产前超声心动图诊断胎儿左心室发育不良综合征

目的 探讨胎儿超声心动图诊断左心室发育不良综合征(HLHS)的临床价值。方法 对18胎HLHS胎儿的临床资料进行回顾性研究,分析其超声心动图特征。结果 18胎HLHS胎儿的超声心动图结果:①心尖四腔心切面:左心室小、心室发育不良。8胎二尖瓣及主动脉瓣闭锁,且左心室重度发育不良;5胎二尖瓣闭锁合并主动脉瓣狭窄及主动脉缩窄;3胎二尖瓣狭窄伴主动脉瓣狭窄及主动脉弓缩窄;2胎二尖瓣狭窄伴主动脉瓣闭锁及主动脉弓缩窄。②三血管切面:主动脉内径明显小于肺动脉,主动脉与肺动脉内径比值为0.25~0.40,平均0.38±0.18,主动脉横弓与动脉导管、肺动脉血流方向相反。③胸骨旁四腔心切面:6胎房间隔增厚,未显示房间隔穿隔血流。12胎胎儿卵圆孔径偏小、显示房间隔左向右分流。结论 胎儿超声心动图可早期诊断胎儿HLHS,结合染色体检查对围生期的监测和临床处理有重要意义。     

胎儿动脉导管异常的超声心动图检查及分析

目的 胎儿动脉导管（DA）异常的超声心动图检查及分析。方法 回顾性分析产前诊断DA异常的70胎资料。二维超声结合彩色多普勒扫查胎儿四腔心切面、左右心室流出道切面、三血管切面及三血管-气管切面等横断面,扫查腔静脉长轴切面、主动脉弓切面及动脉导管弓切面等矢状面。观察DA的走行及与其他大血管的空间位置关系。结果 胎儿DA异常主要由DA缺如、DA功能异常及DA形态异常3类。70胎DA异常中,9胎DA缺如,8胎DA早闭,11胎DA即将闭合,9胎DA逆行灌注血流,33胎DA走行纡曲伴扩张。结论 产前诊断胎儿DA缺如及DA功能性改变意义重大。三血管-气管切面及动脉导管弓切面结合CDFI扫查可明确诊断。     

胎儿完全性大动脉转位产前超声诊断

  目的  探讨超声对胎儿完全性大动脉转位的诊断价值。  方法  回顾性分析2010年3月至2013年7月北京协和医院4例胎儿完全性大动脉转位的产前超声表现, 并与病理结果进行比较。  结果  4例完全性大动脉转位胎儿中, 3例四腔心切面正常, 1例可见室间隔缺损。左室及右室流出道切面4例胎儿可见心室与大动脉连接关系异常, 2例可见室间隔膜部缺损。三血管气管切面4例均仅可见2条血管。  结论  完全性大动脉转位具有特征性超声表现, 重点观察心室流出道切面及三血管气管切面有助于产前正确诊断。     

宫颈癌MRI与病理对照研究

研究背景 超声心动图已成为胎儿心血管疾病最主要的非侵入性诊断技术,目前国内外常规使用的是二维切面超声结合彩色多普勒诊断胎儿先天性心脏病。实时和容积三维超声成像技术也逐渐成熟,已应用到胎儿心脏形态和功能的判断。目的 研究正常胎儿心脏实时和容积三维超声成像的方法步骤,为胎儿先天性心脏病的成像奠定基础。方法应用三维超声心动图和彩色多普勒血流显像仪,对371胎经二维超声判定为正常心脏结构的胎儿进行实时三维超声检查,获取的三维数据通过QLab软件进行后处理,其中满意三维数据339胎,通过切割与旋转,获得四腔心、心室流出道、三血管和大动脉短轴切面观、导管弓、主动脉弓等切面观,分析总结正常胎儿心脏标准切面观的成像方法和步骤。结果 应用QLab软件总结的成像方法对获得满意三维数据的正常胎儿心脏均可较好获得各标准切面观,并节段分析正常胎儿心脏结构及连接顺序。①胎儿内脏位置及四腔心切面:选择腹围标准切面观为基本参考切面,上下平移冠状长轴观的横切面轴线(x轴),根据横切面观的成像判定胎儿体位,确定胎儿头侧和足侧及胎儿左右方位,平移横切面轴线(x轴)至胎儿腹部,对腹横切面适当旋转直至标准腹围切面观成像或脊柱两侧基本对称,同时矢状长轴观可见横切面轴线(x轴)跟随旋转,向头侧平移此时的x轴至心尖水平,则横切面成像为标准四腔心切面。②左心室流出道切面、大动脉短轴及三血管气管切面观成像:标准四腔心的横切面轴线(x轴)向头侧平移至十字交叉水平并适当向头侧旋转约15°可见左心室流出道成像,沿此轴位向头侧平移至大动脉水平,可对大动脉短轴成像,继续向上平移至心底水平可见三血管气管切面成像。③导管弓及主动脉弓切面观成像:矢状轴线及冠状轴线置于降主动脉切面,冠状切面观成像降主动脉长轴,继续将冠状轴线向腹侧前倾约30°,则可成像主动脉弓观,继续向腹侧前倾约5~10°,则导管弓切面观成像。④腔静脉切面观成像:冠状轴线矢状轴线均置于右心房,适当左右或前后平移矢状轴线或冠状轴线则上下腔静脉观成像。结论 实时和全容积三维超声心动图可对正常胎儿心脏进行多切面观察,能系统分析胎儿心脏的结构和方式、大动脉的连接关系,是对二维超声成像的有益补充。     

超声诊断胎儿左心室脂肪瘤1例

晰,右侧可见,左右心室流出道切面显示清楚,心室与大动脉连接正常,两条大动脉在心底呈交叉排列.超声提示:①宫内孕,单活胎,头位;②胎儿左心室占位(脂肪瘤).     

孕早期经腹部超声筛查胎儿先天性心脏病

目的 探讨胎儿颈项透明层(NT)检测期间(孕11~13⁺⁶周)经腹部超声筛查胎儿先天性心脏病的可行性。 方法 于胎儿NT检测期间对200胎单胎妊娠胎儿行超声扫查,主要切面包括四腔心切面、左心室流出道切面、右心室流出道切面和三血管切面;根据头臀长(CRL)将该胎儿分为2组,A组CRL为45~60 mm,B组为61~84 mm,比较两组胎儿心脏的成功检查率。对200胎均于孕中期(18~24周)行常规胎儿超声检查,出生后行新生儿超声心动图检查。 结果 200胎平均CRL为(66.00±4.60) mm。A组88胎中,23胎(23/88,26.14%)胎儿心脏获得成功检查,B组112胎中,85胎(85/112,75.89%)获得成功检查,两组差异有统计学意义(P<0.05)。 结论 孕早期经腹部超声筛查胎儿先天性心脏病是可行的,有望将某些心脏畸形的检出时间提前4~8周。胎儿CRL>60 mm时,胎儿心脏成功检查率明显提高。     

产前超声诊断矫正型大动脉转位

目的 探讨产前超声对矫正型大动脉转位的诊断价值.方法 回顾性分析10例在我院诊断的胎儿矫正型大动脉转位的超声病例资料.利用二维超声心动图获取四腔心切面、主动脉根部短轴切面、主动脉弓切面、双房切面及左、右室流出道切面,并采用心脏三节段分析法进行分析.在四腔心切面上判定心房位置及房-室连接有无异常,在左、右室流出道切面的基础上追踪显示2条大动脉的走行,判定心室-大动脉连接有无异常.结果 10例矫正型大动脉转位的胎儿中,经尸检或生后超声心动图证实有2例为单纯矫正型大动脉转位,4例为矫正型大动脉转位合并室间隔缺损,2例为矫正型大动脉转位合并室间隔缺损及肺动脉狭窄,1例为矫正型大动脉转位合并室间隔缺损、三尖瓣下移畸形,1例为矫正型大动脉转位合并主动脉缩窄.结论 四腔心切面及双流出道切面是诊断矫正型大动脉转位的主要切面.采用三节段分析法及连续追踪法是分析本病的重要方法.     

胎儿主肺动脉窗产前超声心动图特征

目的 探讨胎儿主肺动脉窗（APW）的产前超声心动图特点。方法 回顾性分析经产前超声诊断的16胎APW胎儿的超声心动图特点,包括APW缺损部位、大小、分型、分流情况及合并其他心内、心外畸形情况。结果 胎儿超声心动图诊断的16胎APW胎儿中,引产10胎,出生2胎,失访4胎。4胎接受尸体解剖的胎儿引产标本中,3胎超声心动图结果与病理结果一致,1胎病理证实为共同动脉干。2例出生后接受手术治疗,其超声心动图结果均与手术结果一致。15胎APW中,Richardson Ⅰ型2胎（2/15,13.33%）,Ⅱ型9胎（9/15,60.00%）,Ⅲ型4胎（4/15,26.67%）。APW超声心动图特点为三血管切面或左心室流出道、右心室流出道切面可见主动脉与肺动脉之间的间隔回声失落,CDFI示大动脉水平可见双向分流信号。15胎均合并其他心内、心外畸形,包括主动脉弓异常6胎（6/15,40.00%）、室间隔缺损6胎（6/15,40.00%）、肺动脉异常6胎（6/15,40.00%）、动脉导管异常5胎（5/15,33.33%）、静脉异常4胎（4/15,26.67%）、圆锥动脉干畸形3胎（3/15,20.00%）、Berry综合征3胎（3/15,20%）、法洛四联症1胎（1/15,6.67%）、单脐动脉1胎（1/15,6.67%）。结论 产前超声心动图对APW具有诊断价值,能准确评估APW缺损部位、大小、分型及血流情况,可作为首选检查方法。     

主动脉弓缩窄的产前超声诊断

目的探讨胎儿主动脉弓缩窄(CoA)的产前超声诊断线索、诊断方法与技巧及畸形特征。方法所有胎儿均常规获得四腔心切面、左右心室流出道切面、三血管气管(3VT)切面(即主动脉弓横切面)的灰阶和彩色多普勒血流显像。当四腔心切面发现左心系统偏小、3VT切面显示主动脉弓和动脉导管内径比例失调疑CoA时,进一步获得主动脉弓纵切面和冠状切面(Y平面)并测量峡部内径。结果产前超声共诊断56例CoA患儿,28例有解剖或新生儿超声心动图和手术结果,产前超声误诊和漏诊4例。其中8例合并单心室、心内膜垫缺损、右心室双出口、大动脉转位、永存动脉干等其他严重复杂心脏畸形,7例合并心脏外严重畸形。22例合并室间隔缺损(VSD)和永存左上腔静脉(LSVC)等非复杂心脏畸形。产前超声诊断的28例CoA患儿均首先于3VT切面发现两大动脉内径比例失调,主动脉弓异常小,四腔心切面显示左、右心室比例不对称,左心明显小于右心。此28例CoA患儿中有23例(82.1%)同时获得了3VT切面、主动脉弓纵切面及Y平面,14例于主动脉弓纵切面显示有来自降主动脉的反流。而误诊和漏诊的4例CoA患儿均未能获得满意的主动脉弓纵切面和Y平面。结论 3VT切面显示主动脉弓和动脉导管内径比例失调和四腔心切面不对称、左心偏小是CoA的诊断线索,进一步获取主动脉弓的特殊切面以获得至少2个平面的印证是提高CoA产前诊断率的主要技巧。CoA可以单独发生,也可合并其他心内外畸形。     

时间-空间关联成像技术A平面平推＋旋转法快速筛查孕中期胎儿心脏结构

目的 评价时间-空间关联成像(STIC)技术A平面平推＋旋转法在快速筛查孕中期胎儿心脏结构中的应用.方法 将常规超声检查正常的胎儿400胎分为常规扫查组(200胎)和STIC组(200胎),根据胎儿心脏与探头的相对位置,将STIC组胎儿分为心尖四腔心、横位四腔心及心底四腔心3个亚组.对STIC组使用A平面平推法获得上腹部横切面、四腔心切面、左心室流出道、右心室流出道及三血管切面,并进行动态连续观察; 在三血管切面的基础上,使用A平面旋转法获得主动脉弓及动脉导管弓切面.计算两组胎儿心脏筛查所需时间,评价STIC各亚组所获得图像的质量.结果 应用STIC技术进行胎儿心脏筛查,用时较常规超声筛查明显缩短.心尖四腔心及横位四腔心亚组所获图像质量优于心底四腔心亚组 (P均<0.01).结论 与常规扫查方法相比,应用STIC技术A平面平推法＋旋转法可快速筛查孕中期胎儿心脏结构,具有重要临床应用价值.     

Simple approach to prenatal diagnosis of transposition of the great arteries.

OBJECTIVE: To analyze the most relevant anomalies, seen in a sequential segmental transverse views approach to imaging the fetal heart, that provide clues to the diagnosis of complete transposition of the great arteries (TGA). METHODS: We reviewed retrospectively all the cases of isolated TGA diagnosed in our center or submitted for a second opinion through the spatio-temporal image correlation (STIC) telemedicine (TELE-STIC) program. Only transverse cardiac sweeps were obtained. Digital video clips and STIC volumes were reviewed. The abnormal features on four-chamber, five-chamber, three-vessel (3V) and three vessels and trachea (3VT) views were analyzed. RESULTS: The study population consisted of eight fetuses with TGA with normal extracardiac anatomy. The gestational age ranged from 13 to 32 (mean, 23) weeks. The maternal age ranged from 25 to 42 (mean, 32) years. A normal four-chamber view was seen in seven cases. Only one case demonstrated a significant ventricular septal defect. At the level of the five-chamber view a straight course arterial vessel arose from the left ventricle with lateral branches in all fetuses. In the 3V view, the ascending aorta was seen reaching more anteriorly than was the pulmonary artery in six cases. At the level of the 3VT view, two vessels (transverse aortic arch and superior vena cava) rather than three were seen in all cases. CONCLUSION: Our proposed sequential segmental approach to imaging the fetal heart apparently allows, in five-chamber and 3VT views, clear and confident signs to be detected that aid diagnosis of TGA.     

儿童永存第五主动脉弓超声心动图表现北大核心CSCD

目的观察儿童永存第五主动脉弓(PFAA)的超声心动图表现。方法观察5例经CT血管造影(CTA)及手术确诊PFAA患儿的超声心动图表现,记录相关临床资料。结果5例PFAA,包括1例Weinberg A型及4例Weinberg B型。超声心动图左心室流出道切面均见第五主动脉弓自升主动脉远端发出,胸骨上窝长轴切面见2个并存且平行走行的主动脉弓,4例Weinberg A型上方为第四主动脉弓、下方为第五主动脉弓,均与降主动脉相连;1例Weinberg B型上方第四主动脉弓离断,仅见下方的第五主动脉弓与降主动脉相连。5例中,4例接受PFAA矫治术,术后随访主动脉弓血流均通畅;1例因第五主动脉弓血流通畅而未接受PFAA矫治术。结论不同类型PFAA超声心动图表现存在差异,联合观察左心室流出道切面和胸骨上窝长轴切面有助于提高PFAA检出率。     

胎儿完全性大动脉转位产前超声诊断简

目的探讨超声对胎儿完全性大动脉转位的诊断价值。方法回顾性分析2010年3月至2013年7月北京协和医院4例胎儿完全性大动脉转位的产前超声表现,并与病理结果进行比较。结果4例完全性大动脉转位胎儿中,3例四腔心切面正常,1例可见室间隔缺损。左室及右室流出道切面4例胎儿可见心室与大动脉连接关系异常,2例可见室间隔膜部缺损。三血管气管切面4例均仅可见2条血管。结论完全性大动脉转位具有特征性超声表现,重点观察心室流出道切面及三血管气管切面有助于产前正确诊断。     

Color Doppler examination of the outflow tracts of the fetal heart: a technique for identification of cardiovascular malformations.

The objective was to describe a technique using color Doppler to identify the outflow tracts of the fetal heart by directing the ultrasound transversely through the fetal chest. One hundred second- and third-trimester control fetuses were examined with real-time and color Doppler ultrasound. The ultrasound beam was directed cephalad, in the same transverse plane used to image the four-chamber view, and the outflow tracts were examined. Four fetuses with abnormal cardiovascular anatomy were examined using the above approach, to study the anatomical relationships of the outflow tracts identified with color Doppler ultrasound in normal fetuses.When the ultrasound beam was directed immediately cephalad to the four-chamber view, the aorta was identified as it exited the left ventricle. Further movement of the ultrasound beam cephalad identified the following vessels in a single plane: the main pulmonary artery perpendicular to the ascending aorta; the left pulmonary artery branching from the main pulmonary artery; the full length of the ductus arteriosus; and the transverse arch of the aorta. The ascending aorta, main pulmonary artery, ductus arteriosus and transverse aortic arch were identified in 100% of fetuses. Four fetuses with abnormalities of the outflow tracts (aortic stenosis, aortic regurgitation, pulmonary stenosis and premature constriction of the ductus arteriosus) were imaged using this approach in which pathology was readily identified.This technique enables rapid identification of the outflow tracts in second- and third-trimester fetuses using color Doppler and accurately identifies abnormalities of these vessels.     

初学者应用胎儿心脏超声智能导航技术显示正常胎儿9个切面的初步研究

目的探讨初学者应用胎儿心脏超声智能导航技术（FINE,5D Heart）在胎儿心脏超声检查中的应用价值。 方法选取2015年1月至2015年3月间在浙江大学医学院附属邵逸夫医院行胎儿超声心动图检查的中孕期孕妇80例,由一名胎儿超声心动图专家首先获取9个常规二维超声切面,而后利用时空关联成像（STIC）技术,扫描获得满意的以心尖四腔心为初始切面的心脏容积数据。两位不同胎儿超声心动图检查资历医师应用5D Heart软件对STIC容积图像进行后处理,获得9个切面,分析各切面图像质量,采用Kappa一致性检验,对各切面合格数行观察者内的一致性分析,并与2D图像分别行观察者之间一致性分析。记录并分析应用5D Heart软件所耗时间,采用t检验分析各观察者前后两次耗时差异。 结果纳入研究80例中,9个切面二维图像的总体合格例数：75~80例（合格率93.8%~100.0%）;两位观察者前、后两次图像合格例数73~80（合格率91.3%~100.0%）。两位观察者前、后两次分析的一致性：在四腔心切面、胃泡水平腹部横切面,诊断结果完全一致（Kappa=1）;三血管气管切面（Kappa=0.851~0.882）,一致性优;五腔心切面（Kappa=0.787~0.882）,一致性良-优;主动脉弓切面（Kappa=0.738~0.787）、左心室流出道切面（Kappa=0.709~0.787）、右心室流出道切面（Kappa=0.655~0.794）、上下腔静脉长轴切面（Kappa=0.647~0.649）、动脉导管弓切面（Kappa=0.640~0.707）,一致性良。两位观察者分析与2D图像的一致性：四腔心切面、胃泡水平腹部横切面,两位观察者与2D分析结果完全一致（Kappa=1）;五腔心切面（Kappa=0.851~0.902）,一致性优;动脉导管弓切面（Kappa=0.749~0.820）、主动脉弓切面（Kappa=0.707~0.882）、右心室流出道切面（Kappa=0.661~0.851）、三血管气管切面（Kappa=0.655~0.851）,一致性良-优;左心室流出道切面（Kappa=0.737~0.749）、上下腔静脉长轴切面（Kappa=0.655~0.794）,一致性良。统计俩位观察者首次图像分析平均耗时为（2. 64±1.35）min,各观察者间耗时,差异无统计学意义（P>0.05）。 结论初学者应用5D Heart技术重现的9个切面,基本能够达到与直接获得二维切面相同的合格率与质量,该技术简单易学,重复性好,容易被初学者掌握和应用,有利于胎儿心脏超声检查的推广。     

Prenatal detection of ductal-dependent congenital heart disease: how can things be made easier?

OBJECTIVE: To improve the detection of ductal dependence in fetuses with severe anomalies of the outflow tracts by observing, with directional power Doppler, reverse flow through the aortic arch or ductus arteriosus in a transverse view of the upper mediastinum. METHODS: A slight cranial move of the ultrasound beam from the three-vessel view allows the transverse view of the aortic arch and ductus arteriosus to be visualized simultaneously. This view is orthogonal to the fetal body axis and parallel to the plane of the four-chamber view. In normal fetuses, directional power Doppler interrogation at this level identifies forward flow in both oblique vessels. RESULTS: We examined 43 fetuses with cardiac defects. In five of the cases, there was reversed flow in the aortic arch or ductus arteriosus in addition to severe anomalies of the outflow tracts, including four with hypoplastic left ventricle and one with pulmonary atresia. CONCLUSIONS: Prenatal detection of reversed flow in the aortic arch or ductus arteriosus is associated with complex congenital heart disease with major diminution of forward flow to the corresponding great vessels.     

Three-dimensional ultrasonography of normal fetal heart: comparison with two-dimensional imaging.

Thirty-one high-risk patients (16 to 35 weeks' gestation) underwent two-dimensional and three-dimensional ultrasonography to compare two-dimensional and non-cardiac-gated three-dimensional ultrasonography of the normal fetal heart. After normal two-dimensional studies, three-dimensional sonographic volumes were acquired without cardiac gating in transverse and longitudinal planes. Standard cardiac views were derived from three-dimensional data, analyzed, and rated as follows: (1) not identifiable, (2) identifiable but inadequate for diagnosis, (3) adequate, and (4) excellent. Two-dimensional ultrasonography demonstrated better yields of diagnostically acceptable images of basic echocardiographic views (four-chamber view, 100% for two-dimensional sonography versus 10 to 71% for three-dimensional sonography; right ventricular outflow tract, 42% for two-dimensional versus 6 to 26% for three-dimensional ultrasonography; left ventricular outflow tract, 71% for two-dimensional versus 13 to 45% for three-dimensional sonography). In one subject three-dimensional ultrasonography was superior to two-dimensional sonography in demonstrating an outflow tract. Aortic and ductal arches were not imaged with the two-dimensional technique but were available from the acquired three-dimensional volumes in 3 to 32% and 23%, respectively. False-positive and false-negative findings were observed on three-dimensional ultrasonograms. Overall, compared to two-dimensional ultrasonography, non-cardiac-gated three-dimensional sonography yielded inadequate reconstructed image quality of basic echocardiographic views (four-chamber view, right ventricular outflow tract, left ventricular outflow tract). Three-dimensional ultrasonography, however, shows potential for allowing nonechocardiographers to acquire some diagnostically acceptable views of the aortic and ductal arches.