时间-空间相关成像技术联合反转模式诊断胎儿先天性心脏病

目的评价时间-空间相关成像(STIC)技术联合反转模式在产前诊断胎儿先天性心脏病中的应用价值。方法收集15胎先天性心脏病胎儿和54胎正常胎儿,每胎获取两组容积数据,分别以四腔心胸腔横断切面和主动脉弓长轴切面为初始采集平面,再用反转模式对容积数据进行重建。结果 54胎正常胎儿共获取108组容积数据,对其中103组容积数据成功进行了反转重建;对15胎先天性心脏病胎儿均成功进行反转重建;重建图像均能直观地显示心内结构和心外血管的空间位置关系。结论 STIC技术联合反转模式重建图像可提供更多重要解剖信息,有助于更好地产前可视化诊断胎儿复杂性先心病。     

胎儿主动脉弓离断的产前超声诊断现状

主动脉弓离断是一种罕见的严重先天性心脏病,胎儿期死亡率极高,其胚胎学起源复杂,表现形式多样,且多合并其他畸形,产前超声诊断困难。超声心动图作为目前临床常用的胎儿心脏检查手段,在先天性心脏病的筛查中发挥重要作用。本文主要从二维超声、三维超声在诊断中的应用及超声鉴别诊断方面对胎儿主动脉弓离断的产前超声诊断现状进行综述。     

时间-空间相关成像技术的反转模式在胎儿心血管成像中的应用进展

随着三维及四维超声技术的迅速发展,时间-空间相关成像技术(STIC)已成为研究胎儿心脏的一种相对成熟的技术,其多种成像模式可提供更多结构及血流的相关信息,为临床诊断提供依据。STIC技术的反转模式可更清晰、准确地呈现心室腔和血管腔的立体结构。本文就其在胎儿心血管系统中的研究进展进行综述。     

产前超声筛查中孕期胎儿心脏畸形对诊断染色体异常价值的Meta分析

目的采用Meta分析探讨中孕期胎儿超声心动图检查发现孤立性室间隔缺损、除外孤立性室间缺损的其他心脏及大血管畸形对染色体异常的产前筛查价值。方法检索Cochrane Library、PubMed、EMBASE、SCI、万方、维普、中国知网数据库中的中英文文献,按照纳入和排除标准筛选文献并进行偏倚风险评价,提取相关资料,检验异质性并选择相应的效应模型合并效应量,采用Meta-Disc 1.4软件,计算汇总敏感度、特异度及95%CI,绘制汇总受试者工作特征曲线,计算曲线下面积,对异质性文献进行敏感度分析。结果共纳入12篇文献,6篇文献分析了孤立性室间隔缺损对染色体异常的产前筛查价值,8篇文献分析了其他心脏及大血管畸形对染色体异常的产前筛查价值。采用随机效应模型合并效应量,两组汇总敏感度、特异度分别为32%、99%及29%、99%,SROC AUC分别为0.833 7及0.884 6,两组的汇总敏感度差异无统计学意义(P0.05)。结论中孕期超声心动图显示胎儿心脏畸形对染色体异常有一定的产前筛查价值,胎儿孤立性室间隔缺损是染色体异常的危险因素,存在其他心脏及大血管畸形未使染色体异常的风险增加。     

Imaging of aortico-left ventricular tunnel by three-dimensional echocardiography

Aortico-left ventricular tunnel (ALVT) is a rare congenital heart disease presenting as congestive heart failure in the neonatal or early infantile period due to severe aortic regurgitation (AR). We presented a 1-month-old boy with ALVT, originally diagnosed by two-dimensional echocardiography; however, the detailed anatomical features were not ascertained. Real-time three-dimensional echocardiography (RT3DE) could provide clear images of the three-dimensional structures of ALVT, just the same as those of surgical findings. ALVT originated from the left coronary cusp and ran an oblique path to the subvalvular orifice, having a narrow segment in the middle. RT3DE is a clinically useful diagnostic tool to clarify the detailed anatomy of ALVT.     

产前超声判断胎儿心脏位置的方法

产前心脏超声检查难度较大,识别胎儿心脏位置十分关键。本文就产前心脏超声检查中识别胎儿心脏位置的方法进行综述。     

Preoperative three-dimensional reconstruction of the heart and great vessels in patients with congenital heart disease. Technique and initial results

Magnetic resonance images have been obtained preoperatively in six patients with congenital heart disease. Contiguous sequences of electrocardiogram-triggered spin-echo images have been reconstructed in three-dimensional form to define the size and anatomic relationships to the great vessels and internal cardiac structures. Findings of magnetic resonance imaging were corroborated by angiographic and sector-scan echocardiographic studies and at operation. Individual scan slices were manually edited to separate the heart and great vessels from the blood within them and from extracardiac structures. Surface reconstruction software originally developed for craniofacial and orthopedic surgical planning was adapted for processing of cardiac magnetic resonance image sequences. Preoperative three-dimensional magnetic resonance imaging reconstructions were obtained in patients with aortic coarctation with ventricular septal defect, hypoplastic left ventricle, pulmonary artery atresia with ventricular septal defect, atrial septal defect, partial atrioventricular canal defect with anomalous pulmonary venous drainage, and tetralogy of Fallot with peripheral pulmonary artery stenosis. The reconstructions showed anatomic findings consistent with two-dimensional magnetic resonance imaging, echocardiography, cineangiography, and intraoperative findings. The three-dimensional images have a format that is familiar and consistent with the gross intraoperative appearance of the heart and great vessels. These three-dimensional images can facilitate the interpretation of magnetic resonance scan findings for cardiac surgeons without the sacrifice of significant clinical information.     

Fetal cardiac interventions: an update of therapeutic options

Objective

This article aims to present updated therapeutic options for fetal congenital heart diseases.

Methods

Data source for the present study was based on comprehensive literature retrieval on fetal cardiac interventions in terms of indications, technical approaches and clinical outcomes.

Results

About 5% of fetal congenital heart diseases are critical and timely intrauterine intervention may alleviate heart function. Candidates for fetal cardiac interventions are limited. These candidates may include critical aortic valve stenosis with evolving hypoplastic left heart syndrome, pulmonary atresia with an intact ventricular septum and evolving hypoplastic right heart syndrome, and hypoplastic left heart syndrome with an intact or highly restrictive atrial septum as well as fetal heart block. The advocated option are prenatal aortic valvuloplasty, pulmonary valvuloplasty, creation of atrial communication and fetal cardiac pacing.

Conclusion

Fetal cardiac interventions are feasible at midgestation with gradually improved technical success and fetal/postnatal survival due mainly to a well-trained multidisciplinary team, sophisticated equipment and better postnatal care.     

Fetal echocardiography for early detection of congenital heart diseases

Background

Fetal echocardiography is a complete two-dimensional and Doppler ultrasound evaluation of the human fetal cardiovascular system. It is completely noninvasive, harmless, and also serves as the fetal electrocardiogram.

Aim

To analyze the fetal echocardiographic cases referred to a tertiary cardiac center.

Materials, methods, and results

A total of 478 cases of fetal echocardiograms performed over a period of 5.5 years were compiled and analyzed. Details regarding gestational age, maternal, family history, exposure to teratogens, and reason for referral were recorded. The average gestational age at referral was 24.8 ± 4.6 weeks and maternal age was 24.7 ± 4.3 years. Indications for referrals were abnormal fetal cardiac scan in 128 (26.8 %), previous sibling with congenital heart disease (CHD) in 99 (20.7 %), maternal indications in 87 (18.2 %), echogenic intracardiac focus (EIF) in 87 (18.2 %), high risk in 50 (10.5 %), rhythm problems in 21 (4.4 %), and others (extracardiac malformations) in 6 (1.2 %). In the 87 CHD cases diagnosed, nearly 70 % had complex CHD and 66.7 % were referred only after 22 weeks of gestation. A further 103 cases had EIF, 17 cases had fetal arrhythmia, 3 cases had cardiac masses, and the remaining 268 cases had normal fetal echocardiograms.

Conclusion

Fetal echocardiography can effectively identify abnormal hearts and has enhanced prenatal detection of CHD. The concern in the Indian scenario is the late referrals, lack of follow-up, and financial difficulties, all of which conspire against the chance of the fetus with heart disease getting appropriate treatment.

     

Noninvasive three-dimensional reconstruction of the heart and great vessels by ECG-gated magnetic resonance imaging: a new diagnostic modality

We have developed a new method of computer image processing that allows true three-dimensional (3-D) images of the heart and great vessels to be reconstructed from standard ECG-gated two-dimensional magnetic resonance (MR) images. Contiguous 5-mm thick MR images of the thorax from the level of the cardiac apex to the aortic arch were obtained in 4 normal volunteers and 3 patients with congenital heart disease: 1 with pseudotruncus arteriosus and 1 with a ventricular septal defect, each with Eisenmenger's complex, and 1 with aortic coarctation. Each image could be obtained at up to seven different intervals throughout the cardiac cycle with ECG gating. The scanning procedure is noninvasive and requires no contrast material. Using standard software, images from each interval in the cardiac cycle were edited to isolate pertinent cardiac and great vessel structures. High-resolution 3-D reconstructions were formed for each interval by stacking the edited images. Sequential projection of 3-D reconstructions from each interval yields four-dimensional (includes time) cine views. Both 3-D and cine views can be obtained from any axis or divided in any plane to allow accurate, noninvasive assessment of cardiac and great vessel anatomy, chamber volumes, and regional and global wall motion. Noninvasive 3-D reconstruction of the heart and great vessels provides accurate anatomical data not available from standard cardiac catheterization or other noninvasive diagnostic procedures, and aids in the preoperative planning of the procedure to correct complex congenital malformations.     

实时灰阶二维血流显像联合空间-时间相关成像技术在胎儿心脏超声检查中的应用进展

四维超声扩大了胎儿心脏扫描成像技术的能力,不再局限于二维超声成像,为深入分析先天性心脏病提供了广阔的可能。实时灰阶二维血流显像（B-flow）联合空间-时间相关成像技术（BF-STIC）是近年发展的四维新技术,本文就其在胎儿心血管系统中的应用进展进行综述。     

The natural history of prenatally diagnosed conjoined twins

Background/Purpose: Accurate prenatal diagnosis of complex anatomic connections and associated anomalies has only been possible recently with the use of ultrasonography, echocardiography, and fetal magnetic resonance imaging (MRI). To assess the impact of improved antenatal diagnosis in the management and outcome of conjoined twins, the authors reviewed their experience with 14 cases. Methods: A retrospective review of prenatally diagnosed conjoined twins referred to our institution from 1996 to present was conducted. Results: In 14 sets of conjoined twins, there were 10 thoracoomphalopagus, 2 dicephalus tribrachius dipus, 1 ischiopagus, and 1 ischioomphalopagus. The earliest age at diagnosis was 9 weeks' gestation (range, 9 to 29; mean, 20). Prenatal imaging with ultrasonography, echocardiography, and ultrafast fetal MRI accurately defined the shared anatomy in all cases. Associated anomalies included cardiac malformations (11 of 14), congenital diaphragmatic hernia (4 of 14), abdominal wall defects (2 of 14), and imperforate anus (2 of 14). Three sets of twins underwent therapeutic abortion, 1 set of twins died in utero, and 10 were delivered via cesarean section at a mean gestational age of 34 weeks. There were 5 individual survivors in the series after separation (18%). In one case, in which a twin with a normal heart perfused the cotwin with a rudimentary heart, the ex utero intrapartum treatment procedure (EXIT) was utilized because of concern that the normal twin would suffer immediate cardiac decompensation at birth. This EXIT-to-separation strategy allowed prompt control of the airway and circulation before clamping the umbilical cord and optimized control over a potentially emergent situation, leading to survival of the normal cotwin. In 2 sets of twins in which each twin had a normal heart, tissue expanders were inserted before separation. Conclusions: Advances in prenatal diagnosis allow detailed, accurate evaluations of conjoined twins. Careful prenatal studies may uncover cases in which emergent separation at birth is lifesaving.     

Surgical simulation--a new tool to evaluate surgical incisions in congenital heart disease?

We introduce a new concept for preoperative planning and surgical education in congenital heart disease: surgical simulation. Recent advances in three-dimensional image acquisition have provided a new means to virtually reconstruct accurate morphological models while computer visualisation hardware now allows simulation of elastic tissue deformations interactively. Incision simulation is performed in two patients with complex congenital heart disease to preoperatively evaluate potential corrective surgical strategies. The relevant cardiac morphology was correctly depicted by the virtual models on which arbitrary incisions could be performed. By visualising the morphology in respect to each incision, different surgical strategies could be evaluated pre-operatively. We have taken the first step towards a clinically useful incision simulator for procedures in congenital heart disease and made an initial evaluation. With further developments it is likely that new tools for patient-specific preoperative planning and surgical training will emerge based on the presented ideas.     

Fetal heart assessment in the first trimester of pregnancy: influence of crown-rump length and maternal body mass index

Objective

To evaluate the influence of the crown-rump length and body mass index on sonographic evaluation of the fetal heart using abdominal and vaginal routes in the first trimester of pregnancy.

Methods

We conducted a cross-sectional study with 57 pregnant women between 12-14 weeks (CRL≤ 84 mm). We evaluated the following fetal cardiac plans using the abdominal and vaginal routes: four-chamber view, right ventricle outflow tract, left ventricle outflow tract and aortic arch. We used the B-mode, color Doppler and four-dimensional ultrasonography (spatio-temporal image correlation). To evaluate the influence of crown-rump length and body mass index in the assessment of fetal cardiac planes, we used the t test unpaired.

Results

There were no statistically significant differences in the rates of success and failure between abdominal and vaginal routes in relation to body mass index, however, there was a higher failure rate in vaginal assessment using B mode associated with color Doppler (P<0.01).

Conclusion

The crown-rump length and body mass index had no interference in fetal cardiac assessment in the first trimester of pregnancy.     

产前超声诊断胎儿尿道下裂进展

尿道下裂是胎儿常见泌尿系统先天畸形。产前二维及三维超声检查均可用于诊断胎儿尿道下裂，二者联合可提高诊断效能；在此基础上进行彩色多普勒超声检查可进一步明确尿道开口位置，提高诊断准确率，降低误诊率。本文对产前超声诊断胎儿尿道下裂进展进行综述。     

Resolution of hydrops fetalis in congenital cystic adenomatoid malformation after prenatal steroid therapy

Background/Purpose: Development of hydrops fetalis in fetuses with congenital cystic adenomatoid malformations (CCAM) is a significant risk factor for fetal or neonatal demise. In rare cases, resolution of CCAM has occurred, presumably owing to lesion maturation or involution. Steroid therapy, utilized for lung maturity, has been postulated to accelerate this process. The natural history of hydropic fetuses with CCAM after receiving steroid therapy is presented. Methods: The authors prospectively followed up with 3 patients who had antenatally diagnosed CCAM and nonimmune hydrops fetalis with predicted mortality. All patients declined or were not candidates for fetal intervention and were treated with standard prenatal betamethasone to increase lung maturity. Results: Three fetuses had CCAM and nonimmune hydrops fetalis diagnosed prenatally. After a course of prenatal steroids during the second trimester, all 3 patients had resolution of their hydrops and were delivered at term without respiratory distress. Conclusions: Nonimmune hydrops fetalis in fetuses with congenital cystic adenomatoid malformation is a harbinger for fetal demise. The resolution of hydrops in these patients after receiving steroid therapy is an interesting and compelling observation. Because the mechanism of this process is speculative, further studies are needed to elucidate the relationship between antenatal steroids and maturation of congenital cystic adenomatoid malformation. J Pediatr Surg 38:508-510.     

An introduction to transoesophageal echocardiography: II. clinical applications

Purpose

As progress has been made in the acquisition of cardiac images with transoesophageal echocardiography, the technique has moved from the confines of the cardiology laboratory into the operating room, the intensive care unit, and the emergency department. This has afforded anaesthetists the opportunity to become familiar with, and develop expertise in its practice. The purpose of this article is to present a review of transoesophageal echocardiography with reference to anaesthetic practice.

Source

The principle source of material was a computerized Medline? search of the English language literature from 1986 to 1995.

Principle findings

After discussing the technique of probe insertion, and describing some of the standard images, transoesophageal echocardiography’s clinical utility is critically assessed. Comparisons with available monitoring techniques are made with reference to ventricular function, valvular heart disease, pericardial, aortic and congenital heart disease, and the management of the multiple traumatized patient. Issues of certification and maintenance of competence are also discussed.

Conclusion

Although the benefit of transoesophageal echocardiography is intuitive in many clinical situations, in others, it has not been shown to improve upon presently existing monitoring techniques. The need for adequate training and collaboration with cardiology colleagues is emphasized.     

Atrial Septal Defect Revealed by Repeat Echocardiography in a Brain-Dead Donor: A Case Report

BackgroundThe number of patients undergoing heart transplantation is limited because of the shortage of donor hearts. Expanding the donor pool with precise evaluation of donor heart is the most practical way to increase the number of patients undergoing heart transplantation. However, echocardiographic evaluation of especially right ventricle (RV) in brain-dead donors is challenging. Repeated echocardiography with volume overload may reveal unrecognized congenital heart disease such as atrial septal defect (ASD).Materials and MethodsA case of repeated echocardiography revealed ASD secundum in a donor with significant RV enlargement and dysfunction from previously unknown origin. An almost-discarded donor heart was used in heart transplantation after simple patch closure.ResultsThe patient was discharged after a month. One year later, he has been doing well without significant adverse events.ConclusionsRV dysfunction prior to heart transplantation increases the risk of post-transplant graft failure. Secundum-type ASD and ventricular septal defect, which are relatively common adult congenital heart diseases that cause RV enlargement and dysfunction, are not contraindications for heart transplantation. Our case showed that repeat echocardiography revealed congenital heart disease and rescued the almost-discarded heart. This simple maneuver is essential in donor heart evaluation to maximize the utility of marginal donors.     

Intraoperative transesophageal echocardiography during surgery for congenital heart defects

OBJECTIVE: This study was undertaken to further define the impact of intraoperative transesophageal echocardiography during surgery for congenital heart disease and to determine appropriate indications. METHODS: The impact of transesophageal echocardiography on patient care was assessed in 1002 patients who underwent this procedure during surgery for congenital heart defects. It had major impact when new information altered the planned procedure or led to a revision of the initial repair. The safety of intraoperative transesophageal echocardiography was evaluated by review of the prospective data sheets and the medical record. A simple relative cost analysis was also performed. RESULTS: Patient median age was 9.9 years (range 2 days to 85 years). Transesophageal echocardiography had prebypass or postbypass major impact in 13.8% of cases (n = 138/1002). Major impact was more frequent during reoperations (P <.03). Procedures that benefited most from the additional information were valve repairs (aortic or atrioventricular) and complex outflow tract reconstructions. Partial anomalous pulmonary venous connection, tricuspid valve repair (other than of Ebstein anomaly), simple atrioventricular discordance, aortic arch anomalies, and secundum atrial septal defects had major impact rates less than 5%. No major complications occurred. Minor complications occurred in 1% of patients and were most often observed in infants smaller than 4 kg. Routine use of transesophageal echocardiography for all patients with congenital heart defects proved cost-effective. CONCLUSIONS: On the combined basis of the observed rates of major impact, the minimal complications, and the relative cost advantage, we believe that routine use of transesophageal echocardiography during most intracardiac repairs of congenital heart defects is justified, particularly for patients undergoing repeat operations for congenital cardiac malformations.     

Segmental Waveform Analysis in the Diagnosis of Peripheral Arterial Occlusive Diseases

The duplex exam is widely used in the diagnosis of peripheral arterial occlusive disease. It presents some drawbacks, however, such as calcified plaques, sequential stenosis, and time-consuming examinations. A type of waveform analysis, referred to in this study as segmental analysis, was conducted to try to find solutions to these problems. Parameters of waveform analysis (peak systolic velocity, acceleration time, pulsatility, and resistance indices) taken at the common femoral and popliteal arteries in 177 arterial segments (aortoiliac and femoropopliteal) were compared to angiography results in a prospective manner. The statistical analysis showed an accuracy rate above 95% for all parameters in defining hemodynamic-significant (stenosis and occlusions) lesions in both segments. Also, a combination of measurements (parallel tests) was used to differentiate between hemodynamic-significant stenosis and occlusions, showing sensitivity and specificity rates between 84.8% and 94.8%. Findings from this study show that the hemodynamics of an arterial segment can be evaluated by segmental waveform analysis. It can also be used as a screening test for peripheral arterial occlusive diseases alone or combined with the standard duplex color exam.