冠状动脉介入损伤与急性心包填塞戴军

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1、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.traumaticinjurePredict

2、orsPatient-related:femalegender/olderageVessel-related:tortuosityangulationcalcificationCTOProcedure-related:Highballoon-stentratioHighinflationpressureExtremelydistallocationoftheguidewireDevice-related:Stiffwire/Hydrophilic-coatedwire/cuttingballoon/atheroablativedevices/IvusC

3、lassificationofcoronaryperforationproposedbyEllisetal1994TypeI:extraluminalcraterwithoutextravasationTypeⅡ:pericardialormyocardialblushwithoutcontrastjetextravasationTypeⅢ:extravasationthroughfrank(≥1mm)perforationCavityspilling:perforationintoanatomiccavitychambercoronarysinusA

4、sTreatmentTypeI1.15-30mincarefulobervation2.noenlargeordiminish,nofurtheraction3.protamine(1mgper100uheparin)ACT<150,hemostaticPLfunctiontorestorewhenⅡb/Ⅲareceptoroccupanyfallsto<50%TypeⅡPerfusionballooncathertosealUCGwithoutdelayReversalofanticoagulation:protaminetransfusioninP

5、sreceivedabciximabPericardiocentesiswithtamponade/PTFE-coveredstentCardiacsurgeryreadyfornoachiveveinghemostasisTypeⅢBallooninflation5-10mintoprovidetimeforthepreparationofperfusionballonandpericardiocentesisMustbecompletelysealedwithcoveredstentImmediateaggressivetreatment:volu

6、meresuscitation,catecholamines,pericardiocentesisImmediatereversalofanticoagulation:protamine/PLtransfusioninabciximab-tratmentPathophysiologyThepericardium,whichisthemembranesurroundingtheheart,iscomposedof2layers.Theparietalpericardiumistheouterfibrouslayer;thevisceralpericard

7、iumistheinnerserouslayer.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：①积液的绝对量。②积液的增加速度。③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

8、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