TON THNG CO LUONG THONG TRAI - PHAIBS ao Hu Trung

Muc ch sieu amnh v ton thng khuyet tat nam tang Nh, tan That hay tang ong MachXac nh noi tiep cac tnh mach phoi.Xac nh ton thng phoi hp ( Co/ khong)anh gia kch thc buong tim (Dan) va o day thanh tim ( ph ai)anh gia ap lc ong Mach Phoi

An isolated secundum atrial septal defect results in left-to-right shunting at the atrial level, resulting in a vulume (diastolic) overload and, therefore, dilation of the atria, right ventricle, and pulmonary artery. Arrows indicate extra shunt flow

An isolated ventricular septal defect results in left-to-right shunting at the ventricular level, with volume (diastolic) overload and resultant dilation of the left atrium and left ventricle. Arrows indicate extra shunt flow

Type of ventricular loadsVolume (diastolic) loadIs caused byShuntsValvular insufficiencyResults inChamber dilationPressure (systolic) loadIs cause byStenosesIncreased vascular resistanceResults inHypertrophy

Illustration of the flow patterns in the normal fetal heart. Because flow is necessary for normal development, disruption in the flow at any stage will cause undergrowth (hypoplasia) or absence (atresia) of structures downstream of the disruption

Pressure volume loop relating the pressure in the left ventricle to the volume. The area of the curve is the work performed by the heart. Pressure loads are primarily caused by obstructions, whereas volume loads are caused by shunts and valvular regurgitation. Either type of load results in increased work for the heart.

Illustration of the volume load of aortic regurgitaion. The arrows represent the different flows. The flow out the aortic valve during systole is equal to the mitral flow during diastole plus the backward flow through the aortic valve during diastole. This extra volume (diastolic) load causes enlargement of the left ventricular cavity

CON ONG ONG MACH(PCA-PDA)

Tan suat:5-10% cac benh TBSPhoi thai Giai phau hoc:Bat nguon t cung MC VIPhan gan: MP traiPhan xa:Ong MTuan th 6:55% lu lng tim phoi thaiong: 2 giai oan: 10-16 gico that c (Vai tro PGE1 E2 2-3 tuanhanh lap mo si oxygen) 8 tuan # 90%ongKch thcL2-15mm5-15mmBen trai ( Ben phai? Hai ben?)

Sinh ly benhBenh ly Shunt T->PYeu to : - Kch thc lo thong- Tuan hoan phoi Lu lng Ap lc (TP)- Tang ganh TT that trai- Tuoi thieu thangS sinhTre ln

Con ong ong machDang co ien, khong kem tang ap MP, khong day that phaiCon ong ong mach (ong ln0, lam tang ap MP va day that phaiCon ong ong mach vi luong thong phai trai. V tr luong thong lam mau en chay ve pha ong mach chu xuong

Lam sang Can lam sang3 the lam sang1. Kch thc ong nho Shunt t- Ap lc MP bnh thngTrieu chng c nangPhat trien tng oi bnh thngAT lien tuc (+)Xquang TP : bnh thngECG : cha tang taiSieu am : ong thong nho. Pho SA Doppler van toc lnShunt ln

2. Kch thc ong ln Shunt nhieu Ap lc MP caoTrieu chng c nang ++ - giam canKho th mach nayAT lien tuc T2 vang A6TTTrng mom T1 anhXqTP: Tim to TH phoi tangECG: Tang ganh 2 TSA : ong thong ln. Pho SA Doppler van toc kemBien chng : Suy ho hap. H 2 la. H MC. Suy that trai. VNTMX tr : GP khong ch i

Tang ap MP nang Khong con Shunt ao shuntTrieu chng: Cao ap MP tmSA: Ong thong ln Shunt 2 chieuSA Doppler van toc rat thapTrieu chng tang ap MP

Lam sang Can lam sangI. Kch thc ong nho Shunt t Ap MP BTt trieu chng c nang Phat trien tng oi BT

II. Kch thc ong ln 8mm Shunt nhieu- ALMP caoTrieu chng c nang +++Giam can Bien dang long ngc kho th.

III. Tang ALMP nangKhong con ShuntShunt ao- Khang lc MP cao

CON ONG ONG MACH

Muc tieu sieu amChan oan xac nh: v tr ong ong mach, kch thc.Xac nh chieu luong thong, lu lng, dong chay thong.anh gia ap lc MPKch thc, chc nang buong timCac ton thng phoi hp.

Quy trnh sieu amMat cat canh c truc doc.Khao sat kch thc buong tim, anh gia chc nang tim.Cac ton thng phoi hp.

Mat cat canh c truc ngang- ngang van MC hay cao hn.Hnh anh ong ong mach tren ong mach phoi (MP) trai, noi lien vi ong mach chu (MC) xuong 2D.Sieu am Doppler ghi nhan dong lien tuc cua luong thong, dng tnh t trai sang phai, vi van toc toi a gia va cuoi tam thu.Xac nh chieu luong thong, o chenh, ap gia MC/MP.

Mat cat di sn theo truc ngang: hnh anh ong ong mach.

Mat cat tren hom c truc doc:Hnh anh ong ong mach 2D, va hnh anh Doppler mau dong mau qua ong ong mach.Dau gian tiep cua con ong ong mach vi pho dng th tam trng ngc chieu pho ong mach chu xuong pha di so vi ong ong mach.

Mat cat tren hom c truc doc hi nghieng au do giup thay ro ong ong mach (mui ten) (A-B). (Ao Arch : Cung MC ; PDA : ong M : DA : ong ong mach chu xuong)

Mat cat di sn theo truc ngang cho thay dong mau xoay cua ong ong mach, di Doppler mau co hnh anh nhieu mau

Canh c truc ngang cao : Hnh anh Doppler mau dong mau xoay chay t ong mach chu sang MP qua ong ong mach (A-B-C). Pho Doppler lien tuc dong mau qua ong ong mach. o chenh ap lc MC/MP la 92mmHg (D). Shunt 2 chieu dong mau ngang ong M tren benh nhan con ong M, tang ap MP (E) (DA : MC xuong; AO : MC; FA : dong mau xoay)

SIEU AM TRONG BENH CON TON TAI ONG ONG MACH

MUC CH SIEU AMXac nh ton thngV tr va ng i cua ong ong mach+Mat cat canh c truc ngang chuan ca cao.+Mat cat tren cXac nh luon thongBang sieu am Doppler+Chieu luong thong+Gradient AO/AP3.anh gia ap lc ong mach phoi:PAPS (PAPM?)

CH NH PHAU THUATTHEO DOI HAU PHAU + Con ton tai luong thong+ Ap lc ong Mach Phoi.

THONG LIEN NH

Tan suat: 7-15% cac benh TBS1/1500 s sinhN > Nam (2/1)

Phoi thai hoc Giai phau benhVach nguyen phat (Septum primum) Ben traiVach th phat (Septum secundum) ben phaiLo bau duc (foramen ovale)Thong lien nh va khuyet vach lien nh(inter atrial communication atrial septal defect)

V tr lo thongTLN th phat (CIA.OS)(#PFO: 10-35% BT)TLN tien phat (CIA sinus venosus)10-20% TMC tren 2-3% TMC diTLN xoang vanh (CIA sinus coronaire)

Cac ton thng phoi hpBen tim phai:Bat thng noi lien TMP (Hoan toan va khong hoan toan)TMC tren traiBat thng Ebstein Loan san TPPhnh vach lien nh (Co the CIA X)Hep van MPVan Eustachi- Cac ton thng phoi hp Shunt TPTim ben trai- H van 2 la ( do sa van hau loan san?)- Hep van 2 la (Lutembacher)

Sinh ly benh hoc : Benh ly Shunt trai phai tang nhYeu to sinh ly benh huyet ong hoc:Kch thc lo thong Lu lng mau len phoiChe o ap lc tam nho dan (Compliance) that phaio dan that traiQua trnh hnh thanh cao ap MP(cham yeu to t phat?)

LAM SANG- CAN LAM SANG3 the thng gap:1/ TLN kch thc nho: ( 5 mm/ m)Khong co trieu chng c nangAm thoi TT dang phutT2 tach oiSATM ty le TP/TT - 2/3

2/ TLN kch thc trung bnh: (5-9mm/m)-Van khong trieu chng c nang-ATTT Phut 2/6 T2 x2-XQ Ty le tim / LN (RCT) tang tTuan hoan phoi tang va.-ECG Bloc nh phai khong hoan toan-SATM ty le TP/TT 2/3 - 1

3.TLN kch thc ln (>10mm)-Trieu chng c nang: Khong tang canHan che gang scViem phe quan (+++)-ATTT 2/6 T2 x 2-AT trng tam van 3 la- T1 Tang-XQTP: RCT tang B gia trai phongTuan hoan phoi tang-ECG: Bloc NP khong hoan toan.-SA Ty le TP/ TT>1

Muc tieu sieu amXac nh chan oan, luong thongLu lng dong chay thongKch thc, chc nang cua cac buong timV tr cac tnh mach phoianh gia ap lc ong mach phoiPhat hien cac ton thng phoi hp

Quy trnh sieu am

Mat cat canh c truc doc:anh gia kch thc buong tim phai, chuyen ong nghch thng cua vach lien that.Khao sat ton thng van hai la ( h hai la) i kem.

Mat cat canh c truc ngang- ngang van ong mach chu:-Kch thc ong mach phoi-Lu lng dong mau len phoi, anh gia ap lc ong mach phoi trung bnh va tam trng.-Khao sat dong h van 3 la, anh gia ap lc ong mach phoi tam thu

Mat cat 4 buong canh c:Xac nh v tr, kch thc lo thong (sieu am 2D), chieu luong thong, sieu am Doppler va Doppler mau).Mat cat bon buong t mom: V tr cac tnh mach phoiKhao sat dong h van 3 la, ap lc ong mach phoi tam thu qua dong h 3 la.Mat cat 4 buong di sn:Khao sat v tr , kch thc thong lien nh, chieu luong thon.Khao sat v tr cac tnh mach phoi.

Cac loai thong lien nh va cac mat cat sieu am chnh e nhan dien chung

Canh c truc doc 2D va TM ghi nhan van ong nghch thng cua vach lien that. That phai dan ln, ng knh that phai o c la 4,3mm (A-B). Mat cat 4 buong canh c : khao sat Doppler mau dong chay qua lo thong lien nh t trai sang phai. Pho Doppler dong mau ngang lo thong co dang 3 nh (C-D) (pulm v : tnh mach phoi)

Mat cat 4 buong t mom : khao sat Doppler mau dong chay qua lo thong lien nh t trai sang phai (A). Mat cat 4 buong di sn giup khao sat kch thc lo TLN (lo ln, kch thc = 26mm) (B) va khao sat TLN nhieu lo (TLN lo th phat dl=5mm, TLN kieu xoang tnh mach d2=16.5mm) (D). Doppler mau dong mau qua 2 lo TLN (E). Khao sat TLN kieu xoang tnh mach vi sieu am tim qua thc quan (F)

THONG LIEN THAT

nh ngha: Khiem khuyet tai VLT thong thng TH HT Phoi

Tan suat: 20% cac benh TBS

Phoi thai hoc giai phau benhQua trnh hnh thanh vach lien that

V tr:85% phan mang (lan tren, sau,di)15% con lai phan pheu, phan c, phan nhan

Sinh ly benh hoc

Yeu to: Kch thc lo thongTy le khang lcHe thong tuan hoan phoi / He thong

Phan loai huyet ong hoc. The benh (Type) I ab IIab III - IV

Benh canh lam sangTLT lo nho Benh RogerTLT trung bnhTLT vi tang ap MPTLT vi hep MP

Tien trien va tien lng Vai tro cua sieu am trong benh TLT

Ch nh phau thuat Nguy c va ket qua

Two functional types of ventricular septal defect. A, the small type. The right ventricular wall is not hypertrophied, and the shunt is limited in extent. B, large type. The defect is an unobstructed communication. Right ventricular hypertrophy and pulmonary hypertension are associated. Left-to-right shunting is shown

Large ventricular septal defect with obstructive pulmonary vascular disease and right-to-left shunt

Conditions that may mimic large VSDSingle (common) ventricle without pulmonary stenosisDouble-outlet right ventricle without pulmonary stenosis.Note that defect is remote from both semilunar valvesPersistent truncus arteriosus

MUC TIEU SIEU AMChan oan xac nh v tr lo thong. Kch thc lo thong, hng dong chay thongKch thc cac buong tim, chc nang tam thu cua timAp lc ong mach PhoiTnh lu lng mau ong Mach phoi/ lu lng mau mach he thong (Qp/Qs)Cac benh tim khac phoi hp

Quy trnh sieu amMat cat canh c truc doc:Hnh anh lo thong ( 2D), hnh anh dong mau xoay manh mau xanh luc lap the chay qua lo thong (Doppler mau)Kch thc cac buong tim. Chc nang tam thu cua timKhao sat van ong mach chu: day, sa van, h van.

Mat cat canh c truc ngang ngang van MC-V tr lo thong-o kch thc lo thong-Khao sat chieu luong thong-Khao sat Doppler lien tuc dong mau qua lo thong lien that.Ap lc MP tam trng va trung bnh theo dong h van MP.Ap lc ong mach phoi tam thu - theo dong h van 3 la.Tm hep van MP phoi hpo kch thc lo van MP, than ong mach phoi.

Mat cat 4 buong t momKhao sat tong quat bon buong timV tr lo thong, kch thc lo thongDong h 3 la, ap lc ong mach phoi tam thu (dong h van 3 la)

Mat cat 5 buong t mom:Khao sat ton thng van MC i kem

Mat cat di sn:Khao sat thong lien that, ac biet thong lien that phan c be.

MUC CH SIEU AM TRONG THONG LIEN THATI. CHAN OANV tr khuyet tat:trenPhan quang mang (lan trc)sauVach lien that phan nhanVach lien that phan c beVach lien that phan pheuChieu hng luong thong

II. LNG GIA HUYET ONG HOC that T, nh T, that P, MPQP QSALMP tam thu (PAPS)ALMP trung bnh (PAPM)Dong mau h van 3 la, h MPDong mau luong thongHnh dang vach LT PTT/TP = 4V2 (van toc dong mau luong thong)ALTP tam thu = HA tam thu - P (neu khong co hep MP)

III. PHAT HIEN BIEN CHNGHoi chng EisenmengerH van MCHep di van MCHep pheu MPViem noi tam mac

IV. THEO DOI HAU PHAUShunt ton taiAL ong mach phoi

Mat cat 4 buong canh c : TLT phan mang co kem thong noi that trai-nh phai. Dong mau xoay mau xanh luc lap the chay qua lo TLT hng ve pha nh phai (A). Pho Doppler dong mau ngang qua lo TLT co van toc = 4m/s (B)

Mat cat 4 buong t mom : TLT buong nhan co kch thc ln (d=14mm) (A). Mat cat 5 buong t mom cho thay TLT phan mang co tui phnh vach mang (B).

Mat cat canh c truc doc giup thay hnh anh lo TLT co dong mau xoay chay ngang. o chenh ap lc that trai/that phai la 78mmHg (A-B). Mat cat canh c truc ngang-ngang van MC : TLT di ai ong mach . TLT vung pheu MP (D)

Mat cat canh c truc ngang ngang 2 that : hnh anh TLT phan c be vi ng knh lo thong la 4.3mm va hnh anh Doppler mau dong mau t tr1i sang phai qua lo thong (A-B). Mat cat 4 buong t mom \. TLT phan c be vung gan mom (mui ten (C-D)

BANG PHAN LOAI HUYET ONG

The benhKch thcPAP/ PsRP/RSQP/ RSGr VD/APIaNho

CH NH PHAU THUAT(Ref: Batisse Sidi) tre nhu nhi:TLT co cao ap MP (PAPS 70mmHg) 9-12 thang tuoi TLT co roi loan ho hap (MP dan cao ap) tre ln:TLT rong + cao ap MP (RP 8 n v wood) Neu nghi ng: bang MP + sinh thietTLT khong cao ap MP nhng co trieu chng (TT, NT ln)TLT vung pheu caoTLT type 4nh ngha:Cao ap MP = Ty le ap lc TT/ TP: 0.7