冠状动脉介入损伤与急性心包填塞-戴军.ppt

冠状动脉介入损伤与急性心包填塞 JunDai M D CoronarydiseasecenterFuwaiHeartHospitalCAMS PUMCChina 内容 冠脉血管损伤概念冠脉穿孔分类和处理原则心包填塞病理生理心包填塞的临床表现心包填塞正确处理总结 冠状动脉介入损伤及后果 冠状动脉夹层 内膜与中膜 中膜与外膜分离 血管壁血栓形成和管腔的闭塞冠状动脉穿孔 亚急性心包积血或心包填塞 尤其充分抗血小板抗凝治疗的情况下冠状动脉破裂 急性心包积血处理不及时急性心包填塞ExcludingcaseofKawasakid traumaticinjure Predictors Patient related femalegender olderageVessel related tortuosityangulationcalcificationCTOProcedure related Highballoon stentratioHighinflationpressureExtremelydistallocationoftheguidewireDevice related Stiffwire Hydrophilic coatedwire cuttingballoon atheroablativedevices Ivus ClassificationofcoronaryperforationproposedbyEllisetal1994 TypeI extraluminalcraterwithoutextravasationType pericardialormyocardialblushwithoutcontrastjetextravasationType extravasationthroughfrank 1mm perforationCavityspilling perforationintoanatomiccavitychambercoronarysinus As Treatment TypeI1 15 30mincarefulobervation2 noenlargeordiminish nofurtheraction3 protamine 1mgper100uheparin ACT 150 hemostaticPLfunctiontorestorewhen b areceptoroccupanyfallsto 50 Type PerfusionballooncathertosealUCGwithoutdelayReversalofanticoagulation protaminetransfusioninPsreceivedabciximabPericardiocentesiswithtamponade PTFE coveredstentCardiacsurgeryreadyfornoachiveveinghemostasis Type Ballooninflation5 10mintoprovidetimeforthepreparationofperfusionballonandpericardiocentesisMustbecompletelysealedwithcoveredstentImmediateaggressivetreatment volumeresuscitation catecholamines pericardiocentesisImmediatereversalofanticoagulation protamine PLtransfusioninabciximab tratment Pathophysiology Thepericardium whichisthemembranesurroundingtheheart iscomposedof2layers Theparietalpericardiumistheouterfibrouslayer thevisceralpericardiumistheinnerserouslayer Thepericardialspacenormallycontains20 50mLoffluid 心包积液与心包填塞 心包腔内液体量增加称心包积液 当心包腔内液体量增加到一定程度 心包腔内的压力随之升高 达到一定限度后 引起心室舒张期充盈受阻 心排出量降低 使血液淤滞在静脉系统 产生体循环静脉压 肺静脉压增高等心脏受压症状 称心包填塞 心包积液引起心包内压力升高的程度决定于 积液的绝对量 积液的增加速度 心包本身的物理特性 如果液体的增加速度缓慢 心包被动扩张 心包腔内的积液可达2升而无明显的压力升高 然而 如果液体量快速增加 即使不超过150 200ml 也可引起腔内压力明显升高 在心包纤维化或肿瘤浸润引起心包过度僵硬的情况下 少量液体积聚也可使腔内压力快速增加 PathophysiologicMechanism Intrapericardialpressures transmuraldistendingpressuresinsufficienttoovercome LVdiastolicfilling intrapericardialpressure systemicvenousreturn rightatrialcollapseDuringinspiration intrapericardialandrightatrialpressuresdecreasebecauseofnegativeintrathoracicpressure Thisresultsinaugmentedsystemicvenousreturntoright sidedchambersandamarkedincreaseintherightventricularvolume Becausethepulmonaryvascularbedisavastandcompliantcircuit bloodpreferentiallyaccumulatesinthevenouscirculation attheexpenseofLVfilling Thisresultsinareducedcardiacoutput Symptoms Anxiety restlessnessDiscomfort sometimesrelievedbysittinguprightorleaningforward DifficultyRapidbreathingFainting light headednessPulse weakorabsentLowbloodpressure Signsandtests Peripheralpulsesmaybeweakorabsent Neckveinsmaybedistendedbutthebloodpressuremaybelow HRmaybeover100Breathingmayberapid fasterthan12breathsinanadultperminute Bpmayfall pulsusparadoxical whenthepersoninhalesdeeplyheartSounduncharacteristicallyfaintFluidinthepericardialsacmayshowon Coronaryangiography mayshowotherchangesalso Echocardiogramisfirstchoicetohelpestablishthediagnosis 250mlxfilm 关于Beck氏征问题 急性心包填塞三个典型征象 Beck氏三联征 静脉压升高 动脉压下降 心音遥远 但有此典型征象者仅占病人的 根据血流动力学的变化 机体代偿机理 急性心包填塞时 首先出现静脉压升高 或尿少比动脉压降低更早出现 继而出现动脉压下降 急性介入血性心包填塞特点 一旦超过这些代偿限度 当心包内压力达到约 厘米水柱时 将出现血压下降等心包填塞症象 此时 若不降低心包内压力 将血液排出 当心包腔内压力超过上 下腔静脉压力时 则发生心脏停跳 病人将会导致死亡 在急性心包积血时 心包短时间内积血 毫升便足以引起压迫 形成致命的心包填塞 Expectations prognosis Tamponadeislife threateningifuntreated Theoutcomeisoftengoodiftheconditionistreatedpromptly buttamponademayrecur Treatmenttips FluidsaretheinitialtreatmenttomaintainnormalbloodpressureMedicationsthatincreasebloodpressuremayalsohelpsustainthepatient slifeuntilthefluidisdrained Oxygenreducestheworkloadontheheartbydecreasingtissuedemandsforbloodflow Avoidmechanicalventilationand blockadeDiureticsandnitratesarecontraindicted Pericardiocentesis Removalofpericardialfluidisthedefinitivetherapyfortamponade Pericardiocentesis 1 Thesubxiphoidapproachisextrapleural hence itisthesafestforblindpericardiocentesis A16 or18 gaugeneedleisinsertedatanangleof30 45 totheskin neartheleftxiphocostalangle aimingtowardstheleftshoulder Whenperformedemergently thisprocedureisassociatedwithareportedmortalityrateofapproximately4 andacomplicationrateof17 Pericardiocentesis 2 Echocardiographicallyguidedpericardiocentesis leftintercostalspaceMarkthesiteofentry Measurethedistancefromtheskintothepericardialspace AngleofthetransducerAvoidtheinferiorribmargin SurgicalCare 3 Forahemodynamicallyunstablepatientoronewithrecurrenttamponade providethefollowingcare Surgicalcreationofapericardialwindow Thisinvolvesthesurgicalopeningofacommunicationbetweenthepericardialspaceandtheintrapleuralspace TakeTipsHome 诊断线索 血压随体位改变而有波动首先出现静脉压升高 继而产生动脉压下降 强调早期诊断 果断处理 若等待动脉压下降才诊断 则病程已至晚期 抗休克和治疗性心包穿刺 在处理上强调要减少不必要的诊断性检查和缩短手术前准备时间 尽快解除心脏受压 挽救生命 Conclusions SeriouscomplicationofPCI AngiographicspectrumConsequences life threateningtamponade MI emergentcardiacsurgery deathTypeI Type