经导管冠状动脉介入治疗引起冠状动脉穿孔10例临床分析(2)
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PCI并发冠状动脉穿孔虽然少见,但可产生严重后果,主要不良心脏事件发生率分别为:心包填塞24.2%~46.2%、心肌梗死19.4%~39%、急诊冠状动脉搭桥2.9%~39%、死亡0%~11.5%[1~4],远期有形成假性动脉瘤[3,6]、甚至破裂的危险[7]。Ellis分型为临床评估预后提供了较好的参考。Ⅰ型为完全包裹性穿孔,但有迟发心包填塞的可能,有时与局限性夹层难以区分。本组1例Ⅰ型穿孔,术中疑为夹层,术后4 h出现心包填塞。故对所有可疑或确诊为冠状动脉穿孔患者术后均应密切观察血流动力学变化、常规超声心动图监测,以便及早发现心包出血、及时处理,部分患者可通过鱼精蛋白对抗肝素等措施,使出血停止而避免心包填塞。Ⅱ型穿孔为限制性渗漏,预后相对良好。但因造影剂渗出缓慢,术中每次显影时间较短有可能观察不到造影剂渗出,而使诊断和处理时间延迟。本组1例即因此发生心包填塞。Ⅲ型穿孔造影剂呈喷射状漏出,可迅速出现心包填塞,预后凶险,即使经积极处理,各种不良心脏事件发生率仍远高于前两型[1,3]。
另外,冠状动脉穿孔的处理及预后与术者经验、心态以及导管室设备条件及配合团队等明显相关。如设备老化、影像质量差,术中未能清楚显示因穿孔所致造影剂缓慢渗漏,术后出现心包填塞。心脏导管室应常备带膜支架、弹簧栓、灌注球囊等,并应有具备CABG条件的心脏外科支持。
参 考 文 献
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