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內(nèi)容內(nèi)容 冠脈血管損傷概念 冠脈穿孔分類和處理原則 心包填塞病理生理 心包填塞的臨床表現(xiàn) 心包填塞正確處理 總結(jié)冠狀動(dòng)脈介入損傷及后果 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 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 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 Excluding case of Kawasaki

2、 d. traumatic injurePredictors Patient-related: female gender/ older age Vessel-related: tortuosity angulation calcification CTO Procedure-related: High balloon-stent ratio High inflation pressure Extremely distal location of the guidewire Device-related: Stiff wire/Hydrophilic-coated wire/cutting b

3、alloon/atheroablative devices/IvusClassification of coronary perforation proposed by Ellis et al 1994 Type I: extraluminal crater without extravasation Type : pericardial or myocardial blush without contrast jet extravasation Type : extravasation through frank(1mm) perforation Cavity spilling: perfo

4、ration into anatomic cavity chamber coronary sinus AsTreatmentType I 1. 15-30min careful obervation 2. no enlarge or diminish, no further action 3.protamine (1 mg per 100u heparin) ACT 150, hemostatic PL function to restore whenb/a receptor occupany falls to50%b/a receptor occupany falls to50%Type P

5、erfusion balloon cather to seal UCG without delay Reversal of anticoagulation: protamine transfusion in Ps received abciximab Pericardiocentesis with tamponade/PTFE-covered stent Cardiac surgery ready for no achiveveing hemostasisType Type Balloon inflation 5-10min to provide time for the preparatio

6、n of perfusion ballon and pericardiocentesis Must be completely sealed with covered stent Immediate aggressive treatment: volume resuscitation, catecholamines, pericardiocentesis Immediate reversal of anticoagulation: protamine/ PL transfusion in abciximab-tratmentPathophysiology The pericardium, wh

7、ich is the membrane surrounding the heart, is composed of 2 layers. The parietal pericardium is the outer fibrous layer ; the visceral pericardium is the inner serous layer. The p e r i c a r d i a l s p a c e n o r m a l l y c o n t a i n s 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

8、稱心包積液。 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、肺靜脈壓增高等心臟受壓癥狀，稱心包填塞。 心包積液引起心包內(nèi)壓力升高的程度決定于：積液的絕對(duì)量。積液的增加速度。心包本身的物理特性。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)2升而無(wú)明顯的壓力升高。然而，如果液體量快速增加，即使不超過(guò)150200ml，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，少量液體積聚也可使腔內(nèi)壓力快速增加。 Pathophysiologic Mechanism In

9、trapericardial pressures transmural distending pressures insufficient to overcome LV diastolic filling intrapericardial pressure systemic venous return right atrial collapse During inspiration, intrapericardial and right atrial pressures decrease because of negative intrathoracic pressure. This resu

10、lts 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 accumulates in the venous circulation, at the expense of LV filling. This results in a reduc

11、ed cardiac output. Symptoms Anxiety, restlessness Discomfort, sometimes relieved by sitting upright or leaning forward. Difficulty Rapid breathing Fainting, light-headedness Pulse, weak or absent Low blood pressureSigns and tests1. Peripheral pulses may be weak or absent. 2. Neck veins may be disten

12、ded but the blood pressure may be low.3. HR may be over 1004. Breathing may be rapid (faster than 12 breaths in an adult per minute).5. Bp may fall (pulsus paradoxical) when the person inhales deeply6. heart Sound uncharacteristically faint Fluid in the pericardial sac may show on: Coronary angiogra

13、phy (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)到約厘米水柱時(shí)），將出現(xiàn)血壓下降等

14、心包填塞癥象。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、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)間內(nèi)積血毫升便足以引起壓迫，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 tips Fluids are the initial trea

15、tment to maintain normal blood pressure Medications that increase blood pressure may also help sustain the patients life until the fluid is drained. Oxygen reduces the workload on the heart by decreasing tissue demands for blood flow. Avoid mechanical ventilation and -blockade Diuretics and nitrates

16、 are contraindictedPericardiocentesis ！ Removal of pericardial fluid is 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

17、the left xiphocostal angle, aiming towards the left shoulder. When performed 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

18、the site of entry. Measure the distance from the skin to the pericardial space. Angle of the transducer Avoid the inferior rib margin Surgical Care(3) For a hemodynamically unstable patient or one with recurrent tamponade, provide the following care: Surgical creation of a pericardial window: This i

19、nvolves the surgical opening of a communication between the pericardial space and the intrapleural space. Take Tips Home 診斷線索：血壓隨體位改變而有波動(dòng) 首先出現(xiàn)靜脈壓升高，繼而產(chǎn)生動(dòng)脈壓下降。 強(qiáng)調(diào)早期診斷，果斷處理。若等待動(dòng)脈壓下降才診斷，則病程已至晚期。 抗休克和治療性心包穿刺，在處理上強(qiáng)調(diào)要減少不必要的診斷性檢查和縮短手術(shù)前準(zhǔn)備時(shí)間，盡快解除心臟受壓，挽救生命。 Conclusions Serious complication of PCI: Angiographi

20、c spectrum Consequences: life-threatening tamponade, MI, emergent cardiac surgery, death Type I Type 冠狀動(dòng)脈介入損傷及后果 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 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 冠狀動(dòng)脈破裂：急性心包積血處理不及時(shí)急性心包填塞冠狀動(dòng)脈破裂：急性心包積血處理不及時(shí)急性心

21、包填塞 Excluding case of Kawasaki d. traumatic injure冠狀動(dòng)脈介入損傷及后果 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 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 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 Excluding case of Kawasaki d. traumatic injureSigns and tests1. Peripheral pulses may be weak or absent. 2. Neck veins may be distended but the blood pressure may be low.3. HR may be over 1004. Breathing may be rapid (faster than 12 breaths in an adult per minute).5. Bp may fall (pulsus paradoxical) when the person