Foramen ovale: an ultrasonographic study of its relation to the inferior vena cava, ductus venosus and hepatic veins.

According to the literature, oxygenated blood from the ductus venosus and hepatic veins may either enter the right atrium before flowing through the foramen ovale to the left atrium, or flow directly from the ductus venosus and the hepatic veins to the foramen ovale, bypassing the right atrium. To address this problem, 103 normal fetuses were examined by two-dimensional imaging, M-mode and color Doppler at an average gestational age of 27 weeks (range, 15-40 weeks). The position of the ventricular septum and foramen ovale, and the angle and flow direction of the inferior vena cava, ductus venosus and hepatic veins were recorded. Two pathways for blood were described: a left ductus venosus-foramen ovale pathway that delivers blood directly to the foramen ovale circumventing the right atrium, and a right inferior vena cava-right atrium pathway that delivers blood into the right atrium through the right portion of the proximal inferior vena cava at an angle of 13 degrees to the long axis of the spine. The left and medial hepatic veins enter the left ductus venosus-foramen ovale pathway, and the right hepatic vein enters the right inferior vena cava-right atrium pathway. This supports the hypothesis that oxygenated blood from the ductus venosus and left hepatic veins flows directly through the foramen ovale to the left atrium avoiding extensive mixture in the inferior vena cava and an intermediate entrance to the right atrium.     

Foramen ovale size in the normal and abnormal human fetal heart: an indicator of transatrial flow physiology.

We used fetal echocardiography to measure the sizes of the foramen ovale and atrial septum in 80 human fetuses from 17.5 to 38 weeks gestation. Forty-six fetuses had normal cardiac anatomy, 19 had left heart obstructive lesions, and 15 had right heart obstructive lesions. Pulsed and color flow Doppler studies were incorporated when available. We found that normal fetuses had a foramen ovale/atrial septum size ratio of 0.33 +/- 0.04 (mean +/- SD). In all (52%) fetuses in which it was available, pulsed Doppler study revealed bidirectional, but predominantly right-to-left, flow through the foramen ovale. Fetuses with left heart obstructive lesions had a foramen ovale/atrial septum size ratio smaller than normal (0.28 +/- 0.05; p < 0.001). Seven of nine fetuses with left heart obstructive lesions who had color Doppler studies demonstrated reversal of the normal flow pattern, exhibiting unidirectional left-to-right transforamenal flow. Those with right heart obstructive lesions had a larger than normal foramen ovale/atrial septum size ratio (0.47 +/- 0.04; p < 0.001). Nine fetuses with right heart obstructive lesions had color Doppler studies which demonstrated almost exclusive right-to-left transforamenal flow. We conclude that foramen ovale/atrial septum size ratio and Doppler interrogation of transatrial flow are helpful adjuncts in determining the presence of congenital heart disease in utero. In addition, early detection of abnormal foramen ovale/atrial septum size ratio may predict whether left or right ventricular development will be impaired throughout gestation, even before gross disparity of ventricular size is apparent.     

超声心动图检测卵圆孔和卵圆孔瓣在诊断胎儿房间隔异常中的应用研究

目的超声心动图观察胎儿卵圆孔、卵圆孔瓣的特征,探讨超声诊断胎儿房间隔异常的临床应用价值。方法随机对515例孕24～42周正常胎儿的卵圆孔、卵圆孔瓣的多普勒超声特征进行分析;对440例胎儿心血管畸形高危因素的孕妇进行胎儿心动图专项检查,对胎儿房间隔回声异常者进行胎儿尸体解剖或分娩后超声复查对照。结果超声心动图对515例正常胎儿卵圆孔和卵圆孔瓣的显示率为98．6％（508／515）,卵圆孔径（5．42±1．30）mm;卵圆孔收缩期血流速度（0．45±0．93）m／s、舒张期血流速度（0．29±0．72）m／s。440例胎儿心血管畸形高危因素的孕妇中超声检出23例胎儿房间隔回声异常,其中卵圆孔瓣消失10例、断裂3例、增大10例,其卵圆孔径（9．64±2．58）mm,明显大于正常组（P〈0．05）;23例卵圆孔和卵圆孔瓣显示异常的胎儿,经尸体解剖或分娩后超声复查确定21例有房间隔发育异常或伴有其他畸形,假阳性2例。结论超声检测卵圆孔和卵圆孔瓣对产前诊断胎儿房间隔异常具有重要价值。     

胎儿心脏卵圆孔瓣正常开放与宫内早闭的超声心动图定量分析

目的应用胎儿超声心动图定量分析卵圆孔瓣运动规律以及卵圆孔瓣宫内早闭的血流动力学特点。 方法选取2019年11月至2020年6月在北京百子湾和美妇儿医院进行产前检查,胎儿及母体均未发现异常的孕妇102 例为正常组,依据孕龄将正常组分为3组：组A孕28⁺⁰~32⁺⁶周36例,组B孕33⁺⁰~36⁺⁶周32例,组C孕37⁺⁰~40⁺⁶周34例。另选取超声心动图诊断为胎儿宫内卵圆孔瓣早闭且右心增大的孕妇14例为异常组。应用M型超声心动图检测胎儿卵圆孔瓣运动曲线,测量收缩期（S峰）和舒张期（D峰）运动峰值,S峰持续时间（ST）,1个心动周期持续时间（T）,S峰下降斜率,计算ST/T;应用多普勒超声测量肺动脉瓣、主动脉瓣、动脉导管血流速度,静脉导管阻力指数,脐静脉（腹段）血流速度,跨卵圆孔和下腔静脉入右心房血流速度;应用二维超声测量胎儿卵圆孔径,右心房与左心房横径比值（RA/LA）、右心室与左心室横径比值（RV/LV）。比较并分析各组之间以上参数的差异。 结果正常组胎儿卵圆孔瓣M型超声心动图特点为卵圆孔瓣运动曲线形成的S峰和D峰皆为向左心房单向运动,S峰最大运动峰值大于D峰。正常胎儿S峰最大运动峰值5~7 mm,平均（6.00±0.96）mm。M型超声心动图测量卵圆孔瓣运动曲线S峰运动最大峰值,卵圆孔瓣早闭组与正常组C比较差异有统计学意义［（3.72±0.54）cm vs （6.17±0.94）cm,P＜0.001］,ST/T卵圆孔瓣早闭组较正常组C减小,差异有统计学意义（0.52±0.86 vs 0.59±0.05,P＜0.001）。卵圆孔瓣早闭组胎儿右心扩大,与正常组C比较,RA/LA增大,2组间差异有统计学意义（1.83±0.21 vs 1.19±0.19,P＜0.001）。正常胎儿跨卵圆孔血流速度低于下腔静脉入口血流速度［（40.9±8.9）cm/s vs（52.5±11.5）cm/s,P＜0.05］,卵圆孔瓣早闭组跨卵圆孔血流速度高于下腔静脉入口血流速度［（47.9±10.6）cm/s vs（43.1±7.4）cm/s,P＜0.05］。脐静脉血流速度正常组C高于卵圆孔瓣早闭组,差异有统计学意义［（24.4±4.47）cm/s vs（20.3±5.00）cm/s, P＜0.05］。 结论M型超声心动图显示正常胎儿卵圆孔瓣运动曲线有其自身规律和特点,卵圆孔瓣宫内早闭胎儿卵圆孔瓣开放运动减低。应用M型超声心动图对卵圆孔瓣运动及血流动力学特点进行定量分析研究,有助于准确诊断卵圆孔瓣宫内闭合。     

Unusual eustachian valve function.

The eustachian valve directs oxygen-rich blood from the inferior vena cava toward the foramen ovale and away from the tricuspid valve during fetal development. Ordinarily, it does not prevent reflux of right atrial blood back into the inferior vena cava because it does not function as a true valve. Here we describe an unusual adult patient with severe tricuspid valve regurgitation in whom the eustachian valve did function as a true, albeit regurgitant, valve.     

Foramen ovale changes in growth-restricted fetuses.

OBJECTIVE: In animal experiments hypoxemia induces an increased shunting through the fetal foramen ovale (FO). Based on the hypothesis that the FO is expanded to permit more flow, the aim of this study was to determine the size of the FO in growth-restricted human fetuses. METHODS: Thirty-one women with singleton pregnancies complicated with growth-restriction (< 5th percentile) were examined at 24-39 weeks of gestation. The diameter between the FO valve and the atrial septum was determined during maximum excursion in a horizontal transverse section of the fetal heart, and the transverse diameter of the right atrium (RA) was noted. The pulsatility index (PI) was determined in the umbilical artery (UA) and absent or reversed end-diastolic flow velocity was noted. The measurements were compared with a reference population using Z-scores. RESULTS: In comparison with normally grown fetuses, the growth-restricted fetuses had a normal RA size (P = 0.08) but a smaller FO (P = 0.002), particularly when expressed as a relative size by the ratio FO/RA (P < 0.0001). This effect on the FO and FO/RA was seen mainly at < 32 weeks of gestation (P = 0.003 and P < 0.0001, respectively), and was not significant later in pregnancy. There was a tendency towards a negative relationship between relative size of the FO (FO/RA) and progressive placental compromise (overall P < 0.0001). CONCLUSIONS: Growth-restricted fetuses maintain a normally grown heart (expressed by the RA diameter) but a reduced FO diameter. The effect is seen before 32 weeks and tends to be more marked in fetuses with pronounced hemodynamic compromise of the placenta. This supports the theory that FO shunting is impaired in severely premature fetuses with placental compromise.     

产前超声诊断胎儿单纯肺动脉狭窄

目的 探讨产前超声诊断胎儿单纯肺动脉狭窄的方法 与技巧,提高产前诊断率.方法 回顾性分析18例超声诊断为胎儿单纯肺动脉狭窄的病例资料,对各切面超声特点进行分析总结.结果 18例中5例经尸检证实,12例经产后超声证实为肺动脉瓣狭窄,1例经产后超声证实为肺动脉瓣闭锁.18例中动脉导管弓切面均可检出动脉导管内的反向血流,部分有右房增大、右室心肌肥厚、三尖瓣反流、卵圆孔增大及卵圆瓣活动度减低等征象.结论 动脉导管弓切面检出动脉导管的反向血流及三血管切面内主动脉与肺动脉血流方向相反,对诊断胎儿单纯肺动脉狭窄具有重要提示作用,动脉导管弓切面、双流出道切面及三血管切面是诊断该病的重要切面.     

单纯性卵圆孔瓣开放过度与开放受限胎儿的超声心动图评估

目的探讨单纯性卵圆孔瓣开放过度及开放受限胎儿的超声心动图特征以及卵圆孔瓣膨出指数（ASEI）在评估卵圆孔瓣开放过度和开放受限胎儿中的应用价值,并随访胎儿出生后情况。 方法回顾性选取2012年1月至2020年1月在浙江大学医学院附属邵逸夫医院行胎儿心脏超声检查、诊断为卵圆孔瓣开放过度和开放受限的52例胎儿作为研究组,其中开放过度组22例,开放受限组30例。同时收集108例正常胎儿作为对照组。对3组胎儿的超声心动图定量参数,包括右心房与左心房横径比值（RA/LA）、右心室与左心室横径比值（RV/LV）、肺动脉与主动脉内径比值（PA/AO）、卵圆孔瓣膨出指数（ASEI）等,以及出生后随访结果进行比较分析。 结果卵圆孔瓣开放过度组和开放受限组的RA/LA、RV/LV、PA/AO大于正常组胎儿,差异均有统计学意义（P均＜0.01）。108例正常对照组、30例开放受限组、22例开放过度组胎儿ASEI分别为0.53±0.08（范围：0.38~0.70）、0.27±0.04（范围：0.14~0.33）、0.73±0.04（范围：0.68~0.81）,3组间总体比较差异有统计学意义（F=296.95;P＜0.001）。开放受限组胎儿ASEI小于正常对照组和开放过度组,差异均有统计学意义（P均＜0.001）;开放过度组胎儿ASEI大于正常对照组和开放受限组,差异均有统计学意义（P均＜0.001）。52例中46例（88.5%）出生后超声心动图检查未见明显心血管异常;1例胎儿出生后诊断为主动脉狭窄并接受主动脉球囊扩张术;1例诊断为主动脉弓缩窄;1例诊断为继发孔型房间隔缺损;3例超声心动图提示中度三尖瓣反流,肺动脉收缩压正常（右心室收缩压分别为21、26、24 mmHg）。 结论ASEI能够定量评估单纯性卵圆孔瓣开放过度及开放受限胎儿的卵圆孔开放状态,是评估胎儿卵圆孔开放情况的新的定量参数。多数单纯性卵圆孔瓣开放过度及开放受限胎儿出生后随访结果显示不伴发心脏结构畸形、预后良好。     

Does inferior vena cava size predict right atrial pressures in patients receiving mechanical ventilation?

The inferior vena cava diameter and its respiratory response are used to estimate right atrial pressures in spontaneously breathing patients but its value in patients receiving mechanical ventilation is unvalidated. Forty-nine patients undergoing mechanical ventilation were prospectively evaluated in the intensive or coronary care units with two-dimensional echocardiography of the inferior vena cava and simultaneous measurements of mean right atrial pressures by central venous or pulmonary artery catheter. Correlation between inferior vena cava diameter at expiration and mean right atrial pressure was only 0.58. The correlation between inspiratory change in inferior vena cava diameter and mean right atrial pressure was poor (r = 0.13). Despite these correlations, an inferior vena cava diameter of < or = 12 mm predicted a right atrial pressure of 10 mm Hg or less 100% of the time, but sensitivity was only 25%. An inferior vena cava diameter > 12 mm had no predictive value for right atrial pressure.     

Transcatheter closure for decompression sickness with a patent foramen ovale: A case report

A patent foramen ovale is one of the predisposing factors of neurotic decompression sickness. Transcatheter closure of a patent foramen ovale is effective in the secondary prevention of decompression sickness associated with intracardiac shunt. The size of the umbrella should not be limited to the diagnosis of a patent foramen ovale or an atrial septal defect but should be determined by the supporting force of the soft margin of the atrial septum. The surgical method of patent foramen ovale closure is the same as that of the closure of an atrial septal defect, but the closure umbrella of a patent foramen ovale is different from that of the closure umbrella of an atrial septal defect. The size of the umbrella of the right atrium is larger than that of the left atrium, and it is better to close the atrial septum.     

经永存左上腔静脉植入起搏电极导线的方法探讨

目的初步探讨经永存左上腔静脉植入起搏电极导线的方法。方法 4例永存左上腔静脉合并右上腔静脉缺如的缓慢性心律失常患者,经左上腔静脉植入右心房和右心室起搏电极导线,心房起搏电极固定于右心耳(4例),心室起搏电极分别固定至右心室间隔部(2例)或心尖部(2例)。术后当天、术后3个月及1年分别测试起搏电极参数。结果 4例患者均成功放置右心房(心耳处)和右心室(间隔部或心尖部)起搏电极导线,随访1年,起搏电极参数良好。结论经左上腔静脉植入起搏电极导线具有一定的挑战性,但通过适当的导丝塑形和操作,通常可将导线固定于右心房心耳部和右心室间隔部或心尖部。     

时间-空间关联成像联合B-flow在胎儿永存左上腔静脉产前超声诊断中的应用价值

目的探讨时间-空间关联成像(STIC)联合B-flow在胎儿永存左上腔静脉产前超声诊断中的应用价值。方法对产前胎儿常规二维超声心动图可疑或明确心脏畸形的132例胎儿进行B-flow显像及STIC数据采集,观察有无左上腔静脉,并将产前超声诊断结果与产后新生儿超声心动图及引产后胎儿尸体解剖病理检查结果进行对比分析。结果 132例胎儿中120例在B-flow显像模式下STIC数据采集成功,采集成功率为90.9%(120/132);120例STIC数据采集成功的胎儿中,常规二维超声心动图诊断永存左上腔静脉15例(15/20)。B-flow-STIC诊断永存左上腔静脉20例。其中5例伴无名静脉缺如,4例合并心脏严重复杂畸形(2例合并完全性房室间隔缺损,1例合并三尖瓣发育不良,1例合并右心室双出口,1例合并右位主动脉弓,5例合并室间隔缺损),6例为单纯性永存左上腔静脉。B-flow-STIC修正常规二维超声心动图诊断5例;其中2例常规二维超声心动图诊断为房间隔缺损,1例常规二维超声心动图诊断为完全性房室间隔缺损,1例常规二维超声心动图诊断为心内型肺静脉异位引流,均经B-flow-STIC修正诊断为永存左上腔静脉;1例常规二维超声心动图漏诊,B-flow-STIC诊断为永存左上腔静脉引流至左心房。结论 STIC联合B-flow可清晰显示胎儿永存左上腔静脉及其空间位置关系,有利于提高永存左上腔静脉产前超声诊断准确性。     

Hypoxemia secondary to right-to-left interatrial shunt through a patent foramen ovale in a patient with an elevated right hemidiaphragm

Though uncommon, right-to-left shunt through a patent foramen ovale with normal right-side pressure and with a normal interatrial pressure gradient has been reported. The speculated pathophysiology is attributed to directional blood flow streaming from the vena cava to the left atrium. Hypoxemia secondary to right-to-left shunt with normal pulmonary artery pressure has been extensively documented after right pneumonectomy. Five prior cases have documented hypoxemia secondary to a right-to-left shunt through a patent foramen ovale in the presence of an elevated right hemidiaphragm. This is the sixth documented case of right-to-left shunt through a patent foramen ovale in the presence of an elevated right hemidiaphragm with a similar presentation in which closure of the patent foramen ovale resulted in resolution of hypoxemia.     

完全型冠状静脉窦隔缺损的超声心动图诊断

目的探讨多普勒超声心动图对完全型冠状静脉窦隔缺损(coronary sinus septal defect,CSSD)的诊断价值.方法以经右心导管检查及外科手术治疗的10例完全型冠状静脉窦隔缺损患者为研究对象,回顾性分析其二维及多普勒超声表现.结果 10例完全性CSSD患者中,超声诊断3例,诊断正确率30%;漏诊7例,占70%.10例完全型冠状静脉窦隔缺损患者中,10例均合并左侧上腔静脉残存,9例合并房间隔缺损,其中4例为房室间隔缺损,5例为房间隔缺损或大型房间隔缺损(近似功能性单心房).10例均合并于复杂型先天性心脏病中,其中7例合并右室双出口、法乐四联症、单心室等紫绀型先心病,3例为部分型房室间隔缺损和功能性单心房患者.结论在复杂型先心病合并左上腔静脉残存或房间隔缺损时应警惕完全型冠状窦隔缺损的存在,以免漏诊.     

Creation of high position fetal balloon atrial septoplasty for hypoplastic left heart syndrome and highly restrictive atrial septum: A case report and literature review

BackgroundFetal balloon atrial septoplasty (BAS) is performed through the restrictive foramen ovale in fetal cases with established hypoplastic left heart syndrome (HLHS) and an intact or highly restrictive atrial septum (RAS).MethodsIn the current report, we present a case of high position BAS in a fetus with HLHS/RAS.ResultsEchocardiography confirmed an adequate atrial opening above the foramen ovale and fetal pleural effusion resolved spontaneously 1 day after the procedure.ConclusionTo the best of our knowledge, the creation of a high position hole in the thinner part of the atrial septum, instead of the restrictive tiny hole, has not been reported in fetal cases with HLHS/RAS.     

不同孕周正常胎儿心脏大小的超声检测与临床意义

目的 探讨产前超声检查胎儿心脏生长指标与孕周的相关性.方法 应用二维超声测量14～39周正常胎儿左心房(LA)、右心房(RA)、左心室(LV)、右心室(RV)、主动脉(AO)和肺动脉(PA)内径及卵圆孔大小(FO)、心脏面积(HA)、胸腔面积(TA)、心脏周长(HC)、胸廓周长(TC),分析孕周与测量值的关系. 结果 线性回归分析表明,胎儿时期心脏各腔室大小、AO、PA及室间隔(IVS)厚度随孕龄增加而增大,与孕周呈显著正相关;肺动脉与主动脉内径比值(PA/AO)、左心房与右心房内径比值(LA/RA)、左心室与右心室内径比值(LV/RV)、心脏周长与相应胸廓周长比值(HC/TC)、心脏面积与相应胸廓面积比值(HA/TA)与不同孕周比较各比值变化不明显. 结论胎儿心脏随孕龄增加而增大,其中心脏面积与孕周最具相关性.     

Prenatal detection of foramen ovale obstruction without hydrops fetalis

A case of prenatal echocardiographic diagnosis of obstruction of the foramen ovale is described. Presentation was the ultrasound detection of unexplained marked right atrial and right ventricular dilation without fetal hydrops. It is speculated that fetal outcome depends on the severity and time of onset of foramen ovale obstruction in utero.     

孕中晚期卵圆孔瓣宫内闭合与脐带扭转的相关性研究

目的卵圆孔瓣宫内闭合是妊娠中晚期胎儿出现右心扩大、缺氧、胎儿水肿,甚至宫内死亡的重要原因之一。应用胎儿超声检查观察孕中晚期卵圆孔瓣闭合与脐带扭转之间的关系。方法 8例中晚期胎儿经超声检查发现胎儿心脏卵圆孔瓣宫内闭合。常规检测胎儿心脏结构,除外结构性心脏发育异常,检测胎儿心脏左、右心比例、卵圆孔径、由于卵圆孔瓣部分闭合剩余交通口径,卵圆孔过隔血流速度,静脉导管阻力指数,动脉导管血流速度。对胎儿进行常规生物学指标检测,重点观察胎儿脐带,计算脐带扭转指数。与出生后脐带状况对照。结果卵圆孔瓣宫内闭合的8例胎儿,右心与左心比例增大,卵圆孔瓣闭合呈瘤样膨隆,剩余交通口径明显减小,卵圆孔血流速度未见明显增快。静脉导管阻力指数轻度增高。部分胎儿动脉导管血流速度增加。脐静脉扭转指数均增加。其中顺产2例,剖宫产6例。出生后发现脐带扭转3例,脐带打真结1例,脐带绕颈极紧1例,球拍状胎盘1例。出生后脐带阳性表现占本研究病例75%。结论脐带宫内异常特别是扭转或打结以及其他因素致通过卵圆孔血流量减少,可能是孕中晚期胎儿卵圆孔瓣宫内闭合的重要原因,是胎死宫内的危险因素。     

Changes in inferior vena cava blood flow velocity and diameter during breathing movements in the human fetus.

Breathing movements in the human fetus cause distinct changes in Doppler flow velocity measurements at arterial, venous and cardiac levels. In adults, breathing movements result in a momentary inspiratory collapse of the inferior vena cava vessel wall. The study objective was to quantify the inferior vena cava flow velocity modulation during fetal breathing movements and to evaluate possible inferior vena cava vessel diameter changes in normal third-trimester pregnancies.We studied 57 women after oral administration of dextrose (50 g). In 40 fetuses (n = 19, 27-32 weeks and n = 21, 36-39 weeks), fetal inferior vena cava waveforms were obtained during apnea and fetal breathing activity. In 30 fetuses (27-39 weeks) inferior vena cava vessel diameter changes were studied using the M-mode during apnea and breathing movements. Peak and time-averaged velocities of inferior vena cava flow velocity waveforms showed a gestational age-independent increase of 60-160% during breathing activity. A temporary inferior vena cava vessel wall collapse (range, 50-83%) was recorded, which was significantly different from vessel diameter changes during apnea (range, 11-19%). The marked increase of inferior vena cava flow velocities is due to a raised thoraco-abdominal pressure gradient, which may cause a reduction in vessel size and additional volume flow into the right atrium. The significance of the caval index for recognition of elevated right atrial pressure in abnormal human fetal development needs further investigation.     

胎儿下腔静脉离断的超声诊断分析

[目的]探讨产前超声诊断胎儿下腔静脉离断的价值。[方法]对2007年3月至2012年12月在本院产前超声系统筛查201069例孕妇,诊断胎儿下腔静脉离断34例的声像图特征及漏诊原因进行分析。[结果]胎儿下腔静脉离断诊断率为0．17‰,34例中内脏异位综合征11例（其中左侧异构9例,右侧异构2例）,完全性内脏反位2例;合并心脏畸形18例（房室间隔缺损4例,法洛四联症3例,永存动脉干3例,左上腔静脉3例,右室双出口1例,房室间隔缺损＋肺静脉异位引流1例,法洛四联症＋左上腔静脉1例,永存动脉干＋肺静脉异位引流1例,右室双出口＋肺静脉异位引流1例）;漏诊3例,2例在孕23、24周筛查时漏诊,孕32周复查时检出;1例出生后诊断,随访至今5年余,患儿生长发育正常,无异常临床表现。[结论]上下腔静脉长轴切面、胸腹部斜冠状切面、四腔心切面及上腹部横切面是筛查胎儿下腔静脉离断的重要切面,对产前超声诊断胎儿下腔静脉离断具有重要的临床价值。