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　　【摘要】 目的：利用三尖瓣环位移（tricuspid annular plane systolic excursion，TAPSE）和面积变化分数（fractional area change，FAC）评估正常中晚孕胎儿右心室（right ventricle, RV）收缩功能。方法：分别测量165例正常中晚孕胎儿TAPSE、右心室舒张期末面积（right ventriclar end-diastolic area，RVEDA）及右心室收缩期末面积（right ventriclar end-systolic area，RVESA），计算RV FAC，并观察其与孕周的关系。结果：胎儿TAPSE、RVEDA及RVESA随孕周增加而增加（P＜0.05），RV FAC与孕周无明显相关性（P＞0.05）。 结论：胎儿TAPSE与RV FAC能简便准确的评估右室收缩功能，尤其适用于基层医院。
　　【关键词】超声心动描记术；胎儿；心室功能
　　【中图分类号】R749&&&&&&&&&&&&&&&&& 【文献标识码】A&&&&&&&&&&&&&&&&&&&& 【文章编号】（4-03
　　 Assessment of fetal right ventriclar systolic function using tricuspid annular plane systolic excursion and fractional area change
　　【Abstract】 Objective To quantitatively study fetal right ventriclar systolic function in the normal second and third trimester fetuses by tricuspid annular plane systolic excursion and fractional area change. Methods& 165 healthy fetuses were divided into 5 groups according to the gestational age．To measue tricuspid annular plane systolic excursion(TAPSE）,& right ventriclar end-diastolic area(RVEDA）and right ventriclar end-systolic area(RVESA）, and right ventriclar fractional area change(RV FAC）was calculated, then the correlation between above parameters and gestational age was evaluated.& Results& In normal second and third trimester fetuses，the TAPSE,& RVEDA and RVESA were increased with the growth of GA（P＜0.05）, whereas RV FAC was stable throughout gestation(P&0.05)． TAPSE and RV FAC were not correlated with HR(P&0.05)． Conclusions Both TAPSE and RV FAC could be& simply and accurately measured to evaluate fetal right ventriclar systolic function, and could be propitious to use in countryside hospitals because of lower requirement on the equipment．
　　【Key words】Echocardiography；Fetus；Ventricular function
　　右心室解剖结构复杂，对其收缩功能的评估一直是研究的热点和难点，对于成人的右室收缩功能的评估已有一些较为成熟的方法[1]。由于胎儿循环生理的特殊性，右室在循环过程中的作用更为重要，准确评价胎儿右室收缩功能对于处理胎儿各种发育异常和判断预后均至关重要。综合目前的一些研究，评估胎儿右室收缩功能的方法主要有Tei指数、右室壁运动速度、应变及应变率等，这些指标均能较好的评估右室收缩功能，但这些方法对检查仪器要求较高，且操作复杂，不利于基层医院开展。本研究尝试应用相对较简单的三尖瓣环位移（TAPSE）和右室面积变化率（FAC）来评估胎儿右室收缩功能。
　　1.资料与方法
　　1.1 研究对象
　　2014年6月至2014年12月在浙江萧山医院超声科进行产前超声检查的正常单胎妊娠孕妇165例，年龄21～36岁，平均（26.57&3.16）岁，孕周18～35+6周，平均（30.00&6.91）周。其中，18-23+6周26例，24-27+6周27例，28-31+6周38例，32-35+6周29例，36-40+1周45例。入选条件：（1）孕妇身体健康，无吸烟、糖尿病及高血压等病史；（2）经详细的产前筛查，胎儿无发育异常，大小与孕周相符；（3）经胎儿超声心动图检查，胎儿心脏无结构畸形及心律失常；（4）胎儿心血管整体评分（CVPS）均为10分。
　　1.2仪器与方法
　　1.2.1仪器：应用GE E8彩色多普勒成像仪，& 探头RAB4-8-D，探头频率4-8Hz。
　　1.2.2首先，应用常规产科检查模式对胎儿发育情况进行详细评估，然后切换至胎儿心脏模式进行胎儿超声心动图检查，最后测量TAPSE和FAC。
　　（1）TAPSE的测量：显示胎儿标准四腔心切面，启动M型模式，将取样线置于三尖瓣环，即三尖瓣前叶与右室游离壁交界处，取样线尽量与室间隔平行，夹角小于20&，若胎位不理想则嘱孕妇起床稍加活动后再检查。测量舒张期末至收缩期末的距离，测三个心动周期取平均值。
　　（2）FAC的测量：显示标准胎儿四腔心切面，分别测量舒张期末右室面积（RVEDA）和收缩期末右室面积（RVESA），测量时注意沿着右室肌小梁下的心内膜勾画计算面积，测量三个心动周期取平均值。FAC计算公式：（RVEDA- RVESA）/ RVEDA&100%。
　　1.2.3统计分析：计量资料采用 &均数&标准差&表示，对各组胎儿TAPSE、RVEDA、RVESA及FAC比较采用F检验，并对各变量与孕周进行pearson相关性分析，以P ＜0.05为差异有统计学意义，以上过程均应用SPSS16.0统计学软件完成。
　　2.结果
　　2.1 165例正常中晚孕胎儿右心室TAPSE平均值（0.78&0.25）cm，95%正常参考值范围为0.75～0.82cm；RVEDA平均值（2.89&1.52）cm2，95%正常参考值范围为2.64～3.11cm2；RVESA平均值（1.83&1.01）cm2，95%正常参考值范围为1.67～1.98 cm2；FAC平均值（37.13&6.72）%，95%正常参考值范围为36.10%～38.16%。
　　2.2 各组孕妇例数及年龄，以及胎儿TAPSE、RVEDA、RVESA及FAC等参数的平均值见表1。各组胎儿间TAPSE、RVEDA及RVESA差异有统计学意义，各组胎儿间FAC差异没有统计学意义，见表1。
　　2.3 胎儿TAPSE、RVEDA及RVESA随孕周增加而增长，与孕周均呈显著相关性，胎儿FAC不随孕周增加而增长，与孕周无显著相关性，见表2，见图1-4。
　　3.讨论
　　从本质上来讲，胎儿心血管系统是两个平行的循环系统：（1）来自于胎盘的一部分氧合血通过静脉导管和下腔静脉进入右房，并通过开放的卵圆孔进入左心，供应脑部、心肌及上肢等重要结构；（2）来自于下腔静脉的非氧合血和另一部分通过门静脉和肝静脉回流入下腔静脉的氧合血进入右心，通过动脉导管进入降主动脉供应腹部脏器及下肢。其中，右室约占联合输血量的2/3，左室约占联合输血量的1/3，右室发挥了体循环心室的作用。因此，对胎儿右室功能的的准确评价显得尤为重要。相比于左室，右室的解剖结构更复杂，因此对右室收缩功能的评估远较左室复杂。2010年美国超声心动图学会提出了评价成人右心功能的指南[1]，较为详细的总结了右心功能的方法，其中一些指标，比如TAPSE和FAC，理应也可以用于胎儿右心功能的评估。
　　目前对胎儿右心功能评估的方法主要有：（1）Tei指数法，Tei指数=（等容收缩期时间+等容舒张期时间）/收缩时间，它的优点是不依赖心室的几何形态，较适合评价右心功能，受心脏前后负荷影响小。目前测Tei指数主要有频谱多普勒（PW）法和组织多普勒（TDI）法，虽然Tei指数是一个比较好的指标，但测量过程较繁琐，且测值易受心率影响，须标化心率，尤其是PW法。而且两种方法测的Tei指数值虽然相关性较好，但数值并不一致[1，2]，这给临床应用带来一定的不变。（2）利用组织多普勒或二维应变技术测右室整体或局部的运动速度、位移、应变及应变率等。蒲大容[3]等利用速度向量技术（VVI）检测的170例正常胎儿右室长轴节段功能，发现右室心肌峰值速度由基底段向心尖段递减，且随孕周增加而增加，而应变和应变率无此变化；Paul A. Brooks[4]等利用VVI技术研究了左心发育不全综合征（HLHS）胎儿右室功能，发现相对于正常胎儿，HLHS胎儿右室整体纵向速度、应变及位移均减少，而径向位移增加。这些方法的优点是测量的参数较多，能较全面的评价右室整体甚至节段功能，但测量同样较为繁琐，对人员及检查仪器要求较高，不利于基层医院在日常工作中开展。（3）测量TAPSE，这也是本研究中采用的方法之一。蒋贤辉[5]等利用普通M型超声测量了161例正常胎儿的TAPSE，发现TAPSE与孕周、三尖瓣血流速度及三尖瓣环运动速度显著相关，但和心率无相关性。
　　TAPSE主要反映的是右室的纵向功能。左室的收缩运动较为复杂，不仅有纵向的缩短，也有圆周向的扭转，不同于左室，右室壁心肌纤维以纵行与斜行为主，右室的收缩主要表现为纵向的缩短。因此，TAPSE是反映右室收缩功能较好的指标。在本研究中，正常中晚孕胎儿TAPSE随孕龄增加而增加，与胎心率无明显相关，与蒋贤辉[5]等的研究结果一致。TAPSE已被广泛用于评估成人和儿童的右室收缩功能，成人TAPSE＜16mm被认为右室收缩功能下降，而儿童TAPSE与年龄及体表面积呈正相关[1]。TAPSE测量简单，可重复性强，但其有角度依赖性。在成人与儿童，较易获得标准的心尖四腔心切面，可以准确的测量TAPSE，但在胎儿，受胎方位的影响，有时不容易获得平行于声束的四腔心，需要孕妇起床活动以获得满意的胎位，这给测量带来一定的不便，尤其是晚孕期的胎儿。有作者[6]应用解剖M型超声测量TAPSE，取得较好结果，晚近更有作者[7]应用先进的时空相关成像技术（STIC）测量TAPSE，这些方法对于TAPSE的广泛应用提供了技术基础。
　　对成人的研究显示，右室的FAC与MRI测量的右室射血分数呈正相关，并且是心衰、猝死、休克及肺动脉栓塞致死率的独立预测因子[1]。目前对胎儿右室FAC的研究较少，在本研究中，RVEDA和RVESA随孕周增加而增加，而FAC则不随孕周变化，与胎心率也没有相关性，这一特点使其作为心功能参数可能更易被临床接受。更为重要的是，FAC的测量没有角度依赖，这尤其方便应用于晚孕期胎儿。右室的解剖形态复杂，四腔心切面只能显示流入道部分，因此FAC反映的是右室流入道的功能，流出道的功能没有被体现，这是其不足之处。同成人一样，测量右室面积时，应注意将右室壁肌小梁部分包含在内。
　　综上所述，TAPSE与FAC能较好的评价右室收缩功能，测量方法简便，结果可靠，对检查仪器及人员要求不高，尤其有利于在基层医疗机构的日常诊疗工作中开展。&&&&&&& 【参考文献】
　　[1] Lawrence G.Rudski,Chair,Wyman W.Lai,Jonathan Afilalo,et al.Guidelines for the Echocardiographic Assessment of the Right Heart in Adults:A Report from the American Society of Echocardiography. J Am Soc Echocardiogr -713.
　　[2] 夏永升，孙志丹.组织多普勒与脉冲多普勒超声评估妊娠期高血压状态下胎儿右心室功能.中国医学影像技术，）：.
　　[3] 蒲大客，周启昌，彭清海等.速度向量成像技术检测胎儿右心室长轴节段功能的临床研究.中华超声影像学杂志，）：956-959.
　　[4] Paul A.Brooks,Nee S.Khoo, Andrew S.Mackie,et al. Right Ventricular Function in Fetal Hypoplastic Left Heart Syndrome.J Am Soc Echocardiogr 8-1074
　　[5] 蒋贤辉，赵博文，王蓓等.三尖瓣瓣环位移对正常中晚孕胎儿右心室功能的定量研究.中华超声影像学杂志，）：833-837.
　　[6] J.S.Carvalho,C.O&Sullivan, E.A.Shinebourne,et al. Right and left ventricular long-axis function in the fetus using angular M-mode. Ultrasound Obstet Gynecol 9-622.
　　[7] B. Messing, Y.Gilboa, M.Lipschuetz,et al.Fetal tricuspid annular plane systolic excursion (f-TAPSE): evaluation of fetal right heart systolic function with conventional M-mode ultrasound and spatiotemporal image correlation (STIC) M-mode. Ultrasound Obstet Gynecol 2-188.
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