经右胸切口应用自体心包片修补矫治部分性房室管畸形的临床研究

CLINICAL STUDY ON THE USE OF PERICARDIAL AUTOGRAFT IN THE CORRECTION OF PARTIAL ATRIO-VENTRICULAR CANAL DEFORMITY THROUGH RIGHT THORACOTOMY

目的 探讨经右胸切口体外循环下应用自体心包片矫治部分性房室管畸形的手术方法。方法 全麻气管插管、左侧卧位 ,取右胸外侧切口 (6～ 11cm ) ,于第 4肋间入胸 ,纵行切开心包显露心脏 ,经升主动脉根部插供血管 ,经右心房插上、下腔静脉引流管建立体外循环。 2 8例行中低温体外循环 ,阻断升主动脉 ,灌注心冷停跳液 ,4例在常温体外循环 ,不阻断主动脉 ,心脏跳动下手术。经右心房切口 ,探明心内畸形 ,合并永存左上腔者 ,将Foley尿管经冠状静脉窦放入左上腔静脉 ,气囊注水 ,暂时阻断左上腔静脉 ,显露术野。用 4 - 0 prolene线间断缝合 2～ 4针修补二尖瓣前瓣裂 ,依据原发孔缺损大小剪裁自体心包片 ,用 4 - 0 prolene线连续缝合修补原发孔房缺 ,后下缘缝于二尖瓣前瓣根部后逐渐转移 ,缝在左房面 ,避开传导系统危险区。心内操作完毕 ,心脏复跳 ,缝合右房切口 ,平衡血容量后停机 ,右胸腔置一根引流管、关胸。结果 本组无手术死亡 ,无完全性房室传导阻滞、残余漏等手术并发症。 19例未输异体血 ,平均住院 14 .8d痊愈出院。随访 4～ 5 2个月 ,患者均恢复正常生活及工作。结论 经右胸切口体外循环下应用自体心包片矫治部分性房室管畸形安全可靠 ,创伤小 ,失血量少 ,切口美观 ,并发症少。

Objective To explore the operative method to correct the partial atrio ventricular canal deformity by using pericardial autograft through right thoracotomy under extracorporeal circulation.Methods Tracheal intubation was completed after the general anesthesia.Trachea intubation was completed after the general anesthesia.Right thoracic lateral incision was made in the left lateral position,and the pericardium was cut open longitudinally to reveal the heart.Extracorporeal circulation was established by inserting blood supply tube into the base of ascending aorta and by placing drainage tube into the superior and inferior vena cava through right atrium.Operations were performed after the ascending aorta was blocked and the cooling liquid was infused to stop the heart beating in 28 cases,while operations were done in other 4 cases under normal body temperature without cardiac arrest.After locating the endocardial deformity through the right atrial incision,Foley urinary tube was placed into left superior vena cava and water was infused into airsacs to block the left superior vena cara to reveal the operation field.The anterior leaflet fissures of mitral valves were reparied with 2～4 interrupted 4 0 prolene sutures.According to the size of the primary foramen defects,pericardial autografts were cut off carefully,then the primary foramen defects were sutured continuously.The slice was sutured in the base of anterior leaflet of mitral valve and then onto the surface of left atrium to avoid the damage of conducting system.After that,the heart beating was restarted and the incision was sewed up.When the blood volumes was balanced,the cardiopulmonary machine was shut down.A drainage tube was placed in the right thoracic cavity before the end of the operation.Results No deaths,complete atrio ventricular block or residual leakage occurred in this group.No residual blood transfusion was used in 19 cases.The average hospitalization time was 148 days.The follow up survey in the following 4～52 months showed that all these cases recovered well enough to live a normal life.Conclusion This kind of operation is safe and reliable and can reduce trauma and blood loosing and cause less complications.The pericardial autografts can be easily available and show such advantages as good plasticity,high mechanical intensity,anti infection and no oozing,leakage,hemolysis or embolism.Therefore,it can act as ideal repair material to correct partial atrio ventricular canal defect.