冠状动脉介入损伤与急性心包填塞-戴军.ppt

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 ratio High 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 Ⅱ: pericardial or myocardial blush without contrast jet extravasation Type Ⅲ: extravasation through frank(≥1mm) perforation Cavity spilling: perforation into anatomic cavity chamber coronary sinus 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 to50% Type Ⅱ 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 Ⅲ 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 pericardi