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。     

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。     

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.     

Prenatal detection of restrictive foramen ovale

The foramen ovale is an important communication between the two sides of the heart prenatally, allowing the left ventricle to carry its share of the prenatal circulation and providing flow for growth of left ventricular structures. Restriction of the foramen ovale appears to be a serious disorder of the fetus and can be associated with fetal hydrops, arrhythmias, and other signs of major fetal compromise. This article reviews our experience with restriction of the foramen ovale and provides a summary of the pathologic and echocardiographic literature related to the etiology and effects of restrictive foramen ovale in the fetus.     

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。     

Clinical manifestation and current management of patent foramen ovale

There is increasing interest in the evaluation and treatment of patent foramen ovale, which has been associated with various pathologic conditions, such as cryptogenic stroke, platypnea–orthodeoxia syndrome and migraine. However, optimal treatment of patients with patent foramen ovale has not been established. This article aims to review the clinical manifestation and current therapeutic options for patent foramen ovale.     

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.     

右心声学造影检查对卵圆孔未闭导致偏头痛的诊断价值

目的 探讨右心声学造影检查对卵圆孔未闭导致偏头痛的诊断价值.方法 选取2018年5月至2020年8月我院收治的120例不明原因偏头痛患者作为研究对象,所有患者实施经颅多普勒超声检查、右心声学造影检查.以数字减影血管造影(DSA)检查结果为参照,比较经颅多普勒超声检查与右心声学造影检查对卵圆孔未闭的诊断效能及对卵圆孔未闭...     

Ultrasound assessment of the fetal foramen ovale.

OBJECTIVES: Based on the assumption that the horizontal area between the fetal foramen ovale valve and the atrial septum (the outlet) represents the limiting structure for the foramen ovale flow, our objective was to determine the normal size of this section during the second half of pregnancy. METHODS: One hundred and thirty-eight women with low-risk singleton pregnancies were examined in a cross-sectional study between 18 and 42 weeks of gestation. Using ultrasound imaging and M-mode, the area and diameter between the foramen ovale valve and the atrial septum were determined in a four-chamber view of the fetal heart above the foramen ovale limbus. The inferior vena cava cross section and right atrial width were also determined. RESULTS: The mean foramen ovale width increased from 3 mm at 18 weeks to 6 mm at term. Correspondingly, the horizontal area grew from 15 to 50 mm2. The mean ratio between this area and the area of the inferior vena cava fell from 1 at 18 weeks to 0.5 at term. The ratio between the transverse width of the foramen ovale and the right atrium remained at average 0.45-0.50 until 32 weeks, when a slight reduction was observed towards term. CONCLUSIONS: Normal values for the horizontal cross section and transverse diameter of the foramen ovale outlet were established for the second half of pregnancy. In particular, the horizontal transverse diameter and its ratio to the right atrial width are easy to determine, and use of these measurements is thus suggested for the assessment of the fetal foramen ovale.     

产前超声诊断胎儿卵圆孔血流受限或提前关闭的研究进展

近年来,有关胎儿卵圆孔血流受限或提前关闭的研究逐渐增多,产前超声在胎儿卵圆孔血流受限或提前关闭的诊断及预后评价方面具有重要应用价值。本文就近年来产前超声诊断胎儿卵圆孔血流受限或提前关闭的研究进展进行综述。     

Cryptogenic stroke and patent foramen ovale

A stroke of unknown etiology is commonly referred to as cryptogenic and is diagnosed in a considerable patient population of especially young age. Numerous case-control studies revealed a strong and consistent association between cryptogenic stroke and the presence of a patent foramen ovale. This relationship corroborates paradoxical embolism as likely stroke mechanism in this patient population. In approximately twenty-five percent of patients with cryptogenic stroke, the patent foramen ovale is accompanied by an atrial septal aneurysm, which considerably heightens the risk for recurrent neurological events. Therapeutic measures for secondary prevention in this patient population encompass medical treatment with antiplatelet agents or anticoagulants and surgical or percutaneous closure of patent foramen ovale. Currently, randomised clinical studies compare medical treatment with closure of patent foramen ovale to determine the most effective treatment strategy in this patient population.     

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.     

Patent foramen ovale

Patent foramen ovale is incriminated in patients with cryptogenic stroke; however, concrete evidence that closure of patent foramen ovale using various devices is superior to continued medical therapy is not yet available. Controlled randomized trials are well underway to address this issue.     

CT引导下经皮穿刺卵圆孔阻滞治疗三叉神经痛

目的探讨CT引导下三叉神经毁损疗法治疗三叉神经痛的方法及临床应用.方法 CT引导机为西门子AR型NOVR型.34例患者均根据典型的病史、体征作出三叉神经痛诊断,均有服用药物史,5例为经其他方法治疗后复发.34例中男8例,女26例,年龄55～70岁,平均58岁.CT引导下经皮穿刺卵圆孔,采用22G穿刺针,CT引导进针,确定针尖在卵圆孔时,分次缓慢注射2%阿霉素0.2～0.3 ml(不超过 0.5 ml).结果治疗后观察疗效及并发症,即刻疼痛减轻26例(76.9%),治疗后6个月,32例疼痛消失,2例疼痛减轻.并发症少而轻微,无严重并发症.结论 CT引导下经皮穿刺卵圆孔疗法治疗三叉神经痛是一种微创、疗效好、可重复操作的新技术,值得临床推广应用.     

Editorial

Right-to-left shunt through a patent foramen ovale was searched for in 80 patients with acute ischemic stroke by simultaneously performing transthoracic two-dimensional echocardiography and transcranial Doppler during agitated saline injection. A patent foramen ovale was detected by echocardiography in 14 patients (17.5%). Transcranial Doppler correctly identified all 14 patients, and 7 more patients in whom echocardiographic findings were indeterminate. Prevalence of patent foramen ovale by transcranial Doppler was therefore 26.3% (21 of 80 patients). Concordance between the two tests was 91.3% (73 of 80 patients). The delivery of contrast material to cerebral vessels is therefore demonstrable by transcranial Doppler in all patients diagnosed by contrast echocardiography, suggesting that paradoxical embolization through a patent foramen ovale may be more frequent than previously thought. Transcranial Doppler with contrast injection is a valid alternative in case of poor echocardiographic image quality.     

经胸和经食管超声心动图诊断卵圆孔未闭的对比研究

目的 对比研究经胸超声心动图TTE和经食管超声心动图TEE对卵圆孔未闭(patent foramen ovale，PFO)的诊断方法和诊断价值，及对卵圆孔未闭的临床意义。方法 运用经胸及经食管超声心动图检查，诊断卵圆孔未闭24例，根据患者有无合并其他心脏疾患及合并的心脏疾患的血流动力学特点将患者分为卵圆孔未闭组及卵圆孔开放组。结果 经胸超声心动图通过CDFI观察房水平的穿隔血流对卵圆孔未闭的诊断准确率为58．3％。经食管超声心动图检查能对所有患者做出正确诊断。卵圆孔未闭组可见卵圆孔瓣上缘与继发隔之间裂缝，CDFI显示源于卵圆孔瓣与继发隔交界边缘处的穿隔血流；卵圆孔开放组可见卵圆孔瓣上缘与继发隔之间出现回声缺失，但卵圆孔瓣尚完整，CDFI于缺口处探及垂直于房间隔的穿隔分流束。结论 经食管超声心动图是目前卵圆孔未闭诊断金标准的首选方法。卵圆孔未闭可导致反常栓塞，应予以积极治疗。     

鼻咽癌海绵窦侵犯途径的MRI评价

目的：运用磁共振成像评价鼻咽癌海绵窦侵犯的影像学表现和侵犯途径。方法：回顾性分析经病理证实的140例鼻咽癌海绵窦侵犯病例的MRI图像及临床资料,观察海绵窦受侵的MRI表现和侵犯途径。结果：140例患者,受累海绵窦156侧,单途径侵犯共107侧,双途径侵犯共39侧,3条途径侵犯共8侧,4条途径侵犯共2侧。51侧（32.69%）为卵圆孔单途径受侵,42侧（26.92%）破裂孔单途径受侵,多途径侵犯中卵圆孔、破裂孔作为共同途径共26侧（16.67%）。结论：MRI能较好的评价鼻咽癌海绵窦侵犯情况及其侵犯途径,卵圆孔侵犯是最常见的单一侵犯途径,其次为破裂孔;卵圆孔、破裂孔作为共同途径在多途径侵犯中最常见;经翼腭窝、圆孔途径侵犯海绵窦并不少见。     

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。     

Successful aortic root replacement and shunt closure in a case with rare coexistence of congenital cardiac malformations: bicuspid aortic valve with annuloaortic ectasia,single coronary artery,and patent foramen ovale

This is the first report of rare simultaneous complication of three cardiac malformations: bicuspid aortic valve with annuloaortic ectasia, single coronary artery, and patent foramen ovale. We successfully operated to replace the aortic valve and ascending aorta, and to close the patent foramen ovale.     

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.