超声心动图对儿童完全性肺静脉异位引流诊断价值的探讨

目的　旨在评价超声心动图对完全性肺静脉异位引流 (TAPVD)的诊断价值。方法　对 1987年 9月至2 0 0 2年 11月收治的TAPVD患儿 70例进行分析。均有完整的临床及超声心动图资料 ,其中 35例施行了手术治疗。结果　 70例TAPVD的解剖分型为 :心内型 5 2例、心上型 16例、心下型 2例 ,未发现混合型。 35例施行手术 ,32例与术前超声心动图的诊断一致 ;3例与超声心动图诊断不完全一致 ,其超声心动图诊断分别为 :三房心伴继发孔房缺、左房隔膜伴继发孔房缺、原发孔房缺伴卵圆孔未闭 ,而手术结果均显示为心内型TAPVD伴继发孔房缺。结论　超声心动图检查是诊断TAPVD重要且准确的方法 ,并能确定其分型 ,提供精确的解剖及血流动力学资料。在应用超声心动图诊断TAPVD时 ,应注意与三房心、左房隔膜等疾病进行鉴别。     

小儿室间隔缺损伴主动脉瓣脱垂超声心动图分析

目的 探讨超声心动图早期诊断室间隔缺损伴主动脉瓣脱垂的价值。方法 采用彩色多普勒超声心动图检查室间隔缺损伴主动脉瓣脱垂17例，并与手术进行对照。结果 17例中14例为干下型，3例为膜周型，脱垂瓣叶均为右冠瓣，经VSD脱入右室。与手术所见一致。结论 超声心动图能早期准确诊断室间隔缺损伴主动脉瓣脱垂，为本病术前诊断的主要手段。     

胎儿心律失常的临床意义及预后的研究

目的 总结胎儿心律失常原因，进一步探讨其临床意义及对胎儿预后的影响。方法 采用回顾性分析方法，对26例胎儿心律失常孕妇的情况、胎儿心律失常的临床表现、诊断方法及长期随诊结果进行总结。结果 胎儿心律失常的发生率为0．2％。26例胎儿心律失常中，3例为胎儿心动过速(11．5％)，4例为胎儿心动过缓(15．4％)，19例为不规则胎儿心律(73．1％)；胎儿心律失常平均诊断孕周为35托周(15～41^ 1周)。26例中22例为产前胎心听诊时发现胎儿心律失常；1例为妊娠15周超声检查时发现胎儿心律失常；3例胎心监测发现胎儿心律失常。17例产前进行了胎儿超声心动检查，心脏结构未见异常，其中6例胎儿超声心动检查提示胎儿房性早搏，占35．3％，余未见异常。产后新生儿均存活，随诊24例(92．3％)，16例新生儿进行了超声心动检查，其中2例诊断为先天性心脏病，均为房间膈缺损。先天性心脏病新生儿在心律失常胎儿中发生率为7．7％。结论 大多数心律失常的胎儿预后是好的，心脏畸形的发生率很低。对于持续性心率慢的胎儿，需注意心脏结构异常的存在；对于心律失常胎儿的处理采用期待疗法，根据产科指征决定终止妊娠的方式。     

主、肺动脉的超声观测诊断胎儿心脏大血管畸形的研究

目的 探讨主、肺动脉的超声观测作为产前筛选胎儿心脏大血管畸形主要线索的诊断价值。方法 对100例20～40周正常孕妇采用超声心动图测量主、肺动脉内径，并计算肺动脉内径和主动脉内径比值(PA／AO)。按照PA／AO的正常比值对2683例20周以上孕妇进行胎儿先天性心脏病(CHD)筛选。结果 （1）不同孕龄的胎儿其PA、AO内径随孕龄增加而增大，但是其PA／AO比值相对较为恒定，约为1．0～1．2。(2)多种胎儿心脏大血管畸形包括主动脉弓发育不良、主动脉狭窄、肺动脉狭窄、法乐氏四联征、主动脉缩窄等，其PA／AO比值明显异常。结论 胎儿PA／AO作为产前筛选胎儿CHD指标，尤其是胎儿大血管畸形，是一项实用的指标。     

左心发育不良综合征15例超声心动图研究

目的 探讨左心发育不良综合征超声心动图表现，以提高对超声心动图诊断该疾病的认识。方法 收集15例超声心动图资料完整并经证实的左心发育不良综合征患者，对其超声心动图顺序节段性研究的结果进行分析。结果 本组左心发育不良综合征患者最常见的心血管表现为左心发育不全、二尖瓣极重度狭窄或无孔二尖瓣、主动脉瓣极重度狭窄或无孔主动脉瓣、主动脉发育不良及依赖于右心室及动脉导管的系统循环。多数患者肺静脉回流经房间隔分流至右房室，少数患者左房血流经替代途径回流入右房室，分别为心上型肺静脉异位引流、左旋心房主静脉及部分冠状静脉窦无顶，其中1例同时合并三房心及左旋心房主静脉的病例为罕见病例。结论 超声心动图可揭示左心发育不良综合征所有显著的病理解剖及病理生理特征，可指导外科手术，特别是Norwood手术的治疗。     

白细胞介素2激活脐血单个核细胞体外抗肿瘤活性的实验研究

为探讨白细胞介素２（ＩＬ－２）激活脐血单个核细胞（ＡＣＢ）对白血病细胞株ＨＬ－６０和Ｋ５６２细胞的杀伤作用以及脐血被激活后能否保持其造血祖细胞生成活性（ＰＣＡ），采用３Ｈ－胸腺嘧啶核苷前标记释放法和半固体培养等方法对其进行了研究。结果：ＩＬ－２激活的脐血细胞具有明显的抗肿瘤活性，且不影响其ＰＣＡ。ＩＬ－２激活脐血细胞的最适条件为：（１）细胞浓度为１×１０６ｍｌ；（２）ＩＬ－２浓度为１０００Ｕ／ｍｌ；（３）效靶比为１００１；（４）体外培养７２小时。脐血经ＩＬ－２激活后免疫表型发生明显变化，产生肿瘤坏死因子（ＴＮＦα）及白细胞介素６（ＩＬ－６），且生成大颗粒淋巴细胞（ＬＧＬ）。ＬＧＬ与Ｋ５６２细胞作用后，后者呈凋亡特征。研究结果为临床应用ＡＣＢ治疗白血病提供了实验依据。     

Diagnostic and Perinatal Management of Fetal Extrasystole

Fifty fetuses referred to the Polish Mother's Memorial Hospital for fetal echocardiography between January 1, 1991 and June 1, 1995 were evaluated. The mean fetal gestational age at the time of diagnosis of arrhythmia was 34.1 weeks, and the mean gestational age at the time of delivery was 38.7 weeks. Checkup echocardiographic examinations were performed every 10–14 days, for a mean 2.4 studies per fetus. In most cases (48/50, 96%), premature atrial contractions were present during the first echocardiography examination. The fetal heart study was normal in 30 cases; in 7 (14%) there was tricuspid valve regurgitation, in 7 (14%) an atrial septal aneurysm, in 4 congenital heart defects, in 1 myocardial hypertrophy, and in 1 disproportion in the four-chamber view. Of the 50 fetuses, 43 underwent regular echocardiographic monitoring alone; in 7 cases, based on the presence of additional echocardiographic findings, pharmacotherapy was applied (digoxin, verapamil, or both). Three neonates died after delivery owing to malformations in two cases (one critical aortic stenosis, one spina bifida plus hygroma colli) and due to myocarditis in one case. In six of seven newborns treated in utero, myocarditis was diagnosed after birth (including the one with neonatal demise). Most of the newborns were in good condition after birth, their mean Apgar score being 8.6 and the mean birth weight 3259 g. We concluded that most extrasystoles represent an isolated anomaly, not affecting the fetal condition. Their presence should not influence the obstetric care and may require only echocardiographic monitoring. In most of our cases the premature contractions subsided after birth, although sometimes they preceded fetal supraventricular tachycardia or appeared after congenital myocarditis.     

Echocardiographic assessment of patent ductus arteriosus shunt flow pattern in premature infants

AIMS—To identify the patent ductus arteriosus (PDA) shunt flow pattern using Doppler echocardiography; and to assess whether it could be used to predict the development of clinically significant PDA.
METHODS—Premature infants weighing under 1500 g, who required mechanical ventilation, and in whom daily echocardiography could be performed from day 1 until the ductus closed, and on day 7 to confirm closure, were studied. The PDA shunt flow was identified from four Doppler patterns, and the closed pattern of a closed duct was also presented. Clinically significant PDA was diagnosed when there was colour Doppler echocardiographic evidence of left to right ductal shunt associated with at least two of the following clinical signs: heart murmur (systolic or continuous); persistent tachycardia (heart rate>160/min); hyperactive precordial pulsation; bounding pulses; and radiographic evidence of cardiomegaly or pulmonary congestion.
RESULTS—Of 68 infants enrolled into this study, clincally significant PDA developed in 31. The most recordable sequence of transition change of shunt flow pattern for clinically significant PDA was: pulmonary hypertension pattern, to growing pattern, to pulsatile pattern, to closing pattern, to closed pattern. And that for non-clinically significant PDA was: pulmonary hypertension pattern, to closing pattern, to closed pattern. The growing and the pulsatile patterns were mostly documented in infants with clinically significant PDA. The first documented growing pattern to predict clinically significant PDA gave a sensitivity of 64.5% and a specificity of 81.1%; the first documented pulsatile pattern gave a sensitivity of 93.5% and a specificity of 100%.
CONCLUSION—Doppler echocardiographic assessment of PDA shunt flow pattern during the first 4 days of life is useful for predicting the development of clinically significant PDA in premature infants. At that stage, the closing or closed Doppler pattern indicates that infants are not at risk of developing clinically significant PDA; the growing or pulsatile Doppler pattern indicates a continuing risk of developing clinically significant PDA.

     

Outcome of fetuses with heart disease diagnosed in utero

OBJECTIVE—To review the outcomes of 193 fetuses with cardiac abnormalities detected by echocardiography.METHODS—A total of 422 fetuses between 16 and 41 gestational weeks, referred to paediatric cardiologists for detailed echocardiography, were included in this study.RESULTS—Structural heart defects were found in 55 (28%), isolated arrhythmia in 105 (54%), and other non-structural abnormalities (dilated cardiomyopathy, hypertrophic cardiomyopathy, aneurysm of the foramen ovale, isolated pericardial effusion or echogenic foci) in 33 (17%) of 193 fetuses. Total mortality was 26%. The prognosis was poor in fetuses with structural heart defects; 37 of 55 cases (67%) died in utero or postnatally. Chromosomal abnormality was associated with structural heart defect in 38% of fetuses, of whom 38% died. Among fetuses with isolated arrhythmia survival was 95%. Poor outcome was associated with complete heart block (n=14) in 2 (14%) fetuses with hydrops and heart rate of less than 55 per minute, and with supraventricular tachycardia (n=21) in three (14%) neonates delivered prematurely at a mean gestational age of 33 weeks. Furthermore, nine of 12 fetuses (75%) with structural heart defects and arrhythmia died. Among fetuses with non-structural cardiac abnormalities, survival was 73%. Poor outcome was evident in fetuses with dilated cardiomyopathy in eight of 13 (62%) and with hypertrophic cardiomyopathy in one of eight (13%) of cases.CONCLUSIONS—Factors associated with a poor prognosis were: structural heart defect associated with chromosomal abnormality or arrhythmia, congestive heart failure associated with supraventricular tachycardia or complete heart block, especially if delivery occurs preterm; and fetal hydrops with congestive heart failure and atrioventricular valve regurgitation.     

A randomized controlled trial of a new fetal acoustic stimulation test for fetal well-being

OBJECTIVES: Our purpose was to determine (1) whether a fetal acoustic stimulation test results in more palpable fetal movement compared with a mock test (control) and (2) whether palpated fetal movements after a fetal acoustic stimulation test are accompanied by a reactive nonstress test.STUDY DESIGN: In a randomized controlled trial we studied women seen in the labor and delivery suite for various indications. Women were excluded for multiple gestation, <31 weeks' gestational age, treatment with magnesium sulfate or narcotics, or ruptured membranes. Informed consent was obtained from eligible women, who were then randomized to a test or control group. We placed an acoustic stimulator on the abdomen of each woman, but only the test group was stimulated. We assessed fetal movement by a grading system: 0 = no fetal movement felt by patient or tester, 1 = fetal movement felt by patient only, 2 = fetal movement felt by tester, 3 = visual movement seen by tester. A positive fetal acoustic stimulation test result was defined as one with any fetal movement felt or seen by the tester (grades 2 or 3). We then performed a nonstress test. We compared rates of a positive fetal acoustic stimulation test in the test and control groups with the χ² test. A p value <0.05 was considered significant.RESULTS: We randomized 297 women to the test group and 280 women to the control (mock test) group. Of women tested with the fetal acoustic stimulation test, 81% had fetal movement by palpation or visualization (grades 2 or 3) compared with 19% of the control group (p < 0.0001, odds ratio 19.29, 95% confidence interval 12.42 to 30.07). Of the test group, 283 (95%) had a reactive nonstress test and 14 (5%) had nonreactive tests; the control group had 267 (95%) reactive and 13 (5%) nonreactive nonstress tests. Of 242 patients in the test group with a positive fetal acoustic stimulation test, 236 (98%) had a reactive nonstress test. Of those in the test group with fewer than three contractions per 10 minutes, 164 (89%) had a positive fetal acoustic stimulation test. Of these, 162 (99%) had a reactive nonstress test.CONCLUSION: The fetal acoustic stimulation test evokes significantly more palpated or visualized fetal movement than in controls. Palpated or visualized fetal movement after acoustic stimulation was almost always accompanied by a reactive nonstress test. (Am J Obstet Gynecol 1997;176:1386-8.)