洪珊珊-20150401文献阅读报告：人工瓣膜血栓诊断与治疗

1、LOGO人工瓣膜血栓诊断与治疗人工瓣膜血栓诊断与治疗汇报人：洪珊珊指导老师：张进华专业：抗凝专业LOGO汇报内容人工瓣膜血栓的形成人工瓣膜血栓的形成人工瓣膜血栓的诊断人工瓣膜血栓的诊断人工瓣膜血栓的治疗人工瓣膜血栓的治疗总结总结溶栓治疗溶栓治疗LOGO人工瓣膜血栓的形成v人工瓣膜血栓是瓣膜置换术人工瓣膜血栓是瓣膜置换术后的严重并发症之一。后的严重并发症之一。 发生率：10%/年 发达国家：0.3%-1.3% 发展中国家：6.1% 机械瓣（主动脉瓣+二尖瓣）：0.5%-8% 机械瓣（三尖瓣）：20% 生物瓣：0.03%Gursoy Mo. et al. The current status of

2、 fluoroscopy and echocardiography in the diagnosis of prosthetic valve thrombosisa review article. Echocardiography. 2015, 32: 156-164LOGO人工瓣膜血栓形成的高危因素怀孕怀孕抗凝不足抗凝不足心室功能障碍心室功能障碍多个瓣膜置换多个瓣膜置换房颤房颤左房增大左房增大高危Gursoy Mo. et al. The current status of fluoroscopy and echocardiography in the diagnosis of prosth

3、etic valve thrombosisa review article. Echocardiography. 2015, 32: 156-164LOGO人工瓣膜血栓的危害危害栓塞事件肺栓塞脑动脉及其他外周动脉栓塞人工瓣膜功能的影响瓣膜开启闭合异常，造成瓣膜狭窄甚至闭塞，瓣膜关闭不全F.M. Castilho et al. Thrombolytic therapy or surgery for valve prosthesis thrombosis: systematic review and meta-analysis. J thromb Haemost , 2014, 12:1218-2

4、8LOGO人工瓣膜血栓的评估和管理呼吸困难、栓塞事件二尖瓣/主动脉瓣三尖瓣/肺动脉2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease级：患者有心脏病，但日常活动量不受限制，一般体力活动不引起过度疲劳、心悸、气喘或心绞痛。级：心脏病患者的体力活动轻度受限制。休息时无自觉症状，一般体力活动引起过度疲劳、心悸、气喘或心绞痛。级：患者有心脏病，以致体力活动明显受限制。休息时无症状，但小于一般体力活动即可引起过度疲劳、心悸、气喘或心绞痛。级：心脏病患者不能从事任何体力活动，休息状态下也出现心衰

5、症状，体力活动后加重。经胸彩超经食道彩超LOGO左侧血栓的治疗策略1. 2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease2. 2012 ACCP-9:Antithrombotic and Thrombolytic Therapy for Valvular Disease3. 2012 ESC/EACTS Guidelines on the management of valvular heart diseaseGuideline Surgery FT American Colleg

6、e of Cardiology 2014 American College of Chest Physicians 2012 European Society of Cardiology 2012 For patients with NYHA class III to IV symptoms (Class I, B), or those with a mobile or large thrombus (0.8cm2) (Class IIa, C) All patients with large thrombus area (0.8cm2) (Grade 2C) All critically i

7、ll patients without serious comorbidity(Class I, C) , large (10mm) non-obstructive thrombus with embolism(Class IIa, C) , persistent thrombus despite optimal anticoagulation Recent onset (14 days) of NYHA class I to II symptoms, and a small thrombus (0.8cm2) (Class IIa, B) All patients with small th

8、rombus area (0.8cm2) , all others if contraindications to surgery exit Critically ill patients with serious comorbidity, or impaired cardiac function before developing valve thrombosis, or if surgery is unavailable LOGO人工瓣膜血栓的治疗2014 AHA/ACC Guideline for the Management of Patients with Valvular Hear

9、t DiseaseLOGO溶栓方案Drug Regimen Streptokinase(SK) Classical regimen: loding dose 500,000 IU in 20 min followed by 1,500,000 IU for 10h without heparin Accelerated protocol: loding dose 500,000 IU in 20 min, then 1,500,000 IU over 60 min without heparin Urokinase(UK) High dose: 4,500 IU/Kg/h for 12h wi

10、thout heparin Low dose: 2,000 IU/Kg/h associated with heparin for 24h Recombinant tissue plasminogen activator(rt-PA) High dose: loding dose 10 mg, followed by 90 mg for 90 min or for 3 h without heparin Low dose: loding dose 20 mg then 10 mg/h for 3h without heparin 1. Raymond et al. Fibrinolysis o

11、f Mechanical Prosthetic Valve Thrombosis A Single-Center Study of 127 Case. JACC, 2003, 41(4): 653-8 2. 2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart DiseaseLOGO溶栓的疗程G. Karthikeyan el at. Timing of adverse events during fibrinolytic therapy with streptokinase for left-sid

12、ed prosthetic valve thrombosis. J Thromb Thrombolysis. 2011, 32: 146-149LOGO溶栓效果的评价Ganasan Karthikeyan, et al. Urgent surgery compared with fibrinolytic therapy for the treatment of left-sided prosthetic heart valve thrombosis: a systematic review and meta-analysis of observational studies. Eurpean

13、Heart Journal, 2013, 34:1557-1566经胸彩超X线透视LOGO抗凝SK、UK or rt-PA: fibrinolytic therapy is successfullIntravenous UFH + VKA4-6hVKAArotic: 3.0-4.0Mitral: 3.5-4.5INR1. 2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease 2. G. Karthikeyan el at. Timing of adverse events during

14、 fibrinolytic therapy with streptokinase for left-sided prosthetic valve thrombosis. J Thromb Thrombolysis. 2011, 32: 146-149LOGO溶栓的禁忌症 2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart DiseaseLOGO溶栓的并发症主要出血：颅内出血、外周出血等并发症系统性栓塞：TIA、卒中、非CNS栓塞17.8%死亡F.M. Castilho et al. Thrombol

15、ytic therapy or surgery for valve prosthesis thrombosis: systematic review and meta-analysis. J thromb Haemost , 2014, 12:1218-28LOGO溶栓并发症的时间G. Karthikeyan el at. Timing of adverse events during fibrinolytic therapy with streptokinase for left-sided prosthetic valve thrombosis. J Thromb Thrombolysis. 2011, 32: 146-149LOGO1231. 人工瓣膜血栓是瓣膜置换人工瓣膜血栓是瓣膜置换术后严重的并发症。术后严重的并发症。2. 抗凝不足是其主要原因。抗凝不足是其主要原因。3. 加强患者用药教育尤为重加强患者用药教育尤为重要。要。1. 对怀疑为人工瓣膜血栓的对怀疑为人工瓣膜血栓的应尽早使用应尽早使用TTE、TEE进进行诊断。行诊断。2. 人工瓣膜血栓治疗方案的人工瓣膜血栓治疗方案的选择