冠状动脉介入损伤与急性心包填塞,Jun Dai , M.D. Coronary disease center Fuwai Heart Hospital CAMS & PUMC China,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 Excluding case of Kawasaki d. traumatic injure,Predictors,Patient-related: female gender/ older age Vessel-related: tortuosity angulation calcification CTO Procedure-related: High balloon-stent ratioHigh inflation pressure Extremely distal location of the guidewire Device-related: Stiff wire/Hydrophilic-coated wire/cutting balloon/atheroablative devices/Ivus,Classification 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: perforation into anatomic cavity chamber coronary sinus,As,Treatment,Type I 1. 15-30min careful obervation2. no enlarge or diminish, no further action3.protamine (1 mg per 100u heparin) ACT 150, hemostatic PL function to restore whenb/a receptor occupany falls to50%,Type ,Perfusion 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 hemostasis,Type ,Balloon inflation 5-10min to provide time for the preparation 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-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 inner serous layer. The pericardial space normally contains 20-50 mL of fluid.,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150200ml，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。,Pathophysiologic Mechanism,Intrapericardial 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 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 accumulates in the venous circulation, at the expense of LV filling. This results in a reduced 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 pressure,Signs and tests,Peripheral pulses may be weak or absent. Neck veins may be distended but the blood pressure may be low.HR may be over 100Breathing may be rapid (faster than 12 breaths in an adult per minute).Bp may fall (pulsus paradoxical) when the person inhales deeplyheart Sound uncharacteristically faintFluid 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,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),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 treatment 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 are contraindicted,Pericardiocentesis ！,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 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 the site of entry. Measure the distance from the skin to the pericardial space. Angle of the transducer Avoid the inferior rib margin,