Quantitative evaluation of right atrial function in fetuses with moderate to severe tricuspid regurgitation by two-dimensional speckle tracking echocardiography / 中华超声影像学杂志

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.

Preliminary study of cardiac morphology and function in fetuses with tetralogy of Fallot using fetal heart quantification / 中华超声影像学杂志

Objective:To evaluate the fetal heart shape and function in tetralogy of Fallot (TOF) by fetal heart quantitative analysis (fetal HQ).Methods:A total of 52 fetuses with TOF diagnosed by fetal echocardiography and 200 normal fetuses matched with their gestational weeks from March 2020 to March 2022 at Sir Run Run Shaw Hospital, Zhejiang University were retrospectively evaluated. The basic parameters of fetal cardiac blood vessels in the two groups were measured by fetal HQ technology and conventional M-mode ultrasound technology: aortic valve diameter(AV), pulmonary artery valve diameter(PV), main pulmonary artery diameter (MPA) and Z-score. The overall morphometric measurements including end-diastolic length diameter, transverse diameter, area, and global spherical index (GSI) of the fetal heart in the 4-chamber view(4CV), area and length of the right and left ventricles and their ratios. Measurements of left and right ventricular function included ejection fraction (EF), fraction area change rate (FAC), tricuspid annular plane systolic excursion (TAPSE), left and right ventricular global longitudinal strain (GLS), and left and right ventricular end-diastolic diameter (ED), spherical index (SI), and fractional shortening rate (FS) of 24-segments. The differences of above parameters between TOF group and control group were compared. In addition, the relationships between the absolute value of left and right ventricular GLS of TOF fetus and PV/AV, PV Z-score and MPA Z-score were analyzed. The optimal critical values of GSI, left ventricular EF and left ventricular FAC of TOF fetus were determined by ROC curve, and their corresponding sensitivity and specificity were obtained.Results:Compared with control group, there were significant differences in 4CV end-diastolic length, area, GSI, left ventricular area, left ventricular length, left ventricular EF, left ventricular FAC and left ventricular GLS in TOF group (all P<0.05). There were significant differences in ED between left ventricular 15-24 segments and right ventricular 1-21 segments (all P<0.05). There were significant differences in SI between left ventricular 1-16 segments, 21-24 segments and all segments of right ventricle (all P<0.05). The differences in FS were statistically significant (all P<0.05) when comparing all segments of the left ventricle and 1-2 segments of the right ventricular, and the remaining parameters were not statistically significant (all P>0.05). The left ventricular GLS absolute value of TOF fetuses was positively correlated with PV/AV, PV Z-score and MPA Z-score( rs=0.338, 0.441 and 0.458, all P<0.05), the right ventricular GLS absolute value of TOF fetuses was positively correlated with PV AV, PV Z-score and MPA Z-score( rs=0.418, 0.368 and 0.338, all P<0.05). The optimal critical values of GSI, left ventricular EF, and left ventricular FAC in the diagnosis of fetal TOF were 1.19, 59.05%, and 44.4%, respectively. At this time, the sensitivities of diagnosis of TOF were 0.78, 0.75, and 0.80, respectively. The specificities were 0.88, 0.88 and 0.83, respectively. The areas under ROC curve were 0.89, 0.88 and 0.89, respectively. Conclusions:Fetal HQ technology can provide a simple and reliable quantitative evaluation of fetal heart shape and function, and provide certain theoretical parameters for the study of fetal heart shape and function.

Study on establishing the reference range of atrial septal excursion index and foramen ovale membrane angle in normal fetuses aged 16-40 weeks / 中华超声影像学杂志

Objective:To establish the normal reference range of atrial septal excursion index (ASEI) and foramen ovale membrane angle in normal fetuses aged 16-40 weeks, and to analyze the correlation between ASEI and foramen ovale membrane angle in normal fetuses.Methods:A total of 378 normal singletons with gestational ages of 16-40 weeks undergoing by fetal echocardiography were selected in the Department of Diagnostic Ultrasound & Echocardiography, Sir Run Run Shaw Hospital, Zhejiang University College of Medicine, from January to June 2021, and 349 fetuses successfully finished all measurements. After all fetuses completed the systematic fetal echocardiography, fetal foramen ovale diameter and foramen ovale membrane angle were measured on the four chamber view. The maximum distance of foramen ovale valve from the base of atrial septum to the free wall of left atrium and the transverse diameter of left atrium were measured, and ASEI was calculated. The differences of ASEI, foramen ovale membrane angle and foramen ovale diameter of the groups with different gestational weeks were compared. The correlations among ASEI, foramen ovale membrane angle and foramen ovale diameter were analyzed by Pearson correlation analysis.Results:All 349 fetuses were divided into 6 groups according to their gestational weeks, including 17 cases at 16-20 weeks, 46 cases at 21-24 weeks, 114 cases at 25-28 weeks, 105 cases at 29-32 weeks, 31 cases at 33-36 weeks and 36 cases at 37-40 weeks. The ± s of ASEI was 0.492 7±0.059 7, 95% CI was 0.486 4-0.499 0, 95% normal reference value range was 0.375 7-0.609 8. Significant differences were found in ASEI among different groups( P<0.05). The ± s of foramen ovale membrane angle was (44.03±5.48)°, 95% CI was 43.46-44.61°, 95% normal reference value range was 33.29-54.78°. Significant differences were found in the foramen ovale membrane angle among different groups( P<0.05). The ± s of foramen ovale diameter was (4.32±1.30)mm, 95% CI was 4.18-4.45 mm, the differences among different groups were significant( P<0.05) and foramen ovale diameter was found increased with the increase of gestational weeks. There was a significant positive correlation between ASEI and foramen ovale membrane angle ( r=0.558, P<0.05). There was no correlation between foramen ovale diameter and ASEI and foramen ovale membrane angle ( r=-0.166, -0.084; all P>0.05). Conclusions:The normal reference ranges of ASEI and foramen ovale valve angle of normal fetuses aged 16-40 weeks was successfully established. These parameters may be useful for evaluating diastolic cardiac function by assessing foramen ovale.

Investigation of fetal cardiac size, morphology and function in fetuses with right ventricular outflow obstruction using fetal heart quantification / 中华超声影像学杂志

Objective:To investigate the application value of fetal heart quantification (fetal HQ) in the evaluation of fetal heart size, morphology and function in fetuses with right ventricular outflow obstruction (RVOTO).Methods:Fifty-five fetuses diagnosed as RVOTO by fetal echocardiography in Sir Run Run Shaw Hospital Affiliated to Medical College of Zhejiang University from April 2020 to February 2021 were selected. They were divided into simple pulmonary artery stenosis (PS) group and conus arteriosus malformation (CTD) group according to whether they were combined with other cardiovascular malformations. On the standard four chamber view, the end diastolic basal apical length (4CV length) and transverse width (4CV width) were obtained by fetal HQ analysis technique, and the cardiac global spherical index (4cv-gsi) was calculated. The left and right ventricles (LV and RV) were divided into 24 segments from the base to the apex. The endocardial curve was obtained by total HQ tracking. The 24 segment transverse width (ED), spherical index (SI), short axis shortening (FS) and its Z-score were calculated. The LV and RV of RVOTO fetuses were compared and analyzed from the aspects of heart size, morphology and function.Results:The 4CV length of RVOTO fetal heart was in the normal range, 4CV width increased in varying degrees, GSI decreased, and the whole heart showed spherical changes. In PS group, LV-ED was larger than that of RV and the difference was statistically significant in 5-24 segments( P<0.05). LV was more spherical than RV. There was no significant difference in ED between LV and RV in CTD group( P>0.05), and RV was more spherical than LV. Twenty-four segment FS decreased in different degrees in RVOTO fetal heart, and the decrease of RV was more obvious than that of LV. There was significant difference between the LV and RV in PS group from S5 to 19 ( P<0.05), and there was significant difference between the left and right ventricles in CTD group from S1 to 11 ( P<0.05). Conclusions:Fetal HQ can provide new insights of cardiac size, morphology and function in fetuses with RVOTO.

Application of fetal atrial septal excursion index and comprehensive Z-scores of cardiovascular structures in fetuses with redundancy foramen ovale flap / 中华超声影像学杂志

Objective:To investigate the application of fetal atria septal excursion index (ASEI) combining cardiovascular structure Z-scores in fetuses with redundancy foramen ovale flap (RFOF).Methods:Twenty-two fetuses with RFOF diagnosed by fetal echocardiography in Sir Run Run Shaw Hospital from December 2019 to September 2021 were selected as the RFOF group and 62 normal fetuses as the control group. The movement of the foramen ovale valve was observed in the four chamber view, and the maximum distance of the foramen ovale valve bulging, the total length of the atrial septum, the foramen ovale diameter, the diameters of the aortic valve, the pulmonary valve, the ascending aorta, the aortic isthmus, the descending aorta and the left and right ventricular areas were measured. ASEI, foramen ovale diameter, foramen ovale valve excursion distance, the ratio of foramen ovale diameter to total atrial septum length, aortic valvular annular diameter Z-score(AOV Z-score), pulmonary valvular annular diameter Z-score(PV Z-score), ascending aorta diameter Z-score(AOA Z-score), ascending aorta diameter Z-score (AOA Z-score), aortic isthmus Z-score (AOI Z-score), descending aorta diameter Z-score (AOD Z-score), diastolic right ventricular area Z-score (RV area Z-score) and diastolic left ventricular area Z-score(LV area Z-score) were compared between the two groups. RFOF fetuses were followed up to observe the prognosis.Results:There were significant differences in fetal ASEI, foramen ovale diameter, foramen ovale valve excursion distance, the ratio of foramen ovale diameter to total atrial septum length, AOV Z-score, PV Z-score, AOA Z-score, AOI Z-score, AOD Z-score and LV area Z-score between RFOF group and control group (all P<0.05), but there was no significant difference in RV area Z-score ( P>0.05). Postnatal follow-up outcomes in RFOF group indicated that 17 of 22 cases (77.3%) had live birth, five cases (22.7%) were lost at follow-up. Twelve of 17 live birth cases (70.5%) showed structurally normal heart by postnatal echocardiography, 3 cases (17.6%) showed mild coarctation of the aorta with nonsignificant hemodynamics under clinical follow-up, 2 cases (11.8%) were diagnosed with coarctation of the aorta, pulmonary artery dilation and atrial septal defect, and died after operation, of which one case died of infections pneumonia after operation. Another case was born prematurely at 36 + 4 weeks with a birth weight of 2 650 g, and neotal echocardiography showed ventricular septal defect, atrial septal defect and patent ductus arteriosus. Conclusions:ASEI can quantitatively evaluate the behavior of foramen ovale valve mobility and in combination with Z-scores of cardiovascular structures can be used to assess the morphological changes of fetal hearts. Although some fetuses with RFOF demonstrate left and right ventricular disproportion and coarctation of the aorta in fetal echocardiography, most fetuses have a good prognosis.

Study on the feasibility of automatic quantification of cardiac axis by fetal intelligent navigation echocardiography / 中华超声影像学杂志

Objective:To explore the feasibility of fetal intelligent navigation echocardiography (FINE) in automatic quantitation of cardiac axis (CA).Methods:A total of 62 pregnant women of which 2 with twins′ pregnancy in the second and third trimesters from May to June 2020 in Sir Run Run Shaw Hospital Zhejiang University College of Medicine were enrolled in this non-selective and prospective study. After excluding those who could not be analyzed, they were assigned into four groups according to their CA measuring methods: ①Group with manual measuring CA in systole (CAS); ②Group with manual measuring CA in diastole(CAD); ③Group with CA measured by FINE in three-steps; ④Group with CA measured by FINE in seven-steps. The CAS among groups were compared in order to analyze the consistency and correlation of CAS achieved by different methods, meanwhile, the intra-observer and inter-observer consistency and repeatability were also evaluated.Results:A total of 64 fetuses with 187 volume data were collected, of which 60 cases of fetal data can be included in the study, 57 cases of normal CA, 3 cases of abnormal CA, a total of 158 volume data can be used for data analysis, the success rate was about 84.5%. Because of the small number of abnormal CA cases (3 cases), only 57 cases of normal CA were statistically analyzed in this study. Three-step and seven-step FINE automatic quantitative CA showed significantly different from those obtained with manual measurements of CAD ( P=0.005, P<0.001). There were no significant differences in quantitative analysis of CA between three-step or seven-step FINE and manual measurements of CAS ( P=0.458, 0.883), however, there was no correlation between CA using three-step FINE and manual measurement of CAS ( rs=0.056, P=0.679), but there was a positive correlation between CA using seven-step FINE and manual measurement of CAS ( rs=0.599, P<0.001). The linear regression equation was constructed as follows: Y=10.96+ 0.73 X ( R2=0.431, P<0.001). There was no correlation between three-step method and seven-step method for automatic quantitative CA ( rs=0.158, P=0.241). There was significant difference( P<0.001), but strong correlation between manual measurement of CAS and manual measurement of CAD ( rs=0.973, P<0.001), the average difference was ΔCA=(4.5± 3.8)°. The linear regression equation was constructed as follows: Y=-2.94+ 0.96 X ( R2=0.950, P<0.001). Intra-observer and inter-observer measurements had shown no significant difference in consistency and repeatability (all P>0.05). Conclusions:The measurement of fetal CA by seven-step FINE is superior to the three-step FINE when the fetal CA is in normal range. This may be considered a promising aspect that seven-step FINE automatic quantitation of fetal CA can replace the manual measurement of CAS. Future research is needed to deliminate the reliability of automatic quantification of fetal CA by seven-step FINE with the CA in abnormal range.

Investigation of fetal cardiac function and morphology in fetuses with left ventricular outflow tract obstruction using fetal heart quantification / 中华超声影像学杂志

Objective:To explore the application value of fetal heart quantification (fetal HQ) in evaluation of fetal cardiac function and morphology in fetuses with left ventricular outflow tract obstruction (LVOTO).Methods:Twenty-five fetuses with LVOTO diagnosed by fetal echocardiography in Sir Run Run Shaw Hospital, Zhejiang University Medical College from April to July 2020 were enrolled. The end-diastolic basal apical length(BAL), transverse length (TL), global spherical index (GSI) of fetal four-chamber view, and the left and right ventricular end-diastolic area, long diameter, 24-segment end-diastolic transverse length (ED) and its Z-scores adjusted by gestational age and 24-segment spherical index(SI) were calculated by using fetal HQ. Subsequently the Z-scores of left and right ventricle fractional shortening (FS) in 24 segments were obtained by gestational age.Results:SI of 24-segments of left ventricles in fetuses with LVOTO were significantly different from that of right ventricles (all P<0.05). There was significant difference between left and right ventricular areas ( P<0.05). There was no significant difference between left and right ventricular lengths ( P>0.05). There were significant differences between the 24-segment Z-scores of left and right ventricular ED(all P<0.05). The ratios of RVED to LVED of 24 segments were analyzed by box diagram. The results showed that the transverse length of right ventricle was significantly higher than that of left ventricle. The highest value was 1.49(1.26-1.86), and the lowest value was 1.40(1.26-1.86), both significantly higher than the normal value of 1.19. There were no significant differences between the 1-19-segment Z-scores of left and right ventricular FS( P>0.05). There were significant differences between the 20-24-segment Z-scores of left and right ventricular FS( P<0.05). Conclusions:Fetal HQ can be used to quantitatively analyze left ventricular shape, size and function of fetuses with LVOTO, which provides a new method for quantitative analysis of fetal heart function.

Attention disorder and white matter structure changes in schizophrenia / 中华行为医学与脑科学杂志

Attention is an essential cognitive function which was use to perceive the external world, and it is the basis of all cognitive activities.Other cognitive functions such as working memory, executive function, information processing speed and so on, are also adversely affected in hypoprosexia or hyperfocusing state.Patients with schizophrenia have severe attention disorder, which makes patients unable to successfully complete the task of work or study, thus reduce the quality of life.Attention disorder exists throughout the whole course of this disease, and there is no specific drug for it.In recent years, antipsychotic medications have widespread application, but it has not shown up significantly improvement of attention disorder, worse still, its side effects will exacerbate the disease, which results in the impairment of the patients' ability to learn and explore the novelties.Neuroimaging markers of attention disorder in schizophrenia are the focus of current researches.White matter fibers are important pathways that connect attention networks and maintain the three-dimensional structure of the brain.Previous studies have suggested that attention disorder may be related to abnormalities of white matter fibers connecting various encephalic regions.In particular, abnormalities in the integrity of white matter, such as corpus callosum, cingulum bundle, superior longitudinal fasciculus, inferior fronto-occipital fasciculus, have been reported to be significantly associated with attention disorder in patients with schizophrenia.In this study, the relationship between attention disorder and white matter structure in patients with schizophrenia is reviewed through diffusion tensor imaging (DTI) technique.

A feasibility study of fetal intelligent navigation echocardiography in the prenatal screening of right aortic arch with left-sided ductus arteriosus / 中华超声影像学杂志

Objective:To investigate the feasibility of applying Fetal Intelligent Navigation Echocardiography (FINE) combined with Virtual Intelligent Sonographer Assistance (VIS-Assistance ?) in the prenatal screening of right aortic arch (RAA) with left-sided ductus arteriosus (LDA). Methods:A total of 32 fetuses with RAA and LDA during middle and late pregnancy in Zhejiang University Medical College Affiliated Sir Run Run Shaw Hospital from Jauary 2018 to Jauary 2020 were included in this retrospective study, and the datas about fetal cardiac three-dimensional volume were analyzed. The time-space correlation imaging (STIC) volume data were collected by using FINE by Senior doctor A. The two diagnostic elements of the transverse aortic arch on the right side of the trachea and the "U" -shaped vascular ring, as well as the three-vessel tracheal diagnostic section were obtained by low-aged doctor B and middle-aged doctor C by using VIS-Assistance ? technology. And then the detection rates of diagnostic sections and diagnostic elements for fetuses with RAA and LDA were calculated. The postpartum outcomes of fetuses with RAA and LDA were followed up. Results:Thirty-two fetuses were included in the study after excluding 2 cases due to the poor quality images, and the datas about fetal cardiac three-dimensional volume of the 32 fetuses were analyzed. The detection rate of one diagnostic element (the aortic arch on the right side of the trachea) were 84.4% vs 87.5% before VIS-Assistance ?, and 93.8% vs 93.8% after VIS-Assistance ? for each doctor B and doctor C , respectively. Another diagnostic element ( "U" -shaped vascular ring) were 78.1% vs 87.3% before VIS-Assistance ?, and 90.6% vs 90.6% after VIS-Assistance ? for doctor B and doctor C, respectively. But no significant difference was found before and after VIS-Assistance ? between the two each doctors(all P>0.05). The detection rate of three-vascular tracheal diagnosis view were 65.6% vs 71.9% before VIS-Assistance ? and 84.4% vs 87.5% after VIS-Assistance ? for doctor B and doctor C, respectively. There was significant difference before and after VIS-Assistance ? of doctor C( P<0.05). The scores of image quality after VIS-Assistance ? were significantly higher than that before VIS-Assistance ? for doctor B and doctor C, respectively [3(2.5, 3) vs 3.25(3.0, 3.5), and 3(2.5, 3.5) vs 3.5(3.0, 3.5)]. The agreement between two doctors performing VIS-Assistance ? was investigated using Bland-Altman analysis and the result showed that within 95% of the differences fall in the agreement interval. No obvious clinical symptoms of compression were found in 32 neonates after follow-up. Conclusions:The application of FINE combined with VIS-Assistance ? technology can easily and reliably obtain the key diagnostic view of RAA with LDA (three-vessel and tracheal view), and clearly display all diagnostic elements, having high repeatability and stability. VIS-Assistance ? technology can improve the detection rate and image quality even if the doctor was lack of experience. So it can be used as an effective supplementary means for prenatal screening of RAA and LDA.

A preliminary study of 24-segment spherical indexes of fetal ventricles in the middle and late trimestries by automatic fetal heart quantification / 中华超声影像学杂志

Objective:To explore the clinical application value of fetal heart quantification (fetal HQ) in the analysis of 24-segment spherical index (SI) of fetal heart in normal second and third trimestries.Methods:In July 2019, sixty-five normal singletons with gestational age (GA) of 28(24, 31) weeks were examined by echocardiography in Sir Run Run Shaw Hospital. The global spherical index (GSI) of the heart was measured and the dynamic images of the standard four chamber view were collected. Twenty-four-segment SI of the left and right ventricles were measured by using the fetal HQ analysis system and the correlation between SI and gestational age was analyzed.Results:There were no significant correlations between GSI, SI of left and right ventricles and gestational age ( r s=-0.22-0.14, all P>0.05). The SI of the first segment of left ventricle was lower than those of the other 23 segments (all P<0.05). There were no significant differences of SI among the second to the eleventh segments of the left ventricle (all P>0.05). In the 13th to the 24th segments of the left ventricle, the closer to the apex of the heart, the greater the SI of the segment were noted (all P<0.05). For the right ventricle, the closer to the apex of the heart, the greater the SI of the 4th to the 24th segments were found (all P<0.05), and there were no significant differences in SI among the first to third segment( P>0.05). The success rate of fetal HQ software was 95.4%. Conclusions:The 24-segment SI of RV and LV provides a feasible and reliable quantitative method which allows for the assessment of fetal heart function from the four-chamber view.

Quantification of Z-scores of normal fetal left and right ventricular diameters using early fetal echocardiography / 中华超声影像学杂志

Objective:To investigate the association of left and right ventricular diameters in normal early pregnancy and early middle pregnancy to the biological growth parameters of fetus, and to establish the reference and Z-score model for left and right ventricles.Methods:Two hundred and forty-six fetuses in normal early pregnancy (11-13 + 6 weeks) and early middle pregnancy (14-17 + 6 weeks) from February 2019 to May 2019 in Sir Run Run Shaw Hospital were examined by routine ultrasound. Non-cardiac fetal biometric parameters included crown-rump length (CRL), biparietal diameter (BPD) and femoral length (FL) and gestation age (GA) based on menstrual age were assessed. The left and right ventricular widths (LVW, RVW) and ventricular lengths (LVL, RVL) were measured at the end of diastolic period by obtaining the standard four chamber view of fetal echocardiography. The end-diastolic areas (LVA, RVA) as the products of the ventricular widths and lengths, the global spherical indexes (GSI) of left and right ventricles (LVSI, RVSI), the ratios of left and right ventricular widths (LVW/RVW), the length ratios (LVL/RVL) and the area ratios (LVA/RVA) of both ventricles were calculated.GA, BPD and FL were used as independent variables. The predicted cardiac parameters and its derivative parameters were used as dependent variables. The corresponding reference range was established. The correlation between each standard deviation (SD) and independent variables was analyzed, and the corresponding Z-scores of left and right ventricular diameters were calculated by using the formula. Results:①LVW, RVW, LVL, RVL were found positively correlated with the increase of GA, BPD and FL, and the correlation between GA and LVW, RVW was the highest ( r=0.928, 0.930; all P<0.000 1). ②There was a positive correlation between LVA, RVA and GA ( r=0.868, 0.872; all P<0.000 1). LVSI, RVSI were found negatively correlated with GA ( r=-0.844, -0.861; all P<0.000 1), and LVSI>RVSI. LVW/RVW<1 and almost close to 1, the ratios decreased with the increase of GA( r=0.147, P<0.000 1). LVL/RVL>1, the ratios increased with the increase of GA( r=0.313, P<0.000 1). LVA/RVA>1, but there was no correlation with GA. ③The SD values of LVW, RVW, LVL, RVL positively correlated with independent variables. Taking GA and LVW as an example, the linear regression equation of LVW was Y=-5.338+ 0.549GA ( r=0.928, P<0.000 1), and the linear regression equation of LVW-SD was Y=-0.322+ 0.037GA( r=0.131, P<0.000 1). The Z-scores of LVW, RVW, LVL, RVL, LVA, RVA did not change with the changes of GA, BPD, and FL. Conclusions:The normal reference range and Z-scores of left and right ventricular lengths and widths can be simply and reliably established using statistical analysis, and these parameters might have potentials for more accurately and more early evaluating the normal development of fetal heart.

Clinical value of sonography based volume computer aided display heart (SonoVCADheart) in the display of key diagnostic elements in basic fetal echocardiographic views / 中华超声影像学杂志

Objective:To evaluate the clinical value of sonography based volume computer aided display heart (SonoVCADheart) in the display of key diagnostic elements in basic fetal echocardiographic views.Methods:4D volume data based on fetal four-chamber view of 80 singleton fetuses (including 57 normal fetuses and 23 fetuses with heart abnormalities) were collected by using a volumetric probe from the Sir Run Run Shaw Hospital, Zhejiang University College of Medicine from January 8-22, 2019. Four to five volume datasets based on four-chamber view of the heart were rapidly acquired from each fetus. Three doctors (Doctor A: Engaged in fetal echocardiography diagnosis for more than 15 years, Doctor B and C: 6 months of regular fetal echocardiography training but lack of experience) with different fetal echocardiographic experiences performed off-line processing using SonoVCADheart combined tomographic ultrasound imaging (TUI) at different times to obtain eight standard echocardiographic diagnostic views, and to score the elementary contents of each echocardiographic view. The scores of the same doctor at different times, the scores of less experienced doctors and experienced doctor, and the scores between normal and abnormal fetuses, and the time required for analysis and diagnosis among all doctors were analyzed and compared, respectively. The diagnostic coincidence rates of SonoVCADheart for fetuses with cardiac malformations were also assessed.Results:A total of 279 volume datasets obtained from 57 normal fetuses, an average of 4.89/fetus, and 109 volume datasets obtained from 23 fetuses with cardiovascular abnormalities, an average of 4.74/fetus, and all volume datasets were used for SonoVCADheart analysis. The volume percentage of all the elements in the 8 diagnostic views with image quality≥2 points shown by SonoVCADheart in the normal fetuses was about 70.61%-74.91%, in the abnormal fetuses was about 53.21%-55.96%. There were no significant differences in the scores between the same doctor at different times, the scores between inexperienced doctors, and the scores among experienced and less experienced doctors(all P>0.05). There were significant differences in the scores between normal and abnormal fetuses except for all of the superior and inferior vena cava view and the aorticarch view of doctors A and C(all P<0.05). The time required for experienced doctor A and inexperienced doctors B and C to obtain 8 diagnostic views and to complete the diagnosis was statistically significant ( P<0.05). There was no significant difference in the time required for the inexperienced doctors B and C to obtain 8 diagnostic sections and to complete the diagnosis ( P>0.05). There was statistically significant difference in the diagnosis time required for doctor A using SonoVCADheart and two-dimensional echocardiography in fetuses with cardiovascular malformations ( P<0.05). However, there was no statistically significant difference in the time required in the normal fetus between SonoVCADheart and two-dimensional echocardiography ( P>0.05). The diagnostic coincidence rate of SonoVCADheart for fetuses with cardiac malformations is about 89.91%-90.83%. Conclusions:SonoVCADheart is a repeatable and stable novel fetal heart processing tool enabling displaying eight standard diagnostic sections of the fetal heart, and has potential clinical application value in the standardization of image acquisition and sequence display.

Study on diagnostic performance of fetal intelligent navigation echocardiography for congenital heart defect / 中华超声影像学杂志

Objective:To explore the sensitivity and specificity of fetal intelligent navigation echocardiography(FINE, 5D Heart) in the prenatal detection of congenital heart defect(CHD), and to compare its diagnostic performance with spatiotemporal image correlation(STIC) loop (STICloop).Methods:A total of 250 pregnant women having a singleton pregnancy in the second and third trimesters from April 2018 to May 2019 in Sir Run Run Shaw Hospital, Zhejiang University College of Medicine were enrolled in this prospective study. 2D ultrasound diagnosis has been made before acquiring STIC volume data set. After the appropriateness of each volume data set was preliminarily determined, all identifying informations were concealed and the appropriate volumes were randomly distributed to less experienced sonographer for analysis using 5D Heart software. The sensitivity and specificity, positive and negative likelihood ratios, as well as area under the receiver operating characteristic curve (AUC) of the two methods were determined respectively, and the differences between the two methods were statistically analyzed.Results:The diagnostic performance of 5D Heart for the prenatal detection of CHD was: sensitivity of 95.45% (105/110), specificity of 94.29% (132/140), positive likelihood ratio of 16.72, negative likelihood ratio of 0.05, and AUC of 0.95, respectively. Among cases with confirmed CHD, the 5D Heart diagnosis completely matched the final diagnosis in 77.27% (85/110). The diagnostic performance of STICloop for the prenatal detection of CHD was: sensitivity of 90.91% (100/110), specificity of 92.86% (130/140), positive likelihood ratio of 12.73, negative likelihood ratio of 0.10, and AUC of 0.92. The sensitivity and secificity of 5D Heart in diagnosing CHD were both higher than 90%, and it could successfully detect a broad spectrum of severe fetal CHD. Among cases with confirmed CHD, even the STICloop diagnosis completely matched the final diagnosis in 61.81%(68/110), its diagnostic accuracy was relatively lower than 5D Heart ( P=0.013). However, there were no statistical differences between the two methods in sensitivity and specificity(all P>0.05). Conclusions:The sesitivity and specifity of 5D Heart in diagnosis CHD were both higher than 90%, and it could successfully detect a broad spectrum of severe fetal CHD. STICloop could be used for preliminary screening of CHD, as it has the same high sensitivity and specificity as 5D Heart. Further examination may be recommended when fetal heart abnormalities are suspected.

Value of sonography based volume computer aided display heart in quantitative evaluation of fetal aortic and pulmonary artery diameters / 中华超声影像学杂志

Objective:To explore the feasibility of Sonography based Volume Computer Aided Display Heart (SonoVCADheart) in the display of the fetal ventricular outflow views, and compare diameters of fetal aorta (AO) and pulmonary artery (PA) measured by two-dimensional echocardiography (2DE) and SonoVCADheart.Methods:Eighty singleton fetuses in the second and third trimesters of pregnancy in January 2019 in Sir Run Run Shaw Hospital, Zhejiang University College of Medicine were enrolled. Conventional 2DE examinations were performed. The volume datasets were analyzed offline using the new automatic image processing software SonoVCADheart. The diameters of AO and PA were measured by 2DE and SonoVCADheart, respectively. Pearson correlation analysis was used to evaluate the correlation between the two methods. The consistency of the two methods was verified by Bland-Altman analysis, and he reliability of SonoVCADheart was assessed using the intraclass correlation coefficient (ICC).Results:Fetal ventricular outflow views were successfully obtained using SonoVCADheart in 73(91.2%) of 80 fetuses. There were good correlations between the two methods for measuring the diameters of AO and PA ( r=0.953, 0.971; all P<0.001). The 95% agreement limits of AO and PA were (-0.669, 0.568)mm and (-0.632, 0.580)mm, respectively. ICC demonstrated that SonoVCADheart achieved great repeatability both between and within observers. Conclusions:SonoVCADheart may have potentials for the quantitative evaluation of fetal ventricular outflow tracts with its good repeatability and reliability.

Value of sonography based volume computer aided display heart in quantitative evaluation of fetal aortic and pulmonary artery diameters / 中华超声影像学杂志

Objective@#To explore the feasibility of Sonography based Volume Computer Aided Display Heart (SonoVCADheart) in the display of the fetal ventricular outflow views, and compare diameters of fetal aorta (AO) and pulmonary artery (PA) measured by two-dimensional echocardiography (2DE) and SonoVCADheart.@*Methods@#Eighty singleton fetuses in the second and third trimesters of pregnancy in January 2019 in Sir Run Run Shaw Hospital, Zhejiang University College of Medicine were enrolled. Conventional 2DE examinations were performed. The volume datasets were analyzed offline using the new automatic image processing software SonoVCADheart. The diameters of AO and PA were measured by 2DE and SonoVCADheart, respectively. Pearson correlation analysis was used to evaluate the correlation between the two methods. The consistency of the two methods was verified by Bland-Altman analysis, and he reliability of SonoVCADheart was assessed using the intraclass correlation coefficient (ICC).@*Results@#Fetal ventricular outflow views were successfully obtained using SonoVCADheart in 73(91.2%) of 80 fetuses. There were good correlations between the two methods for measuring the diameters of AO and PA (r=0.953, 0.971; all P<0.001). The 95% agreement limits of AO and PA were (-0.669, 0.568)mm and (-0.632, 0.580)mm, respectively. ICC demonstrated that SonoVCADheart achieved great repeatability both between and within observers.@*Conclusions@#SonoVCADheart may have potentials for the quantitative evaluation of fetal ventricular outflow tracts with its good repeatability and reliability.

Study of Xplane imaging in quantifying the maximal volume of the left and right atria and evaluating atrial function in fetuses with abnormal heart morphology / 中华超声影像学杂志

Objective To explore the feasibility of real-time three-dimensional ultrasound Xplane imaging in quantifying left and right atrial diastolic maximal volume (LAVmax,RAVmax) and evaluating cardiac diastolic function in fetuses with cardiac disease in second and later trimesters.Methods One hundred and forty-four fetuses with abnormal heart morphology at 16-34 weeks of gestational age were included and divided into 3 groups according to the influence of pathological changes on atrial volume:group A with symmetrical left and right atrial volume,group B with decreased left atrial volume and increased right atrial volume and group C with increased left atrial volume and decreased right atrial volume,and the fetus were also divided into 2 groups according to the law of fetal development:the middle pregnancy group (16-27+6 weeks) and the late pregnancy group (28-34+6 weeks).Using the "Xplane" mode of volume probe,the maximal atrial volume was calculated automatically by tracing method and three-path line method.The correlation between the two methods in quantitative LAVmax was validated by paired sample t test and Pearson correlation analysis.The correlation between LAVmax,RAVmax and gestational age were analyzed by curve fitting.The volumes of bilateral chambers and the average weekly growth rates of E peak,A peak and E/A value of mitral and tricuspid orifices were calculated and compared.Results There was no significant statistical difference between the maximal volume of the left atrium obtained by the tracing method and the three-diameter line method (P ＞0.05),and there was high correlation between the two methods in the comparison of the maximal volume of the left atrium (r =0.90,0.88,0.85;all P ＜0.01).The data of group A,B and C showed that LAVmax and RAVmax could increase with the increase of gestational weeks in a certain period of abnormal state,and had a good correlation with them(LAVmax:r =0.78,0.74,0.78,all P ＜0.005;RAVmax:r =0.79,0.77,0.78,all P ＜0.005).The average weekly growth rate of RAVmax showed an advantage in group A,B and C.Especially in group C with reduced right atrium,the growth rate of right atrium was 8.15 ％,which was higher than that of group B with decreased left atrium by 5.06％.The weekly growth rates of E peak and E/A in tricuspid orifice were also higher than those in mitral orifice.The E peak and E/A values of tricuspid orifice in group C were 4.05％ and 0.60％,respectively,higher than those in group B,which were 2.58％ and 0.02％.Peak A showed an increase in growth rate in group B and group C with decreased atria,peak A values in group B and group C increased by 4.01 ％ and 2.19％,respectively.Conclusions The right ventricular dominance of fetal heart can still be reflected in certain stages of disease,and the atrial active systolic may play a regulatory role in the filling of cardiac blood flow.Real-time three-dimensional ultrasound Xplane imaging could be used to quantify the atrial volume of fetuses with abnormal heart morphology in second and later trimesters and to preliminary assess atrial function combined with the changes of atrioventricular valve orifice hemodynamics.Real-time three-dimensional ultrasound Xplane imaging technology has obvious advantages of simple,safe,non-invasive,simultaneous and high repeatability in measuring fetal atrial volume.

Study of Xplane imaging in quantifying the maximal volume of the left and right atria and evaluating atrial function in fetuses with abnormal heart morphology / 中华超声影像学杂志

Objective@#To explore the feasibility of real-time three-dimensional ultrasound Xplane imaging in quantifying left and right atrial diastolic maximal volume (LAVmax, RAVmax) and evaluating cardiac diastolic function in fetuses with cardiac disease in second and later trimesters.@*Methods@#One hundred and forty-four fetuses with abnormal heart morphology at 16-34 weeks of gestational age were included and divided into 3 groups according to the influence of pathological changes on atrial volume: group A with symmetrical left and right atrial volume, group B with decreased left atrial volume and increased right atrial volume and group C with increased left atrial volume and decreased right atrial volume, and the fetus were also divided into 2 groups according to the law of fetal development: the middle pregnancy group (16-27+ 6 weeks) and the late pregnancy group (28-34+ 6 weeks). Using the " Xplane" mode of volume probe, the maximal atrial volume was calculated automatically by tracing method and three-path line method. The correlation between the two methods in quantitative LAVmax was validated by paired sample t test and Pearson correlation analysis. The correlation between LAVmax, RAVmax and gestational age were analyzed by curve fitting. The volumes of bilateral chambers and the average weekly growth rates of E peak, A peak and E/A value of mitral and tricuspid orifices were calculated and compared.@*Results@#There was no significant statistical difference between the maximal volume of the left atrium obtained by the tracing method and the three-diameter line method (P>0.05), and there was high correlation between the two methods in the comparison of the maximal volume of the left atrium (r=0.90, 0.88, 0.85; all P<0.01). The data of group A, B and C showed that LAVmax and RAVmax could increase with the increase of gestational weeks in a certain period of abnormal state, and had a good correlation with them(LAVmax: r=0.78, 0.74, 0.78, all P<0.005; RAVmax: r=0.79, 0.77, 0.78, all P<0.005). The average weekly growth rate of RAVmax showed an advantage in group A, B and C. Especially in group C with reduced right atrium, the growth rate of right atrium was 8.15%, which was higher than that of group B with decreased left atrium by 5.06%. The weekly growth rates of E peak and E/A in tricuspid orifice were also higher than those in mitral orifice. The E peak and E/A values of tricuspid orifice in group C were 4.05% and 0.60%, respectively, higher than those in group B, which were 2.58% and 0.02%. Peak A showed an increase in growth rate in group B and group C with decreased atria, peak A values in group B and group C increased by 4.01% and 2.19%, respectively.@*Conclusions@#The right ventricular dominance of fetal heart can still be reflected in certain stages of disease, and the atrial active systolic may play a regulatory role in the filling of cardiac blood flow. Real-time three-dimensional ultrasound Xplane imaging could be used to quantify the atrial volume of fetuses with abnormal heart morphology in second and later trimesters and to preliminary assess atrial function combined with the changes of atrioventricular valve orifice hemodynamics. Real-time three-dimensional ultrasound Xplane imaging technology has obvious advantages of simple, safe, non-invasive, simultaneous and high repeatability in measuring fetal atrial volume.

Value of smart-planes fetal heart in quantitative analysis of aortic and pulmonary artery diameters / 中华超声影像学杂志

Objective To explore the feasibility of smart-planes fetal heart ( S-planes FH ) in the display of the fetal ventricular outflow views ,and to compare diameters of fetal aorta ( AO) and pulmonary artery (PA) measured using two-dimensional echocardiography(2DE) and S-planes FH . Methods One hundred and eighty-five fetuses with gestational age of 17 - 36 weeks were enrolled . Each fetus had undergone conventional 2DE examination and the three-dimensional fetal cardiac volume datasets were obtained . The volume datasets were analyzed offline using S-planes FH . The diameters of AO and PA were measured by 2DE and S-planes FH ,respectively . Pearson correlation analysis was used to evaluate the correlation between the two methods for measuring the diameters of AO and PA . The consistency of the two methods was verified by Bland-Altman analysis . Results Fetal ventricular outflow views were successfully obtained using S-planes FH in 173 ( 93 .5％ ) cases of 185 fetuses whose ventricular outflow views were satisfactorily obtained by fetal 2DE . There were close correlations between the two methods in measuring the diameters of AO and PA ( r = 0 .84 , P = 0 .04; r = 0 .81 , P = 0 .00 ) . Bland-Altman analysis showed a close consistency between the two methods ,and their 95％ confidence intervals were ( -1 .17 ,1 .00) and ( -1 .79 ,1 .02) ,respectively . Conclusions There is a close consistency between S-planes FH and 2DE in measuring fetal AO and PA . S-planes FH may have potential for the evaluation of fetal ventricular outflow .

The quantification of Z-score of the color flow widths of atrioventricular valves in the fetuses with dilation of the coronary sinus / 中华超声影像学杂志

Objective To calculate Z-score for mitral and tricuspid color blood flow widths in normal fetuses and fetuses with dilated coronary sinuses ( CS ) using fetal echocardiography ,and explore the application value of Z-score of the color flow widths of atrioventricular valves in normal fetuses and fetuses with dilated CS . Methods Two hundred and thirty-eight normal fetuses (control group) with a gestational age of 16 to 38 weeks were studied by color Doppler echocardiography . Gestational age ( GA ) ,biparietal diameter (BPD) ,femoral length (FL) ,aortic inner diameter (AOd) ,pulmonary artery diameter (PAd) ,and heart area ( HA) were measured as independent variables ,and mitral and tricuspid valve color flow widths were measured as the dependent variables . Z-score models were established by regression analysis . Thirty fetuses with dilated CS (dilated CS group) from 22 to 33 weeks'gestation were involved . The Z-score of the CS fetus was calculated based on the established Z-score models and were compared with those of the normal fetuses . Results The independent sample t-test showed that there were no significant differences in the Z-scores of the blood flow width of the fetal mitral and tricuspid valves between dilated CS group and control group ( P >0 .05) . Conclusions The simple dilated CS does not affect the mitral valve diastolic blood flow ,so there is no significant effect on the filling of left ventricular blood flow .

Application value of fetal heart ultrasound intelligent navigation technique in display of key diagnostic elements in rapid screening views of fetal echocardiography / 中华医学超声杂志（电子版）

Objective To evaluate the application value of fetal heart echocardiography intelligent navigation (5D Heart) in the display of key diagnostic elements in five rapid screening fetal echocardiographic views.Methods Three hundred and eighty-four 3D volume datasets of 220 normal singleton fetuses in the second and third trimesters were acquired.After processing the datasets using 5D Heart,five rapid screening views were acquired,and 21 key diagnostic elements of the five cardiac diagnostic sections were graded.The 2 test was used to compare the difference in the key diagnostics elements of the five rapid screening views between 5D heart and the traditional technique.Pearson correlation was used to compare the detection rate of key diagnostic elements between 5D Heart technique and traditional two-dimensional echocardiography in normal fetuses and fetuses with congenital heart disease.The rank sum test was used to detect the consistency and reliability of the results.Results A total of 384 fetal volume datasets were obtained from 220 fetuses,of whom 317 heart volume datasets were available for analysis,with a success rate of 82.6％.There was no difference in the key diagnostic elements of the five rapid screening views between 5D heart and the traditional technique (x2=5.17,P=0.27).Compared with the abnormal fetal heart group (89.6％),the detection rate of diagnostic elements in the normal fetal heart group was 85.2％ (r=0.94,P=0.02).No significant differences were found when comparing the grading results of one observer in different periods of time,the grading results between two experienced doctors,or the grading results among the experienced doctor and one relatively inexperienced doctor (P ＞ 0.05).Conclusions Fetal cardiac ultrasound intelligent navigation technique has high reliability and repeatability in obtaining fetal rapid screening views and displaying fetal elemental diagnostic information.It has tremendous potential in standardized data collection and analysis of cardiac diagnostic sections in fetuses with congenial heart disease,as well as in training and teaching,remote medical consultation,and screening in primary hospitals.