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Hep Van ĐMC
Hep Van ĐMC
I. Sinh l bnh
Hp van MC c trng bi qu trnh hp dn l van MC, gy tng dn hu gnh
ca tht tri. duy tr cung lng tim, tht tri s bp vi sc bp tm thu cao hn, lm
tng p lc ln thnh tim, dn n ph i ng tm tht tri (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) nhng ng thi li lm gim gin n ca tht tri. Tht tri gin km s lm gim
qu trnh y th ng tht tri trong giai on u ca thi k tm trng khin tin gnh
tht tri b ph thuc rt nhiu vo s co bp nh tri. Tht tri cng dy ln, 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 trng tht tri tng lm gim p lc ti mu ng
mch vnh, gy p cc ng mch nh trong c tim v di ni tm mc, cng lm gim
hn na cung cp xy cho c tim trong khi nhu cu vn tng cao, s gy biu hin au
ngc v cc triu chng lm sng... Nu van MC hp kht m cung lng tim vn bnh
thng th chnh p trung bnh qua van thng ln hn 40mmHg. Tuy nhin, khi suy tim,
cung lng tim thp, chnh p qua van v vn tc dng chy qua van cng s thp cho d van
MC hp kht. Do vy, mt s bnh nhn hp van MC kht li cha c triu chng trong khi
s khc ch hp van MC va c biu hin triu chng. Quyt nh iu tr phu thut
thay van MC ch yu da vo s c hay khng c cc triu chng lm sng ch s o nh
din tch l van hay chnh p qua van s khng phi l yu t chnh a ra ch nh thay
van MC.
xut hin triu chng c nng, t l sng cn gim xung rt nhanh chng nu khng m: thi
gian sng ch khong 2-3 nm do c nguy c t t. t t xy ra bnh nhn hp van MC
c triu chng c nng do cc ri lon nhp tht tm tht tri ph i v ri lon chc
nng hoc th pht do thiu mu c tim:
o Khi bnh nhn c au ngc th t l sng cn ch t 50% sau 5 nm,
o Khi c ngt th t l sng cn ch t 50% sau 3 nm,
o Khi c suy tim th thi gian sng trung bnh < 2 nm.
Do vy, s xut hin cc triu chng c nng l mt mc rt quan trng trong tin trnh
pht trin t nhin ca bnh hp van MC. Tuy nhin cn ch l triu chng kh nhn ra v
d b b lc bnh nhn ti khm theo lch.
bt gy huyt phi. Cc tnh trng ri lon y tht tri nh rung nh hoc cn tim nhanh
c th gy ra triu chng suy tim r rt.
o Nhp tim nhanh lc ngh bnh nhn HC nng l mt trong nhng du hiu
u tin ca tnh trng cung lng tim gim thp.
V. Thm d cn lm sng
1. in tm
in tm thng c dy nh tri (80%) v ph i tht tri (85%). t khi xy ra ri
lon nhp, nu c th ch yu giai on cui v a s l rung nh, nht l khi c km bnh
van hai l. C th gp bloc nh tht nu c vim ni tm mc gy bin chng pxe vng van.
o Siu m tim qua thc qun c th o trc tip c din tch l van (2D) cng
nh rt c ch nh gi hnh thi van MC trong bnh hp van MC bm
sinh.
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Nh
Va
Kht
< 3,0
3,0 - 4,0
> 4,0
< 25
25 40
> 40
> 1,5
1,0 - 1,5
< 1,0
< 0,6
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VIII. 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 phu thut 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. Khi hp van MC ti mc nng, th triu chng c xu
hng xut hin v phi m thay van ch trong vng 3 nm. Bnh nhn ln tui hp kht van
MC th vic m sm khi cha c triu chng c li hn so vi vic ch 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 cao v hn ch c nguy c cao t t. Nu bnh nhn c din tch l van
MC 1,0 cm2 km theo hp ng k MV th nn m thay van MC phi hp vi bc cu
ni ch vnh.
1. iu tr ni khoa
o Bt buc phi iu tr khng sinh d phng vim ni tm mc nhim khun cho mi
bnh nhn hp van MC khi lm cc th thut c nguy c. Cn iu tr phng thp
th pht nhng bnh nhn hp van MC do thp. Bnh nhn hp van MC c tng
huyt p th khi iu tr thuc h huyt p phi iu chnh liu v phi hp thuc ht
sc thn trng. Ngoi nhng ny, chng h c phc iu tr ni khoa c th no
i vi bnh hp van MC khng c triu chng lm sng. Nu bnh nhn c triu
chng c nng th phi phu thut thay van ch khng phi l iu tr ni khoa.
o Khng hn ch hot ng th lc nu hp van MC nh cha c triu chng, k c thi
u th thao. Bnh nhn hp van MC va-kht nn trnh cc hot ng th thao
mang tnh i khng c lin quan n vn c ln. Cc dng hot ng khc vn c th
thc hin bnh thng, nhng cn lm nghim php gng sc trc nh gi mc
gng sc ph hp.
o Bnh nhn cha c triu chng c nng (din tch l van MC > 1,0 cm2) th iu tr
c mc ch thay i cc yu t nguy c, phng tin pht bnh l ng mch vnh,
duy tr nhp xoang v khng ch huyt p. Tt c bnh nhn phi c t vn v
hng dn k 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.
o iu tr suy tim nhm vo vic kim sot cn bng dch gim huyt phi, thng
ch bng thuc li tiu. Tuy nhin, cung lng tim bnh nhn HC nng ph thuc
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nhiu vo tin gnh, nn cn rt thn trng, trnh dng li tiu 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 ng k tin gnh,
c th gy gim ti mu no v ngt. Digoxin thng ch c ch nh cho bnh
nhn HC c suy tim nht l khi rung nh. iu tr HC c suy tim bng thuc khng h
ci thin tin lng sng ca bnh nhn. Hn na, iu tr ni khoa tch cc bnh
nhn hp van MC nng ri lon chc nng tht tri khng h c li m cn nguy
him.
o Trnh dng cc thuc gin mch cho bnh nhn hp ch n thun.
o Trong mt s bnh cnh hp h van MC, HC phi hp h van hai l, HC
phi hp bnh mch vnh th c th cn nhc vic dng cc thuc gin mch
song nn ht sc thn trng. Trn l thuyt, bnh nhn h van nhiu s c li
khi dng thuc gin mch; bnh nhn c bnh mch vnh cng c li v gim
hu gnh s lm 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.
o 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).
o 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). Rung nh nhanh chng v d dng gy gim
cung lng tim v huyt phi, ng thi tng nhu cu xy (do nhp nhanh). Bi vy,
cn iu tr tch cc rung nh ngay t lc mi khi pht bnh nhn HC nng nhm
chuyn v nhp xoang.
o Ch nh t bng ngc dng 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 ch 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.
Nong van MC bng bng c th lm gim va chnh p qua van MC, nhng din
tch l van sau nong t khi vt qua 1,0 cm2. Bn cnh , t l gp cc bin chng cp/nng
kh cao ln ti >10% ng thi ti hp v triu chng lm sng s li nng ln ch trong vng
6-12 thng. T l t vong ca th thut ny khong 2-5%. 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).
Ch nh iu tr tm thi bng nong van MC bng bng bnh nhn hp van MC
cng cn cn nhc k. a s bnh nhn hp van MC kht cha c triu chng c nng nu
c mt bnh l ngoi khoa khc (khng phi tim mch) u c th phu thut thay van cp
cu vi nguy c tng i thp nu theo di st v m bo cn bng dch trong lc gy m
v sau m. Nh vy i vi nhm bnh nhn ny khng c ch nh nong van MC tm thi
bng bng. Nu thc s cn phi gii quyt hp van MC th bnh nhn nn c m thay
van MC trc.
3. Phu thut
i vi hp van MC kht, van vi, c triu chng lm sng, bnh nhn tui
trng thnh, phu thut thay van MC l bin php iu tr duy nht c hiu qu. Thay van
ng mch ch c a chung hn m sa van v nu ch sa, sau khi gt mng v ly vi
l van, cc l van hay b co rt, gy h van ngay sau phu thut v dn dn mc h s tng
ln sau m. Tuy nhin, nu bnh nhn tr tui hn, b hp van MC bm sinh hoc do di
chng thp tim, van cha vi th vn c th sa van MC. M thay van MC n thun
khng km bnh mch vnh hoc cc bnh nng khc th t l t vong quanh phu thut ch
khong 2-3%. T l sng cn sau m thay van MC vo khong 85% sau 10 nm.
La chn loi van MC thay ph thuc vo rt nhiu yu t nh tui, nguy c khi
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, phu thut bao gm cc loi:
o 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 ny rt tt v huyt ng, khng cn dng thuc chng ng, t
vi ho hn so vi cc van sinh hc khc, c th ln ln theo pht trin ca c th, c
c tnh chng nhim trng rt cao nn rt ph hp lm tr nh hoc bnh
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nhn vim ni tm mc nhim khun song i hi k thut cao v thi gian ko di, d
gy ra nhiu ri lon sau m. Tin lng lu di li ph thuc vo mc h 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).
o 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 tm mc nn c ch nh khi vim ni tm mc nhim
khun trn van nhn to.
o Thay van sinh hc (d loi): thng c ch nh cho bnh nhn tui > 70. Trong
vng 10 nm, 80-90% van s 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 bnh nhn u c chnh p qua van ngay sau m (v b cn
tr mt phn do vng van, khung ) mc nhiu hn so vi van c hc v th cn
chn loi van c kch thc ln nht (nu c) khi thay gim bt chnh p qua
van.
o Thay van c hc: cc loi van thng dng l St. Jude Medical, Metronic-Hall v
Carbomedics. Bnh nhn sau thay van loi ny phi ung thuc chng ng gim
nguy c to huyt khi van v cc bin chng tc mch khc. bn ca loi van
ny l cao nht nu duy tr c iu tr chng ng v d phng khng sinh cn thn
trong nhiu nm.
Bin chng tim tng sau m thay van MC thng 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 trn 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
Thng thng, ch nh m thay van MC khi (1) bnh nhn c triu chng c nng (nh
au ngc, ngt, suy tim); (2) nhm bnh nhn cha c triu chng c nng nhng p ng
bt thng vi gng sc (xut hin triu chng lm sng hoc c tt huyt p) hay khi c km
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theo cc yu t khc nh: (3) cn lm th thut/phu thut ln, c nguy c cao hoc c ch
nh bc cu ni ch vnh, cn phu thut ng mch ch hoc cc van tim khc; (4) c ri
lon chc nng tm thu tht tri (phn s tng mu tht tri di 50%; hoc (5) bnh nhn
tui tr v hp van MC rt kht (chnh p qua van MC > 100 mmHg, din tch l van <
0.6cm2; chnh p trung bnh > 60 mmHg, vn tc dng mu qua van MC > 5.0 m/sec).
4. iu tr cc trng hp hp van MC
4.1. Hp van MC c triu chng lm sng
Nu hp van MC c triu chng lm sng, thay van MC s ci thin cc triu
chng v ci thin tin lng sng r rt. Kt qu tt do phu thut em li ph thuc mt
phn ln vo chc nng ca tht tri. Phn s tng mu tht tri gim bnh nhn hp van
MC ch yu l do hu ti tng qu mc nn s khi phc/ci thin r sau m thay van. Ngay
c nu chc nng tht tri gim do nguyn nhn khc, th tht tri cng hi phc tt sau m
thay van, d khng hon ton. Do vy nu khng c nhng bnh nng phi hp khc, thay
van MC c ch nh gn nh tuyt i mi bnh nhn hp van MC kht c triu
chng. Tui khng phi l yu t chng ch nh ca phu thut do tin lng sau m nhm
bnh nhn cao tui cng tng ng vi nhm bnh thng. Thay van MC cn c tin
hnh ngay khi xut hin cc triu chng do t t c nguy c xy ra k c trong thi gian ch
i.
hin v tin trin ca cc triu chng c nng. Nng BNP trong huyt thanh cng l mt
yu t tin lng nng. Nhng nhm bnh nhn ni trn l nhm nguy c cao, c th xy ra
cc bin c xu d cha c triu chng, do vy cn theo di st sao hn bng siu m tim
cng nh cn nhc ch nh m thay van MC sm.
4.3. Hp van MC cn phu thut bc cu ni ch vnh hoc phu thut tim khc
Bnh nhn hp van MC kht, d c hay khng c triu chng, nu cn phu thut
bc cu ni ch vnh (do bnh MV) cng nn thay van MC cng thi im khi phu thut
bc cu ni ch vnh. Tng t nh vy, bnh nhn hp van MC kht nu cn phu thut
trn mt van tim khc (v d sa van hai l) hoc to hnh gc MC cng cn thay van MC
lun khi phu thut. i vi nhng bnh nhn hp van MC v cn m bc cu ni ch vnh,
thng vn c ch nh m thay van MC ng thi. Tuy nhin i vi hp van MC nh
khng c ch nh thay van MC ng thi vi cc phu thut tim khc.
IX. Theo di
o Bnh nhn hp van ng mch ch khi cha c triu chng c nng nn c gii
thch k v tin trnh ca bnh, theo di st v hng dn ti khm ngay khi c bt
k triu chng c nng no nh gim dung np gng sc, au ngc khi gng sc, kh
th, chong, ngt Mi ln ti khm, bnh nhn cn c hi k li v triu chng
c nng (bnh s), khm lm sng chi tit kt hp vi siu m tim hay nghim php
gng sc (nu cn).
o Bnh nhn hp van MC kht cn c theo di bng siu m tim mi nm/ln hoc
khi c biu hin thay i hay tin trin ca cc triu chng c nng. Nu hp van
MC va th cn theo di bng siu m tim 1-2 nm/ln v ch cn theo di 3-5
nm/ln vi bnh nhn hp van MC nh.
o Bnh nhn thay van MC cn c lm siu m Doppler tim sau m 1-6 tun
nh gi hot ng ca van v chnh p qua van nhn to, lm mc theo di. Sau
bnh nhn cn c theo di v kim tra bng siu m tim nh k 6 thng-1nm/ln.
Nu thay van c hc, bnh nhn cn c kim tra hiu qu chng ng mu (bng t
l prothrombin, INR) nh k iu chnh liu ph hp: vi van MC c hc n
thun th nn duy tr INR t 2 n 3, nu c c van hai l c hc (hai van c hc) th
nn duy tr INR t 3 n 4,5 (tham kho thm bi van nhn to).
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