二维斑点追踪技术定量评估中重度三尖瓣反流胎儿右心房功能的研究

Quantitative evaluation of right atrial function in fetuses with moderate to severe tricuspid regurgitation by two-dimensional speckle tracking echocardiography

目的探讨二维斑点追踪(2D-STE)技术在定量正常胎儿右心房整体纵向峰值应变(PRAGLS)以及其在评估中大量三尖瓣反流(TR)胎儿右房功能中的应用价值。方法选取2020年10月至2022年5月在浙江大学医学院附属邵逸夫医院接受胎儿超声心动图检查并被诊断伴发中重度TR的胎儿25例作为病例组,孕周25.00(24.00,30.00)周;另选取正常单胎100例作为对照组,孕周25.83(23.00,28.75)周。获取标准的基底或心尖四腔心切面动态图像,通过TOMTEC-ARENA离线心脏分析软件进行分析,获取两组胎儿PRAGLS值,测量两组胎儿常规产科超声及胎儿心脏超声参数:胎儿心率(FHR)、双顶径(BPD)、股骨长(FL)、主动脉瓣环内径(AO)、肺动脉瓣环内径(PA)、肺主比(PA/AO)、右房收缩末期长径(RAESL)、右房收缩末期横径(RAESD)、右房收缩末期面积(RAESA)、右室舒张末期横径(RVEDD)及三尖瓣环收缩期瓣环位移(TAPSE);病例组同时测量TR峰值速度及峰值压差。比较两组胎儿PRAGLS以及其他各参数之间的差异,并对两组胎儿PRAGLS与孕周(GA)及各常规测量参数的相关性进行分析。用组内相关系数(ICC)对观察者内及观察者间进行重复性检验。结果两组间PRAGLS差异有统计学意义(t=11.55,P<0.01);两组间TAPSE差异有统计学意义(Z=3.45,P=0.01);两组间AO、PA、PA/AO、RAESL、RAESD、RAESA差异有统计学意义(均P<0.05),两组间孕妇年龄、GA、FHR、BPD、FL及RVEDD差异无统计学意义(均P>0.05)。对照组PRAGLS与GA呈中等度负相关(r=-0.47,P<0.01),与BPD、FL、AO、PA、RAESL、RAESD、RAESA、RVEDD存在相关性(rs=-0.50、-0.46、-0.39、-0.43、-0.45、-0.36、-0.43、-0.32,均P<0.05),与孕妇年龄、FHR、PA/AO、TAPSE无明显相关性(均P>0.05);病例组PRAGLS与GA及各常规参数均无明显相关性(均P>0.05)。对照组PRAGLS值的测量者间及测量者内ICC分别为0.87、0.79,病例组PRAGLS值的测量者间及测量者内ICC分别为0.94、0.97,具有较好的一致性。结论2D-STE在中重度TR胎儿右房功能评估中具有良好的可行性和可重复性,中重度TR胎儿PRAGLS降低,提示中重度TR胎儿右房储备功能显著降低,胎儿右房应变为胎儿心脏功能异常改变的定量分析提供了新的参考指标。

Objective To explore the application value of two-dimensional speckle tracking echocardiography(2D-STE)in measuring the global longitudinal peak strain of the right atrium(PRAGLS)in normal fetuses and evaluating PRAGLS in assessing right atrial function in fetuses with moderate and severe tricuspid regurgitation(TR).Methods A total of 25 fetuses diagnosed with moderate and severe TR,who underwent fetal echocardiography at Run Run Shaw Hospital,Zhejiang University College of Medicine between October 2020 and May 2022,were selected as the case group.Their gestational age ranged from 25.00(24.00,30.00)weeks.Additionally,100 normal singleton fetuses were chosen as the control group,with a gestational age of 25.83(23.00,28.75)weeks.Standard basal or apical four-chamber clips were acquired and inputted into TOMTEC-ARENA offline cardiac analysis software for analysis.The fetal PRAGLS values of the two groups were obtained,as well as the routine obstetric ultrasound measurements and fetal echocardiographic parameters of both groups:fetal heart rate(FHR),biparietal diameter(BPD),femur length(FL),aortic annulus inner diameter(AO),pulmonary annulus inner diameter(PA),PA/AO ratio,right atrial end-systolic length(RAESL),right atrial end-systolic diameter(RAESD),right atrial end-systolic area(RAESA),right ventricular end-diastolic diameter(RVEDD),and tricuspid annular plane systolic excursion(TAPSE).The peak TR velocity and pressure gradient were simultaneously measured in the case group.The differences in fetal PRAGLS and other parameters between the two groups were compared and analyzed.The correlation between fetal PRAGLS and gestational age(GA)and routine measurements was assessed for both groups.Intra-and inter-observer repeatability tests were conducted using the intragroup correlation coefficient(ICC).Results A significant difference in PRAGLS was observed between the two groups(t=11.55,P<0.01).The TAPSE difference between the two groups was also statistically significant(Z=3.45,P=0.01).Notable differences were found in AO,PA,PA/AO,RAESL,RAESD,and RAESA between the two groups(all P<0.05),but no significant differences were identified in age,GA,FHR,BPD,FL,and RVEDD between the two groups(all P>0.05).PRAGLS in the control group exhibited a moderate negative correlation with GA(r=-0.47,P<0.01)and were correlated with BPD,FL,AO,PA,RAESL,RAESD,RAESA,and RVEDD(r=-0.50,-0.46,-0.39,-0.43,-0.45,-0.36,-0.43,-0.32,all P<0.05).No significant correlation was observed with maternal age,FHR,PA/AO,and TAPSE(all P>0.05).No significant correlation between PRAGLS and GA or other conventional parameters was found in the case group(all P>0.05).The inter-measurer and intra-measurer ICC of PRAGLS in the control group were 0.87 and 0.79,respectively,while the inter-measurer and intra-measurer ICC of PRAGLS in the case group were 0.94 and 0.97,respectively,demonstrating good consistency.Conclusions 2D-STE exhibits strong feasibility and reproducibility in assessing fetal atrial function.Fetuses with moderate and severe TR display decreased PRAGLS,suggesting impaired right atrial reservoir function.Right atrial strain introduces a novel method for evaluating fetal cardiac function.