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作者研究了一组孤立性室间隔缺损的心脏,以确定其外科解剖,并明确房室传导组织与缺损边缘的关系。全组检查了63个心脏,也研究了其中12例的房室传导系统的连续切片。正如Soto Becker.Moulaert,lie和Anderson以前所建议的,所有缺损可分为膜部型,肌部型和动脉下漏斗部三种类型。膜部缺损的特点是中心纤维体形成其部分边缘。这一事实说明,当经过右心房径路到达缺损时,传导组织经常位于外科医生的右侧。心室传导组织的确切解剖关系取决于膜部缺损是否延及肌性空间隔的入口、小梁或漏斗部而异。在入口缺损和小梁间的缺损未分支的传导束离边缘最近,经常包绕在室间隔的膜性残留部分内,但在另外一些标本中也发现未分支传导束和传导束分支远离室上嵴,并延伸至室间隔的左心室而。在漏斗部膜部缺损时,在远离室上嵴处可发现传导组织。与以上所见形成对照,外科医生经右心房检查入口部肌性缺损时,则穿透支和未分支传导束与缺损的左侧缘相关。在小梁和漏斗部肌性缺损,以及动脉在下漏斗部缺损时,若缺损的房侧缘是肌性,则传导组织又出现在远离缺损的边缘处。 Truex Bishof和lev的研究第一次确定了室间隔缺损时心脏传导系统的经路并革新了他们的手术纠治方法。然而,尽管这些研究指出房室束与膜部缺损的室上嵴有关,但外科医生通过这一事实,即在修补室间隔缺损时,在入口部肌性缺损的上方,仍可能引起房室分离或束支传导阻滞。这可能反映出对房室束的穿透部位,其与纤维膜的关系在缺损边缘处以及束支与室上嵴的关系,均缺乏确切的认识。关于纤维膜的问题极为重要。因为Goor和Lilleher提示纤维(白)组织与传导组织无关。它与室上嵴的关系很重要,因为法鲁氏四联症时嵴部通常没有束支分支。这一认识促使某些作者建议直接在室上嵴上缝合。然而有些四联症心脏的传导组织可能直接与室上嵴关联,因而在手术修补时有相当大的危险。正如Lev以前所提示的,法鲁氏四联症时所见的传导组织分布变异,在孤立性室间隔缺损时亦同样存在。因为新近研究提示,所谓“膜性”缺
The authors studied a group of isolated heart defects with ventricular septal defects to determine their surgical anatomy and to clarify the relationship between atrioventricular tissue and the margin of the defect. The whole group examined 63 hearts and also studied serial sections of atrioventricular conduction system in 12 of them. As Soto Becker.Moulaert, lie and Anderson previously suggested, all defects can be divided into membranous, muscular and under the funnel three types. Membrane defect is characterized by the central fiber body to form part of its edge. This fact shows that when the defect passes through the right atrial path, the conductive tissue is often on the right side of the surgeon. The exact anatomy of ventricular conduction depends on whether the membranous defect extends to the entrance to the muscular space, the trabecula, or the funnel. Defects between the entry defect and the trabeculae Unbranched conductive bundles are often wrapped around the membranous residual portion of the ventricular septum nearest the edges, but in other specimens it is also found that the unbranched conductive bundles and the conductive bundle branches are far away from the chamber Crista, and extends to the left ventricular septal compartment. In the funnel Department of membrane defects, far away from the supraspinatus can be found in the conductive tissue. In contrast to what has been seen above, when the surgeon examines the muscular defect at the entrance through the right atrium, the penetrating and non-branching bundles are associated with the left margin of the defect. In the trabecular and funnel Department of muscle defects, and arteries in the lower part of the funnel defect, if the defect side of the housing is muscular side, the conduction tissue and appear in the edge away from the defect. Truex Bishof and lev’s study identified, for the first time, the pathways of the cardiac conduction system in VSD and revolutionized their surgical approach. However, while these studies indicate that the atrioventricular bundle is associated with the supraspinous defect in the membranous segment, the surgeon may still be able to cause atrioventricular separation over the muscular defect at the entry site by repairing the ventricular septal defect Or bundle branch block. This probably reflects a lack of exact understanding of the site of penetrating the atrioventricular bundle, its relationship to the fibrous membrane at the defect margin, and the relationship between the bundle branch and supracondyral ridge. The issue of fiber membranes is extremely important. Because Goor and Lilleher suggest that fibrous (white) tissue is not associated with conductive tissue. Its relationship with the suprascapal crest is important because there is usually no branching at the crest of the tetralogy of Fallot. This understanding prompted some authors to suggest suturing directly on the supraspinatus. However, some of the tetralogy of the heart of conductive tissue may be directly associated with the supraspinatus, and therefore there is considerable risk of surgical repair. As Lev previously suggested, the distribution of conductive tissue seen in Faro’s tetralogy of Fall is also present in isolated VSD. Because of recent research suggests that the so-called “membranous” lack