冠状动脉介入损伤与急性心包填塞-戴军
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精品课件 perforation
Treatment
Type 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 whenⅡb/Ⅲa receptor occupany falls to<50%
精品课件
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。
精品课件
精品课件
精品课件
精品课件
Pathophysiologic Mechanism
Intrapericardial pressures↑→ transmural distending pressures insufficient to overcome → LV diastolic filling ↓↓
精品课件
Type Ⅱ
Perfusion balloon cather to seal UCG without delay Reversal of anticoagulation: protamine
transfusion in Ps received abciximab Pericardiocentesis with
↑ 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.
精品课件
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 serΒιβλιοθήκη Baiduus layer. The pericardial space normally contains 20-50 mL of fluid.
精品课件
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
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
精品课件
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
Must be completely sealed with covered stent Immediate aggressive treatment: volume
resuscitation, catecholamines, pericardiocentesis Immediate reversal of anticoagulation: protamine/ PL transfusion in abciximabtratment
High inflation pressure Extremely distal location of the guidewire
Device-related: Stiff wire/Hydrophiliccoated wire/cuttin精g品课件
Classification of coronary perforation proposed by Ellis et al 1994
As
Type I: extraluminal crater without extravasation
Type Ⅱ: pericardial or myocardial blush without contrast jet extravasation
Type Ⅲ: extravasation through frank(≥1mm)
tamponade/PTFE-covered stent Cardiac surgery ready for no achiveveing
hemostasis
精品课件
Type Ⅲ
Balloon inflation 5-10min to provide time for the preparation of perfusion ballon and pericardiocentesis
精品课件
Predictors
Patient-related: female gender/ older age
Vessel-related: tortuosity angulation calcification CTO
Procedure-related: High balloon-stent ratio
Treatment
Type 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 whenⅡb/Ⅲa receptor occupany falls to<50%
精品课件
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。
精品课件
精品课件
精品课件
精品课件
Pathophysiologic Mechanism
Intrapericardial pressures↑→ transmural distending pressures insufficient to overcome → LV diastolic filling ↓↓
精品课件
Type Ⅱ
Perfusion balloon cather to seal UCG without delay Reversal of anticoagulation: protamine
transfusion in Ps received abciximab Pericardiocentesis with
↑ 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.
精品课件
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 serΒιβλιοθήκη Baiduus layer. The pericardial space normally contains 20-50 mL of fluid.
精品课件
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
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
精品课件
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
Must be completely sealed with covered stent Immediate aggressive treatment: volume
resuscitation, catecholamines, pericardiocentesis Immediate reversal of anticoagulation: protamine/ PL transfusion in abciximabtratment
High inflation pressure Extremely distal location of the guidewire
Device-related: Stiff wire/Hydrophiliccoated wire/cuttin精g品课件
Classification of coronary perforation proposed by Ellis et al 1994
As
Type I: extraluminal crater without extravasation
Type Ⅱ: pericardial or myocardial blush without contrast jet extravasation
Type Ⅲ: extravasation through frank(≥1mm)
tamponade/PTFE-covered stent Cardiac surgery ready for no achiveveing
hemostasis
精品课件
Type Ⅲ
Balloon inflation 5-10min to provide time for the preparation of perfusion ballon and pericardiocentesis
精品课件
Predictors
Patient-related: female gender/ older age
Vessel-related: tortuosity angulation calcification CTO
Procedure-related: High balloon-stent ratio