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。

Echocardiographic evaluation of fetuses with isolated restrictive foramen ovale flap or redundant foramen ovale flap

ObjectiveTo investigate the echocardiographic characteristics of fetuses with isolated restrictive foramen ovale flapor redundant foramen ovale flap, to explore the application value of atrial septal excursion index (ASEI) in the evaluation of redundant foramen ovale flap and restrictive foramen ovale flap fetuses, and to follow the postnatal situation of fetuses. MethodsFifty-two fetuses with a diagnosis of restrictive foramen ovale flap (n=30) or redundant foramen ovale flap (n=22) by fetal echocardiography from January 2012 to January 2020 were selected retrospectively, and their initial and follow-up echocardiograms as well as pregnancy outcomes were reviewed. As controls, 108 normal fetuses with matched gestational age were randomly selected. Echocardiographic measurements included right atrial diameter to left atrial diameter ratio (RA/LA), right ventricular width to left ventricular width ratio (RV/LV), and pulmonary artery diameter to aortic diameter ratio (PA/AO). ASEIs in the three groups were calculated. All parameters were compared among the fetuses with restrictive foramen ovale flap, those with redundant foramen ovale flap, and controls. ResultsThe ratios of RA/LA, RV/LV, and PA/AO in restrictive foramen ovale flap fetuses and redundant foramen ovale flap fetuses increased compared with those of the controls (P＜0.01). ASEI of the 108 fetuses in the control group was 0.53±0.08 (range: 0.38-0.70). ASEI of the 30 fetuses in the restrictive foramen ovale flap group was 0.27±0.04 (range: 0.14-0.33). ASEI of the 22 fetuses in the redundant foramen ovale flap group was 0.73±0.04 (range: 0.68-0.81). ASEIs among the three groups differed significantly (F=296.95, P＜0.001). ASEI in fetuses with restrictive foramen ovale flap significantly decreased compared with those of the controls and redundant foramen ovale flap fetuses (P＜0.001), and ASEI in fetuses with redundant foramen ovale flap significantly increased compared with those of the controls and restrictive foramen ovale flap fetuses (P＜0.001). Postnatal fellow-up by postnatal echocardiography demonstrated that 46 out of 52 cases (88.5%) had a structurally normal heart, one had aortic valvular stenosis and underwent aortic balloon dilatation, one had coarctation of the aortic arch, one had secondary atrial septal defects, and three had moderate tricuspid regurgitation with normal pulmonary artery systolic pressure (right ventricular systolic pressure was 21, 26, and 24 mmHg, respectively). ConclusionASEI is a novel parameter that can quantitatively evaluate the features of the foramen ovale in fetuses with isolated restrictive foramen ovale flap or redundant foramen ovale flap. Most of the fetuses with isolated restrictive foramen ovale flap or redundant foramen ovale flap have no associated structural heart malformations and therefore have a good prognosis.