超声心动图对胎儿先天性心脏病产前诊断价值的Meta分析

目的探讨超声心动图用于胎儿先天性心脏病（CHD）的产前诊断价值。方法检索Cochrane 图书馆、PubMed、OVID、Springer数据库、中国期刊全文网、万方数据库和中国生物医学文献数据库（从1990年1月至2009年1月）中的文献，按照诊断试验的严格纳入标准筛选文献，提取纳入文献的特征信息。采用Meta-DiSc 1.4软件进行Meta分析，检验异质性，并根据异质性结果选择相应的效应模型。对所有文献予以加权定量合并，计算敏感度和特异度及其95%CI。绘制汇总受试者工作特征（SROC）曲线，并计算曲线下面积（AUC），最后进行敏感度分析。结果共纳入文献18篇，检查胎儿77 939例。7篇文献采用基本心脏超声检查（BCEE）筛查胎儿CHD，研究间具异质性，采用随机效应模型，汇总敏感度、特异度和SROC AUC分别为41.7%、99.9%和0.9787。12篇文献采用扩展心脏超声检查（ECEE）筛查胎儿CHD，研究间具异质性，采用随机效应模型，汇总敏感度、特异度和SROC AUC分别为66.9%, 99.9%和0.9956。ECEE的敏感度显著高于BCEE（χ2=63.93，P<0.05）。对BCEE和ECEE筛查胎儿CHD的文献进行分层和敏感度分析，两种检查方法在妊娠中至晚期筛查胎儿CHD的敏感度均高于妊娠中期（χ2分别为5.47和39.37， P均<0.05）；ECEE筛查存在CHD低危因素孕妇的胎儿CHD的敏感度低于所有孕妇和存在CHD高危因素孕妇胎儿的敏感度, 差异有统计学意义（χ2分别为81.82和156.58，P均<0.05）；ECEE筛查所有孕妇与存在CHD高危因素孕妇的胎儿CHD的敏感度差异无统计学意义（χ2=1.67，P>0.05）。结论超声心动图对胎儿CHD的诊断敏感度较高，适用于早期筛查胎儿CHD，但仍需进一步前瞻性、多中心的研究对胎儿筛查人群和超声切面的选择等方面进行卫生经济学评估，探讨适合中国国情的胎儿CHD的最优化超声筛查操作规范。

Meta-analysis of the value of fetal echocardiography for the prenatal diagnosis of congenital heart disease

Objective To evaluate the value of fetal echocardiography for the prenatal diagnosis of congenital heart disease. Methods A search in Cochrane Library, PubMed, OVID, Springer, China National Knowledge Infrastructure (CNKI), Wanfang Chinese Periedieal Database and Chinese Bio-medicine Database ( CBM ) was performed to identify relevant English and Chinese language articles from Jan 1990 to Jan 2009. Inclusion criteria were established based on validity criteria for diagnostic research. Subsequently, the characteristics of the included articles were extracted. Statistical analysis was performed by employing Meta-Dise 1.4 and SPSS 12.0 software. Heterogeneity of the included articles was tested, which was used to select proper effect model to calculate pooled weighted sensitivity and specificity. Summary receiver operating characteristic (SROC) curve was made and the area under the curve (AUG) was calculated. Finally, sensitivity analysis waa performed. Results Eighteen articles were included, with a total of 77 939 fetuses. Seven articles meeting with inclusion criteria were analyzed for the value of basic cardiac echocardiographic examination (BCEE) for the prenatal diagnosis of congenital heart disease. The pooled sensitivity and specificity were 41.7% and 99. 9% respectively, AUC =0. 978 7. Twelve articles meeting with inclusion criteria were analyzed for the value of extended cardiac echocardiographie examination (ECEE). The pooled sensitivity and specificity were 66. 9% and 99. 9% respectively, AUG = 0. 995 6. The sensitivity of ECEE was significantly higher than that of BCEE (x<'2> = 63. 93, P < 0. 05). The random-effect model was used in the analysis because of the heterogeneity. The layering research and sensitivity analysis were performed on the BCEE and ECEE. The sensitivity of BCEE and ECEE for the prenatal diagnosis of congenital heart disease during the second to third trimester was significantly higher than that during the second trimester (x<'2> = 5.47,39. 37, P < 0. 05 ) ; The sensitivity of ECEE for the prenatal diagnosis of congenital heart disease for the fetuses of low-risk pregnant women was lower than that of the unselected or high-risk pregnant women (x<'2> = 81.82,156. 58, P < 0. 05 ) ; The sensitivity of ECEE for the prenatal diagnosis of congenital heart disease for the fetuses of unselected pregnant women was not different from that of high-risk pregnant women(x<'2> = 1.67 ,P > 0. 05 ). Conclusions The results suggested that fetal echocardingraphy was highly accurate and suitable for the prenatal diagnosis of congenital heart disease. Further multieentre and prospective studies are still needed to optimize the ultrasound section and screening subjects by a cost-effectiveness analysis, and develop an operation guideline on fetal echocardiography for the prenatal diagnosis of congenital heart disease suitable for China.