房间隔入路的解剖学研究及临床应用

The Study on Surgical Approach via Atrial Septum in Lesions of the Left Heart

对３３具尸体的房间隔的大小、构成及周围重要组织结构进行观察和测量。提出房间隔切开时的正确方向、安全长度及可能发生的危险。结合４６６例临床应用，讨论了避免切口合并症发生及发生后的正确处理方法。

Trans-atrial septal inscision through right atrium has been commonly employed for left heart surgery .Excessive extension of the atrial septal incision in different directions may injure left atria wall A major hemorrhage may occur if the incised left atrial wall is left on repaired .This anatomical study on 33 cadavers is to find out the safety limit of trans-atrial septal incision in different directions .The in -vestigations were ,therefore, focused on measurements of the vertical and antieroposterior diameters, and wall thickness of fossa ovalis .Dis-tances between the margin of fossa ovalis and various parts of left atrial wall to where the septal incision may be extended were also deter-mined and the atrial wall thickness was reoorded as well .The results showed the average vertical diameter of fossa ovalis was 19.6±6.2mm ,A-P diameter 15.2±4.5 mm and thickness was 1.1±0.5mm .The average length between the margin of the fossa ovalis to differ-ent parts of the atrial wall and their thickness varied .In vertical extension ,the average length was 13.2 ±3.1mm and wall thickness 5.3±22.2 mm ;in extension to theorifice of superior vena cava ,the length was 18.1±4.9mm ,and wall thickness 4.6±1.9mm; in anterior extension ,the length 8.7 ±3.1mm, and wall thickness 4.0±1.3mm ,in posterior extension ,the length and wall thickness in extension to the orifice of infertor vena cave and wal thickness In the authors 'series of 466 cases of surgical treatment of left heart lesions through trans-atrial septal approach ,incisional complications oocurred in 12 cases with an incidence of 12%. In 10 cases ,atrial dome was involved in the vertical extension of the incision ; in 1 case ,the root of aorta was injured dur-ing anteior incision extension ;in another case ,extension toward the orifice of inferior vena cave incised the inferior wall of left atrium .Troublesome hemorrhage occurred after cardiac reduscitation .The hidden part of the extended incision on the left atrial wall was successful-ly reparied after re-institution of PCB in 7 cases The other 3 patients died of uncontrolled bleeding and prolonged bypass Bs\ased on the aforementioned investigation datae on cadavers and the clinical experience ,t he authours suggest that in patients without enlrged left atrium, it is probably safe to limit the vertical extensio of septal incision within 10mm from the upper margin of the fossa ovalis .The safe length of incisional extension toward the orific of superior vena cava can be a little longer than the vertical extension .In anterior extension of the incision ,extra -precaution should be taken because of limited safe length and the easiness of injury to root of aorta .The same principle can be applied to the extenion of incision toward the orifice of inferior vena cave.