s pht trin ca nhiu ngnh k thut song song nh hnh Hnh 17 Lng gi tn thng ng mch vnh bng cc phn mm chp vnh nh lng QCA [48]. nh x-quang c phn gii cao, k thut vi tnh h tr. Chp vnh nh lng u tin c gii thiu bi

Greg Brown v cng s ti i hc Washington 30 nm trc. u tin cng vic ny c thc hin bng tay xc nh ng vin ca mch tn thng vnh sau chp vnh. V tip xc nh gi tr kch thc tht so vi kch thc catheter l kch thc m chng ta bit trc (qui i ra milimet). Trn c s dng hnh li trn khng gian ba chiu tnh ton. Ngy nay cng vic ny c s ha hon ton da vo cc phn mm chuyn dng tuy nhin hai im mu cht ca vn l xc nh kch thc tht nh da vo kch thc catheter v xc nh ng vin ca mch nh vo tng phn gia m mm khng c thuc cn quang vi lng mch cha y thuc cn quang (hnh 17). Trn c s cng vic thng tin hnh offline phn tch tn thng vnh nh vo phn mm vi tnh vit sn. Cng vic u tin ca ngi phn tch l chn ly mt hnh nh r nht t qu trnh chp mch trc . Tip theo l chn gi tr tham chiu t kch thc tht ca catheter my nhn bit kch
Hnh 18 Mc hp tn thng theo ng knh (Diametre) v theo din tch hnh cng vic nh lng tn thng ct ngang (Area) tng ng.[59]

thc tht qui i ra milimet nhm tin

- 42 -

khi c yu cu. Phn vic cn li l chng ta ch ra on tn thng cn phn tch. Cng vic tip l qu trnh x l t ng ca my t cho ra cc gi tr mc hp phn trm v ng knh nng nht ca tn thng, mc hp din tch ct ngang ca tn thng tng ng (hnh 18) [24],[48],[59]. 3.10. Siu m ni mch ( IntraVascular Ultrasound System- IVUS ) Mc du chp vnh tiu chun cho thy mc hp khu knh n thun m cung cp rt t thng tin v thnh mch bnh. K t khi gii thiu u tin vo s dng lm sng 1988 n nay n c s dng kt hp trong chp vnh v Hnh 19 u d siu m trong lng mch[45] b tc kt qa ca chp mch vnh thng thng. Siu m ni mch (IVUS) ng thng s dng sng m thanh phn nh hnh nh v thnh ng mch trong hnh nh ct lp hai chiu tng t nh mt mt ct m hc. Vi u d catheter s dng tn s cao hn ng k hn so vi siu m tim khng xm ln (20-40 so vi 2-5 MHz) cho phn gii cao (150 m cho cc ng thng mch vnh), chm tia siu m thm nhp gii hn 4-8 mm t nh ng thng. Kch thc ca cc ng thng ny vo khong 0,87 -1,17 mm c th lun vo ng thng dn ng 6 Fr (hnh 19) [45],[56],[59],[63]. K thut cng tng t nh chp vnh sau khi cho heparin v dn vnh ngi phu thut vin phi y ng thng siu m cn thn theo dy dn c Hnh 20 Ct ngang mch mu bnh thng biIVUS [67]
Ni Mc o Ngoi Trung Mc Lng Mch

- 43 -

t trong nhnh mch ch cn thm khm. Hnh nh c ghi li t ng trn u video c th nh gi li sau. ng thng siu m c ko li bng my khuyn co tc 0,5-1,0 mm/s ghi hnh c tt nht. Mch mu bnh thng c hin th qua siu m ni vnh vi 3 lp: lp ni mc, lp trung mc v lp mng n hi ngoi (the external elastic membrane -EEM). Pha ngoi lp mng n hi thng khng r rng do m c quan xung quanh (hnh 20) [45],[56],[59],[63],[67]. S kt hp cc lt ct ngang theo din tin thi gian m catheter siu m c ko li chm ra ngoi v c ti dng nh li cho ta thy hnh nh lng mch ct dc nh dng siu m M -mode (hnh 21).

Hnh 21 Ct dc mch mu th hin bi IVUS [59]. Cch tnh ton mt s thng s ca IVUS - Din tch lng mch(L Area mm2) phn din tch nm trong ni mc (hnh22). - Din tch trong mng n hi ngoi (EEM Area) (kch thc ct ngang ton b thn mch). - Din tch mng x va = Din tch mng n hi - Din tch lng mch. - ng knh lng mch ln nht v nh nht ca on mch kho st (mm). - ng knh thn mch (EEM) ln nht nh nht. - dy mng x va ln nht v nh nht.

- 44 -

- Phn trm xm chim din tch mng x va = [(EEM AreaL Area)/EEM Area] x 100.

Hnh 22 Ct ngang mch mu c mng x va [61] - Th tch mng x va c tnh TAV (Total Atheroma Volume- mm3) = Tng ca (cc din tch x va X dy cc lt ct) Thc t my tnh TAV hiu chnh nh sau TAVhc = [(EEM Area L Area)/n] x (S trung v ca cc thit din ct ngang c thm khm) Trong n l s lt ct thm khm c trn tn thng ca bnh nhn - Phn trm th tch mng x va y quan nim th tch trong mng n hi ngoi (EEM) ca on mch kho st l 100%. PAV (Percent Atheroma Volume) = [ (EEM Area L Area)/ EEM Area] x 100. ( y tt c cc lt ct tn thng n trn bnh nhn) - T ti cu trc (RR - remodeling ratio) T ng knh EEM ti tn thng so vi ng knh EEM bnh thng u gn ca tn thng. Tnh trng ti cu trc thn mch l bin i tt yu ca thn mch chu tn thng x va. Tnh trng ti cu trc ny cng a dng v vy ngi ta chia ra cc kiu ti cu trc khc nhau tin trong nh gi tn thng mch

- 45 -

mu vnh. Ti cu trc dng khi RR>1,05; Ti cu trc trung bnh khi RR = 0,95 n 1,05; Ti cu trc m khi RR < 0,95.(Hnh 23) [45],[49],[56],[59] [61],[63], [67].

u gn

u xa

u gn

u xa

Hnh 23 Cc dng ti cu trc thn mch A dng, B m [67] IVUS cn cho ta thy c cc tn thng x va nt v ci ngun ca hi chng vnh cp, mng vi ha trong tn thng mch(hnh 24).[56]

Hnh 24 Tn thng nt v tri, canxi ha thnh mch phi [56]

- 46 -

KT LUN
Cho d s pht trin vt bc ca k thut hnh nh c phn gii cao kt hp vi kh nng tuyt vi ca cng ngh vi tnh s ha c nhiu vn tng chng nh khng th no thc hin c vi kh nng con ngi bng cc phn mm chuyn dng cao. Nhiu k thut chn on hnh nh khng xm nhp cho php chn on nhiu bnh khc nhau k c bnh ng mch vnh ra i v c p dng rng ri v t r kh nng u vit ca n. Tuy nhin cho n nay chp ng mch vnh chn lc vn c xem l tiu chun vng ca chn on bnh ng mch vnh m cha th c k thut no thay th c. Mt d chp ng mch vnh tim n cc ri ro song ngy nay trong k nguyn stent th nht thit vic nm vng cc bc k thut, thc hnh thun thc cc thao tc chp vnh v nh gi tn thng ng mch vnh chnh xc cng nh tin hnh tc v hng ngy lo luyn l iu cn thit i vi cc nh tim mch hc can thip trong cng tc mang tnh chuyn mn cao v trnh nhim ln ny, l mt i hi khng cn con ng u tin no khc m bo cho ngi bnh c cu cha tn tnh vi hiu qu ti u nht v vi an ton mc cao nht.

- 47 -

TI LIU THAM KHO

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cuu_SPECT _tim.pdf. 4. Nguyn Thanh Hin, "Chin lc ti ti mu trong hi chng mch vnh cp khng ST chnh ln", Thi s tim mch hc, Hi Tim mch TPHCM, 2005, (89), tr. 21-27. 5. Phm Ngc Hoa v cs, cng hng t tim trong nh gi thiu mu v sng cn c tim, dieu-tri-noi-khoa.com, 2009, http://www.dieu-tri-noikhoa.com/mri-trong-danh-gia-thieu-mau-va-song-con-co-tim.php. 6. Phm Gia Khi v cs, Khuyn co ca Hi Tim Mch hoc Vit nam v chn on v iu tr bnh tim thiu mu cc b mn tnh, Khuyn co v cc bnh tim mch v bnh chuyn ha giai on 2006 - 2010, Hi Tim mch Quc gia Vit nam, 2006, tr. 87-105. 7. Nguyn Ph Khng, Lm sng Tim Mch, Nxb Y Hc, H Ni, 2001. 8. Hunh Vn v Cs, Khuyn co ca Hi Tim Mch hoc Vit nam v p dng lm sng in tm gng sc trong chn on bnh ng mch vnh mn tnh, Khuyn co v cc bnh tim mch v bnh chuyn ha

- 48 -

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