u y khoa cap nhat https://www.facebook.com/groups/489 DIEN TAM DO TRONG MAY TAO NHIP May tao nhip tim la mot thiét bi dién tl duc cay ghép vao trong co thé dé diéu tri cdc réi loan nhip cham hoae gitip tai déng b6 co tim. Dién tam 4d & bénh nhan cd mang may tao nhip c6 nh@ng dac diém riéng biét cn dug nhan biét va phan tich ky cang. 4. PHAN LOAI MAY TAO NHIP Bang 14.1. Phan loai cac may tao nhip tim ere ae omit ) Cau tao miter ael-Umet ye Mét than may — Dién crc co thé dat tai Mét buéng are ne wi ahs, a va mét dién ce nhi phai hoac that phai ae Hai dién cuc dat lan nee Mot than may a ee Hai buoéng lwot tai nhi phai va a hai dié Cc i ¥ Poe that phai Ba dién cy dat ln luot tai nhi phai, that phai va xoang tinh mach vanh Ba budng (may tai ~Mdt than may dng bé co tim) va ba dién cyc 2. DANH PHAP QUY UOC CUA MAY TAO NHIP Bang 14.2. Phan loai cac may tao nhip tim folate) Chit cai Chi cai Chir cai | edna: 1) EUR su) altar the 3 titted tial tao} Budng tao Buéng Dap &ng Khan&ng Tao nhip nhip nhancam voinhan dapteng — nhiéu vi cam tan sé tri 446 || zalonhom duy nhat 0528112107uy khoa cap nhat https://www.facebook.com/groups/489022: Dién tam dé trong may tao nhip || 147 led Ter 1] dau tién Khéng A=NhT B= That D=2 budng 3. DAC DIEM DIEN TAM BO CO MAY TAO NHIP bed a er) bia bed a Vor) alta) O=Khéng O=Khéng A= Nhiv B = That D=2 budng T =Kich thich |= Uc ché D= Ca hai chtec nang 3.1. Que xung (Spike) tao nhip best aer-1) alte g Khéng R=Co dap tng Chit cai Que xung (Spike) la déu hiéu DTP quan trong nhat dé nhan biét bénh nhan co duoc dat may tao nhip: * Spike cO dang nét nhd, sat nét di ngay phia truoc P (tao nhip nhi) ho&c QRS (tao nhip that) * Thdi gian que ng&n, thuong 2 ms * Cé thé kho thay & tat ca cdc chuyén dao + Bién dé tuy thudc vao vi tri va loai dién ce: = Spike trong tao nhip thuong tam mac cé bién dé nhd hon so véi tao nhip ndi tam mac * Spike khi tao nhip don cy (unipolar) co bién dé lon hon nhiéu so véi tao nhip Iwéng ce (bipolar) zalo nhom duy nhat 0528112107at https://www.facebook.com/groups/489 oa cap 148 || Sé tay dién tam a6 Unipolar | i Unipolar Bipolar | sy SS Hinh 44.4. Hinh anh que xung (Spike) trong tao nhip voi dién cwc don cyc (phai) va dién cyre lw6ng cure (trai) Hinh 14.2. DTD ghi nhan cé cac nhip dugc may kich thich ty d6ng voi hinh anh spike (mdi tén xanh), c6 cdc nhip ndi tai duoc may nhan cam va Wc ché kich thich tao nhip (mti tén dé) zalo nhom duy nhat 0528112107uy khoa cap nhat https://www.facebook.com/groups/489022: Bién tam dé trong may tao nhip || 149 3.2. Tao nhip nhi + Spike tao nhip di sat phia truéc song P * Hinh dang séng P khac nhau tuy theo vi tri dat dién cuc nht, thong cd dang khac P xoang (gan gidng P xoang khi dién circ dat tai vj tri cao cla nhi phai) ° Sau séng P nhi la phic bd QRS triv khi cd bat thuong dan truyén nhi that. Ht Hinh 14.3. DTD tao nhip nhi voi spike di sat trvéc séng P (mai tan dd) 3.3. Tao nhip that * Spike tao nhip di sat phia trwéc phtrc b6 QRS + Tuy theo vi tri dat dién cywc ma phirc b6 QRS cé hinh dang khac nhau: = Tao nhip that phdi tao ra phtrc b6 QRS dang block nhanh trai * Tao nhip thuong tam mac that trai tao ra phtrc b6 QRS dang block nhanh phai * Doan ST va séng T ngu¢c hung voi phic b6 QRS : iL : ANT 1 2 i} \ } | i pe eA } Ht \if Ape \ Y y V _ Hinh 14.4. DTD tao nhip that véi spike di sat truoc phurc bd QRS zalo nhom duy nhat 0528112107Hinh 414.5. A: tao nhip that phai (QRS dang block nhanh trai). B: tao nhip that trai (QRS dang block nhanh phai 4. DIEN TAM BO TRONG CAC CHE BQ TAO NHIP 4.4. Tao nhip mét buéng nhi + Dién cywe duy nhat dat & nhi phai + Spike tao nhip di truée séng P, sau méi song P déu dan mét phtrc bd QRS binh thuong, thanh manh | | | Hinh 14.6. DTD tao nhip mét budng nhi zalo nhom duy nhat 0528112107y khoa cap nhat https://www.facebook.com/groups, Dign tam dé trong may tao nhip || 15 4.2. Tao nhip mét buéng that * Dién cwc duy nhat dat & that phai * DTD tao nhip that phai voi spike di trvéc QRS, QRS gidn r6ng dang block nhanh trai va Am 6 V1 * Vector QRS tiy thudc vao vi tri dién cue tai that phai: * Kich thich mom that phai: Vector QRS hvéng Ién tran (am & Dil, Dil, aVF; dwong & DI, aVL) Kich thich vaéch buéng téng that phai: Vector QRS hw6ng xuéng didi (dong véi séng R vu thé 6 Dil, Dill, aVF; 4m & DI, aVL), khéng c6 khdc & dinh song R © cae chuyén dao thanh duoi; & chuy&n dao truéc ngyc, QRS chuyén tiép tty Am sang duo'ng xay ra som (tai hoac truéc V4). « Kich thich thanh tw do buéng téng that phai: Vector QRS hudng xuéng dudi (duong voi séng R wu thé & DIl, Dill, aVF; m 6 DI, aVL), c6 khAc 6 dinh séng R& cc chuyén dao thanh dui; & chuyén dao truéc ngyc, QRS chuyén tiép tir am sang duong xay ra muén (tte hoac sau V5). * Cé tinh trang phan ly nhi that. Hinh 14.7. DTD tao nhip tai mém that phai (tao nhip that phai voi truce QRS hung |én trén) zalo nhom duy nhat 0528112107uy oa cap nhat https://www.facebook.com/groups/489' 152. || Sé tay dign tam dd T we w wy 1 freee err m™) rama Via Hees ey era ate eb EEE aN ells SUNT RIT SIS holy LH Hinh 44.8. PTD tao nhip tai vach budng téng that phai (tao nhip that phai voi truce QRS hwdng xuéng dudi; R & chuyén dao thanh duéi khéng co khdc; trvéc ngye thi QRS chuyén tiép som & V3) x voi wayne MM enyniny ASS “yn Vy a Vy \ \\ vt\-A xX AACS My [4th ak tit Pool Vey TCIM AP UP Gt i } f it | ra od wr AYA AAA Ay Ate \| Ed Hinh 14.9. DTD tao nhip tai thanh ty do budng téng that phai (tao nhip that phai vdi truc QRS huong xudng dui; R & chuyén dao thanh dudi cd khac; trwéc ngyc thi QRS chuyén tiép muén 0 V5) zalo nhom duy nhat 0528112107uy khoa cap nhat hittps://www.facebook.com/groups/48902m Dign tam dé trong may tao nhip || 153 4.3. Tao nhip hai buéng | * MOt dién cyc dat & nhi phai, mét dién cuc dat & that phai * DTD phy thuéc vao phuong thtrc tao nhip ctia may: * Nhan cam nhi, tao nhip that (din cye nhi nhan cam nhip xoang ndi tai va tre ché tao nhip nhi, tao nhip that di ngay sau nhip xoang): spike tao nhip that theo sau méi song P xoang va trud’c QRS * Tao nhip nhi, tao nhip that (dién cyc nhi va that lan lugt khong nhan cam dug nhip ni tai va tao nhip nhi — that): spike tao nhip di trvéc mai séng P va méi QRS * Tao nhip nhi, nhan cam that (dién cuc nhi tao nhip nhi, dién cue that nhan cam nhip that néi tai va tre ché tao nhip that): spike tao nhip di truéc P nhi (twong ty DTD tao nhip mét budng nhi) * Nhan caém nhi, nhan cam that (dién cue nhi va that déu nhan cam dug nhip néi tai va tre ché tao nhip nhi va that): DTD binh thuong, khéng co spike + Déng bé nhi that ATRIAL vl y= = yt rl i Hinh 14.10. Dac diém DTD trong tao nhip hai budng (Atrial: nhi, Ventricular: that, Sense: nhan cam, Pace: tao nhip) zalo nhom duy nhat 0528112107uy khoa cap nhat https://www.facebook.com/groups/48902: 154 || Sé tay dién tam do net Bos as on caer cen asf yy eyy/ “ty rer Banya Hinh 14.14. DTD cia mot bénh nh&n nam 78 tudi bi suy nut xoang kam block nhi that cao d6, duoc dat may tao nhip vinh vin 2 buéng. DTD cho thdy may tao nhip [in luot ca nhi va that 4.4. Tao nhip ba budng (may tai déng bé co’ tim: CRT) + Mat dién cyc dat & nhi phai, mot dién cyc dat & that phai, mét dién cue dat & xoang tinh mach vanh + May téi ddng bé co’ tim gitip tao nhip cling luc that trai va that phai, gitip hai tht co bop déng bé theo [4p trinh cai sn, nhan biét hiéu qua bang déu hiéu QRS hep lai sau dat may ¢ DTD tao nhip hai budng that: spike di trréc QRS, QRS gin réng dang block nhanh phai va duong 0 V1 zalo nhom duy nhat 0528112107uy khoa cap nhat https://www.facebook.com/groups/489022, Dién tam dé trong may tao nhip || 155 Tru@c CRT Sau CRT dean mane ai PP vv m a v3 AMS mAs 1 1 yey an ear] ye me Heche “he , avi LU vs ALL we tots * # * f A VF Armpssve ” jn ave AIAN v6 aA ‘ yoy 4 m4 Hinh 14.12. DTD truec (QRS gidn réng) va sau khi dat CRT (QRS hep lai) Alte oi “¥ ESS Hinh 14.13. DTD sau dat may tai déng bé co’ tim, tao nhip hai budng that (spike di trvéc QRS, QRS dang block nhanh phai va dvong & V1) zalo nhom duy nhat 0528112107uy khoa cap nhat https:/Avww.facebook.com/groups/4890ae. 156 || Sé tay dién tam ad 5. MOT SO BAT THUONG TAO NHIP THUONG GAP 5.1. That bai tao xung 5.1.1. Dac diém dién tam dé + May khéng phat xung khi dugc chi dinh ¢ Spike tao nhip khéng hién dién khi cho doi « Nhan biét boi khodng ngung dai hon khoang tw dong hay khdng cd spike tao nhip & cudi khoang thoat Hinh 14.14. DTD may tao nhip that bai tao xung (cd mét Khoang ngung khéng cé spike tao nhip dai hon khoang ty dong) 5.1.2. Nguyén nhan ° May bj tat * Ché ndi bi léng hoadc gay ° Diléch dién cwc ° May hét pin | ¢ Nh&n cam qua mirc. 5.2. That bai tao nhip 5.2.1. Dac diém dién tam dé * May phat xung nhwng khéng khiv cu dugrc budng tim can kich thich » Nhan biét boi sau spike tao nhip khéng cé séng khtr cye zalo nhom duy nhat 0528112107uy khoa cap nhat https://www.facebook.com/groups/489022: Digén tam dé trong may tao nhip || 157 = Hinh 14.15. DTD may tao nhip that bai tao nhip (c6 spike tao nhip nhung khdng cé séng Khir crc theo sau) 5.2.2. Nguyén nhan * BDién cwe di léch * Nguéng kich thich tang + Nhdi mau co tim c4p * Thting tim ° Xung d6ng xay ra trong thdi gian tro’ ndi tai. 5.3. Nhan cam kém (Undersensing) 5.3.1. Dac diém dién tam dé + May khéng nhan biét cé nhip ni tai ctia benh nhan * Nhan biét bdi cdc spike tao nhip roi gan cdc nhip néi tai hon khoang thoat, spike nam l6n x6n qua suét chu chuyén tim (may lién tuc tranh chap voi nhip néi tai clia bénh nhan) Hinh 14.16. DTD may tao nhip nhan cam kém (spike roi gan cac nhip ndi tai, may tranh chap nhip néi tai) 5.3.2. Nguyén nhaén * Ché d6 khéng ding bd * Hoat déng that ndi tai roi vao giai doan tro © Dién cye di l&ch hay nhdi mau co’ tim zalo nhom duy nhat 0528112107uy khoa cap nhat https://www.facebook.com/groups/48902#- 158 || Sé tay dién tam ad * Bién thé QRS thap * Ch6 néi bj dirt * May tao nhip co Idi ° Pin yéu. 5.4. Nhan cam qua mirc (Oversensing) 5.4.1. Dac diém dién tam dé + May nhan dién cdc hoat déng dién bén ngoai hay hoat d6ng dién ndi tai sai nhu la sv kién Wc ché + Nhan biét béi vang spike tao nhip va that bai phat spike Hinh 14.17. PTD may tao nhip nhan cém qua mic (cac phic b6 dau tién véi spike di truéc QRS la cac phic bd dugc tao nhip, sau d6 la mét doan nhiéu dién khién cho may nhan cam nham la nhip néi tai cia bénh nhan nén dn dén tre ché tao nhip, DTD & doan nay vang cac spike tao nhip) 5.4.2. Nguyén nhan * Ngu@ng nhan cam qua cao « Nhiéu dién tir + Bién thé co * Dién thé sng T. zalo nhom duy nhat 0528112107uy khoa cap nhat https://www.facebook.com/groups/489022: DIEN TAM BO TRONG MOT SO BENH LY KHAC 4. THUYEN TAC PHO! CAP 1.1. Dac diém dién tam dd Thuyén tac phdi cp cé thé cd mét hoac nhidu dau hiéu sau: ¢ Nhip nhanh xoang (44%) « Block nhanh phai (18%) + Dau higu tang ganh that phai (lién quan dén tang dp dong phdi nang): song T dao ngugrc & cac chuyén dao truoc ngwe bén phai (V1-4) + thanh diroi (Dil, Dill, aVF) (34%) Truc léch phai (16%) Song R wu thé & V1 (gin that phai) Lon nhi phai (P phé): sng P & Dil > 2,5 mm (9%) Dau hiéu S, Q,, T,, (ddu hiéu kinh dién): séng $ sau & DI, song Q 6 Dil, song T dao ngug'c & Dill (20%) Tim xoay theo chiéu kim déng hd: chuyén dao chuyén tiép (R/S = 1) doi vé phia V6 voi song S wu thé & V6 Réi loan nhip nhanh tai nhi: rung nhi, cudng nhi, nhip nhanh nhi (8%) Thay ddi ST-T khéng dac hiéu, bao gém ST chénh [én va chénh xudng (50%) 1.2. Dac diém dién tam dé Cac bién déi DTD trén khéng hoan toan d&c hiéu cho huyén tac phdi cap. C6 thé gap trong cac trong herp tam phé cap (viém phdi nang, dot cAp COPD/hen phé quan, tran khi mang phdi,...) hay tam phé man (COPD, xo’ phdi, bénh phai m6 ké, ngung thé khi ngii tac nghén....). zalo nhom duy nhat 0528112107] 159