冠状动脉介入损伤与急性心包填塞-戴军.ppt
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1、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 in
2、jure,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/atheroab
3、lative 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 an
4、atomic cavity chamber coronary sinus,As,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 whenb/a receptor occupany falls to50%,Type ,Perfusion balloon cather to seal UCG without
5、 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 M
6、ust 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
7、 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
8、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
9、 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 r
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