定量组织速度成像与频谱多普勒对胎儿心脏传导时间间歇的对照研究
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摘要
目的:探讨定量组织速度成像技术在胎儿心脏传导时间间歇研究中的应用价值,确立正常胎儿的心脏传导时间参考值。
对象:2007年12月至2008年6月随机抽取能清楚显示纵位四腔心标准切面的正常单胎妊娠胎儿78名。孕妇年龄19-41岁,平均(28±4)岁,孕龄17-41周,平均(30±8)周。入选对象胎儿超声心动图均未见明显心血管畸形及持续心律不齐,左室流入道与流出道交界处PD频谱E、A不融合,能够清晰辨认。
方法:选取纵位的胎儿心尖四腔心标准切面,在彩色组织速度成像(TVI)条件下存取3个完整心动周期的动态二维图像,将速度取样点置于二尖瓣环水平获取心肌组织速度曲线,操作时尽可能使多普勒声束平行于心室壁走行以获取沿长轴方向的最大瓣环运动速度图。同时,在纵位的心尖五腔心标准切面,将取样线放置于左室流入道与流出道交界处,获取PD频谱,取样线与血流方向接近平行或夹角＜15°。分别采用QTVI和PD测量胎儿的房室传导时间(AV)和心室开始收缩到下一心动周期心房开始收缩的时间间期(VA),采用T检验比较两种方法测量的一致性。胎儿心脏传导时间与孕周、胎心率进行直线相关分析。采用SPSS 13.0统计学软件包进行分析。
结果:QTVI测量AV为(119.44±7.00)ms,95%CI:(117.86～121.01)ms;VA为(298.58±22.17)ms,95%CI:(292.85～303.06)ms;PD测量AV为(121.88±8.05)ms,95%CI:(120.07～123.70)ms:VA为(295.58±22.17)ms,95%CI:(290.58～300.58)ms。胎儿心脏传导时间与孕周呈正相关,与胎心率呈负相关。QTVI、PD两种方法测量AV在不同心率胎儿的比较差异无统计学意义,VA在不同心率胎儿的比较差异有统计学意义;QTVI、PD两种方法测量AV、VA在不同孕周胎儿的比较差异无统计学意义。
结论:QTVI可简便快速地测定胎儿心脏传导时间,对于胎儿房室传导异常的评估具有潜在的应用价值。
Objective:To assess the values of quantitative tissue velocity imaging in studying normal fetal heart conduction time intervals.
Methods:Totally 78 fetuses between 17 and 41 week's gestation underwent detailed echocardiograms.Atrio-ventricular conduction time interval(AV) and the time interval from onset of ventricular contraction to the onset of atrial contraction of next cardiac cycle(VA) were measured by quantitative tissue velocity imaging(QTVI) and pulse Doppler(PD) echocardiography.
Results:QTVI-AV was(119.44±7.00) ms(95%CI 117.86～121.01ms).QTVI-VA was 298.58±22.17 ms(95%CI 292.85～303.06 ms).PD-AV was 121.88±8.05 ms(95%CI 120.07～123.70ms).PD-VA was 295.58±22.17ms(95%CI 290.58～300.58 ms).2-tailed T test revealed no systematic difference between the 2 approaches used to measure AV and VA.Gestational age and AV intervals were positively correlated with all imaging modalities,and significantly negatively correlated with fetal heart rate.
Conclusions:This study established the normal values of fetal heart conduction time intervals.The usage of QTVI in fetal heart conductional time intervals has important potential clinical utility in assessing fetal arrhythmia.
对象:2007年12月至2008年6月随机抽取能清楚显示纵位四腔心标准切面的正常单胎妊娠胎儿78名。孕妇年龄19-41岁,平均(28±4)岁,孕龄17-41周,平均(30±8)周。入选对象胎儿超声心动图均未见明显心血管畸形及持续心律不齐,左室流入道与流出道交界处PD频谱E、A不融合,能够清晰辨认。
方法:选取纵位的胎儿心尖四腔心标准切面,在彩色组织速度成像(TVI)条件下存取3个完整心动周期的动态二维图像,将速度取样点置于二尖瓣环水平获取心肌组织速度曲线,操作时尽可能使多普勒声束平行于心室壁走行以获取沿长轴方向的最大瓣环运动速度图。同时,在纵位的心尖五腔心标准切面,将取样线放置于左室流入道与流出道交界处,获取PD频谱,取样线与血流方向接近平行或夹角＜15°。分别采用QTVI和PD测量胎儿的房室传导时间(AV)和心室开始收缩到下一心动周期心房开始收缩的时间间期(VA),采用T检验比较两种方法测量的一致性。胎儿心脏传导时间与孕周、胎心率进行直线相关分析。采用SPSS 13.0统计学软件包进行分析。
结果:QTVI测量AV为(119.44±7.00)ms,95%CI:(117.86～121.01)ms;VA为(298.58±22.17)ms,95%CI:(292.85～303.06)ms;PD测量AV为(121.88±8.05)ms,95%CI:(120.07～123.70)ms:VA为(295.58±22.17)ms,95%CI:(290.58～300.58)ms。胎儿心脏传导时间与孕周呈正相关,与胎心率呈负相关。QTVI、PD两种方法测量AV在不同心率胎儿的比较差异无统计学意义,VA在不同心率胎儿的比较差异有统计学意义;QTVI、PD两种方法测量AV、VA在不同孕周胎儿的比较差异无统计学意义。
结论:QTVI可简便快速地测定胎儿心脏传导时间,对于胎儿房室传导异常的评估具有潜在的应用价值。
Objective:To assess the values of quantitative tissue velocity imaging in studying normal fetal heart conduction time intervals.
Methods:Totally 78 fetuses between 17 and 41 week's gestation underwent detailed echocardiograms.Atrio-ventricular conduction time interval(AV) and the time interval from onset of ventricular contraction to the onset of atrial contraction of next cardiac cycle(VA) were measured by quantitative tissue velocity imaging(QTVI) and pulse Doppler(PD) echocardiography.
Results:QTVI-AV was(119.44±7.00) ms(95%CI 117.86～121.01ms).QTVI-VA was 298.58±22.17 ms(95%CI 292.85～303.06 ms).PD-AV was 121.88±8.05 ms(95%CI 120.07～123.70ms).PD-VA was 295.58±22.17ms(95%CI 290.58～300.58 ms).2-tailed T test revealed no systematic difference between the 2 approaches used to measure AV and VA.Gestational age and AV intervals were positively correlated with all imaging modalities,and significantly negatively correlated with fetal heart rate.
Conclusions:This study established the normal values of fetal heart conduction time intervals.The usage of QTVI in fetal heart conductional time intervals has important potential clinical utility in assessing fetal arrhythmia.
引文
[1]Saxena A,Shrivastava S,Kothari SS.Value of antenatal echocardiography in high risk patients to diagnose congenital cardiac defects in fetus.Indian J Pediatr,1995,62:575-582.
[2]Ayed K,Gorgi Y,Sfar I,et al.Congenital heart block associatod with maternal anti SSA/SSB antibodies:a report of four cases.Pathol Biol(Paris),2004,52(3):138-147.
[3]Dancea A,Fouron JC,Miro J,et al.Correlation between electrocardiographic and ultrasonographic time-interval measure-ments in fetal lamb heart.Pediatr Res,2000,47:324-328.
[4]Fouron JC,Proulx F,Mir(?) J,et al.Doppler and M-mode ultrasonography to time fetal atrial and ventricular contractions.Obstet Gynecol.2000 Nov;96(5 Pt 1):732-736.
[5]Dancea A,Fouron JC,Miro J,et al.Correlation between electrocardiographic and ultrasonographic time-interval measure-ments in fetal lamb heart.Pediatr Res,2000,47:324-328.
[6]Andelfinger G,Fouron JC,Sonesson SE,et al.Reference values for time intervals between atrial and ventricular contractions of the fetal heart measured by two Doppler techniques.Am J Cardiol,2001,88:1433-1436.
[7]赵博文,汤富刚,潘美,等.频谱多普勒及M型超声心动图检测胎儿心律失常的临床研究.中国超声医学杂志,2003,19:591-594.
[8]Horigome H,Ogata K,Kandori A,et al.Standardization of the PQRST waveform and analysis of arrhythmias in the fetus using vector magnetocardiography.Pediatric Research,2006,59(1).
[9]吴细香,刘建军,刘永岭,等.定量组织多普勒速度图评价正常胎儿心室壁及其整体运动.中国超声医学杂志,2006,26:546-548.
[10]朱小虎,高云华,刘兰.组织速度成像技术对冠心病左室壁收缩运动异常的评价.中国超声医学杂志,2005,19:896-900.
[11]Stinstra J,Golbach E,van Leeuwen P,et al.Multicentre study of fetal cardiac time intervals using magnetocardiography.BJOG,2002,109:1235-1243.
[12]Rein A J,O'Donnell C,Geva T,et al.Use of tissue velocity imaging in the diagnosis of fetal cardiac arrhythmias.Circulation,2002,106:1827-1833.
[13]Rein AJ,O'Donnell CP,Colan SD,et al.Tissue velocity Doppler assessment of atrial and ventricular electromechanical coupling and atrioventricular time intervals in normal subjects.Am J Cardiol,2003,92:1347-1350.
[14]Chan LY,Fok YW,Wong JT,et al.Reference charts of gestation-specific tissue Doppler imaging indices of systolic and diastolic functions in the normal fetal heart.Am Heart J,2005,150:750-755.
[15]Marwick TH.Clinical applications of tissue Doppler imaging:a promise fulfilled.Clinic 2003,89:1377-1378.
[16]Andelfinger G,Fouron JC,Sonesson SE,et al.Reference values for time intervals between atrial and ventricular contractions of the fetal heart measured by two Doppler techniques.Am J Cardiol,2001,88:1433-1436.
[17]Nii M,Hamilton RM,Fenwick L,et al.Assessment of fetal atrioventricular time intervals by tissue Doppler and pulse Doppler echocardiography:normal values and correlation with fetal electrocardiography.Heart,2006,92:1831-1837.
[18]赵博文,吕江红,徐海珊,等.组织多普勒成像在胎儿心律失常中的应用研究.中华超声影像学杂志,2006,11:831-835.
[19]Tutschek B,Zimmermann T,Buck T,et al.Fetal tissue Doppler hocardiography:detection rates of cardiac structures and quantitative assessment of the fetal heart.Ultrasound Obstet Gynecol,2003,21:26-32.
[20]Greenbaum RA,Ho SY,Gibson DG,et al.Left ventricular fibre architecture in human.Br Heart J,1981,45:248-263.
[21]Nii M,Shimizu M,Roman KS,et al.Doppler tissue imaging in the assessment of atrioventricular conduction time:validation of a novel technique and comparison with electrophysiologic and pulsed wave Doppler-derived equivalents in an animal model.J Am Soc Echocardiogr 2006,19:314-21.
[22]Rosenthal D,Friedman DM,Buyon J,et al.Validation of the Doppler PR interval in the fetus.J Am Soc Echocardiogr 2002:1029-30.
[23]Bolnick AD,Borgida AF,Egan JF,et al.Influence of gestational age and fetal heart rate on the fetal mechanical PR interval.J Matern Fetal Neonatal Med,2004,15:303-305.
[24]Wheeler T,Murrills A.Patterns of fetal heart rate during normal pregnancy.Br J Obstet Gynaecol 1978,85:18-27.
[25]Stewart PA,Tonge HM,Wladimiroff JW.Arrhythmia and structural abnormalities of the fetal heart.Br Heart J.1983 Dec;50(6):550-554.
[1]Jaeggi E,Fouron JC,Drblik SP.Fetal atrial flutter:diagnosis,clinical features,treatment,and outcome.J Pediatr,1998,132.335-339.
[2]Saxena A,Shrivastava S,Kothari SS.Value of antenatal echocardiography in high risk patients to diagnose congenital cardiac defects in fetus.Indian J Pediatr,1995,62:575-582.
[3]Vlagsma R,Hallensleben E,Meijboom EJ.Supraventricular tachycardia and premature atrial contractions in fetus.Ned Tijdschr Geneeskd,2001,145:295-299.
[4]卓晶如主编.临床胎儿心电图.北京:北京医科大学中国协和医科大学联合出版社,1995.34-41.
[5]Kariniemi V,Ahopelto J,Karp PJ,et al.The fetal magnetocardiogram[J].J PerinatMed,1974,2:214-216.
[6]Quinn A,Weir A,Shahani U,et al.Antenatal fetal magneto cardiography:a new method for fetal surveillance[J].Br J Obstet Gynecol,1994,101:866- 870.
[7]Hamada H,HorigomeH,Asaka M,et al.Prenatal diagnosis of long Qtsyndrome using fetal magnetocardiography[J].Prenat Diagn,1999,19:667-680.
[8]Wakai RT,LeutholdAC,MartinCB.Atrial andventricular fetal heartrate patterns in isolated congenital complete heart block detected by magnetdardiography[J].Am J Obstet Gynecol,1998,179:258-260.
[9]Hofbeck M,Ulmer H,Beinder E,et al.Prenatal findings in patients with pro-longed QT interval in the neonatal period[J].Heart,1997,77:198-209.
[10]Men(?)ndezT,Achenbach S,HofbeckM,et al.Prenatal diagnosis of QT prolongation by magnetocardiography[J].Pacing Clin Electrophysiol,2000,23:1305-1307.
[11]Menendez T,Achenbach S,Beinder E,et al.Usefulness of magnetocardiography for the investigation of fetal arrythmias[J].Am J Cardiol,2001,88(3):334-336.
[12]Horigome H,Ogata K,Kandori A,et al.Standardization of the PQRST waveform and analysis of arrhythmias in the fetus using vector magnetocardiography.Pediatric Research,2006,59(1).
[13]Quartero HW,Stinstra JG,Golbach EG,et al.Clinical implications of fetal magnetocardiography.Ultrasound Obstet Gynecol.2002 Aug;20(2):142-153.
[14]Campbell JQ,Best TH,Eswaran H,et al.Fetal and maternal magnetocardiography during flecainide therapy for supraventricular tachycardia.Obstet Gynecol,2006,108(3 Pt 2):767-771.
[15]Smith FE,Langley P,Trahms L,et al.Errors in repolarization measurement using magnetocardiography.Pacing and Clinical Electrophysiology,2002,25(8):1223-1229.
[16]Stewart PA,Tonge HM,Wladimiroff JW.Arrhythmia and structural abnormalities of the fetal heart.Br Heart J.1983 Dec;50(6):550-554.
[17]Copel JA,Liang RI,Demasiok K,et al.The clinical significance of the irregular fetal heart rhythm.Am J Obstet Gynecol,2000,182:813-819.
[18]Jurgens J,Chaoui R.Three-dimensional multiplanar time-motionultrasound or anatomical M-mode of the fetal heart:a new technique in fetal echocardiography.Ultrasound Obstet Gynecol,2003,21:119-123.
[19]Gembruch U,Bald R,Hansmann M.Color-coded M-mode Doppler echocardiography in the diagnosis of fetal arrhythmia.Geburt-Shilfe Frauenheilkd,1990,50:286-290.
[20]Reed Kl,Appleton CP,A nderson CF,Shenker L,Sahn DJ.Doppler studies of vena cava flows in human fetuses.Insights into normal and abnormal cardiac physiology. Circulation 1990;81:498-505.
[21]Carvalho JS,Prefumo F,Ciardelli V,et al.Evaluation of fetal arrhythmias from simultaneous pulsed wave Doppler in pulmonary artery and vein.Heart.2007Nov;93(11):1331-1333.
[22]赵博文,潘美,张松英等.胎儿心律失常的超声心动图检测及其临床意义.中华妇产科杂志,2004,6:365-368.
[23]Greenbaum RA,Ho SY,Gibson DG,et al.Left ventricular fibre architecture in human.Br Heart J,1981,45:248-263.
[24]Paladini D,Lamberti A,Teodoro M,et al.Tissue Doppler imaging of the fetal heart.Ultrasound Obstet Gynecol,2000,16:530-535.
[25]Harada K,Tsuda A,Orino T,et al.Tissue Doppler imaging in the normal fetus.Int J Cardiol,1999,71:227-234.
[26]Rein AJ,O'Donnell C,Geva T,et al.Use of tissue velocity imaging in the diagnosis of fetal cardiac arrhythmias.Circulation.2002 Oct 1;106(14):1827-33.
[27]Oztune F,Besikei R,Eroglu AG..Fetal arrhythmias:diagnosis,treatment and prognosis.Anadoln Kardiyol Derg,2003,3(3):211-215.
[2]Ayed K,Gorgi Y,Sfar I,et al.Congenital heart block associatod with maternal anti SSA/SSB antibodies:a report of four cases.Pathol Biol(Paris),2004,52(3):138-147.
[3]Dancea A,Fouron JC,Miro J,et al.Correlation between electrocardiographic and ultrasonographic time-interval measure-ments in fetal lamb heart.Pediatr Res,2000,47:324-328.
[4]Fouron JC,Proulx F,Mir(?) J,et al.Doppler and M-mode ultrasonography to time fetal atrial and ventricular contractions.Obstet Gynecol.2000 Nov;96(5 Pt 1):732-736.
[5]Dancea A,Fouron JC,Miro J,et al.Correlation between electrocardiographic and ultrasonographic time-interval measure-ments in fetal lamb heart.Pediatr Res,2000,47:324-328.
[6]Andelfinger G,Fouron JC,Sonesson SE,et al.Reference values for time intervals between atrial and ventricular contractions of the fetal heart measured by two Doppler techniques.Am J Cardiol,2001,88:1433-1436.
[7]赵博文,汤富刚,潘美,等.频谱多普勒及M型超声心动图检测胎儿心律失常的临床研究.中国超声医学杂志,2003,19:591-594.
[8]Horigome H,Ogata K,Kandori A,et al.Standardization of the PQRST waveform and analysis of arrhythmias in the fetus using vector magnetocardiography.Pediatric Research,2006,59(1).
[9]吴细香,刘建军,刘永岭,等.定量组织多普勒速度图评价正常胎儿心室壁及其整体运动.中国超声医学杂志,2006,26:546-548.
[10]朱小虎,高云华,刘兰.组织速度成像技术对冠心病左室壁收缩运动异常的评价.中国超声医学杂志,2005,19:896-900.
[11]Stinstra J,Golbach E,van Leeuwen P,et al.Multicentre study of fetal cardiac time intervals using magnetocardiography.BJOG,2002,109:1235-1243.
[12]Rein A J,O'Donnell C,Geva T,et al.Use of tissue velocity imaging in the diagnosis of fetal cardiac arrhythmias.Circulation,2002,106:1827-1833.
[13]Rein AJ,O'Donnell CP,Colan SD,et al.Tissue velocity Doppler assessment of atrial and ventricular electromechanical coupling and atrioventricular time intervals in normal subjects.Am J Cardiol,2003,92:1347-1350.
[14]Chan LY,Fok YW,Wong JT,et al.Reference charts of gestation-specific tissue Doppler imaging indices of systolic and diastolic functions in the normal fetal heart.Am Heart J,2005,150:750-755.
[15]Marwick TH.Clinical applications of tissue Doppler imaging:a promise fulfilled.Clinic 2003,89:1377-1378.
[16]Andelfinger G,Fouron JC,Sonesson SE,et al.Reference values for time intervals between atrial and ventricular contractions of the fetal heart measured by two Doppler techniques.Am J Cardiol,2001,88:1433-1436.
[17]Nii M,Hamilton RM,Fenwick L,et al.Assessment of fetal atrioventricular time intervals by tissue Doppler and pulse Doppler echocardiography:normal values and correlation with fetal electrocardiography.Heart,2006,92:1831-1837.
[18]赵博文,吕江红,徐海珊,等.组织多普勒成像在胎儿心律失常中的应用研究.中华超声影像学杂志,2006,11:831-835.
[19]Tutschek B,Zimmermann T,Buck T,et al.Fetal tissue Doppler hocardiography:detection rates of cardiac structures and quantitative assessment of the fetal heart.Ultrasound Obstet Gynecol,2003,21:26-32.
[20]Greenbaum RA,Ho SY,Gibson DG,et al.Left ventricular fibre architecture in human.Br Heart J,1981,45:248-263.
[21]Nii M,Shimizu M,Roman KS,et al.Doppler tissue imaging in the assessment of atrioventricular conduction time:validation of a novel technique and comparison with electrophysiologic and pulsed wave Doppler-derived equivalents in an animal model.J Am Soc Echocardiogr 2006,19:314-21.
[22]Rosenthal D,Friedman DM,Buyon J,et al.Validation of the Doppler PR interval in the fetus.J Am Soc Echocardiogr 2002:1029-30.
[23]Bolnick AD,Borgida AF,Egan JF,et al.Influence of gestational age and fetal heart rate on the fetal mechanical PR interval.J Matern Fetal Neonatal Med,2004,15:303-305.
[24]Wheeler T,Murrills A.Patterns of fetal heart rate during normal pregnancy.Br J Obstet Gynaecol 1978,85:18-27.
[25]Stewart PA,Tonge HM,Wladimiroff JW.Arrhythmia and structural abnormalities of the fetal heart.Br Heart J.1983 Dec;50(6):550-554.
[1]Jaeggi E,Fouron JC,Drblik SP.Fetal atrial flutter:diagnosis,clinical features,treatment,and outcome.J Pediatr,1998,132.335-339.
[2]Saxena A,Shrivastava S,Kothari SS.Value of antenatal echocardiography in high risk patients to diagnose congenital cardiac defects in fetus.Indian J Pediatr,1995,62:575-582.
[3]Vlagsma R,Hallensleben E,Meijboom EJ.Supraventricular tachycardia and premature atrial contractions in fetus.Ned Tijdschr Geneeskd,2001,145:295-299.
[4]卓晶如主编.临床胎儿心电图.北京:北京医科大学中国协和医科大学联合出版社,1995.34-41.
[5]Kariniemi V,Ahopelto J,Karp PJ,et al.The fetal magnetocardiogram[J].J PerinatMed,1974,2:214-216.
[6]Quinn A,Weir A,Shahani U,et al.Antenatal fetal magneto cardiography:a new method for fetal surveillance[J].Br J Obstet Gynecol,1994,101:866- 870.
[7]Hamada H,HorigomeH,Asaka M,et al.Prenatal diagnosis of long Qtsyndrome using fetal magnetocardiography[J].Prenat Diagn,1999,19:667-680.
[8]Wakai RT,LeutholdAC,MartinCB.Atrial andventricular fetal heartrate patterns in isolated congenital complete heart block detected by magnetdardiography[J].Am J Obstet Gynecol,1998,179:258-260.
[9]Hofbeck M,Ulmer H,Beinder E,et al.Prenatal findings in patients with pro-longed QT interval in the neonatal period[J].Heart,1997,77:198-209.
[10]Men(?)ndezT,Achenbach S,HofbeckM,et al.Prenatal diagnosis of QT prolongation by magnetocardiography[J].Pacing Clin Electrophysiol,2000,23:1305-1307.
[11]Menendez T,Achenbach S,Beinder E,et al.Usefulness of magnetocardiography for the investigation of fetal arrythmias[J].Am J Cardiol,2001,88(3):334-336.
[12]Horigome H,Ogata K,Kandori A,et al.Standardization of the PQRST waveform and analysis of arrhythmias in the fetus using vector magnetocardiography.Pediatric Research,2006,59(1).
[13]Quartero HW,Stinstra JG,Golbach EG,et al.Clinical implications of fetal magnetocardiography.Ultrasound Obstet Gynecol.2002 Aug;20(2):142-153.
[14]Campbell JQ,Best TH,Eswaran H,et al.Fetal and maternal magnetocardiography during flecainide therapy for supraventricular tachycardia.Obstet Gynecol,2006,108(3 Pt 2):767-771.
[15]Smith FE,Langley P,Trahms L,et al.Errors in repolarization measurement using magnetocardiography.Pacing and Clinical Electrophysiology,2002,25(8):1223-1229.
[16]Stewart PA,Tonge HM,Wladimiroff JW.Arrhythmia and structural abnormalities of the fetal heart.Br Heart J.1983 Dec;50(6):550-554.
[17]Copel JA,Liang RI,Demasiok K,et al.The clinical significance of the irregular fetal heart rhythm.Am J Obstet Gynecol,2000,182:813-819.
[18]Jurgens J,Chaoui R.Three-dimensional multiplanar time-motionultrasound or anatomical M-mode of the fetal heart:a new technique in fetal echocardiography.Ultrasound Obstet Gynecol,2003,21:119-123.
[19]Gembruch U,Bald R,Hansmann M.Color-coded M-mode Doppler echocardiography in the diagnosis of fetal arrhythmia.Geburt-Shilfe Frauenheilkd,1990,50:286-290.
[20]Reed Kl,Appleton CP,A nderson CF,Shenker L,Sahn DJ.Doppler studies of vena cava flows in human fetuses.Insights into normal and abnormal cardiac physiology. Circulation 1990;81:498-505.
[21]Carvalho JS,Prefumo F,Ciardelli V,et al.Evaluation of fetal arrhythmias from simultaneous pulsed wave Doppler in pulmonary artery and vein.Heart.2007Nov;93(11):1331-1333.
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