心包填塞评分指南

Triagestrategyforurgentmanagementof

cardiactamponade:apositionstatementoftheEuropeanSocietyofCardiologyWorkingGrouponMyocardialandPericardialDiseases

Introduction

Cardiactamponadeisaconditioncausedbythecompressionoftheheartduetosloworrapidaccumulationoffluid(exudate),pus,blood,clots,orgaswithinthepericardialspaceresultinginimpaireddiastolicfillingandcardiacoutputduetoincreasedintrapericardialpressure.

Promptrecognitionofcardiactamponadeiscriticalsincetheunderlyinghaemodynamicdisordercanleadtodeathifnotresolvedbypercutaneousorsurgicaldrainageofthepericardium.IntroductionAllinterventionalprocedures(i.e.percutaneouscoronaryintervention,transcatheteraorticvalveimplantation,pacemaker/implantablecardioverterdefibrillatorimplantation,arrhythmiasablation,endomyocardialbiopsy)areemergingcausesofcardiactamponade.Althoughrare,cardiactamponademayalsooccurinpregnancyandinpost-partum.Neverprogressingtocardiactamponade：Pericardialtransudatescausedbyheartfailureorpulmonaryhypertension.Pericardialtransudatesinthelasttrimesterofnormalpregnancy

Introduction(i)whichpatientsneedimmediatedrainageofthepericardialeffusion？(ii)Isechocardiographysufficientforguidanceofpericardiocentesisorshouldpatientbetakentothecardiaccatheterizationlaboratory？(iii)Whoshouldbetransferredtospecialized/tertiaryinstitutionorsurgicalservice？(iv)Whattypeofmedicalsupportisnecessaryduringtransportation？Clinicaldiagnosis(1)Cardiactamponadeshouldbesuspectedinpatientspresentingwithhypotension,jugularvenousdistension,pulsusparadoxus,tachycardia,tachypnea,and/orseveredyspnoea;(2)AdditionalsignsmayincludelowQRSvoltages,electricalalternans,enlargedcardiacsilhouetteonchestX-ray.imaging

(1)Echocardiographyisthediagnosticmethodofchoiceinsuspectedcardiactamponadeandshouldbecarriedoutwithoutdelay.(2)CTandCMRarenotpartoftheroutineevaluationofpatientswithsuspectedcardiactamponade;theyareusefultoruleoutconcomitantdiseasesinvolvingthemediastinumandlungsinpatientswithlargepericardialeffusions.Differentialdiagnosis

Differentialdiagnosisshouldincludeconstrictivepericarditis,congestiveheartfailure,andadvancedliverdiseasewithcirrhosis.managementofcardiactamponade1.Aorticdissectionandpost-infarctionruptureofthefreewallareindicationsforurgentsurgicaldrainagethatshouldnotbedelayedinanywaybypericardiocentesis2.Pericardiocentesisisespeciallyrecommendedwhenapurulent,tuberculous,orneoplasticpericarditisissuspected,orinpatients,whoremainsymptomatic,despitemedicaltreatment3.Duetothehighincidenceoftamponade(aboutone-third)duringthefollow-upoflargeeffusions(>20mm)withoutcardiactamponade,planningelectivedrainageisreasonableinsuchpatients.4.Pericardialdrainagemaynotbenecessarywhentheeffusionislarger,thereisnohaemodynamicimpairment,anditresolvesspontaneouslyorunderanti-inflammatorytreatment

OXIDATIVEDAMAGE

Morethan50studiesnowconvincinglyshowthatflavonoidspossesspotentantioxidantactivityinvitro.Goodsupportforalackofsystemicantioxidantactivityofflavonoidsinvivocomesfromstudiesshowingthatinhibitionofatherosclerosisinanimalmodelsisnotassociatedwithmarkersofchangeinoxidativedamage.Thus,itispossiblethatantioxidantactivityisnotanimportantmechanismforbenefitsofteaflavonoidsonendothelialfunction,atherosclerosisandcardiovasculardiseaserisk.['ɒksɪdeɪtɪv]Indicationstotransferthepatients

toaspecializedortertiaryinstitution

uncorrectedcoagulopathy,ongoinganticoagulanttherapywithINR>1.5,thrombocytopaenia<50000/mm3,small,posterior,and/orloculatedeffusions

Selectionofthepercutaneousvs.

SurgicaltechniqueIfthepericardialeffusioncannotbereachedbyaneedleoracatheter,surgicaldrainageisrequired,usuallythroughasubcostalincision.surgicaldrainageisdesirablewithpurulentpericardialfluid,intrapericardialbleeding,andinthosewithclottedhemopericardiumorthoracicconditionsthatmakepericardiocentesisdifficultorineffective.

Thedisadvantagesoftheopensurgicalproceduresremaingeneralanaesthesia(riskofsuddenhypotensioninpatientswithlargeeffusions/cardiactamponade),aneedtoperforma6-to8-cmverticalincisionintheupperabdomenaswellastoresectthexiphoidprocessinsomecases.脓性麻醉Approachandtheguidance

forpericardiocentesisNowadays,pericardiocentesisshouldnotbeperformedasablindprocedure.

Echocardiographyshouldidentifydistributionandsizeoftheeffusion.Themostusefullocationforpericardiocentesisistheoneclosesttothelargestamountoftheeffusion.Urgentpericardiocentesiscanbesafelyandsuccessfullyperformedasasimpleecho-guidedprocedureorthepatientcanbetakentothecatheterizationlaboratoryApproachandtheguidance

forpericardiocentesisDependingonthedistributionoftheeffusion,itcanbedrainedpercutaneouslyusingtheintercostal(apical)orsubxyphoidapproachorsurgicallyinthepresenceofmassiveadhesionsorcontraindicationsforpericardiocentesis.

Apig-tailcathetershouldbeinsertedfordrainageoftheeffusion;ifthistoolisnotavailablein