Khuyến cáo (2023) của Liên chi Hội Tim mạch Tp. Hồ Chí Minh về chẩn đoán và điều trị bệnh van tim (Phần 5)

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

(…)

12. Hẹp van hai lá

Nguyên nhân gây hẹp van hai lá chủ yếu là thấp tim và thoái hóa. Thấp tim là nguyên nhân gây hẹp van hai lá hàng đầu trên toàn thế giới. Mặc dù tỷ lệ mắc thấp tim đã giảm đáng kể ở các nước phát triển nhưng vẫn còn là một vấn đề nhức nhối ở các nước đang phát triển, đặc biệt ở người trẻ. Hẹp hai lá do thoái hóa liên quan đến vôi hóa vòng van hai lá là một cơ chế riêng và tỷ lệ của bệnh sẽ tăng một cách có ý nghĩa theo tuổi.  Hẹp hai lá do hai nguyên nhân này đều gặp nhiều hơn ở nữ giới. Ngoài ra, trong một số ít các trường hợp, hẹp hai lá do lá van cứng mà không có dính các mẹp van có thể do xạ trị, bệnh tim carcinoid hoặc các bệnh chuyển hóa di truyền.

12.1. Các giai đoạn của hẹp van hai lá

Các giai đoạn của hẹp van hai lá được xác định dựa trên triệu chứng, giải phẫu van hai lá, huyết động van hai lá và hậu quả của tắc nghẽn van hai lá lên nhĩ trái và tuần hoàn phổi (Bảng 17). Bệnh van hai lá do thấp là nguyên nhân chính gây hẹp hai lá với đặc điểm giải phẫu phản ánh quá trình tiến triển của bệnh. Mức độ ảnh hưởng lên huyết động được thể hiện qua diện tích van đo bằng phương pháp vẽ viền trực tiếp trên hình ảnh siêu âm tim 2D hoặc 3D hoặc tính bằng thời gian bán giảm áp lực (PHT). Định nghĩa hẹp hai lá khít dựa trên mức độ nặng của triệu chứng cũng như mức độ hẹp van mà can thiệp có thể giúp cải thiện triệu chứng. Vì vậy diện tích lỗ van hai lá ≤ 1,5 cm² được coi là hẹp hai lá khít, thường tương ứng với chênh áp trung bình qua van từ trên 5 mmHg đến 10 mmHg ở tần số tim bình thường. Tuy nhiên, chênh áp trung bình qua van hai lá phụ thuộc tốc độ dòng chảy, thời gian đổ đầy tâm trương và tần số tim. Thời gian bán giảm áp lực cũng có những hạn chế nhất định và phục thuộc vào khả năng giãn (compliance) của nhĩ trái và thất trái cũng như mức độ hẹp hai lá. Có thể sử dụng các phương pháp tính diện tích lỗ van hai lá khác như sử dụng phương trình liên tục hoặc công thức Gorlin nếu kết quả đo không thống nhất. Điều này thường xảy ra trong hẹp hai lá do thấp.

12.2. Hẹp van hai lá hậu thấp

12.2.1.Đánh giá

Hẹp khít van hai lá được xác định khi diện tích van hai lá ≤ 1,5 cm². Dính các mép van kèm theo dày lá van sau là cơ chế quan trọng nhất gây hẹp. Siêu âm tim là phương tiện đầu tay để chẩn đoán, đánh giá mức độ hẹp và các ảnh hưởng huyết động do hẹp van hai lá. Trong khi đo diện tích lỗ van bằng cách vẽ viền trên siêu âm tim 2D là phương pháp để đánh giá mức độ hẹp của van, chênh áp trung bình qua van và áp lực động mạch phổi phản ánh những hậu quả về huyết động và có vai trò tiên lượng bệnh. Đo diện tích van bằng siêu âm tim 3D qua thành ngực cũng có giá trị hỗ trợ chẩn đoán. Siêu âm tim qua thành ngực thường cung cấp thông tin đủ để quản lý bệnh một cách thường quy. Các thang điểm đã được xây dựng nhằm đánh giá mức độ phù hợp để can thiệp nong van hai lá qua da. Nên tiến hành siêu âm thực quản để loại

Bảng 17. Các giai đoạn trong hẹp van hai lá theo khuyến cáo của ACC/AHA năm 2020 ⁽¹⁾

Cần đo chênh áp trung bình qua van hai lá để đánh giá ảnh hưởng về huyết đọng của hẹp van hai lá, chênh áp trung bình thường ≥ 5 mmHg tới 10 mmHg trong hẹp hái khít; tuy nhiên do chênh áp trung bình bị thay đổi do tần số tim và dòng chảy qua van hai lá nên thông số này không được đưa vào tiêu chuẩn phân độ.

Trừ huyết khối nhĩ trái trước trước can thiệp nong van hoặc sau khi có các biến cố thuyên tắc do huyết khối, và thu thập thêm thông tin về giải phẫu van hai lá (vùng mép van và bộ máy dưới van) trước can thiệp nếu chất lượng hình ảnh siêu âm tim qua thành ngực không tối ưu. Các nghiệm pháp gắng sức được chỉ định nếu bệnh nhân không có triệu chứng hoặc các triệu chứng không tương xứng với mức độ hẹp van. Siêu âm tim gắng sức thể lực có thể cung cấp thêm các thông tin khách quan hơn siêu âm tim gắng sức với dobutamin thông qua sự thay đổi chênh áp qua van hai lá và áp lực động mạch phổi. Siêu âm tim đóng vai trò quan trọng để theo dõi liên tục trong và sau can thiệp cũng như theo dõi người bệnh dài hạn.

12.2.2. Chỉ định can thiệp

Phương pháp can thiệp (nong van hay phẫu thuật), cũng như thời gian thích hợp nên được lựa chọn dựa trên đặc điểm lâm sàng, giải phẫu của van và bộ máy dưới van và ý kiến chuyên gia. Nhìn chung, can thiệp chỉ nên tiến hành ở bệnh nhân hẹp hai lá có ý nghĩa lâm sàng (hẹp hai lá mức độ vừa đến khít) do nguyên nhân hậu thấp (diện tích van ≤ 1,5 cm²) bởi can thiệp có hiệu quả đáng kể ở nhóm bệnh nhân này. Ở các nước phát triển, nơi tỷ lệ hẹp van hai lá do thấp khớp và số ca nong van hai lá thấp, chỉ nên tiến hành nong van bởi với các chuyên gia để tăng tính an toàn và tỷ lệ thành công của thủ thuât. Ở các nước đang phát triển cần nỗ lực giúp người bệnh được nong van hai lá bởi khả năng tiếp cận điều trị khó khăn do nguyên nhân kinh tế. Nong van hai lá qua da nên là lựa chọn ban đầu cho các bệnh nhân có mức độ vôi hóa và tổn thương bộ máy dưới van mức độ nhẹ đến vừa và có những đặc điểm lâm sàng phù hợp.

Quản lý bệnh nhân hẹp khít van hai lá do thấp tim được tóm tắt trong Hình 11, chỉ định và chống chỉ định nong van hai lá qua da tóm tắt ở Bảng 18.

12.2.3. Điều trị nội khoa

Thuốc lợi tiểu, chẹn beta giao cảm, digoxin, chẹn kênh canxi nhóm non-dihydrolpyridine, và ivabradine có thể cải thiện triệu chứng. Thuốc chống đông kháng vitamin K với mục tiêu INR 2 – 3 được chỉ định với các bệnh nhân rung nhĩ. Bệnh nhân hẹp hai lá mức độ vừa đến khít có rung nhĩ nên duy trì chống đông kháng vitamin K thay vì các thuốc chống đông đường uống thế hệ mới (NOACs). Hiện nay chưa có các bằng chứng thuyết phục về việc sử dụng NOACs trong trường hợp này với một thử nghiệm lâm sàng ngẫu nhiên đang bắt đầu được tiến hành (INVICTUS VKA NCT 02832544). Các biện pháp sốc điện chuyển nhịp hay cô lập tĩnh mạch phổi đều không được chỉ định trước khi can thiệp nong van hai lá ở bệnh nhân có hẹp hai lá đáng kể vì chúng không có tác dụng duy trì nhịp xoang lâu dài. Nếu rung nhĩ mới xuất hiện và nhĩ trái chỉ giãn mức độ vừa, nên tiến hành sốc điện chuyển nhịp sớm sau khi can thiệp thành công, cũng nên xem xét chuyển nhịp ở các bệnh nhân chưa đến mức hẹp van hai lá khít. Amiodarone là thuốc hiệu quả nhất trong duy trì nhịp tim sau chuyển nhịp. Ở bệnh nhân nhịp xoang, thuốc chống đông đường uống được khuyến cáo sử dụng trong trường hợp bệnh nhân có các biến cố tắc mạch hệ thống hoặc có huyết khối trong nhĩ trái và nên thực hiện siêu âm qua thức quản ở các trường hợp có nhiều âm cuộn trong siêu âm hoặc nhĩ trái giãn lớn (đường kính nhĩ trái đo trên siêu âm M-mode trên 50 mm hoặc chỉ số thể tích nhĩ trái trên 60 ml/m²).

12.2.4. Theo dõi

Bệnh nhân hẹp hai lá có ý nghĩa nhưng không có triệu chứng nên được theo dõi lâm sàng và siêu âm tim định kỳ mỗi năm, thời khoảng theo dõi có thể dài hơn (2 – 3 năm) trong các trường hợp hẹp vừa. Theo dõi các bệnh nhân sau nong van thành công tương tự các bệnh nhân không triệu chứng, nên theo dõi thường xuyên hơn nếu tái hẹp xảy ra.

12.2.5. Các trường hợp đặc biệt

Nếu các trường hợp tái hẹp xảy ra sau phẫu thuật hoặc sau nong van qua da, tái can thiệp trong hầu hết các trường hợp là thay van, tuy nhiên có thể nong van qua da đối với một số bệnh nhân phù hợp nếu cơ chế tái hẹp chủ yếu là dính lại mép van.

Ở các bệnh nhân có hẹp hai lá khít kết hợp với tổn thương van động mạch chủ nặng, phẫu thuật được ưu tiên hơn nếu bệnh nhân không có chống chỉ định với phẫu thuật. Quản lý các bệnh nhân chống chỉ định với phẫu thuật là khó khăn và yêu cầu sự đánh giá chuyên sâu, cá nhân hóa của nhóm chuyên gia tim mạch (heart team). Trong trường hợp hẹp hai lá khít, tổn thương van động mạch chủ mức độ vừa, nong van hai lá qua da có thể được tiến hành để trì hoãn cho đến khi phẫu thuật sửa chữa cả hai van. Ở các bệnh nhân có hở van ba nhiều, có thể xem xét nong van hai lá qua da ở các bệnh nhân vẫn duy trì được nhịp xoang, giãn nhĩ trái mức độ vừa, hở ba lá nhiều thứ phát do tăng áp động mạch phổi. Trong các trường hợp khác, nên phẫu thuật cả hai van.

Ở người già có hẹp van hai lá do thấp, nếu nguy cơ phẫu thuật cao, nong van hai lá qua da là lựa chọn cần thiết, thậm chí là chỉ chăm sóc giảm nhẹ. Điều trị cho bệnh nhân hẹp van hai lá khít chênh áp thấp (diện tích lỗ van ≤ 1,5 cm² và chênh áp trung bình dưới 10 mmHg) là vấn đề khó bởi các bệnh nhân này thường già và giải phẫu van thường không lý tưởng.

13. Hẹp van hai lá do vôi hóa vòng van

13.1. Đánh giá

Ở các bệnh nhân có thoái hóa và vôi hóa vòng van van hai lá, khó đánh giá mức độ nặng của van trên siêu âm tim và các phép đo thường quy thiếu tính xác thực (lack validation). Đo viền diện tích lỗ van (planimetry) thường thiếu tin cậy do sự vôi hóa và hình thái lỗ van không đều. Chênh áp trung bình qua van có ý nghĩa tiên lượng. Để đánh giá mức độ hẹp, cần đánh giá cả tình trạng rối loạn khả năng giãn (compliance) của thất trái và nhĩ trái trước khi chỉ định can thiệp. Nếu bệnh nhân có kế hoạch can thiệp, siêu âm tim thường được sử dụng để đánh giá ban đầu và cần chụp cắt lớp vi tính là để đánh giá mức độ và vị trí vôi hóa và mức độ phù hợp để can thiệp.

13.2. Chỉ định can thiệp

Lựa chọn điều trị, bao gồm phẫu thuật và can thiệp qua đường ống thông đều là thủ thuật nguy cơ cao, và thiếu bằng chứng từ các thử nghiệm ngẫu nhiên. Thậm chí nếu thủ thuật thành công và chênh áp qua van giảm, áp lực trung bình nhĩ trái vẫn tiếp tục tăng do giảm khả năng giãn (low compliance) của nhĩ trái và thất trái.

Với những người lớn tuổi có thoái hóa van hai lá và vôi hóa vòng van, phẫu thuật có tính thách thức cao về mặt kỹ thuật và nguy cơ cao. Vì không có tổn thương mép van, hẹp hai lá do thoái hóa không phù hợp để nong van hai lá qua da. Với những bệnh nhân có triệu chứng không thể phẫu thuật và có giải phẫu van phù hợp, kinh nghiệm thực tế cho thấy thay van hai lá qua da (bằng cách sử dụng van TAVI tự nở trên bóng nhưng đảo chiều để đặt vào vị trí van hai lá) có thể thực hiện được ở một số bệnh nhân hẹp hai lá khít phù hợp, khi được thực hiên tại các trung tâm có nhiều kinh nghiệm sau khi có kế hoạch cẩn thận và phối hợp nhiều phương tiện chẩn đoán hình ảnh. Chuỗi các ca lâm sàng nhiều nhất đến nay chỉ bao gồm 116 bệnh nhân. Tuy nhiên, tỷ lệ tử vong cao đặc biệt là do nguy cơ gây tắc nghẽn đường ra thất trái, và tiên lượng trung hạn cũng kém hơn can thiệp đặt van trong van. Chuỗi ca lâm sàng gần đây cho thấy các kết quả đã được cải thiện do các bệnh nhân được lựa chọn cẩn thận và sử dụng các phương pháp tiếp cận khác nhau, cũng như cùng sử dụng các biện pháp khác như đốt cồn vách liên thất cùng lúc hoặc dự phòng hoặc cắt bỏ lá trước van hai lá.

Gần đây, một chuỗi các ca lâm sàng sơ bộ gợi ý rằng thay van hai lá qua đường ống thông với van hai lá nhân tạo chuyên dụng có tính khả thi và có thể cải thiện triệu chứng.

Khuyến cáo về chỉ định nong van hai lá qua ống thông và phẫu thuật van hai lá ở bệnh nhân hẹp khít van hai lá (diện tích van ≤ 1,5 cm²) theo ESC năm 2021⁽¹⁸⁾.

Các đặc điểm không phù hợp cho nong van hai lá qua da được định nghĩa bởi sự có mặt của một số đặc điểm dưới đây. Đặc điểm lâm sàng bao gồm: tuổi cao, tiền sử phẫu thuật tách van, khó thở NYHA IV, rung nhĩ dai dẳng, tăng áp động mạch phổi nhiều.  Các đặc điểm giải phẫu van: Điểm siêu âm tim trên 8, điểm Cormier 3 (vôi hóa van hai lá mở rộng đánh giá bới nội soi huỳnh quang), diện tích nhĩ trái rất nhỏ, hở van ba lá nhiều.

Bảng 18. Chống chỉ định nong van hai lá qua da ở bệnh nhân hẹp hai lá khít do thấp

^a Nong van hai lá qua da có thể xem xét ở bệnh nhân có diện tích van trên 1,5 cm² có triệu chứng không thể lý giải bởi các các nguyên nhân khác và giải phẫu phù hợp để nong van.

Hình 11. Quản lý bệnh nhân hẹp hai lá khít (diện tích lỗ van ≤ 1,5 cm²) theo ESC 2021⁽¹⁸⁾

^a Nguy cơ huyết khối cao: Tiền sử có huyết khối hệ thống, âm cuộn đặc trong nhĩ trái, rung nhĩ mới khởi phát. Nguy cơ cao huyết động mát bù: áp lức động mạch phổi trên 50 mmHg lúc nghỉ, cần phẫu thuật ngoài tim mạch lớn, mong muốn có thai.

^b Phẫu thuật tách van có thể xem xét ở các nhóm phẫu thuật có kinh nghiệm với các bệnh nhân có chống chỉ định với NVHL qua da.

^c Xem khuyến cáo chỉ định cho NVHL và phẫu thuật van hai lá xem ở mục 7.2.
^d Phẫu thuật nếu các triệu chứng xuất hiện khi gắng sức mức độ thấp và nguy cơ phẫu thuật thấp.

NVH: nong van hai lá.

TÀI LIỆU THAM KHẢO

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