造影结果的判读及病变类型的分析-黄文晖课件

1、造影结果的判读及病变类型的分析黄文晖广东省人民医院广东省心血管病研究所从造影片我们要看什么？如何体位的片中判断正常的冠脉血管？如何判断病变的血管？常用的一些分类通过不同的病变类型如何考虑介入治疗的难度？从造影片我们要看什么？血管的情况肺野的情况心包情况现场还要注意压力的变化正常冠状动脉RCABasic AnatomyOrigin right aortic sinus(lower origin than LCA)Course Down right AV groove toward crux of the heart, gives off PDA(85%) from which septals a

2、rise, continues in LAV groove giving off posterior LV branches(posterolaterals). PDA may originate more proximally, bifurcate early or be small with part of “its territory” supplied by an acute marginal branch.RCAOther BranchesConus Artery(圆锥支) usually very proximal; courses anteriorly and upward ov

3、er the RV outflow tract toward the LAD. May be an important Source of collaterals.SA Nodal Artery(窦房结动脉) (60%) usually 2nd branch of RCA-courses obliquely backward through uper portion of aterial septum and anteromedial wall of the RA-supplies SA node,usually RA and sometimes LA RCAOther BranchesPDA

4、(后降支) Supplies inferior wall, ventricular septum, posteromedial papillary muscle.AV Nodal Artery (房室结支) Arises at or near crux; supplies AV node.Right ventricular(Acute marginal Branches锐缘支) Arise from mid RCA; Supply anterior RV; may be a collateral source.LCALMOptimal Views LAO caudal and cranial;

5、 AP-caudal, cranial or flat. Limit views. May need IVUSLADCourse down the anterior interventricular groove-usually reaches apex. In 22% of cases does not reach apexLCABranches septals and diagonals-supply lateral wall of LV, anterolateral papillary muscle; 37% have median ramus( courses like 1st dia

6、gonal).LAD supplies anterolateral, apex and septum; 45%-55% of left ventricle.LCXBranches obtuse marginal, posterolaterals-supply posterolateral LV, anterolteral papillary muscles. SA node artery 38%Supplies 15%-25% of LV, unless dominant(supplies 40-50% of LV).LAO Caudal ViewAHA/ACC冠脉病变分类A型病变散在病变(长

7、度10mm)向心型狭窄容易插管到病灶部位各节段间成角450 血管表面较平滑无钙化或很轻度钙化不是管腔完全闭塞狭窄部位不在血管开口处无重要分支狭窄管腔内无血栓B型病变病变成管状(10-20mm).偏心型狭窄近端节段中度弯曲各节段间成角450 -900 血管表面不光滑中度或重度钙化管腔完全闭塞2cm)近端节段过度弯曲节段间成角900管腔完全闭塞3个月不能防止主要的分支受损移植静脉退行性变易碎破TIMI心肌灌注分级(TMPG)0级:心肌无明显组织灌注,罪犯血管区域无毛玻璃样改变或心肌显影,提示组织水平灌注低下。1级：造影剂缓慢灌注心肌，但不能从微血管排空，毛玻璃样改变或罪犯血管区域心肌显影不能从微血管清除，心肌显影在开始下一个造影序列（间隔30秒）时仍然存在。TIMI心肌灌注分级(TMPG)2级：造