Nghin cu ng dng

K thut o Phn Sut D Tr Lu Lng Mch

Vnh (FFR) nh gi v hng dn can thip

cc tn thng phc tp trn chp mch vnh

Ti Bnh Vin Ch Ry

PGS TS BS V Thnh Nhn Khoa Tim Mch Can Thip BV Ch Ry

Hi Tim Mch Can Thip TP HCM

T VN

Theo WHO, bnh tim mch l nguyn nhn gy t vong

hng u hin nay trn th gii. Bnh mch vnh l

nguyn nhn gy t vong hng u trong bnh l tim mch

Chp MV cn quang hin vn l phng php ch yu

hng dn ch nh can thip MV qua da.

Tuy nhin vic xc nh chnh xc mt ch hp c gy

thiu mu cc b c tim hay khng ti thng vn cn l

vn phc tp nu ch da n thun trn hnh nh chp

mch cn quang.

KHNG NG B GiA GII PHU V

SINH L HC

CCH TNH FFR

RADI ANALYZER Pressure wire

TRANG THIT B

Ngng iu tr FFR

MC TIU NGHIN CU

Mc tiu tng qut

ng dng Phn Xut D Tr Lu Lng Mch Vnh

(FFR) trong ch nh can thip cc tn thng phc tp

trn chp mch cn quang.

Mc tiu chuyn bit

1. Xy dng mt quy trnh o phn sut d tr lu lng

mch vnh (da trn y vn)

2. nh gi tnh an ton, tnh hiu qu ca k thut o FFR

bnh nhn c tn thng phc tp (c nh ngha

l nhng tn thng hp 40 70% trn QCA).

I TNG V PP NGHIN CU

Dn s nghin cu:

Bn BMV khm v iu tr ti BVCh Ry t 6/2011- 30/6/2013

Tiu chun chn bnh:

Cc bnh nhn c ch nh chp mch vnh cn quang v c

ch nh o FFR

ng tham gia nghin cu.

C y thng tin d liu theo yu cu ca nghin cu

Tiu chun loi bnh:

Khng ng tham gia nghin cu

Khng d kin lm sng v cn lm sng

Can thip khng c FFR hng dn.

Cht lng hnh nh chp mch vnh khng t.

Cht lng hnh nh o FFR khng t.

Phng php nghin cu

Thit k nghin cu: Quan st, theo di dc, tin cu

C mu= Z2 x P(1-P)/d2 = 1.962 x 0.1 x 0.9/0.052 #139 bn

Cc bc thu thp s liu

Thng tin c bn: (tui, gii, yu t NCTM, chn on LS).

Cc thng s c bn v CMV: mc hp.

Mc nh hng trn chc nng da trn FFR

nh gi kt qu tc thi ca th thut qua ch s FFR.

Cc bin c tim mch nng: 12 thng

T vong do mi nguyn nhn

Nhi mu c tim

Ti thng mch mu ch

T l sng cn.

I TNG V PP NGHIN CU

Quy trnh o FFR.

Heparin 60 - 70 UI/kg.

Nitroglycerin (100-200g) bolus IC loi tr co tht.

Kim tra p lc v xc nh v tr 0 (zero).

Khi cm bin ca p lc n u ng thng, p lc ca u

ng thng v ca dy p lc c ng nht.

a cm bin vt qua tn thng.

Trc khi o, dn h vi mch ti a bng Adenosine IC

MV phi liu IC ln lt l 40, 60, 80, 100 g,

MV tri liu IC ln lt l 60, 90, 120, 150 g.

Cng liu thuc s c s dng o FFR sau t stent.

I TNG V PP NGHIN CU

X l s liu: phn mm STATA10.0

Bin s nh lng c tnh gi tr trung bnh.

Bin s nh tnh c tnh theo t l.

Kim nh phn phi bnh thng bng php kim Shapiro Wilk

So snh 2 trung bnh phn phi bnh thng bng php kim T-test

So snh 2 phn phi khng bnh thng bng php kim phi tham

s Wilcoxon Rank test.

So snh nhiu phng sai bng php kim Bartlett test

So snh nhiu trung bnh bng php kim ANOVA.

So snh t l bng php kim 2.

Vi khong tin cy 95%, s khc bit c xem l c ngha thng

k khi gi tr p < 0.05.

I TNG V PP NGHIN CU

140 BN, 2/3 l nam, tui 63,49 10,33 (min 42; max 86). Tng s 197 tn thng c o FFR.

T l thnh cng 100%, sau can thip 100% FFR>0.90

Bin chng:

1. Do thao tc: t vong =0, thng mch vnh =0, bc tch ni

mc =0.

2. Do Adenosine:

co tht ph qun = 0,

tt huyt p phi dng vn mch = 0,

nhp chm phi x tr = 0,

ngng xoang = 0.

Khi dng Adenosin n 150 g c 3 trng hp block AV II v

1 ngng xoang 3 giy chim t l 4/140 (2,88%).

KT QU V BN LUN

KT QU V BN LUN

Hc vn v mc hot ng th lc

Trnh S bnh nhn Phn trm

i hc/ Sau i hc 33 23.6

Di i hc 107 76.4

Mc tp luyn S bnh nhn Phn trm

Khng tp hoc tp

khng ng k

101 72.1

Tp luyn 1-2 ln/tun 17 12.1

Tp luyn 3 ln/tun 22 15.7

KT QU V BN LUN

So Snh tui v gii

Hunh

Ngc

Long[3]

Nguyn

Cu

Li[2]

Phm

Gia

Khi[1]

Pierre

Legalegy[

16]

Javier

Courtis [11]

chng ti

Gii

Nam

(%)

83,7

82,8

79,4

68

80

66,91%

Hunh

Ngc

Long[3]

Nguyn

Cu

Li[2]

Phm

Gia

Khi[1]

Pierre

Legalegy [16]

Javier

Courtis [11]

chng ti

Tui

trung

bnh

61,512,5

58,34,7

59,958,3

59 10

6210

63,4910,33

KT QU V BN LUN T l BN theo s lng yu t nguy c. >81% c > 3 YTNC

KT QU V BN LUN 3 yu t nguy c thng gp nht

Tc gi Ht thuc

l

Tng

huyt p

Ri lon

lipid mu

i tho

ng

Tin cn

gia nh

Pierre Legalery

(n = 407) [16]

62% 47% 71% 25% KGN

Weerayut

(n = 60) [27]

28% 80% 78% 52% 0%

Sants Anna (n = 250) [7]

25,2% 84,4% 48% 22,5% 40,8%

Phm Nguyn

Vinh (n = 462)[5]

22,5% 65,2% 62,1% 21% KGN

Chng ti

(n = 115)

60,15% 67,63% 74,1% 23,74% 9,35%

KT QU V BN LUN Phn b chc nng tht tri EF

34%

61%

KT QU V BN LUN

Cc thuc ang s dng

Thuc Phn trm

Khng tiu cu 100

c ch men chuyn/ c

ch th th

100

Statin 97,2

Chn Beta 90,65

Nitrat 66,91

KT QU V BN LUN

So snh cc v tr gii phu hc

ng mch vnh Javier Courtis [11] Pierre Legalery [16] Chng ti

LMCA 21% 1% 6,12%

LAD 66% 64% 48,98%

RCA 9% 21% 24,7%

LCx 4% 14% 16,84%

D 0% 0% 4,59%

KT QU V BN LUN So snh mc hp ca cc TT gia cc nhnh

LMCA LAD D LCx

LAD P = 0,97

D P = 1 P = 0,99

LCx P = 0,96 P = 0,99 P = 0,98

RCA P = 1 P = 0,78 P = 1 P = 0,80

MV S MV (%) Mc hp

LMCA 12 (6,1%) 57,4 8,9

LAD 97 (49,2%) 59,1 7,9

LCx 33 (16,8%) 59,5 9,1

RCA 45 (22,8%) 57,2 5,8

D 10 (5,1%) 57,8 5,8

Tng 197 (100%)

KT QU V BN LUN

So snh FFR trong tng mch v gia cc mch

MV FFR > 0,80 FFR 0,80 P

LMCA 1,75% 12,2% 0,0030

LAD 35,96% 67,07% 0,0001

LCx 23,68% 7,32% 0,0030

RCA 32,46% 10,98% 0,0001

D 6,14% 2,44% 0,22

m FFR LMCA m FFR LAD

mFFR LCx P = 0,004 P = 0,0001

mFFR RCA P = 0,012 P = 0,0010

KT QU V BN LUN Tng quan nghch gia QCA v FFR:

Tc gi R P

Chng ti -0,36 < 0,0001

Fernando Mendes StaAnnant [11] -0,33 < 0,0001

Weerayut Nunrungroj [38] -0,4 < 0,006

KT QU V BN LUN

Nu can thip tt c th c 100 BN s tn thm 60x40 triu=

2,4 t (chi ph trung bnh t 1 stent thng). Nu t stent

thuc th phi tn thm 60x70 triu = 4,2 t.

Tin Plavix i km 22.000 /vin x365 ngy # 8 triuBN/ nm x

60 BN = 480 triu/ nm.

Chi ph hin nay lm FFR #8 triu/bn x 100 BN= 800 triu,

tit kim c 1,6-3,4 t.

FFR Michalis

Hamilos [13]

Pierre

Legalery [16]

(QCA 40-60%)

Pim [21] Chng ti

(QCA 40-70%)

FFR > 0.80 64,8% 67% 65% 58,16%

FFR 0.80 35,2% 33% 35% 41,84%

KT QU V BN LUN

Cc bnh nhn lm th thut khng ng ch nh cn c

nguy c b s c do th thut mang li.

Da trn QCA: NC FAME, 2009, 1005 BN, : s lng

stent/BN = 2.7 1.2 so vi 1.9 1.3 nhm FFR (p

KT QU V BN LUN

ng t l sng cn ng t l sng cn khng

bin c

KT LUN

o FFR gip thy thuc quyt nh ngay trong phng

thng tim cch x tr ph hp.

Tim adenosine IC vi liu tng dn, MV phi ti 100

g v MV tri ti 150 g l quy trnh an ton.

Chi ph sng lc tit kim l t 2,5-5 ln nu can thip

i tr.

Gim nguy c s c tim mch nng cn 1/3 so vi khng

c can thip nu tn thng c FFR < 0.80.

o FFR nh vy an ton, kinh t v c ch.

CM N S THEO DI CA QU V