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H? van ??ng m?ch ch? (Aortic valvular regurgitation)

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H? van ??ng m?ch ch?
(Aortic valvular regurgitation)

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1. ??i c??ng.
- H? van ??ng m?ch ch? l tnh tr?ng van ??ng m?ch ch? ?ng khng kn gy ra tnh tr?ng mu tro ng??c t? ??ng m?ch ch? v? bu?ng th?t tri trong th?i k? tm tr??ng.
- B?nh ???c Vieusens m t? t? th? k? th? XVII. Sau ? ??n th? k? th? XIX, nhi?u tc gi? m t? hon ch?nh h?n b?ng lm sng c?a b?nh.
- Bao gi? h? van ??ng m?ch ch? c?ng l t?n th??ng b?nh l th?c th?.
2. Nguyn nhn c?a h? van ??ng m?ch ch?.
2.1. Do th?p tim:
- L nguyn nhn ph? bi?n nh?t, chi?m ??n 75% t?ng s? b?nh nhn h? van ??ng m?ch ch?. T?n su?t c?a nguyn nhn ny ?ang gi?m r ? cc n??c pht tri?n cng v?i s? m?t ?i nhanh chng c?a b?nh th?p tim.
- H? van ??ng m?ch ch? do th?p th??ng g?p ? ng??i tr? tu?i; nam g?p nhi?u h?n n?; hay k?t h?p v?i b?nh c?a van 2 l.
- Cc l van ??ng m?ch ch? b? x? dy, co rt gy ra tnh tr?ng van ??ng m?ch ch? ?ng khng kn trong th tm tr??ng; ?i khi c dnh cc mp van gy ra h?p van ??ng m?ch ch?, t?o thnh b?nh van ??ng m?ch ch?.
2.2. Do vim mng trong tim nhi?m khu?n:
- L nguyn nhn th??ng g?p nh?t gy h? van ??ng m?ch ch? c?p tnh. H? van ??ng m?ch ch? do vim mng trong tim nhi?m khu?n th??ng l h? n?ng v nhanh chng gy suy tim.
- T?n th??ng gi?i ph?u b?nh l cc n?t si bm vo cc l van, vng van ??ng m?ch ch?, xoang Valsalva v c th? c p xe vng van. Cc n?t si c th? bong ra ?? l?i cc v?t lot v th?ng ? van ho?c ph h?y cc b? t? do c?a van gy h? van ??ng m?ch ch?. Ni chung, t?n th??ng van do vim mng trong tim nhi?m khu?n r?t nghim tr?ng.
2.3. Do bc tch thnh ??ng m?ch ch? c?p tnh:
- B?nh nhn b? ?au ng?c d? d?i (c th? c s?c) v pht hi?n ???c m?t ti?ng th?i tm tr??ng m?i xu?t hi?n ? vng nghe tim c?a van ??ng m?ch ch? (lin s??n III c?nh ?c tri ho?c lin s??n II c?nh ?c ph?i).
- Do ph?n ??u c?a ??ng m?ch ch? b? bc tch nn cc l van ??ng m?ch ch? m?t ?i?m t?a trn thnh ??ng m?ch ch?, lm cc l van b? ??y vo th?t tri trong th tm tr??ng gy h? van ??ng m?ch ch?.
- Th??ng g?p ? ng??i gi, c v?a x? ??ng m?ch.
2.4. B?m sinh:
- Van ??ng m?ch ch? 2 l: th??ng gy h?p ??ng m?ch ch? k?t h?p.
- H?i ch?ng Marfan: chi di, thn mnh ng?n, gin cc dy ch?ng, bn l?ch th?y tinh th?, g?c ??ng m?ch ch? gin v h? van ??ng m?ch ch?.
- H? ??ng m?ch ch? k?t h?p v?i h?p eo ??ng m?ch ch?.
- H? ??ng m?ch ch? k?t h?p v?i thng lin th?t cao, ???c g?i l h?i ch?ng Laubry- Pezzi.
2.5. Do giang mai:
- L hi?n t??ng vim ??ng m?ch ch? ? cc mp van v cc l van do giang mai gy h? van ??ng m?ch ch?. T?n th??ng x? th??ng lan ??n l? ??ng m?ch vnh gy h?p ho?c t?c ??ng m?ch vnh d?n ??n cc c?n ?au th?t ng?c trn lm sng.
- V cc l van khng dnh v?i nhau nn khng c h?p van ??ng m?ch ch? k?t h?p.
- Ngy nay, b?nh c xu h??ng gi?m do b?nh giang mai th??ng ???c ch?n ?on v ?i?u tr? s?m.
- Ch?n ?on nguyn nhn ph?i d?a vo cc ph?n ?ng huy?t thanh.
2.6. Do lo?n d??ng:
Do lo?n d??ng gy ra tnh tr?ng vng van ??ng m?ch ch? b? gin r?ng, c th? gy sa van d?ng nhy, l van m?m nho ho?c vi ho. ?y c?ng l nguyn nhn hay g?p hi?n nay, nh?t l ? ng??i cao tu?i c nh?ng m?ng x? v?a ??ng m?ch ch?.
2.7. Do cc nguyn nhn khc.
- H? van ??ng m?ch ch? c th? g?p trong b?nh vim c?t s?ng dnh kh?p ho?c h?i ch?ng Reiter. C 3-5% b?nh nhn vim c?t s?ng dnh kh?p c h? van ??ng m?ch ch?. C? ch? b?nh sinh lo?i ny khng r rng. Khng th?y t?n th??ng trn l van. Hay c r?i lo?n d?n truy?n trong tim.
- H? van ??ng m?ch ch? do ch?n th??ng: ch?n th??ng ng?c gy rch ??ng m?ch ch? ln, ??t rch cc l van. Nguyn nhn ny r?t hi?m g?p.
- H? van ??ng m?ch ch? do vim kh?p d?ng th?p: trn m?t van c nh?ng u h?t gy t?n th??ng van. Th??ng km theo t?n th??ng van 2 l, van 3 l v van ??ng m?ch ph?i. Nguyn nhn ny c?ng r?t hi?m g?p.
- Do v? ti phnh Valsalva.
- Do vim ??ng m?ch ch? ? b?nh Takayasu.
3. Sinh l b?nh.
Trong h? van ??ng m?ch ch?, do van ?ng khng kn nn c s? tro ng??c dng mu t? ??ng m?ch ch? v? th?t tri ? th tm tr??ng lm cho th? tch th?t tri cu?i tm tr??ng t?ng ln, bu?ng th?t tri gin ra, huy?t p tm tr??ng gi?m. Do mu ?i vo ??ng m?ch vnh ? th tm tr??ng nn khi c h? van ??ng m?ch ch?, c m?t l??ng mu t? ??ng m?ch ch? tr? v? th?t tri lm cho l?u l??ng mu vo ??ng m?ch vnh t? ??ng m?ch ch? t ?i v c th? gy c?n ?au th?t ng?c trn lm sng.
Do th? tch th?t tri cu?i tm tr??ng t?ng nn ? th?i k? tm thu, th?t tri ph?i co bp m?nh ?? t?ng l??ng mu l?n h?n bnh th??ng vo ??ng m?ch ch? gy t?ng huy?t p tm thu.
V huy?t p tm thu t?ng, huy?t p tm tr??ng gi?m nn chnh l?ch gi?a hai tr? s? huy?t p ny t?ng ln (g?i l huy?t p dong).
N?u r?i lo?n huy?t ??ng trn m n?ng n? s? l ngu?n g?c t?o nn cc tri?u ch?ng ngo?i bin c?a h? van ??ng m?ch ch?.
Giai ?o?n ??u ch? c th?t tri gin trong th tm tr??ng, sau ? xu?t hi?n ph ??i c? tim do t?ng co bp v ?? thch ?ng v?i t?ng p l?c trong bu?ng tim. Lu di s? d?n ??n suy ch?c n?ng tm thu, gi?m cung l??ng tim v xu?t hi?n suy tim tri trn lm sng.
4. Lm sng v c?n lm sng.
4.1. Lm sng:
4.1.1. Hon c?nh pht hi?n:
V h? van ??ng m?ch ch? ???c dung n?p t?t nn khng gy tri?u ch?ng lm sng trong th?i gian kh di. Th??ng pht hi?n b?nh khi:
- Tnh c? khm s?c kho? m?t cch h? th?ng.
- B?nh nhn ?i khm v h?i h?p, kh th?, ?au ng?c...
4.1.2. Tri?u ch?ng c? n?ng:
Th??ng xu?t hi?n mu?n, khi ? c th b?nh ? n?ng: kh th? khi g?ng s?c, ?au ng?c, h?i h?p tr?ng ng?c, c?n kh th? k?ch pht...
4.1.3. Tri?u ch?ng th?c th?: r?t quan tr?ng cho ch?n ?on.
+ Khm tim:
- Th?y m?m tim ??p m?nh khi nhn v s? (d?u hi?u n?y d?ng vm c?a Bard). M?m tim th??ng ??p ? v? tr xu?ng d??i v sang tri h?n so v?i bnh th??ng.
- Nghe tim th?y ti?ng th?i tm tr??ng ? lin s??n II c?nh b? ?c ph?i v nh?t l ? lin s??n III c?nh ?c tri. ? l tri?u ch?ng ch? y?u v quan tr?ng nh?t trn lm sng ?? ch?n ?on h? van ??ng m?ch ch?. Ti?ng th?i th??ng c ??c ?i?m: nh? nhng, m d?u nh? ti?ng th?; lan d?c x??ng ?c ho?c xu?ng m?m tim; xu?t hi?n ngay sau ti?ng T2, c??ng ?? gi?m d?n v ch?m d?t tr??c ti?ng T1; nghe r h?n ? t? th? b?nh nhn ??ng ho?c ng?i ci mnh ra tr??c, th? ra h?t c? v nn th?.
- C th? nghe ???c m?t s? t?p m khc:
. Th?i tm thu nh? ? lin s??n II c?nh b? ?c ph?i ho?c lin s??n III c?nh ?c tri, g?i l ti?ng th?i tm thu ?i km do h?p l? ??ng m?ch ch? t??ng ??i (v c s? gia t?ng th? tch t?ng mu tm thu).
. ? m?m tim, c th? nghe ???c ti?ng rung tm tr??ng ? th?i k? gi?a tm tr??ng v ti?n tm thu, g?i l ti?ng rng austin Flint.
C? ch? c?a ti?ng rng tm tr??ng austin Flint l do dng mu t? ??ng m?ch ch? tr? v? th?t tri trong th tm tr??ng ho quy?n v?i dng mu ?? t? nh? tri xu?ng th?t tri; b?n thn dng mu t? ??ng m?ch ch? tro ng??c l?i th?t tri c lc lm cho l van tr??c ngoi c?a van 2 l b? ??y l?i gy h?p l? van 2 l c? n?ng.
. Ti?ng clc m? van ??ng m?ch ch?: nghe g?n ? ??u th tm thu t?i m?m tim do s? gin ??t ng?t c?a ??ng m?ch ch?.
+ Cc d?u hi?u ngo?i bin: th?y r khi c h? van ??ng m?ch ch? n?ng khng km theo h?p l? van hai l.
- C s? gin r?ng ?? cch bi?t c?a huy?t p: huy?t p tm tr??ng gi?m r, huy?t p tm thu t?ng. Khi huy?t p tm tr??ng < 50 mmHg th th??ng l h? van ??ng m?ch ch? n?ng.
- ??ng m?ch c? n?y m?nh lm c? g?t g theo nh?p tim g?i l d?u hi?u Musset.
- ??ng m?ch n?y m?nh nh?ng x?p nhanh, th??ng th?y ? ??ng m?ch quay g?i l m?ch Corrigan.
- Nhn th?y m?ch mao m?ch: th tm thu th?y mu h?ng v th tm tr??ng th?y mu ti nh?t ? mng tay b?nh nhn ho?c mi khi p nh? vo ?.
- Nghe ???c ti?ng th?i kp ? ??ng m?ch l?n nh? ??ng m?ch ?i (ti?ng th?i Durozier).
4.2. C?n lm sng:
4.2.1. X quang tim-ph?i:
- Chi?u tim-ph?i th?y d?u hi?u gi?t dy chung tim-??ng m?ch ch? v th?t tri t?ng ??ng do th?t tri ph?i c? co bp ?? t?ng mu vo ??ng m?ch ch? m?t l??ng mu l?n h?n bnh th??ng.
- Th?t tri gin to bi?u hi?n b?ng cung d??i tri gin to, ko di v m?m tim h? th?p trn phim th?ng; m?t kho?ng sng sau tim trn phim nghing tri.
- C th? th?y vi ho van ??ng m?ch ch?.
- Hnh ?nh ? tr? tu?n hon ? ph?i th??ng x?y ra mu?n.
- Theo di cc ch? s? tim-l?ng ng?c nhi?u l?n c gi tr? theo di ???c ti?n tri?n c?a b?nh.
4.2.2. ?i?n tim:
- ?i?n tim bnh th??ng n?u c h? van ??ng m?ch ch? m?c ?? nh?.
- Th??ng th?y hnh ?nh t?ng gnh tm tr??ng th?t tri:
. Tr?c tri.
. Ch? s? Sokolow-Lyon >35 mm.
. R cao ? V5 v V6 (>25 mm).
. Th?i gian xu?t hi?n nhnh n?i ?i?n ? V5 v V6 > 0,045s.
. Sng Q su ? V5 v V6 (d?u hi?u Dushan).
. T cao, d??ng tnh v ??i x?ng ? V5 v V6.
- Giai ?o?n sau c hnh ?nh t?ng gnh tm thu v tm tr??ng h?n h?p: T ngh?ch ??o, m tnh v khng ??i x?ng, ch?ng t? ? c ph ??i th?t tri.
- Hay c r?i lo?n d?n truy?n v bl?c nhnh tri khng hon ton.
4.2.3. Tm thanh c? ??ng ??:
- Th?y ti?ng th?i tm tr??ng c t?n s? cao b?t ??u ngay sau ti?ng T2.
- ??ng m?ch c?nh ?? c d?ng nhnh ln th?ng ??ng, ch? ?i ??nh v hm b? m?t.
4.2.4. Thng tim:
- B?m thu?c c?n quang vo g?c ??ng m?ch ch? khi thng tim tri th?y c dng mu ph?t ng??c v? th?t tri ? th?i k? tm tr??ng.
- ?o th?y p l?c tm tr??ng c?a ??ng m?ch ch? h?, p l?c cu?i tm tr??ng ? th?t tri t?ng.
4.2.5. Siu m tim:
L ph??ng php xt nghi?m r?t quan tr?ng, cho php xc ??nh ch?n ?on, ?nh gi tnh tr?ng n?ng hay nh?, cc t?n th??ng ph?i h?p v theo di ti?n tri?n c?a h? van ??ng m?ch ch?.
- D?u hi?u gin ti?p:
. Gin bu?ng th?t tri, dy thnh th?t tri.
. ? siu m TM th?y d?u hi?u rung l tr??c van hai l, ?i khi c c? hnh ?nh rung l sau van 2 l v vch lin th?t.
- D?u hi?u tr?c ti?p:
. Th?y r dng ph?t ng??c t? ??ng m?ch ch? v? th?t tri ? th?i k? tm tr??ng trn siu m Doppler mu.
. C th? th?y van dy, vi ho do th?p kh?p c?p; th?y n?t si do vim mng trong tim nhi?m khu?n; bc tch ??ng m?ch ch?, gin vng van do lo?n d??ng; van ??ng m?ch ch? ch? c 2 l v cc t?t b?m sinh k?t h?p khc nh? thng lin th?t, gin g?c ??ng m?ch ch?. Siu m gip cho ch?n ?on ???c nguyn nhn gy h? van ??ng m?ch ch?.
- B?ng siu m Doppler, ng??i ta c th? ?nh gi ???c l??ng mu tro ng??c t? ??ng m?ch ch? v? th?t tri (b?ng cch tnh l?u l??ng tim qua van ??ng m?ch ch? tr? ?i l?u l??ng tim qua van hai l ho?c van ba l ho?c van ??ng m?ch ph?i).
L??ng mu ph?t ng??c qua van ??ng m?ch ch? = L?u l??ng tim qua van ??ng m?ch ch? - L?u l??ng tim qua van 2 l.
T? ? tnh ???c phn s? h? theo cng th?c:

Th? tch nht bp qua van ??ng m?ch ch? - Th? tch nht bp qua van 2 l.
Phn s? h? (%) = -----------------------------------------------------------------------
Th? tch nht bp qua van ??ng m?ch ch?

L??ng mu ph?t ng??c qua van ??ng m?ch ch? ? m?t chu k? tim
= -----------------------------------------------------------------------------
Th? tch nht bp qua van ??ng m?ch ch?
- Tnh t? s? gi?a ???ng knh dng h? van ??ng m?ch ch? v ???ng knh ???ng ra th?t tri t?i c?a s? siu m quan st tim theo tr?c d?c; tnh t? s? gi?a di?n tch dng h? ch? v di?n tch ???ng ra th?t tri t?i c?a s? siu m quan st tim theo tr?c ngang c?t qua van ??ng m?ch ch?. ?y l nh?ng ch? s? c gi tr? ?? ?nh gi m?c ?? c?a h? van ??ng m?ch ch?.
- Siu m cn cho bi?t ch?c n?ng th?t tri v nh?t l theo di gin th?t tri ti?n tri?n theo th?i gian.
- Lm siu m qua th?c qu?n khi: nghi vim mng trong tim nhi?m khu?n, lo?n d??ng ??ng m?ch ch?, bc tch ??ng m?ch ch?, v khi hnh ?nh siu m qua thnh ng?c khng r.
5. Ch?n ?on.
5.1. Ch?n ?on xc ??nh:
Ch?n ?on d?a vo:
- Ti?ng th?i tm tr??ng ? vng van ??ng m?ch ch?.
- Cc tri?u ch?ng ngo?i bin c?a h? van ??ng m?ch ch?.
- ?i?n tim v X quang tim-ph?i th?y dy, gin th?t tri.
- Siu m tim c cc hnh ?nh tr?c ti?p v gin ti?p c?a h? van ??ng m?ch ch?.
- Thng tim, ch?p bu?ng tim c dng mu ph?t ng??c t? ??ng m?ch ch? v? th?t tri ? th tm tr??ng.
5.2. Ch?n ?on m?c ?? h? van ??ng m?ch ch?:

M?c ?? h? van ?MC
Ch? tiu
H? van ?MC
m?c ?? nh?
H? van ?MC
m?c ?? v?a
H? van ?MC
m?c ?? n?ng
- Th? tch dng ph?t ng??c t?
?MC v? th?t tri

- Phn s? h?

- Chi?u di dng h? van
?MC

- ???ng knh (ho?c di?n tch)
dng h? van ?MC
? 30ml


? 30%
? 1/3 chi?u di th?t tri
? 30% ???ng knh (ho?c di?n tch) ???ng ra th?t tri
31 - 60ml


31 - 50%

> 1/3-2/3 chi?u di th?t tri

31- 60% ???ng knh (ho?c di?n tch) ???ng ra th?t tri
> 60ml


> 50%

> 2/3 chi?u di th?t tri

> 60% ???ng knh (ho?c di?n tch) ???ng ra th?t tri



5.3. Ch?n ?on phn bi?t:
5.3.1. V?i h? van ??ng m?ch ph?i:
V h? van ??ng m?ch ph?i gy ra ti?ng th?i tm tr??ng (ti?ng th?i Graham-Still) ? lin s??n II c?nh b? tri x??ng ?c, r?t g?n v?i vng nghe t?p m c?a van ??ng m?ch ch?. Hay g?p ? ng??i b? h?p l? van 2 l c t?ng p l?c ??ng m?ch ph?i ho?c cc tr??ng h?p h? van ??ng m?ch ph?i b?m sinh, b?nh tim-ph?i m?n tnh... Khng th?y c cc tri?u ch?ng ngo?i bin c?a h? van ??ng m?ch ch?. X quang th??ng th?y cung gi?a tri v?ng (hnh ?nh c?a t?ng p l?c ??ng m?ch ph?i).
Ch?n ?on xc ??nh b?ng siu m Doppler mu.
5.3.2. V?i h?p l? van 2 l:
C th? nh?m gi?a rng austin Flint v?i rng tm tr??ng c?a h?p l? van 2 l. Khi c h?p l? van 2 l s? th?y T1 ?anh ? m?m, cl?c m? van 2 l pha trong m?m tim, T2 tch ?i ? ?y tim; ?i?n tim th?y dy th?t ph?i; X quang th?y nh? tri to v th?t ph?i to, t?ng p l?c ??ng m?ch ph?i; siu m cho php ch?n ?on xc ??nh.
6. Ti?n tri?n.
H? van ??ng m?ch ch? th??ng di?n bi?n th?m l?ng trong nhi?u n?m. Khi tri?u ch?ng c? n?ng ? xu?t hi?n th b?nh ti?n tri?n nhanh chng, tin l??ng x?u v r?t d? t? vong.
N?u ? ?au ng?c m khng ph?u thu?t th th??ng b?nh nhn ch?t sau 4 n?m. Khi ? c suy tim th th??ng t? vong sau 2 n?m.
7. Bi?n ch?ng.
7.1. Suy tim tri:
Suy tim tri xu?t hi?n mu?n v?i bi?u hi?n kh th? v? ?m v kh th? khi g?ng s?c, hen tim, ph ph?i c?p. Sau ? s? suy tim ton b?. ?i?u tr? n?i khoa t k?t qu?.
7.2. Vim mng trong tim nhi?m khu?n:
Bi?n ch?ng ny r?t hay g?p, nh?t l ? ng??i c van ??ng m?ch ch? ch? c 2 l van.
C?n ph?i ?i?u tr? tri?t ?? cc ? vim nhi?m trn c? th? v dng khng sinh d? phng khi lm cc th? thu?t ? cc b?nh nhn b? h? van ??ng m?ch ch?.
7.3. C?n ?au th?t ng?c:
Hay c ? ng??i b? h? van ??ng m?ch ch? n?ng. C?n ?au th?t ng?c c ??c ?i?m: gi?ng nh? cc c?n ?au th?t ng?c khc nh?ng t ph? thu?c vo g?ng s?c, c th? x?y ra c? khi ngh?; th?i gian ?au ko di, t gi?m ?au khi dng cc thu?c gin ??ng m?ch vnh.
8. ?i?u tr?.
8.1. N?i khoa:
8.1.1. D? phng vim mng trong tim nhi?m khu?n b?ng cch gio d?c nguy c? ny cho b?nh nhn hi?u ?? t? ?? phng; dng khng sinh d? phng; khi can thi?p th? thu?t; ?i?u tr? cc ? nhi?m khu?n (n?u c).
8.1.2. ?i?u tr? nguyn nhn gy h? van ??ng m?ch ch?: ?i?u tr? d? phng, ch?ng th?p tim, giang mai, v?a x? ??ng m?ch...
8.1.3. ?i?u tr? suy tim khi c cc tri?u ch?ng c?a suy tim tri: ?n nh?t t??ng ??i (3-5 gam mu?i/ngy), h?n ch? v?n ??ng th? l?c, thu?c c??ng tim, l?i ti?u...
8.1.4. ?i?u tr? b?ng thu?c gin m?ch trong th?i gian di (nh? thu?c ?c ch? canxi, ?c ch? men chuy?n), th?m ch thu?c ?c ch? bta lm ch?m s? xu?t hi?n v ti?n tri?n c?a suy tim do lm gi?m dng mu ph?t ng??c, c?i thi?n ch?c n?ng th?t tri.
8.2. Ngo?i khoa:
- Thay van ??ng m?ch ch? ho?c s?a van khi h? van ??ng m?ch ch? do ch?n th??ng (van Starr- Edwards ho?c van sinh h?c Lonneseu, Hancock).
- Ph?i ch? ??nh nhanh chng v d?t khot v?i nh?ng b?nh nhn h? van ??ng m?ch ch? m?c ?? n?ng, huy?t p tm tr??ng < 50 mmHg, huy?t p chnh l?ch ?ng k? gi?a tm thu v tm tr??ng, siu m Doppler th?y c dng h? l?n, ch?p b?m thu?c c?n quang g?c ??ng m?ch ch? th?y kh?i l??ng l?n thu?c tr? v? th?t tri ? th?i k? tm tr??ng.
- Nn ph?u thu?t khi cc tri?u ch?ng ?au ng?c, suy tim m?i xu?t hi?n; X quang th?y tim to ra nhanh, siu m th?y bu?ng th?t tri gin nhanh theo th?i gian.
- Ring h? van ??ng m?ch ch? c?p n?ng do vim mng trong tim nhi?m khu?n v do ch?n th??ng m ?i?u tr? n?i khoa th?y suy tim khng h?i ph?c th nn ch? ??nh m? s?m.
Sau m?, b?nh nhn ph?c h?i s?c kho? t?t, s?ng lu v?i ?i?u ki?n ?i?u tr? ch?ng ?ng v d? phng nhi?m khu?n t?t.

References

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