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中华医学超声杂志（电子版）

中华医学超声杂志（电子版） ›› 2024, Vol. 21 ›› Issue (05) : 460 -469. doi: 10.3877/cma.j.issn.1672-6448.2024.05.003

妇产科超声影像学

16~40周正常胎儿左心房后间隙指数及其Z评分的定量研究
王水清1, 赵博文2,†(), 潘美2, 彭晓慧2, 陈冉2, 马明明2, 狄敏2   
  1. 1. 310016　杭州，浙江大学医学院附属邵逸夫医院超声科、浙江省胎儿心脏超声诊断技术指导中心、浙江大学邵逸夫临床医学研究所;315324　浙江省慈溪市第三人民医院超声科
    2. 310016　杭州，浙江大学医学院附属邵逸夫医院超声科、浙江省胎儿心脏超声诊断技术指导中心、浙江大学邵逸夫临床医学研究所
  • 收稿日期:2023-08-15 出版日期:2024-05-01
  • 通信作者: 赵博文
  • 基金资助:
    浙江大学科学技术研究院一般横向项目(校合-2021-KYY-518053-0055); 浙江省基础公益研究计划项目(LGF20H180043)

Quantitative assessment of posterior left atrial space index (PLASI) and PLASI Z-score in normal fetuses at 16-40 weeks of gestation

Shuiqing Wang1, Bowen Zhao2,†(), Mei Pan2, Xiaohui Peng2, Ran Chen2, Mingming Ma2, Min Di2   

  1. 1. Department of Diagnostic Ultrasound & Echocardiography, Sir Run Run Shaw Hospital, Zhejiang University College of Medicine, Technical Guidance Center for Fetal Echocardiography of Zhejiang Province & Sir Run Run Shaw Institute of Clinical Medicine of Zhejiang University, Hangzhou 310016, China;Department of Ultrasound, Cixi Third People's Hospital, Cixi 315324, China
    2. Department of Diagnostic Ultrasound & Echocardiography, Sir Run Run Shaw Hospital, Zhejiang University College of Medicine, Technical Guidance Center for Fetal Echocardiography of Zhejiang Province & Sir Run Run Shaw Institute of Clinical Medicine of Zhejiang University, Hangzhou 310016, China
  • Received:2023-08-15 Published:2024-05-01
  • Corresponding author: Bowen Zhao
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引用本文：

王水清, 赵博文, 潘美, 彭晓慧, 陈冉, 马明明, 狄敏. 16~40周正常胎儿左心房后间隙指数及其Z评分的定量研究[J]. 中华医学超声杂志（电子版）, 2024, 21(05): 460-469.

Shuiqing Wang, Bowen Zhao, Mei Pan, Xiaohui Peng, Ran Chen, Mingming Ma, Min Di. Quantitative assessment of posterior left atrial space index (PLASI) and PLASI Z-score in normal fetuses at 16-40 weeks of gestation[J]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2024, 21(05): 460-469.

目的

建立16~40周正常胎儿左心房后间隙指数（PLASI）及其Z评分等多参数的正常参考值范围，并探讨其与胎儿生物学生长参数的相关性。

方法

前瞻性选取2022年7月至12月浙江大学医学院附属邵逸夫医院402例16~40周的正常单胎胎儿，获得胎儿生物学生长参数（双顶径、股骨长、孕周）。通过在胎儿超声心动图标准四腔心切面上分别使用二维及M型超声心动图测量左心房后间隙舒张末期宽度（LA-DAO-2DD、LA-DAO-MMD）、左心房后间隙收缩末期宽度（LA-DAO-2DS、LA-DAO-MMS）、降主动脉舒张末期内径（DAOd-2DD、DAOd-MMD）、降主动脉收缩末期内径（DAOd-2DS、DAOd-MMS），分别计算左心房后间隙舒张末期指数（PLASI-2DD、PLASI-MMD）及左心房后间隙收缩末期指数（PLASI-2DS、PLASI-MMS）。以孕周、双顶径及股骨长作为自变量，以实际的心脏各测值为应变量，应用回归分析建立最佳模型，计算并分析残差（实际测值与从方程计算得出的预测值之间的差），调整标准差（SD）运用绝对残差加权回归方法，以确定残差变化的SD相对于自变量落在正常范围内。根据回归方程，计算相应参数的Z评分。

结果

（1）正常胎儿的LA-DAO-2DD、LA-DAO-2DS、LA-DAO-MMD、LA-DAO-MMS、DAOd-2DD、DAOd-2DS、DAOd-MMD、DAOd-MMS随孕周、双顶径和股骨长的增加而变化，呈显著相关，其中二维及M型超声心动图分别以DAOd-2DS、DAOd-MMS与孕周的相关性最好（r=0.874、0.858，P均<0.001）。（2）PLASI-2DS、PLASI-MMS与孕周、双顶径和股骨长之间未见明显相关性，PLASI-2DD、PLASI-MMD与孕周、双顶径和股骨长之间呈负相关（PLASI-2DD与孕周：r=-0.228，P<0.001；PLASI-MMD与孕周：r=-0.121，P=0.016；PLASI-2DD与双顶径：r=-0.246，P<0.001；PLASI-MMD与双顶径：r=-0.135，P=0.007；PLASI-2DD与股骨长：r=-0.223，P<0.001；PLASI-MMD与股骨长：r=-0.128，P=0.010）。（3）LA-DAO-MMS、PLASI-MMD的SD与各自变量呈简单线性关系（LA-DAO-MMS与孕周：r=0.120，P=0.016；PLASI-MMD与孕周：r=-0.158，P=0.002；LA-DAO-MMS与双顶径：r=0.136，P=0.006；PLASI-MMD与双顶径：r=-0.159，P=0.001；LA-DAO-MMS与股骨长：r=0.136，P=0.006；PLASI-MMD与股骨长：r=-0.163，P=0.001）。DAOd-2DS、DAOd-2DD、LA-DAO-2DS、LA-DAO-2DD、DAOd-MMS、DAOd-MMD、LA-DAO-MMS、LA-DAO-MMD的Z评分值随孕周、双顶径、股骨长的增长保持相对恒定（P均>0.05）。

结论

本研究建立了16~40周正常胎儿的PLASI及PLASI Z评分等多参数正常值范围，得出了其与孕周、双顶径和股骨长的相关性。

关键词: 超声心动描记术, 胎儿, 左心房后间隙, Z评分
Objective

To determine the normal reference ranges of multiple parameters such as posterior left atrial space index (PLASI) and PLASI Z-score in normal fetuses from 16 to 40 weeks of gestation and assess their correlation with fetal biological growth parameters.

Methods

A total of 402 singleton fetuses with gestational age between 16 and 40 weeks were prospectively selected from July to December 2022 at the Affiliated Sir Run Run Shaw Hospital, Zhejiang University School of Medicine. Fetal biometric growth parameters including biparietal diameter (BPD), femur length (FL), and gestational age (GA) were obtained. End-diastolic width of the posterior left atrial space (LA-DAO-2DD, LA-DAO-MMD), end-systolic width of the posterior left atrial space (LA-DAO-2DS, LA-DAO-MMS), end-diastolic internal diameter of the descending aorta (DAOd-2DD, DAOd-MMD), and end-systolic internal diameter of the descending aorta (DAOd-2DS, DAOd-MMS) were measured by two-dimensional (2D) and M-mode echocardiography on the standard four-chamber views of fetal echocardiography, respectively. The posterior left atrial space end-diastolic index (PLASI-2DD, PLASI-MMD) and the posterior left atrial space end-systolic index (PLASI-2DS, PLASI-MMS) were calculated, respectively. BPD, FL, and GA were taken as independent variables, and the actual cardiac values of each measurement were taken as response variables. And regression analysis was applied to construct the best model, and the residuals (the difference between the actual measured values and the predicted values calculated from the equations) were calculated and analyzed. Then, the standard deviation (SD) was adjusted using absolute residual-weighted regression to determine the SD of the change in residuals relative to the independent variable falling within the normal range. According to the regression equation, the corresponding Z scores were calculated.

Results

LA-DAO-2DD, LA-DAO-2DS, LA-DAO-MMD, LA-DAO-MMS, DAOd-2DD, DAOd-2DS, DAOd-MMD, and DAOd-MMS in normal fetuses were significantly correlated with increasing GA, BPD, and FL. Among them, the correlation of DAOd-2DS and DAO-MMS with GA was the best in two-dimensional and M-mode echocardiography (r=0.874 and 0.858, respectively; P<0.001 for both). PLASI-2DS and PLASI-MMS had no significant correlation with GA, BPD, or FL. PLASI-MMD showed a negative correlation with GA, BPD, and FL (GA and PLASI-2DD: r=-0.228, P<0.001; GA and PLASI-MMD: r=-0.121, P=0.016; BPD and PLASI-2DD: r=-0.246, P<0.001; BPD and PLASI-MMD: r=-0.135, P=0.007; FL and PLASI-2DD: r=-0.223, P<0.001; FL and PLASI-MMD: r=-0.128, P=0.010). The SD of LA-DAO-MMS and PLASI-MMD showed a simple linear relationship with their respective variables (GA and LA-DAO-MMS: r=0.120, P=0.016; GA and PLASI-MMD: r=-0.158, P=0.002; BPD and LA-DAO-MMS: r=0.136, P=0.006; BPD and PLASI-MMD: r=-0.159, P=0.001; FL and LA-DAO-MMS: r=0.136, P=0.006; FL and PLASI-MMD: r=-0.163, P=0.001). The Z-score values of DAOd-2DS, DAOd-2DD, LA-DAO-2DS, LA-DAO-2DD, DAOd-MMS, DAOd-MMD, LA-DAO-MMS, and LA-DAO-MMD remained relatively constant with the growth of GA, BPD, and FL (P>0.05 for all).

Conclusion

This study has established the normal range of PLASI and PLASIZ scores for normal fetuses between 16 to 40 weeks of gestation, and determined their correlation with GA, BPD, and FL.

Key words: Echocardiography, Fetal, Post left atrial space, Z-score
图1 二维超声心动图测量左心房后间隙指数图示 注：RV为右心室，LV为左心室，RA为右心房，LA为左心房，DAo为降主动脉；a为左心房后间隙宽度，b为降主动脉内径，左心房后间隙指数=a/b
图2 M型超声心动图测量左心房后间隙指数图示 注：C1为收缩末期左心房后间隙宽度，C2为舒张末期左心房后间隙宽度，D1为收缩末期降主动脉内径，D2为舒张末期降主动脉内径，左心房后间隙指数=C/D
表1 二维超声及M型超声心动图测量的胎儿PLAS、DAOd和PLASI相关参数（）
指标 16~20+6周（19例） 21~24+6周（85例） 25~28+6周（186例） 29~32+6周（94例） 33~40周（18例）
DAOd-2DS（mm） 3.31±0.48 4.27±0.40 5.03±0.51 5.72±0.48 6.29±0.41
DAOd-2DD（mm） 2.27±0.39 2.99±0.37 3.54±0.44 4.11±0.49 4.69±0.35
LA-DAO-2DS（mm） 1.29±0.15 1.49±0.17 1.73±0.16 2.08±0.23 2.36±0.24
LA-DAO-2DD（mm） 2.02±0.27 2.38±0.34 2.66±0.33 3.14±0.34 3.38±0.38
DAOd-MMS（mm） 3.28±0.56 4.20±0.38 4.96±0.50 5.60±0.47 6.07±0.61
DAOd-MMD（mm） 2.25±0.43 3.00±0.41 3.56±0.44 4.05±0.46 4.55±0.60
LA-DAO-MMS（mm） 1.35±0.22 1.58±0.16 1.81±0.20 2.17±0.24 2.46±0.31
LA-DAO-MMD（mm） 1.95±0.35 2.37±0.32 2.72±0.35 3.20±0.38 3.39±0.37
PLASI-2DS 0.39±0.05 0.35±0.04 0.35±0.04 0.36±0.03 0.38±0.04
PLASI-2DD 0.90±0.11 0.80±0.12 0.76±0.10 0.77±0.09 0.72±0.09
PLASI-MMS 0.41±0.05 0.38±0.04 0.37±0.04 0.39±0.04 0.41±0.06
PLASI-MMD 0.88±0.11 0.80±0.13 0.77±0.11 0.80±0.10 0.75±0.11
表2 以孕周、双顶径、股骨长预测胎儿PLAS及PLASI的直线回归模型参数
参数 斜率 截距 r值 P值 F值
孕周
DAOd-2DS 0.2087 -0.655 0.874 <0.001 1293.80
DAOd-2DD 0.1632 -0.881 0.827 <0.001 868.41
LA-DAO-2DS 0.0780 -0.348 0.846 <0.001 1009.51
LA-DAO-2DD 0.1047 -0.124 0.764 <0.001 559.53
PLASI-2DS 0.0001 0.353 0.004 0.930 0.01
PLASI-2DD -0.0072 0.971 -0.228 <0.001 21.87
DAOd-MMS 0.1979 -0.448 0.858 <0.001 1112.19
DAOd-MMD 0.1542 -0.644 0.793 <0.001 675.47
LA-DAO-MMS 0.0806 -0.336 0.825 <0.001 853.52
LA-DAO-MMD 0.1111 -0.262 0.762 <0.001 552.70
PLASI-MMS 0.0005 0.365 0.037 0.459 0.55
PLASI-MMD -0.0040 0.895 -0.121 0.016 5.91
双顶径
DAOd-2DS 0.0731 0.110 0.862 <0.001 1160.36
DAOd-2DD 0.0572 -0.284 0.817 <0.001 801.22
LA-DAO-2DS 0.0270 -0.038 0.824 <0.001 848.02
LA-DAO-2DD 0.0360 0.306 0.739 <0.001 482.55
PLASI-2DS 0.0000 0.358 -0.011 0.828 0.05
PLASI-2DD -0.0028 0.961 -0.246 <0.001 25.74
DAOd-MMS 0.0690 0.297 0.843 <0.001 980.49
DAOd-MMD 0.0538 -0.069 0.780 <0.001 620.52
LA-DAO-MMS 0.0279 -0.020 0.805 <0.001 738.83
LA-DAO-MMD 0.0384 0.178 0.742 <0.001 490.20
PLASI-MMS 0.0001 0.370 0.025 0.617 0.25
PLASI-MMD -0.0016 0.893 -0.135 0.007 7.39
股骨长
DAOd-2DS 0.0832 0.871 0.843 <0.001 985.83
DAOd-2DD 0.0640 0.364 0.786 <0.001 645.62
LA-DAO-2DS 0.0302 0.269 0.792 <0.001 674.20
LA-DAO-2DD 0.0412 0.667 0.728 <0.001 450.83
PLASI-2DS -0.0002 0.363 -0.036 0.471 0.52
PLASI-2DD -0.0029 0.921 -0.223 <0.001 20.96
DAOd-MMS 0.0795 0.967 0.835 <0.001 917.79
DAOd-MMD 0.0615 0.480 0.766 <0.001 567.01
LA-DAO-MMS 0.0310 0.309 0.769 <0.001 578.14
LA-DAO-MMD 0.0438 0.574 0.727 <0.001 448.93
PLASI-MMS -0.0001 0.381 -0.015 0.765 0.09
PLASI-MMD -0.0017 0.874 -0.128 0.010 6.65
表3 以孕周、股骨长、双顶径预测胎儿PLAS及PLASI标准差的直线回归模型参数
参数 斜率 截距 r值 P值 F值
孕周
DAOd-2DS 0.0078 0.175 0.085 0.089 2.91
DAOd-2DD 0.0072 0.186 0.088 0.078 3.13
LA-DAO-2DS 0.0025 0.091 0.060 0.227 1.47
LA-DAO-2DD 0.0034 0.206 0.051 0.309 1.04
PLASI-2DS -0.0010 0.063 -0.104 0.036 4.41
PLASI-2DD -0.0024 0.169 -0.102 0.042 4.16
DAO-MMS 0.0078 0.191 0.085 0.088 2.93
DAO-MMD 0.0073 0.206 0.080 0.108 2.59
LA-DAO-MMS 0.0053 0.037 0.120 0.016 5.85
LA-DAO-MMD 0.0044 0.200 0.060 0.228 1.46
PLASI-MMS -0.0005 0.052 -0.045 0.365 0.82
PLASI-MMD -0.0040 0.218 -0.158 0.002 10.23
双顶径
DAOd-2DS 0.0017 0.291 0.049 0.326 0.97
DAOd-2DD 0.0037 0.142 0.123 0.013 6.18
LA-DAO-2DS 0.0011 0.098 0.075 0.135 2.25
LA-DAO-2DD 0.0016 0.203 0.066 0.186 1.75
PLASI-2DS -0.0003 0.058 -0.096 0.053 3.75
PLASI-2DD -0.0006 0.143 -0.072 0.151 2.07
DAOd-MMS 0.0022 0.276 0.067 0.182 1.79
DAOd-MMD 0.0023 0.260 0.069 0.167 1.91
LA-DAO-MMS 0.0022 0.047 0.136 0.006 7.52
LA-DAO-MMD 0.0011 0.258 0.041 0.415 0.67
PLASI-MMS -0.0002 0.053 -0.058 0.247 1.35
PLASI-MMD -0.0014 0.204 -0.159 0.001 10.36
股骨长
DAOd-2DS 0.0031 0.263 0.072 0.151 2.07
DAOd-2DD 0.0039 0.218 0.101 0.044 4.08
LA-DAO-2DS 0.0023 0.068 0.117 0.019 5.54
LA-DAO-2DD 0.0026 0.188 0.087 0.080 3.08
PLASI-2DS -0.0005 0.060 -0.122 0.015 6.03
PLASI-2DD -0.0012 0.163 -0.121 0.015 5.97
DAOd-MMS 0.0033 0.260 0.080 0.111 2.55
DAOd-MMD 0.0031 0.269 0.077 0.125 2.36
LA-DAO-MMS 0.0030 0.050 0.136 0.006 7.57
LA-DAO-MMD 0.0019 0.238 0.057 0.255 1.30
PLASI-MMS -0.0003 0.054 -0.068 0.176 1.84
PLASI-MMD -0.0017 0.194 -0.163 0.001 10.96
表4 以 孕周、股骨长、双顶径预测胎儿二维及M型超声心动图测量的PLAS多参数Z评分
指标 范围 参考值范围 均数±标准差 r值 P值
孕周
DAOd-2DS -3.021~3.248 -2.026~2.024 -0.001±1.033 0.009 0.857
DAOd-2DD -2.666~2.950 -1.946~1.946 0.000±0.993 -0.001 0.984
LA-DAO-2DS -3.226~5.088 -2.098~2.100 0.001±1.071 -0.021 0.672
LA-DAO-2DD -2.550~4.324 -1.985~1.985 0.000±1.013 -0.005 0.918
DAOd-MMS -2.946~3.977 -1.988~1.986 -0.001±1.014 0.011 0.824
DAOd-MMD -3.235~4.368 -1.978~1.978 -0.000±1.009 0.006 0.899
LA-DAO-MMS -2.522~4.288 -2.062~2.07 0.004±1.054 -0.040 0.427
LA-DAO-MMD -3.256~2.888 -1.991~1.991 0.000±1.016 -0.003 0.952
双顶径
DAOd-2DS -3.145~2.905 -2.023~2.023 0.000±1.032 -0.001 0.977
DAOd-2DD -2.812~3.420 -1.951~1.953 0.001±0.996 -0.012 0.817
LA-DAO-2DS -2.717~4.923 -2.044~2.048 0.002±1.044 -0.031 0.540
LA-DAO-2DD -2.461~4.101 -1.981~1.983 0.001±1.011 -0.011 0.818
DAOd-MMS -2.942~3.649 -1.966~1.966 -0.000±1.003 0.002 0.964
DAOd-MMD -2.918~4.512 -1.980~1.980 -0.000±1.010 0.001 0.980
LA-DAO-MMS -2.578~3.751 -2.021~2.033 0.006±1.034 -0.054 0.282
LA-DAO-MMD -3.292~2.945 -1.989~1.989 0.000±1.015 -0.005 0.914
股骨长
DAOd-2DS -3.300~3.943 -2.066~2.066 -0.000±1.054 0.003 0.952
DAOd-2DD -2.710~4.457 -1.987~1.987 0.000±1.014 -0.003 0.946
LA-DAO-2DS -2.757~5.276 -2.106~2.116 0.005±1.077 -0.041 0.414
LA-DAO-2DD -2.680~4.112 -1.986~1.988 0.001±1.014 -0.011 0.832
DAOd-MMS -3.181~3.907 -2.021~2.021 -0.000±1.031 0.004 0.936
DAOd-MMD -3.406~4.410 -1.999~1.999 -0.000±1.020 0.001 0.977
LA-DAO-MMS -2.557~7.014 -2.161~2.175 0.007±1.106 -0.048 0.337
LA-DAO-MMD -3.123~3.833 -2.034~2.034 0.000±1.038 -0.004 0.937
图3 根据孕周得出胎儿心脏参数Z评分分布区间。图a~d分别为LA-DAO-2DS、LA-DAO-2DD、LA-DAO-MMS和LA-DAO-MMD不同孕周的Z评分 注：2DS为二维超声心动图的收缩末期测值，2DD为二维超声心动图舒张末期测值，MMS为M型超声心动图的收缩末期测值，MMD为M型超声心动图的舒张末期测值，LA-DAO为左心房后壁至降主动脉前壁的垂直距离
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