Khuyến cáo (2023) của Liên chi Hội Tim mạch Tp. Hồ Chí Minh về chẩn đoán và điều trị bệnh van tim (Phần 2)

Trưởng ban: PGS.TS. PHẠM NGUYỄN VINH

Tham gia biên soạn: PGS.TS. HỒ HUỲNH QUANG TRÍ,

TS.BS. TRẦN VŨ MINH THƯ, BS CKII. LÊ THỊ ĐẸP,

BS CKII. TRẦN THỊ TUYẾT LAN, ThS.BS. HUỲNH THANH KIỀU,

ThS.BS. PHẠM ĐỖ ANH THƯ, BS CKI. PHẠM THỤC MINH THỦY

Biên tập: LƯƠNG BÍCH NHUNG, TRẦN THỊ THANH NGA

(…)

9.2. Chẩn đoán

9.2.1. Triệu chứng lâm sàng:

Triệu chứng lâm sàng của hẹp van động mạch chủ (ĐMC) gồm cơn đau thắt ngực (60%), khó thở khi gắng sức (90%), xây xẩm hoặc ngất (35%).

Khám lâm sàng trong hẹp van ĐMC có mạch nhỏ và chậm trễ (Pulsus parvus and tardus). Nghe tim có âm thổi tâm thu dạng quả trám ở liên sườn hai bờ phải xương ức lan lên cổ. Tiếng T1 bình thường, T2 bình thường hoặc tách đôi đảo ngược.

9.2.2. Các cận lâm sàng cần làm trong chẩn đoán hẹp van ĐMC

9.2.2.1. Điện tâm đồ

Có hình ảnh dày thất trái, tăng gánh tâm thu thất trái. Một số trường hợp hẹp van ĐMC nặng nhưng ECG bình thường như ở người già, cơ tim sợi hóa. Chống chỉ định làm trắc nghiệm gắng sức ở bệnh nhân hẹp van ĐMC nặng.

9.2.2.2. X-quang tim phổi: có thể thấy hình ảnh dày thất trái.

9.2.2.3. Siêu âm tim

Giúp chẩn đoán xác định hẹp van, độ nặng, cơ chế, tình trạng lá van và ảnh hưởng huyết động lên tim như kích thước buồng tim, phân xuất tống máu thất trái, áp lực động mạch phổi và các tổn thương kết hợp khác.

Chỉ định siêu âm tim khi bệnh nhân có thay đổi triệu chứng, có mắc bệnh nội khoa cấp tính khác (ví dụ: nhiễm trùng, thiếu máu, xuất huyết tiêu hóa,..), có thai, trước phẫu thuật ngoài tim, hoặc làm định kỳ mỗi năm ở bệnh nhân hẹp van ĐMC mức độ trung bình đến nặng.

9.2.2.4. Trắc nghiệm gắng sức bằng thảm lăn hoặc xe đạp

Bệnh nhân hẹp van ĐMC nặng không triệu chứng (giai đoạn C1) có thể làm trắc nghiệm gắng sức để đánh giá những thay đổi sinh lý và xác định thật sự không có triệu chứng cơ năng (loại IIa, MCC B). Chỉ định này thường áp dụng cho bệnh nhân có triệu chứng mơ hồ, người lớn tuổi ít vận động nên khó đánh giá triệu chứng cơ năng. Khi gắng sức nếu triệu chứng đau ngực, khó thở, tụt huyết áp xảy ra, người bệnh có chỉ định điều trị can thiệp van ĐMC.

Chống chỉ định làm trắc nghiệm gắng sức ở bệnh nhân hẹp chủ nặng, có triệu chứng (giai đoạn D1) do có nguy cơ ảnh hưởng huyết động nặng (loại III, MCC B). Các biến chứng khi làm gắng sức có thể là ngất, nhịp nhanh thất và tử vong.

9.2.2.5. Siêu âm tim gắng sức Dobutamin liều thấp

Bệnh nhân hẹp van ĐMC nặng, chênh áp lực ngang van thấp, phân suất tống máu giảm (cung lượng tim thấp, phân suất tống máu thấp) cần được làm siêu âm dobutamine liều thấp (Hình 2) để xác định hẹp van ĐMC nặng thật sự hay giả hẹp van nặng; và đánh giá dự trữ co bóp thất trái.

Bệnh nhân được truyền dobutamine liều khởi đầu 2.5 – 5.0 mcg/kg/phút, tăng liều mỗi 3 – 5 phút, mỗi lần tăng 2.5 – 5.0 mcg/kg/ph, liều tối đa là 10 – 20 mcg/kg/phút. Trong mỗi mức liều mỗi 3 – 5 phút, bệnh nhân được khảo sát:

• Điện tâm đồ: đo nhịp tim
• Siêu âm tim: đo vận tốc dòng máu ngang van ĐMC, chênh áp trung bình, diện tích mở van (theo phương trình liên tục), thể tích nhát bóp

Ngưng nghiệm pháp khi:

• Đạt được liều dobutamine tối đa 20 mcg/kg/ph
• Nhịp tim tăng thêm 10 – 20 nhịp so với ban đầu hoặc nhịp tim trên 100 lần/phút
• Có triệu chứng cơ năng, tụt huyết áp hoặc rối loạn nhịp nặng.
• Kết luận được có hẹp van thật sự với vận tốc ngang van tăng ≥ 4 m/giây, chênh áp trung bình ≥ 40 mmHg và DTMV ≤ 1.0 cm².

Chỉ số cung lượng thất (Svi) lúc ban đầu dưới 35 ml/m² thì gọi là cung lượng tim giảm.

Ở liều dobutamine tối đa, nếu SVi tăng thêm trên 20% so với ban đầu thì kết luận còn dự trữ co bóp thất trái. Trường hợp hẹp van ĐMC nặng giai đoạn D2, nếu bệnh nhân còn dự trữ co bóp thất trái thì tiên lượng sau mổ tốt hơn bệnh nhân mất dự trữ co bóp thất trái.

Hình 2. Sơ đồ thực hiện siêu âm tim gắng sức Dobutamine liều thấp ⁽⁵⁾

9.2.2.6. MSCT tim

Để đánh giá mức độ dãn ĐMC lên, mức độ vôi hóa lá van, mức độ hẹp van ĐMC, tìm “porcelain aorta” (ĐMC sứ hóa), khảo sát các thông số trước khi thay van ĐMC qua thông tim.

Điểm vôi hóa của van ĐMC nếu trên 1300 đơn vị Agaston ở nữ, trên 2000 đơn vị Agaston ở nam là có liên quan đến hẹp van ĐMC nặng. Ngoài ra, CT còn giúp đo đường kính vòng van ĐMC, chiều dài lá van, khoảng cách từ vòng van ĐMC đến các lỗ xuất phát mạch vành ở bệnh nhân thay van ĐMC qua da.

9.2.2.7. Chụp mạch vành và thông tim

Chỉ định chụp động mạch vành thường quy trước can thiệp van ĐMC

• Hẹp van ĐMC ở bệnh nhân có cơn đau thắt ngực hoặc có yếu tố nguy cơ bệnh mạch vành.
• Hẹp van ĐMC ở bệnh nhân nam từ 40 tuổi trở lên, nữ mãn kinh

Thông tim xác định chẩn đoán hẹp van ĐMC nặng

• Bệnh nhân có triệu chứng lâm sàng nghẽn đường ra thất trái tuy nhiên siêu âm không xác định được.
• Có sự bất tương hợp quan trọng giữa triệu chứng lâm sàng với kết quả siêu âm tim hay cận lâm sàng hình ảnh không xâm nhập khác. Thông tim đo sự chênh áp lực ngang van ĐMC xác định có hẹp van ĐMC nặng không.

Theo khuyến cáo của Hội Tim mạch Hoa Kỳ 2020, các cận lâm sàng cần thực hiện ở bệnh nhân hẹp van ĐMC được trình bày trong Bảng 7.

Bảng 7. Các cận lâm sàng ban đầu cần thực hiện ở bệnh nhân hẹp van ĐMC ⁽¹⁾

9.3. Điều trị nội khoa

• Điều trị nội khoa hẹp van ĐMC nặng có nhiều hạn chế, tránh làm nặng thêm triệu chứng của người bệnh. Các thuốc tim mạch nên được dùng liều thấp tăng dần, tránh giảm mạnh tiền tải và theo dõi sát đáp ứng của người bệnh.
• Điều trị bệnh cơ bản đi kèm như tăng huyết áp, rối loạn lipid máu, bệnh tim thiếu máu cục bộ, suy tim,…(nếu có) theo các hướng dẫn chuẩn.
• Ức chế men chuyển hoặc chẹn thụ thể angiotensin II ở bệnh nhân sau TAVI có thể xem xét sử dụng nhằm kéo dài đời sống, giảm tử vong.
• Dùng chẹn bêta khi suy tim PSTM ≤ 40%, sau nhồi máu cơ tim cấp và/hoặc có cơn đau thắt ngực
• Dùng lợi tiểu khi có suy tim sung huyết, lưu ý nên dùng liều thấp
• Digitalis khi có rung nhĩ kèm suy tim PSTM giảm.
• Dùng statin để phòng ngừa tiên phát và thứ phát bệnh tim mạch do xơ vữa theo các khuyến cáo hiện nay.

Bảng 8. Hướng dẫn điều trị nội khoa hẹp van ĐMC ⁽¹⁾

9.3.1. Thời điểm can thiệp

Bệnh nhân hẹp van ĐMC nặng cần được theo dõi sát và điều trị can thiệp thay van ĐMC kịp thời. Chỉ định điều trị can thiệp được trình bày trong Bảng 9.

Chỉ định thay van ĐMC loại I gồm:

• Hẹp van ĐMC nặng có triệu chứng (giai đoạn D1 và D2).
• Hẹp van ĐMC nặng giai đoạn D3 với triệu chứng cơ năng được cho là do hẹp chủ nặng gây ra.
• Hẹp van ĐMC nặng không có triệu chứng, nhưng PSTMTT giảm dưới 50% (giai đoạn C2).
• Hẹp van ĐMC nặng kèm theo mổ tim do chỉ định khác.

Chỉ định thay van ĐMC loại IIa gồm:

• Hẹp van ĐMC nặng không triệu chứng, giai đoạn C1, có nguy cơ phẫu thuật thấp kèm theo 1 trong những điều sau đi kèm thì cân nhắc thay van ĐMC cho người bệnh sớm:
• Hẹp rất nặng với v trên 5.0 m/giây
• Hẹp van tiến triển nhanh với mức độ tăng vận tốc dòng máu qua van ĐMC trên 0.3 m/giây/năm khi theo dõi liên tục bằng siêu âm tim.
• Trắc nghiệm gắng sức dương tính với giảm khả năng gắng sức, xuất hiện triệu chứng hoặc huyết áp tụt ≥ 10 mmHg khi gắng sức tối đa so với ban đầu.
• Tăng peptide lợi niệu BNP trên 3 lần giới hạn bình thường.

Ngoài ra, cân nhắc thay van ĐMC (chỉ định loại IIb) trong trường hợp hẹp chủ trung bình kèm chỉ định mổ tim khác, hoặc hẹp van ĐMC nặng không triệu chứng giai đoạn C1, khi theo dõi liên tục với cận lâm sàng hình ảnh thấy phân suất tống máu thất trái giảm dần và dưới 60%. Những trường hợp này nên cân nhắc giữa lợi ích và nguy cơ trước khi quyết định.

Bảng 9. Chỉ định điều trị can thiệp hẹp van ĐMC ⁽¹⁾

Hình 3. Chỉ định can thiệp thay van trong hẹp van ĐMC ⁽¹⁾

AVAi,  Aortic Valve Area (index), Chỉ số diện tích mở van ĐMC; SVI, Stroke Volume Index, Chỉ số cung lượng thất; AVR, Aortic Valve Replacement; Thay van động mạch chủ; SAVR, Surgical Aortic Valve Replacement; Thay van động mạch chủ bằng phẫu thuật; ĐMC, Động Mạch Chủ; PSTMTT, Phân suất tống máu thất trái; BNP, B-type natriuretic peptide; TAVi; Transcatheter Aortic Valve Implantation, Thay van động mạch chủ qua da ; rP, độ chênh áp lực; ETT, Exercise Treadmill Test, Trắc nghệm gắng sức thảm lăn.

9.3.2. Chọn lựa phương pháp can thiệp

Chọn lựa phương pháp điều trị can thiệp thay van ĐMC bao gồm: (1) chọn loại van nhân tạo (van cơ học hay sinh học); và (2) phương pháp thay van (phẫu thuật thay van– [SAVR] hay thay van qua thông tim – [TAVI]).

Việc chọn lựa van sinh học hay van cơ học căn bản dựa vào độ tuổi của người bệnh, chống chỉ định hoặc không thể điều trị thuốc kháng đông lâu dài và đặc biệt làm mong muốn của người bệnh sau khi đã được giải thích đầy đủ về lợi ích và nguy cơ của từng loại van (Bảng 10). Bệnh nhân càng cao tuổi (trên 65 tuổi) chỉ định thay van sinh học càng được ưu tiên lựa chọn; người trẻ (dưới 50 tuổi) ưu tiên chọn van cơ học. Người trong khoảng 50 – 65 tuổi thì cân nhắc đặc điểm cụ thể từng bệnh nhân để lựa chọn. Bệnh nhân không có khả theo dõi điều trị hoặc không muốn uống thuốc kháng đông lâu dài thì nên chọn van sinh học, tuy nhiên phải chấp nhận nguy cơ thay van lần nữa do thời hạn sử dụng van sinh học ngắn hơn van cơ học.

Tất cả bệnh nhân cần thay van ĐMC cơ học sẽ được phẫu thuật thay van. Đối với van sinh học có thể thay van qua phẫu thuật hoặc qua thông tim. Chỉ định phương pháp can thiệp nào nên được ưu tiên chọn lựa được trình bày trong Bảng 11.

Thay van động mạch chủ bằng phẫu thuật được ưu tiên chọn lựa ở người trẻ tuổi (dưới 65 tuổi), thời gian sống ước đoán còn lại dài (trên 20 năm) và nguy cơ phẫu thuật thấp.

Đối với người cao tuổi (trên 80 tuổi), có nhiều bệnh nội khoa đi kèm, nguy cơ phẫu thuật cao hoặc chống chỉ định phẫu thuật, thời gian sống ước đoán còn lại thấp (dưới 10 năm) và không có chống chỉ định về mặt giải phẫu khi làm TAVI thì ưu tiên lựa chọn TAVI.

Ngoài ra, còn có một số đặc điểm khác của người bệnh cũng ảnh hưởng đến quyết định lựa chọn thay van bằng phẫu thuật hay thông tim sẽ được trình bày trong Bảng 12.

Bảng 10. Hướng dẫn chọn lựa van nhân tạo ĐMC ⁽¹⁾

Bảng 11. Hướng dẫn chọn lựa phương pháp can thiệp bằng phẫu thuật hay qua thông tim ⁽¹⁾

Bảng 12. Các yếu tố cân nhắc lựa chọn khi thay van ĐMC bằng phẫu thuật hay qua thông tim ⁽¹⁸⁾

(Còn nữa…)

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