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1、冠狀動脈介入損傷與急性心包填塞JunDai,M.D.CoronarydiseasecenterFuwaiHeartHospitalCAMS&PUMCChina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)冠狀動脈介入損傷及后果冠狀動脈夾層：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脈破裂：急性心包積血處理不及時急性心包填塞ExcludingcaseofKawasakid.t
2、raumaticinjurePredictorsPatient-related:femalegender/olderageVessel-related:tortuosityangulationcalcificationCTOProcedure-related:Highballoon-stentratioHighinflationpressureExtremelydistallocationoftheguidewireDevice-related:Stiffwire/Hydrophilic-coatedwire/
3、cuttingballoon/atheroablativedevices/IvusClassificationofcoronaryperforationproposedbyEllisetal1994TypeI:extraluminalcraterwithoutextravasationTypeⅡ:pericardialormyocardialblushwithoutcontrastjetextravasationTypeⅢ:extravasationthroughfrank(≥1mm)perforationCa
4、vityspilling:perforationintoanatomiccavitychambercoronarysinusAsTreatmentTypeI1.15-30mincarefulobervation2.noenlargeordiminish,nofurtheraction3.protamine(1mgper100uheparin)ACT<150,hemostaticPLfunctiontorestorewhenⅡb/Ⅲareceptoroccupanyfallsto<50%TypeⅡPerfusio
5、nballooncathertosealUCGwithoutdelayReversalofanticoagulation:protaminetransfusioninPsreceivedabciximabPericardiocentesiswithtamponade/PTFE-coveredstentCardiacsurgeryreadyfornoachiveveinghemostasisTypeⅢBallooninflation5-10mintoprovidetimeforthepreparationofpe
6、rfusionballonandpericardiocentesisMustbecompletelysealedwithcoveredstentImmediateaggressivetreatment:volumeresuscitation,catecholamines,pericardiocentesisImmediatereversalofanticoagulation:protamine/PLtransfusioninabciximab-tratmentPathophysiologyThepericard
7、ium,whichisthemembranesurroundingtheheart,iscomposedof2layers.Theparietalpericardiumistheouterfibrouslayer;thevisceralpericardiumistheinnerserouslayer.Thepericardialspacenormallycontains20-50mLoffluid.心包積液與心包填塞心包腔內(nèi)液體量增加稱心包積液。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
8、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：①積液的絕對量。②積液的增加速度。③心包本身的物理特性。如果液體的增加速度緩慢，心包被動擴(kuò)張，心包腔內(nèi)的積液可達(dá)2升而無明顯的壓力升高。然而，如果液體量快速增加，即使不超過150～200ml，也可引起腔內(nèi)壓力明顯升高。在心包
