1、人工瓣膜血栓诊断与治疗,汇报内容,溶栓治疗,人工瓣膜血栓的形成,人工瓣膜血栓是瓣膜置换术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 fluoroscopy and echocardiography in the diagnosis of prosthetic valve thrombosisa review article. Echocardiography. 2015, 32
2、: 156-164,人工瓣膜血栓形成的高危因素,Gursoy Mo. et al. The current status of fluoroscopy and echocardiography in the diagnosis of prosthetic valve thrombosisa review article. Echocardiography. 2015, 32: 156-164,人工瓣膜血栓的危害,F.M. Castilho et al. Thrombolytic therapy or surgery for valve prosthesis thrombosis: system
3、atic review and meta-analysis. J thromb Haemost , 2014, 12:1218-28,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
4、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症状，体力活动后加重。,经胸彩超,经食道彩超,左侧血栓的治疗策略,2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease 2012 ACCP-9:Antithrombotic and Thrombolytic Therapy for Valvular Disease 2012 ESC/EACTS Guidelines on the managemen
5、t of valvular heart disease,人工瓣膜血栓的治疗,2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease,溶栓方案,Raymond et al. Fibrinolysis of Mechanical Prosthetic Valve Thrombosis A Single-Center Study of 127 Case. JACC, 2003, 41(4): 653-8 2014 AHA/ACC Guideline for the Management of
6、Patients with Valvular Heart Disease,溶栓的疗程,G. Karthikeyan el at. Timing of adverse events during fibrinolytic therapy with streptokinase for left-sided prosthetic valve thrombosis. J Thromb Thrombolysis. 2011, 32: 146-149,溶栓效果的评价,Ganasan Karthikeyan, et al. Urgent surgery compared with fibrinolytic
7、therapy for the treatment of left-sided prosthetic heart valve thrombosis: a systematic review and meta-analysis of observational studies. Eurpean Heart Journal, 2013, 34:1557-1566,经胸彩超,X线透视,抗凝,SK、UK or rt-PA: fibrinolytic therapy is successfull,Intravenous UFH + VKA,4-6h,VKA,Arotic: 3.0-4.0,Mitral:
8、 3.5-4.5,INR,1. 2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease2. G. Karthikeyan el at. Timing of adverse events during fibrinolytic therapy with streptokinase for left-sided prosthetic valve thrombosis. J Thromb Thrombolysis. 2011, 32: 146-149,溶栓的禁忌症,2014 AHA/ACC G
9、uideline for the Management of Patients with Valvular Heart Disease,溶栓的并发症,17.8%,死亡,F.M. Castilho et al. Thrombolytic therapy or surgery for valve prosthesis thrombosis: systematic review and meta-analysis. J thromb Haemost , 2014, 12:1218-28,溶栓并发症的时间,G. Karthikeyan el at. Timing of adverse events d
10、uring fibrinolytic therapy with streptokinase for left-sided prosthetic valve thrombosis. J Thromb Thrombolysis. 2011, 32: 146-149,1,2,3,人工瓣膜血栓是瓣膜置换术后严重的并发症。抗凝不足是其主要原因。3. 加强患者用药教育尤为重要。,对怀疑为人工瓣膜血栓的应尽早使用TTE、TEE进行诊断。2. 人工瓣膜血栓治疗方案的选择主要根据血栓大小及心功能分级。,总结,溶栓治疗的选择应充分考虑患者是否存在禁忌症。2. 溶栓方案的制订应从溶栓药物的选择、疗程、效果评价等方面进行考虑。,临床药师可以从患者用药教育、治疗方案的选择、溶栓方案的制订、 抗凝治疗的监护等方面充分发挥作用。,,Thank You !,,
