摘要
目的：
应用全容积实时三维超声心动图评价中晚孕期正常胎儿右心室功能。
资料与方法：
一、研究对象
自2009年5月至2009年8月在浙江大学医学院附属邵逸夫医院常规行胎儿超声心动图检查的1 15名孕妇,年龄17～40岁(平均27.6±3.8岁),孕周20～40周(平均29.1±4.6周),符合以下条件作为本研究对象：单胎,产科常规超声检查未见明显异常,胎儿超声心动图未见明显心血管畸形及持续心律不齐。
二、仪器与方法
仪器为Philips iE33型彩色多普勒超声诊断仪,采用S5-1,X3-1探头,频率1.0～5.0MHz。
1.一般产科检查：确定胎位,测量双顶径、股骨长,以估算胎儿孕龄。以胎儿胎位、脊柱、肝脏、胃泡、降主动脉、卵圆孔膜方向等判别左、右心室。
2.测量：分别存储三个心动周期的动态图像,包括标准胎儿四腔心切面,右室心尖两个正交平面,即右室四腔心和二腔心切面,及心脏四腔心切面的全容积图像等。应用三种方法：Shimazaki法、双平面Simpson法以及全容积实时三维超声心动图方法来描记及计算胎儿右室舒张末期容积(end-diastolic volume, EDV)、收缩末期容积(end-systolic volume, ESV)、每搏输出量(stroke volume, SV)、射血分数(ejection fraction, EF)以及心输出量(cardiac output, CO).
三、统计学分析
采用SPSS13.0统计学软件包进行分析。计量资料表示为x±s,三种方法获得的数值结果两两比较,进行方差分析、SNK检验,三种方法与孕周进行直线相关与回归分析,随机挑选30名孕妇,用配对t检验对两个观察者、同一观察者(间隔半日)前后两次的三种方法测量右室EDV的重复性及一致性检验。以P＜0.05作为差异有统计学意义。
结果：
剔除图像质量较差的6例后,共有109例胎儿纳入分析,进行95%可行区间比较,Shimazaki法测得的RVEDV范围从2.70ml到3.54ml,RVESV范围从0.90ml到1.23ml,SV范围从1.78ml到2.33ml,CO范围从255.07ml到331.42ml,EF范围从42%到56%；Simpson法测得的RVEDV范围从1.47ml到1.94ml,RVESV范围从0.49 ml到0.69ml,SV范围从0.96ml到1.26ml,CO范围从138.13到181.07ml,EF范围从53%到68%；RT-3DE测得的RVEDV范围从1.39ml到1.80ml,RVESV范围从0.46ml到0.62ml,SV范围从0.91ml到1.19ml,CO范围从131.06ml到170.37ml,EF范围从52%到68%。Shimazaki法各容积参数范围均大于Simpson法和全容积RT-3DE,而全容积RT-3DE的结果与Simpson法的结果相比较,前者测值的95%可信区间相对集中。结果Shimazaki法与双平面Simpson法两者比较差异有统计学意义(P<0.05),Shimazaki法与全容积实时三维超声心动图的结果比较差异有统计学意义(P<0.05),而Simpson法与全容积实时三维超声心动图的结果比较,差异无统计学意义(P>0.05)。三种方法测值随孕周均呈直线变化趋势,Simpson法与三维法的测值随孕周变化呈直线增长的趋势更为明显。两个观察者之间及同一观察者前后两次的重复性检验t检验结果为,Shimazaki法、Simpson法测得数据两个观察者及同一观察者的重复性比较结果差异有统计学意义(P<0.05),而实时三维两个观察者及同一观察者的重复性比较结果差异无统计学意义(P>0.05)。
结论：
全容积实时三维超声心动图能够不依赖于任何解剖假设准确地评价胎儿右室心功能,是评估胎儿右室功能可行且具有较好的重复性的超声心动图定量方法。
Objective:
To evaluate the normal fetal right ventricular function in second and third trimester by using full volume real-time three-dimensional echocardiography (RT-3DE)
Study Populations and Methods:
From May 2009 to October 2009, we randomly enrolled 115 consecutive pregnant women, of whom 109 were recruited into study group (age 27.6±3.8 years, range 17～40 years, gestation age 29.1±4.6 weeks, range 20～40weeks).Six were ruled out because of poor echocardiographic image quality.
A detailed echocardiographic examination was performed with a Philips iE33 ultrasound system with 1.0～5.0 MHz sector transducer and full-volume matrix probe.
1. General obstetrics examination:fetal position was assessed and fetal gestational age was estimated by measuring biparetal diameter and femur length. Left or right ventricle was distinguished by fetal position, spine, liver, aerogastria, descending aorta or the blood direction of foramen of ovale.
2. Three cardiac cycles of the fetal echocargiograms were captured in cine-loop format including:a four-chamber view on two-dimensional echocardiography, two right ventricular reverse planes (a four-chamber view and a two-chamber view), a four-chamber "Full volume"imaging on RT-3DE.2DE right ventricular volumes were measured by Shimanaki rule and biplane Simpson's method. Fetal RT-3DE right ventricular volumes were outlined and calculated by the analysis software of "Full volume" imaging of RT-3DE. The right ventricular end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV), ejection fraction (EF) and cardiac output (CO) measured by three different calculations were compareded
3. Statistic analysis
All statistics were carried out using SPSS 13.0 software. A probability value<0.05 was considered as statistically significant.
Results:
One hundred and nine fetuses ranging from 20+2 to 40+1 gestational weeks were included, six fetuses with poor echocardiographic image quality were excluded.The fetuses diagnosed during the study period were examined with a cardiac anomaly and their ventricular volumes were compared with three different calculations.95% confidence in Shimanaki rule RVEDV ranged from a mean of 2.70ml to a mean of 3.54ml,RVESV ranged from a mean of 0.90ml to 1.23ml, SV ranged from a mean of 1.78ml to a mean of 2.33ml, CO ranged from a mean of 255.07ml to a mean of 331.42ml,EF ranged from a mean 42%of to a mean of 56%.In biplane Simpson's method RVEDV ranged from a mean of 1.47ml to a mean of 1.94ml,RVESV ranged from a mean of 0.49ml to 0.69ml, SV ranged from a mean of 0.96ml to a mean of 1.26ml, CO ranged from a mean of 138.13ml to a mean of 181.07ml,EF ranged from a mean 53%of to a mean of 68%.In RT-3DE RVEDV ranged from a mean of 1.39ml to a mean of 1.80ml,RVESV ranged from a mean of 0.46ml to 0.62ml, SV ranged from a mean of 0.91ml to a mean of 1.19ml, CO ranged from a mean of 131.06ml to a mean of 170.37ml,EF ranged from a mean 52%of to a mean of 68%.In Shimanaki rule every volume parameters were over estimated. Compared with biplane Simpson's method,the RT-3DE volume parameters were concentrative. The result showed that there were significant difference between Shimazaki rule and biplane Simpson's method (P<0.05).There were significant difference between Shimazaki rule and RT-3D (P<0.05), too, There was no difference between biplane Simpson's and RT-3DE(P>0.05).Three methods were positively correlated with gestational age, biplane Simpson method and RT-3DE much more significantly compared with Shimazaki rule.A paired t test directly compared intraobserver and interobserveron the three caculations.In Shimazaki rule and Simpson method it revealed no systematic difference (P>0.05),but in RT-3DE it revealed significant systematic difference(P<0.05).
Conclusion:
RT-3DE provides an accurate volume measuring method for irregular shaped RV for its independent of geometric assumption in calculating volumes. It may offer a useful approach for better understanding the characteristic of fetal myocardial properties during fetal heart development. Then they are useful to evaluate the changing of the fetal heart function along with the advancing gestational ages.;real-time three-dimensional echocardiograpy evaluation of the fetal heart right ventricular function is feasible and reproducible.
引文
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