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 & PUMCChina内容内容w冠脉血管损伤概念冠脉血管损伤概念w冠脉穿孔分类和处理原则冠脉穿孔分类和处理原则w心包填塞病理生理心包填塞病理生理w心包填塞的临床表现心包填塞的临床表现w心包填塞正确处理心包填塞正确处理w总结总结冠状动脉介入损伤及后果冠状动脉介入损伤及后果w冠状动脉夹层：内膜与中膜、中膜与外膜分冠状动脉夹层：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离：血管壁血栓形成和管腔的闭塞w冠状动脉穿孔：亚急性心包积血或心包填塞，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尤其充分抗血小板抗凝治疗的情况下w冠状动脉破裂：急性心包积血处理不及时急冠状动脉破裂：急性心包积血处理不及时急性心包填塞性心包填塞wExcluding case of Kawasaki d. traumatic injurePredictorswPatient-related:femalegender/olderagewVessel-related:tortuosityangulationcalcificationCTOwProcedure-related:Highballoon-stentratioHighinflationpressureExtremelydistallocationoftheguidewirewDevice-related:Stiffwire/Hydrophilic-coatedwire/cuttingballoon/atheroablativedevices/IvusClassification of coronary perforationproposedbyEllisetal1994wType I:extraluminal crater without extravasation wType : pericardial or myocardial blush without contrast jet extravasationwType : extravasation through frank(1mm) perforationwCavity spilling: perforation into anatomic cavity chamber coronary sinus AsTreatmentTypeI1.15-30mincarefulobervation2.noenlargeordiminish,nofurtheraction3.protamine(1mgper100uheparin)ACT150,hemostaticPLfunctiontorestore whenbb/a receptor /a receptor occupanyoccupany falls to50%falls to50%TypewPerfusionballooncathertosealwUCGwithoutdelaywReversalofanticoagulation:protaminetransfusioninPsreceivedabciximabwPericardiocentesiswithtamponade/PTFE-coveredstentwCardiacsurgeryreadyfornoachiveveinghemostasisType wBallooninflation5-10mintoprovidetimeforthepreparationofperfusionballonandpericardiocentesiswMustbecompletelysealedwithcoveredstentwImmediateaggressivetreatment:volumeresuscitation,catecholamines,pericardiocentesiswImmediatereversalofanticoagulation:protamine/PLtransfusioninabciximab-tratmentPathophysiologyThe 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 2 0 - 5 0 mL o f f l u i d .心包积液与心包填塞心包积液与心包填塞心包腔内液体量增加称心包腔内液体量增加称心包积液心包积液。 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，称压增高等心脏受压症状，称心包填塞心包填塞。 心包积液引起心包内压力升高的程度决定于：心包积液引起心包内压力升高的程度决定于：积液的积液的绝对绝对量量。积液的增加积液的增加速度速度。心包本身的心包本身的物理物理特性。如果液体特性。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的增加速度缓慢，心包被动扩张，心包腔内的积液可达2升升而无明显的压力升高。然而，如果液体量快速增加，即使不而无明显的压力升高。然而，如果液体量快速增加，即使不超过超过150200ml，也可引起腔内压力明显升高。在心包纤，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。也可使腔内压力快速增加。 PathophysiologicMechanismwIntrapericardial pressures transmural distending pressures insufficient to overcome LV diastolic filling w intrapericardial pressure systemic venous return right atrial collapse wDuring 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. SymptomswAnxiety, restlessness wDiscomfort, sometimes relieved by sitting upright or leaning forward. wDifficulty Rapid breathing wFainting, light-headedness wPulse, weak or absent wLow blood pressureSigns and tests1.Peripheralpulsesmaybeweakorabsent.2.Neckveinsmaybedistendedbutthebloodpressuremaybelow.3.HRmaybeover1004.Breathingmayberapid(fasterthan12breathsinanadultperminute).5.Bpmayfall(pulsusparadoxical)whenthepersoninhalesdeeply6.heartSounduncharacteristicallyfaint Fluid in the pericardial sac may show on: Coronary angiography (may show other changes also) 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。急性急性介入血性介入血性心包填塞特点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，积血毫升便足以引起压迫，形成致命的心包填塞。形成致命的心包填塞。 Expectations (prognosis)Tamponadeislife-threateningifuntreated.Theoutcomeisoftengoodiftheconditionistreatedpromptly,buttamponademayrecur.TreatmenttipswFluidsaretheinitialtreatmenttomaintainnormalbloodpressurewMedicationsthatincreasebloodpressuremayalsohelpsustainthepatientslifeuntilthefluidisdrained.wOxygenreducestheworkloadontheheartbydecreasingtissuedemandsforbloodflow.wAvoidmechanicalventilationand-blockadewDiureticsandnitratesarecontraindictedPericardiocentesis！Removalofpericardialfluidisthedefinitivetherapyfortamponade！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)Echocardiographicallyguidedpericardiocentesis:leftintercostalspaceMarkthesiteofentry.Measurethedistancefromtheskintothepericardialspace.AngleofthetransducerAvoidtheinferiorribmarginSurgical Care(3)Forahemodynamicallyunstablepatientoronewithrecurrenttamponade,providethefollowingcare:Surgicalcreationofapericardialwindow:Thisinvolvesthesurgicalopeningofacommunicationbetweenthepericardialspaceandtheintrapleuralspace.TakeTipsHomew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。w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。w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。ConclusionswSeriouscomplicationofPCI:wAngiographicspectrumwConsequences:life-threateningtamponade,MI,emergentcardiacsurgery,deathwTypeIwType