中晚孕期胎儿心房内径定量评估心房比例失调胎儿心脏畸形的价值

Value of quantitative fetal atrial size parameters in assessing cardiac malformations in fetuses with atrial disproportion in middle and late trimesters

目的探讨心房内径多参数在中晚孕期心房比例失调胎儿心脏畸形诊断中的价值。方法选取2022年3月至2022年11月在浙江大学医学院附属邵逸夫医院超声科经胎儿超声心动图发现心房比例失调的胎儿39例作为病例组,选取同期孕龄相匹配的正常胎儿250例作为对照组。获取胎儿超声心动图标准四腔心切面,于收缩末期分别测量两组胎儿心房大小参数,包括左心房横径(LAW)、左心房长径(LAL)、左心房面积(LAA)、右心房横径(RAW)、右心房长径(RAL)、右心房面积(RAA),并分别计算RAL/LAL、RAW/LAW、RAA/LAA。分析正常对照组左、右心房大小参数与孕龄的相关性,对比上述各参数在病例组与对照组之间的差异,并采用ROC曲线分析RAL/LAL、RAW/LAW、RAA/LAA鉴别胎儿心脏异常的敏感度和特异度。同时,对病例组胎儿进行6个月的随访观察。结果LAL、LAW、LAA、RAL、RAW、RAA均随孕龄的增长而增大,与孕龄呈正相关关系(r=0.803、0.840、0.885、0.817、0.816、0.897,P均<0.05)。而RAL/LAL、RAW/LAW、RAA/LAA与孕龄无相关性(P均>0.05),RAL/LAL、RAW/LAW、RAA/LAA的正常参考值(95%CI)分别为1.002±0.090(0.991~1.013)、1.096±0.097(1.084~1.108)、1.064±0.092(1.052~1.075)。病例组胎儿的RAL、RAW、RAA、RAL/LAL、RAW/LAW、RAA/LAA明显高于正常组,差异有统计学意义(P均<0.05);病例组胎儿的LAW、LAA小于正常组,差异有统计学意义(P均<0.05);而两组间LAL差异无统计学意义(P>0.05)。RAL/LAL、RAW/LAW、RAA/LAA的ROC曲线下面积(AUC)分别为0.789、0.977、0.994,分别取1.05、1.30、1.23作为RAL/LAL、RAW/LAW、RAA/LAA的最佳截断值时,诊断胎儿心脏异常的敏感度分别为74.4%、87.2%、97.4%,特异度分别为71.6%、98.8%、96.0%。39例病例组胎儿中12例引产,余27例胎儿出生后超声心动图均提示心脏异常。结论胎儿心房内径比值RAL/LAL、RAW/LAW、RAA/LAA可定量评估胎儿心房比例失调,为发现胎儿心脏异常提供参考依据,当各比值超过相应截断值时应高度警惕胎儿心脏异常的存在。

Objective To evaluate the value of multiple atrial size parameters in assessment of fetal cardiac malformations in fetuses with atrial disproportion in middle and late trimesters.Methods Thirty-nine fetuses with atrial disproportion detected by fetal echocardiography at the Department of Diagnostic Ultrasound&Echocardiography,Sir Run Run Shaw Hospital,Zhejiang University College of Medicine from March 2022 to November 2022 were selected as a case group,and 250 normal fetuses matched for gestational age during the same period were selected as a control group.Fetal echocardiographic standard four-chamber views were obtained,and atrial size parameters were measured at end-systole,including left atrial width(LAW),left atrial length(LAL),left atrial area(LAA),right atrial width(RAW),right atrial length(RAL),and right atrial area(RAA),and the ratio of RAL to LAL(RAL/LAL),the ratio of RAW to LAW(RAW/LAW),and the ratio of RAA to LAA(RAA/LAA)were calculated subsequently.The correlation between the left and right atrial size parameters and the gestational weeks of fetuses in the control group was analyzed.The above parameters were then compared between the two groups.Additionally,receiver operating characteristic(ROC)curve analysis was performed to assess the sensitivity and specificity of RAL/LAL,RAW/LAW,and RAA/LAA in identifying fetal cardiac anomalies.Meanwhile,a 6-month follow-up was conducted for fetuses in the case group.Results LAL,LAW,LAA,RAL,RAW,and RAA were all positively correlated with gestational weeks in fetus of the control group(r=0.803,0.840,0.885,0.817,0.816,and 0.897,respectively,all P<0.05).In contrast,no correlation was found between RAL/LAL,RAW/LAW,and RAA/LAA and gestational weeks(all P>0.05).The normal reference ranges(95%confidence intervals)for RAL/LAL,RAW/LAW,and RAA/LAA were 1.002±0.090(0.991~1.013),1.096±0.097(1.084~1.108),and 1.064±0.092(1.052~1.075),respectively.RAL,RAW,RAA,RAL/LAL,RAW/LAW,and RAA/LAA were significantly increased in the case group compared with those of the control group(all P<0.05),and LAW and LAA were decreased significantly compared with those of the control group(both P<0.05),while there was no statistically significant difference in LAL between the two groups(P>0.05).The area under the ROC curve(AUC)values of RAL/LAL,RAW/LAW,and RAA/LAA for diagnosing fetal cardiac anomalies were 0.789,0.977,and 0.994,respectively.When the optimal cut-off values of RAL/LAL,RAW/LAW,and RAA/LAA were 1.05,1.30,and 1.23,respectively,their sensitivity for diagnosing fetal cardiac anomalies was 74.4%,87.2%,and 97.4%,respectively,and their specificity was 71.6%,98.8%,and 96.0%,respectively.Among the 39 fetuses of the case group,12 were induced,and cardiac anomalies were detected in all the other 27 cases by postnatal echocardiography.Conclusion Fetal atrial size ratios such as RAL/LAL,RAW/LAW,RAA/LAA can be used to quantitatively assess fetal atrial disproportion,which can provide a reference for the detection of fetal cardiac anomalies.When each of the ratios exceeds the corresponding cut-off value,the possibility of fetal cardiac anomalies should be highly suspected.