u y khoa cap nhat https://www.facebook.com/groups/4890: ROI LOAN NHIP DI TRUYEN 4. HOI CHUNG QT DAI HOi chtrng QT dai l& mét dang réi loan nhip di truyén, co thé nhan biét trén DTD, lién quan dén réi loan tai circ co’ tim, lam tang nguy co’ réi loan nhip that ac tinh gay ngat hoc dét tte do tim. Trén DTD, QT dai khi QTe (tinh theo céng thir Bazett): | + > 450 ms 6 nam » >460 ms 6 ni | Bang 13.1. Thang diém Schwartz higu chinh (ESC 2022) Dac diem Dau hiéu trén dién tam d6* QTc (tinh theo céng thtrc Bazett) * 2480 ms 3,5 ° 460 —-479 ms 2 + 450 — 459 ms (6 nam gidi) f QTc phut tht tu giai doan phuc hdi tty nghiém 1 phap gang strc > 480 ms Xoan dinh 2 Séng T luan chuyén (T wave alternans)”” 1 Séng T cé kh4c & ba chuy&n dao 4 TAn sé tim th4p theo tudi 0.5 1.1. Dac diém dién tam dé 432 |) ~ zalonhom duy nhat 0528112107ny khoa cap nhat https://www.facebook.com/groups/489022 Réi loan nhip di truyén || 133 Dac diém Lice a Ger) Ngat (khéng tinh diém dng thoi cho ca ngat va xoan dinh) * Co stress 2 * Khdng stress 1 ice ae men) Thanh vién khac trong gia dinh dwg chan 1 doan xac dinh cé hdi chteng QT dai*** C6 thanh vién trong gia dinh dét tir khéng giai 0,5 thich dug (trudc tudi 30)*** Xét nghiém gen Co dét bién gen bénh ly 3,5 *Khi khéng c6 thuéc hode réi loan khéc 4nh hudéng téi déu hiéu trén dién tim “Song T luén chuyén duoc dinh nghia [a su thay déi luan phién vé bién dé hay phan cue cia hai hinh dang séng T khac nhau trong khi khoang RR khéng thay d6i Khong tinh diém 2 muc nay & cung mét thanh vién trong gia dinh Chan doan hGi ching QT dai khi tang diém > 3 diém zalo nhom duy nhat 0528112107ny khoa cap nhat https://www.facebook.com/groups/48902s 134 || Sé tay dién tam dd 7h pay I eet p erets Bebe aoe i BEtrblo-caaen, ddd pd Hinh 13.4. DTD ctia mot bénh nhan nam 36 tudi co tién st ngat, nhap vién vi ngung hé hap tuan hoan dug’ cp ctru thanh céng, bénh nhan dugc chan doan héi chteng QT dai bam sinh (QTc tinh theo céng thtrc Bazett = 602 ms) Bang 13.2. Dac diam DTD cac type cia héi ching QT dai (khac nhau & dac diém song T) Type Dac diém DTD LQT1 S6ng T bat dau som va rong phan day LQT2 S6ng T thudng bién dé thdp va c6 khac (2 dinh) LQT3 Doan ST dang dién dai voi sng T xuat hién muén | zalo nhom duy nhat 0528112107Binh thuong Khdi phat bdi tiéng én d6t ngét, ha kali mau va giai doan hau san — QT. T xuat hién Tugn LaT3 Hinh 13.2. Cac 6&c diém DTD va hoan canh khéi phat ctia cac type héi chteng QT dai2 1.2. Chan doan phan biét Cn loai triv cée nguyén nhan thw phat gay QT dai truéc khi chan doén hGi chtéeng QT dai bém sinh: * QT dai do bat thuong chuyén héa: ha kali mau, ha magie mau, ha calci mau, ché 46 an protein l6ng, chaén 4n tam than, nhugc giép * QT dai do thudc * QT dai do ha than nhiét * Rédi loan nhip cham: suy nut xoang, block AV d6 2 hoac 3. 2. HOI CHUNG QT NGAN H@i chteng QT ng&n la mat bénh ly kénh ion cia tim, lién quan d6t bién di truy&n troi tran NST thuOng, gay rit ngan thoi gian tai cre, c6 thé gay ngt ho&c dat tiv do tim. zalo nhom duy nhat 0528112107uy khoa cap nhat https://www.facebook.com/groups/4890: 136 || Sé tay dign tam ad 2.1. Dac diém dién tam dd Bang 13.3. Thang diém Gollob trong chan doan héi chteng QT ngan Frets tu) oe TMA RUM am ean * QTc (tinh theo céng thtrc Bazett) » <370ms » <350 ms = <330 ms won = * Khoang cach tir diém J dén dinh séng T < 120 ms 1 BTU RU) ° Tién str dOt ngdt ngung tim ¢ Duo ghi nhan nhip nhanh that da hinh hay rung 2 that « Ng&t khong ré nguyén nhan 1 * Rung nhi 1 Bieeme emi) * Thé hé thir nhat hoac thé hé thw hai co kha nang cao mac héi chtvng QT ngan ¢ Thé hé ther nhat hoac thé hé thy hai dot tte dotim = 1 voi ti thiét Am tinh © Héi chteng dt tir & tré nha nhi 1 * Kiéu gen duong tinh 2 * Dét bién cé y nghia cha xac dinh trong gen tha 1 pham zalo nhom duy nhat 0528112107ny khoa cap nhat https://www.facebook.com/groups/489022: Réi loan nhip di truyan || 137 Chan doan hgi ching QT ngan dya vao téng diém © <2 diém: it kha nang * 3 diém: kha nang trung binh * 24 diém: kha nang cao VWI i LY Sr BL | Www at ats Mc hnce | PPV VOW A ran — SA Ann aire {n VAS = Hinh 13.3. DTD cla mot bénh nhan nam 44 tudi dug chan doan hdi cht’ng QT ng&n voi QTc = 313 ms (Bazett) 2.2. Chan doan phan biét * Ré6i loan chuy&n héa va dién giai nhu tang kali mau, toan chuyén héa va ha calci mau ° Tang than nhiét * Tac dung cla thudc digitalis, acetylcholin hay catecholamin * Thiéu mau cuc bé co tim * Cuong phé vi. 3. HOI CHUNG BRUGADA H@i ching Brugada la mét bénh ly cia kénh natri, cé tinh chat gia dinh. Bénh lién quan dén dot bién di truyén tréi tren NST thung & gen SCN5A, lam gia tang nguy co réi loan nhip that gay ngat, dt tle do tim. zalo nhom duy nhat 0528112107uy khoa cap nhat https://www.facebook.com/groups/4890 2. 138 || Sé tay dign tam dd 3.1. Dac diém dién tam dd + DTD véi bat thuéng doan ST-T kiéu hinh Brugada 6 it nhat 1 chuyén dao truéc tim bén phai; V1 hoadc V2; dat & khoang lién suwon 2, 3 hoac 4 * C6 badang DTD cilia héi chteng Brugada voi cac kiéu hinh ST-T khac nhau twong teng (Bang 13.4 va Hinh 13.5) Hinh 13.4. DTD clia b@nh nhan mac héi chirng Brugada voi ST chénh lén & cac chuyén dao trén budng téng that phai; & khoang lién sun 2, 3, 4 Bang 13.4. Dac diém DTD cua cac type hdi chtng Brugada = Type 2 | BAY otoae) Bién dé séng J 22mm 22mm 22mm Song T Am Duong hoaéc Duong hai pha Dang cong Dang 16m Dang l6m Dang ST-T vor én xudng (hinh = xudng (hinh yen ngya) yén ngva) Doan ST (phan Chénh Chénh én Chénh len tan cling) xudng tt tty =1mm <1 mm zalo nhom duy nhat 0528112107uy khoa cap nhat https://www.facebook.com/groups/489022: Réi loan nhip ditruyén || 139 v2 v3 v4 V5 v6 BEE rte = = Hinh 13.5. Cac kiéu hinh ST-T khdc nhau twong tng voi ba type ctia héi chteng Brugada Ht epeppepedd fl Hleble vp pbd| i Sti ll A Lee Hinh 13.6. DTD cia mét bénh nhan nam 47 tudi mac hdi chtrng Brugada type 1 (J > 2mm, ST chénh lén dang vom, di xudng tir tty va T am & V1-3) zalo nhom duy nhat 0528112107uy khoa cap nhat https://www.facebook.com/groups/489 140 || Sé tay dién tam a6 Hinh 13.7. DTD cla mot bénh nhan nam 38 tudi mac hdi cheng Brugada type 2 (ST chénh lén dang yén ngya voi J > 2mm & V1-2, phan tan cling clia ST chénh lén > 1 mm) 3.2. Chan doan phan biét Mét sé tinh trang bénh ly cé thé co dac diém DTD giéng héi chteng Brugada: * Block nhanh phai khéng dién hinh * Bénhco tim that phai gay loan nhip ° Taicwcsom * Viém mang ngoai tim cap * Nhdi mau co’ tim cép ST chénh Ién © Phi dai that trai * Lém nguc bam sinh ° Ha than nhiét. 4. HOI CHUNG TAI CU’C SOM (HOI CHUNG SONG J) Thuat ngé “héi chtrng tai cc som” hay “hdi cheng sdng J” dugc stv dung dé m6 ta mét bién thé QRS-T dé véi bat thuong diam J trén dién tam dd. Tai cc som cé thé lanh tinh, hay gap © nhi@ng ngudi tré tudi knde manh va khéng cd bénh tim thyc tén. Tuy nhién, trong mot sé trong hap, tai cwe som cé lién quan dén gia tang nguy co’ rung that va dét tt, duoc goi la tai cyc som ac tinh. zalo nhom duy nhat 0528112107y khoa cap nhat https://www.facebook.com/groups/489 Ri loan nhip ditruyén || 141 4.1. Dac diém dién tam 4d + Diém J chénh lén 20,1 mV (1 mm) @ it nhdt hai chuy&n dao lién tiép ctia thanh duéi (Dil, DIII, aVF) va/hoac thanh bén (Dl, aVL, V4-6) + Diém J tao ra mot song dang moc, dug gai la sng J (séng duong & phan cudi phtrc b6 QRS va kéo dai tir QRS dén doan ST cong vom |én) Bang 13.5. Phan loai duoc dé xuat ctia dang song J theo vi tri giai phau Vi tri gidi Thanh Thanh duéi phau truécbén that trai that trai Chuyén dao |, V4-V6 I, UI, aVE 6 diém J hay séng J bat thuong Tién lwong Hiém khi Co nguy coréiloan co réiloan nhip nguy nhip cao hiém hon That trai va that phai Thanh duoi, thanh bén cua that trai va that phai Nguy co’ réi loan nhip cao nhat zalo nhom duy nhat 0528112107u y khoa cap nhat https://www.facebook.com/groups/4890. 142 || Sé tay dién tam 4d nh Jt Lon abe a 3 ieeay (omeaona cca af t sea Ait ee ae A ae iH pessoas HOR oe Hinh 13.8. DTD ghi nhan hinh anh dang tai circ som ctia mat bénh nhan nam 28 tuéi voi diém J chénh lén 1 mm va tao thanh mét song dang moc 6 cac chuyén dao thanh trvéc bén that trai (V4-6) 4.2, Chan doan phan biét * Nhdi mau co tim cAp * \Viém mang ngoai tim c4p Tai cyc som ‘Viém mang ngoai tim cap } | V6 | } { i | Ke Ph aE nti Hinh 13.9. Ti lé dO chénh lén ctia doan ST/chiéu cao clia song T trong tai cc sém (< 0,25) va trong viém mang ngoai tim cAp (> 0,25) zalo nhom duy nhat 0528112107uy khoa cap nhat https://www.facebook.com/groups/489022 Réi loan nhip di truyén || 143 Bang 13.6. Cac d&c diém ECG phan biét tai cwc som véi viém mang ngoai tim cAp ea : Viém mang ngoai Tai cvc som tim cap ST chénh lén = ST chénh lén lan toa khu tr @ thanh hau hét chuyén dao Doan ST ie es 2 2 dudiva/hodc chi va chuyén dao thanh bén trwéc nguc PR khén ‘ Doan PR . x) PR chénh xudng chénh xuong Moc (song J) Co Khéng Ti lé d6 chénh lén cia doan STichiéu < 0,25 > 0,25 cao cua song T 5. BENH CO’ TIM LOAN SAN THAT PHAI Bénh co tim loan san that phai hay con ggi Ia “bénh co tim that phai gay rdi loan nhip” la mét bénh ly di truyén trdi trén NST thugng. Bénh cé nguy co gay ra nhieng réi loan nhip that de doa tinh mang. 5.1. Dac diém dién tam dé Bang 13.7. Cac tiéu chuan DTD trong tiéu chuan chan doén bénh co’ tim loan sn that phai theo ECG-Realted Task Force 2010 Bat thuong tai cuc Tiéu chuan chinh * Dao nguoc séng T & cac chuyén dao truéec tim phai (V1, | V2 va V3) hoc xa hon & bénh nhan > 14 tudi (khi khong 6 block nhanh phai hoan toan voi QRS = 120 ms) zalo nhom duy nhat 0528112107uy khoa cap nhat https://www.facebook.com/groups/ 4890 144 || Sé tay dién tam 46 Tiéu chuan phy * Dao ngugc séng T @ chuyén dao V1 va V2 & bénh nhan > 14 tudi (khi khéng cé block nhanh phai hoan toan) hodc & V4, V5 hodc V6 * Bao ngugc song T 6 chuyén dao V1-4 & bénh nhan > 14 tudi khi cé sw hién dién ciia block nhanh phai hoan toan Bat thuong khir cuc/dan truyen Tiéu chuan chinh * Song epsilon (tin hiéu bién d6 thap lap lai gitea phan két thuc cla phtrc b6 QRS va khdi dau cia séng T) & cdc chuyén dao truéc tim phai (V1-V3) Tiéu chuan phy Dién thé mudn trén PTD tin hiéu trung binh cé & > 1/3 } chuyén dao khong cé QRS gidn 2 110 ms & chuyén dao DTD chuadn fQRS (filtered QRS) = 114 ms Thoi gian cla phan cudi QRS 40 mV (khoang thdi gian tin hiéu bién 66 th4p) 2 38 ms Gia tri trung binh binh phuong (gia tri higu dung) dién thé ctia doan 40 ms cudi s 20 mV . Thoi gian hoat dong phan cudi ctia QRS = 55 ms tinh ter day clia song S dén diém két thtic cia QRS, bao gdm R’, & V1, V2, hoac V3, khi khéng cé block nhanh phai hoan toan Tiéu chuan chinh * Nhip nhanh that kéo dai hoac khong kéo dai dang block nhanh trai voi truc hudng lén trén (QRS 4m hay v6 dinh © chuyén dao Il, Ill va aVF va dwong & chuyén dao aVL) zalo nhom duy nhat 0528112107uy khoa cap nhat https://www.facebook.com/groups/489022s Réi loan nhip ditruyén || 145 Tiéu chuan phu + Nhip nhanh that kéo dai hoac con nhanh that ngan dang budng téng that phai, hoac dang block nhanh trai voi truc huéng xuéng duéi (QRS dwong & chuyén dao Il, Ill va aVF va &m & chuyén dao aVL) hoac truc kh6éng xac dinh ° Holter ECG 24 gid ghi nhan > 500 ngoai tam thu that Bén canh cac tiéu chuan trén DTD, tiéu chudn chan doan bénh co tim loan san that phai con bao gdm: sv thay ddi vé cdu tric ho&c chtrc nang ciia co’ tim, d&c diém mé hoc va tin can gia dinh. SVS SEPIA Val a4 ~ fe : f | Song Epsilon Hinh 13.10. Bénh nh&n nam 52 tudi vao vién vi ng&t, ghi nh&n cé nhieng con nhanh that lién tuc trén monitor theo déi. DTD ngoai con ghi nhan sdng T Am & V1-4, c6 ngoai tam thu that xudt phat ti that phai (QRS 4m & V1-2), séng epsilon & V1. Bénh nhan duc chyp MRI tim va duoc chan doan mac bénh co’ tim loan san that phai zalo nhom duy nhat 0528112107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