冠狀動(dòng)脈介入損傷與急性心包填塞-戴軍

1、.冠狀動(dòng)脈介入損傷與急性心包填塞Jun Dai , M.D. Coronary disease center Fuwai Heart Hospital CAMS & PUMCChina.內(nèi)容內(nèi)容w冠脈血管損傷概念冠脈血管損傷概念w冠脈穿孔分類和處理原則冠脈穿孔分類和處理原則w心包填塞病理生理心包填塞病理生理w心包填塞的臨床表現(xiàn)心包填塞的臨床表現(xiàn)w心包填塞正確處理心包填塞正確處理w總結(jié)總結(jié).冠狀動(dòng)脈介入損傷及后果冠狀動(dòng)脈介入損傷及后果w冠狀動(dòng)脈夾層：內(nèi)膜與中膜、中膜與外膜分冠狀動(dòng)脈夾層：內(nèi)膜與中膜、中膜與外膜分離：血管壁血栓形成和管腔的閉塞離：血管壁血栓形成和管腔的閉塞w冠狀動(dòng)脈穿孔：亞

2、急性心包積血或心包填塞，冠狀動(dòng)脈穿孔：亞急性心包積血或心包填塞，尤其充分抗血小板抗凝治療的情況下尤其充分抗血小板抗凝治療的情況下w冠狀動(dòng)脈破裂：急性心包積血處理不及時(shí)急冠狀動(dòng)脈破裂：急性心包積血處理不及時(shí)急性心包填塞性心包填塞wExcluding case of Kawasaki d. traumatic injure.PredictorswPatient-related: female gender/ older agewVessel-related: tortuosity angulation calcification CTOwProcedure-related: High balloo

3、n-stent ratio High inflation pressure Extremely distal location of the guidewirewDevice-related: Stiff wire/Hydrophilic-coated wire/cutting balloon/atheroablative devices/Ivus.Classification of coronary perforation proposed by Ellis et al 1994 wType I: extraluminal crater without extravasation wType

4、 : pericardial or myocardial blush without contrast jet extravasationwType : extravasation through frank(1mm) perforationwCavity spilling: perforation into anatomic cavity chamber coronary sinus As.TreatmentType I 1. 15-30min careful obervation 2. no enlarge or diminish, no further action 3.protamin

5、e (1 mg per 100u heparin) ACT 150, hemostatic PL function to restore whenb/a receptor occupany b/a receptor occupany falls to50%falls to50%.Type wPerfusion balloon cather to seal wUCG without delaywReversal of anticoagulation: protamine transfusion in Ps received abciximabwPericardiocentesis with ta

6、mponade/PTFE-covered stentwCardiac surgery ready for no achiveveing hemostasis.Type wBalloon inflation 5-10min to provide time for the preparation of perfusion ballon and pericardiocentesiswMust be completely sealed with covered stent wImmediate aggressive treatment: volume resuscitation, catecholam

7、ines, pericardiocentesiswImmediate reversal of anticoagulation: protamine/ PL transfusion in abciximab-tratment.Pathophysiology The pericardium, which is the membrane surrounding the heart, is composed of 2 layers. The parietal pericardium is the outer fibrous layer; the visceral pericardium is the

8、inner serous layer. The pericardial space normally contains 2 0 - 5 0 m L o f f l u i d . .心包積液與心包填塞心包積液與心包填塞 心包腔內(nèi)液體量增加稱心包腔內(nèi)液體量增加稱心包積液心包積液。 當(dāng)心包腔內(nèi)液體量增加到一定程度，心包腔內(nèi)的壓力隨之升當(dāng)心包腔內(nèi)液體量增加到一定程度，心包腔內(nèi)的壓力隨之升高，達(dá)到一定限度后，引起心室舒張期充盈受阻，心排出量高，達(dá)到一定限度后，引起心室舒張期充盈受阻，心排出量降低，使血液淤滯在靜脈系統(tǒng)，產(chǎn)生體循環(huán)靜脈壓、肺靜脈降低，使血液淤滯在靜脈系統(tǒng)，產(chǎn)生體循環(huán)靜脈壓、肺靜脈壓增高等

9、心臟受壓癥狀，稱壓增高等心臟受壓癥狀，稱心包填塞心包填塞。 心包積液引起心包內(nèi)壓力升高的程度決定于：心包積液引起心包內(nèi)壓力升高的程度決定于：積液的積液的絕對(duì)絕對(duì)量量。積液的增加積液的增加速度速度。心包本身的心包本身的物理物理特性。如果液體特性。如果液體的增加速度緩慢，心包被動(dòng)擴(kuò)張，心包腔內(nèi)的積液可達(dá)的增加速度緩慢，心包被動(dòng)擴(kuò)張，心包腔內(nèi)的積液可達(dá)2升升而無(wú)明顯的壓力升高。然而，如果液體量快速增加，即使不而無(wú)明顯的壓力升高。然而，如果液體量快速增加，即使不超過(guò)超過(guò)150200ml，也可引起腔內(nèi)壓力明顯升高。在心包纖，也可引起腔內(nèi)壓力明顯升高。在心包纖維化或腫瘤浸潤(rùn)引起心包過(guò)度僵硬的情況下，少量液

10、體積聚維化或腫瘤浸潤(rùn)引起心包過(guò)度僵硬的情況下，少量液體積聚也可使腔內(nèi)壓力快速增加。也可使腔內(nèi)壓力快速增加。 .Pathophysiologic Mechanism wIntrapericardial pressures transmural distending pressures insufficient to overcome LV diastolic filling w intrapericardial pressure systemic venous return right atrial collapse wDuring inspiration, intrapericardial a

11、nd right atrial pressures decrease because of negative intrathoracic pressure. This results in augmented systemic venous return to right-sided chambers and a marked increase in the right ventricular volume. Because the pulmonary vascular bed is a vast and compliant circuit, blood preferentially accu

12、mulates in the venous circulation, at the expense of LV filling. This results in a reduced cardiac output. .SymptomswAnxiety, restlessness wDiscomfort, sometimes relieved by sitting upright or leaning forward. wDifficulty Rapid breathing wFainting, light-headedness wPulse, weak or absent wLow blood

13、pressure.Signs and testsn Peripheral pulses may be weak or absent. n Neck veins may be distended but the blood pressure may be low.n HR may be over 100n Breathing may be rapid (faster than 12 breaths in an adult per minute).n Bp may fall (pulsus paradoxical) when the person inhales deeplyn heart Sou

14、nd uncharacteristically faint Fluid in the pericardial sac may show on: Coronary angiography (may show other changes also) Echocardiogram is first choice to help establish the diagnosis! 250ml x film.關(guān)于Beck 氏征問(wèn)題 急性心包填塞三個(gè)典型征象（Beck氏三聯(lián)征）：靜脈壓升高、動(dòng)脈壓下降、心音遙遠(yuǎn)。但有此典型征象者僅占病人的。 根據(jù)血流動(dòng)力學(xué)的變化（機(jī)體代償機(jī)理），急性心包填塞時(shí)，首先出現(xiàn)靜脈

15、壓升高（或尿少比動(dòng)脈壓降低更早出現(xiàn)），繼而出現(xiàn)動(dòng)脈壓下降。 .急性急性介入血性介入血性心包填塞特點(diǎn)心包填塞特點(diǎn) 一旦超過(guò)這些代償限度（當(dāng)心包內(nèi)壓力達(dá)到一旦超過(guò)這些代償限度（當(dāng)心包內(nèi)壓力達(dá)到約厘米水柱時(shí)），將出現(xiàn)血壓下降等心約厘米水柱時(shí)），將出現(xiàn)血壓下降等心包填塞癥象。此時(shí)，若不降低心包內(nèi)壓力包填塞癥象。此時(shí)，若不降低心包內(nèi)壓力（將血液排出），當(dāng)心包腔內(nèi)壓力超過(guò)上、（將血液排出），當(dāng)心包腔內(nèi)壓力超過(guò)上、下腔靜脈壓力時(shí)，則發(fā)生心臟停跳，病人將下腔靜脈壓力時(shí)，則發(fā)生心臟停跳，病人將會(huì)導(dǎo)致死亡。在急性心包積血時(shí)，心包短時(shí)會(huì)導(dǎo)致死亡。在急性心包積血時(shí)，心包短時(shí)間內(nèi)積血毫升便足以引起壓間內(nèi)積血毫升便足以引

16、起壓迫，形成致命的心包填塞。迫，形成致命的心包填塞。 .Expectations (prognosis) Tamponade is life-threatening if untreated. The outcome is often good if the condition is treated promptly, but tamponade may recur.Treatment tipswFluids are the initial treatment to maintain normal blood pressure wMedications that increase blood

17、pressure may also help sustain the patients life until the fluid is drained.wOxygen reduces the workload on the heart by decreasing tissue demands for blood flow.wAvoid mechanical ventilation and -blockadewDiuretics and nitrates are contraindicted.Pericardiocentesis ！ Removal of pericardial fluid is

18、 the definitive therapy for tamponade！.Pericardiocentesis(1)The subxiphoid approach is extrapleural; hence, it is the safest for blind pericardiocentesis.A 16- or 18-gauge needle is inserted at an angle of 30-45 to the skin, near the left xiphocostal angle, aiming towards the left shoulder. When per

19、formed emergently, this procedure is associated with a reported mortality rate of approximately 4% and a complication rate of 17%.Pericardiocentesis(2) Echocardiographically guided pericardiocentesis : left intercostal space Mark the site of entry.Measure the distance from the skin to the pericardial sp