冠状动脉瘘PPT课件.ppt

.,1,冠状动脉瘘（CoronaryArteryFistulae）,汇报题目：,.,2,疾病定义：,冠状动脉瘘(coronaryarteryfistulae，CAF)是指冠状动脉与心腔、冠状静脉、肺动脉之间的异常连接，最早由德国解剖学家WilhelmKrause于1865年提出。CAF在普通人群中的发病率为0.002%,占冠脉造影畸形的0.13%-0.22%,其中90%以上与右心系统或心脏直接相连接的动、静脉血管如肺动脉、上腔静脉、冠状窦之间形成沟通,流向相对低压的静脉系统,本质上产生左向右分流的血流动力学效应,病因分类：,1.先天性CAF：,2.获得性CAF：,胎儿心血管系统发育时局部心肌发育停止，心肌肌小梁间的窦状间隙无法退化，从而形成CAF。常伴随其他心脏结构畸形，如法洛四联症、单室心、动脉导管未闭等。,外伤、心脏外科手术、介入手术等。,.,3,临床表现：,症状：,体征：,1.通常无明显症状。2.老年患者中可能会出现呼吸困难、心绞痛，偶尔会有心律失常。3.左向右分流大的如冠状动脉-左室瘘容易导致左心室容量超负荷,出现充血性心力衰竭的症状。,1.通常无明显体征。2.有体征的患者表现为心前区连续性杂音。,.,4,W,诊断：,非侵入性检查：,侵入性检查：,1.X线，ECG通常无特异性表现。2.心超：二维超声心动图显示有瘘的那支冠状动脉明显扩张。:无论哪支冠状动脉瘘至哪个心腔均显示左心房、左心室和主动脉根部内径增大：彩色多普勒血流显像（CDFI）在瘘的心腔或肺动脉内显示异常血流束信号3.冠脉CTA:表现为异常的冠状动脉及其分支增粗，迂曲，严重者可呈瘤样扩张，往往在瘘口周围明显彭大，通过异常的通道，血流可分流入不同的心腔及大血管。,冠状动脉造影：是CAF诊断的金标准，可显示CAF的起源、走行、分布、瘘口位置及大小、瘤样扩张及窃血现象等信息。,.,5,治疗：,1.CAF是否需要治疗取决于其对血流动力学的影响,2.通常认为对分流甚小、血流动力学影响不大、且无临床症状的孤立的CAF无需治疗。3.对于血流动力学显著异常、存在临床症状的或暂时虽无血流动力学影响,但远期可能产生严重并发症的需积极给与治疗。,治疗人群：,治疗方法：,1.保守治疗：感染性心内膜炎的预防和对症药物治疗;2.瘘道封堵：介入治疗方式包括可控弹簧圈栓塞、支架植入、自膨胀伞，状封堵器、新型Amplatzer血管塞治疗等;3.外科手术：方式有结扎或/和补片、人工血管转流或移植等,.,6,Case1:,A72-year-oldwomanpresentedwithepisodesofextremeexhaustionandfatigueoccurringatrest.Acontinuousmurmur(neverbeforedocumented)washeardwidelyovertheprecordium.Theeffortelectrocardiogramandechocardiogramwerenormal.,.,7,Atcardiaccatheterization,aleft-to-rightshuntof1.29:1(Qp:Qs)wasfound.Coronaryangiography(AandB)showedonefistula(F)arisingintherightcoronaryartery(RCA)andendinginthepulmonaryartery(PA),Asecondfistulaarisingintheleftanteriordescendingartery(LAD),alsoterminatinginthepulmonaryartery.,.,8,Multislicecomputedtomographicangiography(CandD)showedthetwofistulas(F1andF2)enteringthepulmonaryarteryseparately.Anattemptatcoilembolizationoftherightcoronaryarteryfistulafailedandthepatientwasreferredforsurgicalligationofthefistulas.Post-operativelyhersymptomshavedisappeared.,.,9,Case2:,A36-years-oldhealthyathlete.ECGshowedatypicalpostero-septalaccessorypathwaywithleftventricularpre-excitationatwarm-up.TheECGalterationdisappearedduringtheexerciseintheabsenceofsymptomsandotherabnormalities.Physicalexaminationwasnormal.Familyhistorywasunremarkableforheartdisease.,.,10,Theathleteunderwenttwo-dimensionaltrans-thoracicechocardiographytoexcludetheunderlyingcardiacdiseases;Colour-DopplerexaminationrevealedananomalousdiastolicjetofflowdirectedintothemainpulmonaryarterytrunkontheleftsideAcoronaryarteryfistulawassuspectedeventhoughleft-to-rightshuntwasnotsignificant(Qp/Qsratio1.2)andtherewerenosignsofpulmonaryorsystemicoverload.,.,11,Cardiaccomputedtomography(CCT)wasperformed.Itshowedacomplexfistulaoriginatingfromalltheproximalcoronariesanddrainingintothemainpulmonaryartery,fistulizingintothepulmonaryarterytrunk(C;arrowhead)andsurroundingthemainpulmonaryartery.（D;arrowheads）Thefistulashowedamainbodyrightontopoftheproximalsegmentofthemainpulmonaryartery(DF;asterisk)andalsoconnectionwithbronchialarteries(E,F;arrowheads）,.,12,ADDTITLE,Conventionalcoronaryangiographyconfirmedthefindings(GI;arrowheads).,Inviewofthelackofsymptom