Study On The Correlation Between The Fetal Tricuspid Regurgitation In Echocadiography And Congenital Heart Disease

Objective:By studying the different characteristics of the tricuspid regurgitation and related parameters to quickly distinguish physiological and pathological tricuspid regurgitation; And further,to quickly distinguish the different types of fetal congenital heart disease with pathological tricuspid regurgitation.Methods:From January 2012 to December 2014, 952 cases withfetal tricuspid regurgitation were diagnosed by prenatal ultrasound in Hebei Provincial Children’s Hospital and all of the cases were successfully followed-up. 952 cases were devided into two groups, physiological regurgitation group(538 cases) and pathological tricuspid regurgitation group(414cases). According to different etiology, pathologic tricuspid regurgitation groupis subdivided into the right heart obstructive disease group, right ventricular volume overload diseases group, tricuspid valve structure abnormal group and cardiomyopathy with cardiac dysfunction patients. The fetus with two or more than two kinds of disease, were not included in the group study. 30 cases in each group were randomly selected into the study. Pregnant women aged from 20 to 44 years, the average age was 28.9 years.The pregnancy period was from 19 to 38 weeks, the average gestational was 26.4 weeks. The E8 ultrasonoscope and TOSHIBA aplio 500 were used to examine fetal heart. The pregnant women lied horizontally or slopingly.Firstly, examine the fetal structure and estimate gestational weeks.According to fetal head and spine,we can decide the position of the baby. Then,fetal echocardiographic examination condition was used to evaluate the structure and function of the fetal heart comprehensively.In Four chamber view, when the sound beamparallel toventricular septal, measure and calculate the following data: tricuspid regurgitation peak velocity(VTR), regurgitant jet root width(WTR), the ratio of regurgitant jet length and right atrial length(LTR/LRA), the ratio of regurgitant jet area and right atrium area(ATR/ARA), the ratio of regurgitation continuously time and ventricular systolic time(TTR/TS), the ratio of right ventricular transverse diameter and left ventricular transverse diameter(DRV/DLV), the ratio of right atrial diameter and left atrial transverse diameter(DRA/DLA),the ratio of right ventricular wall thickness and left ventricular wall thickness(TRV/TLV),the ratio of right ventricular wall thickness and ventricular septal thickness the ratio(TRV/TIVS) and the Z-Scores of tricuspid valve ring size. SPSS17.0 statistical software was used. The data of the research was expressed as mean( x ±2s),95% confidence interval was set to( x ±2s), Differences among groups were compared with one-factor analysis of variance.Results: 1 Statistics of fetal physiology tricuspid regurgitation and related parameters. VTR=1.16±0.43m/s,WTR=1.68±0.42 mm,LTR/LRA=0.22±0.02,ATR/ARA=0.35± 0.06,TTR/TS=0.35 ± 0.06,Z=0.17 ± 0.96,DRA/DLA=1.12±0.10,DRV/DLV= 1.08±0.05,TRV/TLV=1.03±0.09,TRV/TIVS=1.04±0.09. 2 Statistics of pathology tricuspid regurgitation and the results compared with physiology tricuspid regurgitation. All pathological tricuspid regurgitation cases include 30 cases of right heart obstructive diseases(11 cases of pulmonary valve stenosis, 3 cases of pulmonary artery stenosis, 6 cases of intrauterine systolic arterial catheter, 4 cases of right ventricular dysplasia),30 cases of right ventricular volume overload(the foramen ovale shunting restriction, atrial septal aneurysm in 12 cases, the foramen ovale closed early in 1 cases, double outlet right ventricle in 3 cases, coarctation of the aorta in 6 cases, 4 cases of interruption of aortic arch, left ventricular dysplasia in 4 cases),30 cases of tricuspid structureabnormality(7 cases of Ebstein malformation, 9 cases of tricuspid hypertrophy, 6 cases of tricuspid valve dysplasia, 4 cases of tricuspid cleft, 5 cases of tricuspid valve accessories abnormality),30 cases of cardiomyopathy,(13 cases of dilated cardiomyopathy, 4 cases of hypertrophic cardiomyopathy, 8 cases of endocardial fibroelastosis, 5 cases of myocardial dense non). Fetal pathological tricuspid regurgitation peak velocity was 2.45 ±1.13m/s,more increased than physiological regurgitation(1.16±0.43m/s).The root width of the pathological regurgitation is 3.10± 1.14 mm, about two times of the root width of physiological regurgitation 1.68±0.42 mm.Aspects of regurgitation time, pathological regurgitation time was significantly prolonged, TTR/TS=0.82 ± 0.24, physiological regurgitation TTR/TS=0.35 ±0.06.for the regurgitant jet length, regurgitant jet area, fetal pathological tricuspid regurgitation was also significantly increased, LTR/LRA=0.80±0.23, ATR/ARA=0.51±0.26, compared with physiological tricuspid regurgitation, LTR/LRA=0.22 ± 0.02, ATR/ARA=0.35 ± 0.06.When the pathological regurgitation exists, Theratio of right atrial increased, DRA/DLA= 1.41±0.45, right ventricular wall thickened.compared with DRV/DLV, TRV/TIVS, there were no significant differences between the pathologic regurgitation and physiological regurgitation. 3Analysis of fetalpathological tricuspid regurgitation by ROC. The parameters we studied in pathological tricuspid regurgitation group were drawed the ROC curve.And we obtained the sensitivity, specificity and Area Under the Curve by ROC, and significant test. Results found that the accuracy of TTR/TSis highest, sensitivity and specificity are respectively 86.7%, 98.3%.VTR,WTR,ATR/ARA,TRV/TLVhas great value on defining properties of tricuspid regurgitation. DRA/DLA, DRV/DLV, TRV/TIVS no significant difference in pathologic regurgitation and physiological regurgitation. 4Parameters of fetal tricuspid regurgitation in each group. Tricuspid regurgitation peak velocity in the group of right heart obstructive diseases, group of right heart volume overload and group of tricuspid structure abnormal increased in degrees.Especially inright heartobstructive diseases(3.66±0.73m/s). Root width of tricuspid regurgitation beam for comparison:There were significant differences between each group of pathological tricuspid regurgitation and physiological tricuspid regurgitation. The width in tricuspid valve structure abnormal group is the most obvious(3.46±1.18mm). The length ratioof tricuspid regurgitation and right atrium(LTR/LRA) for comparison:There were significant differences between each group of pathological and physiological tricuspid regurgitation. The ratio of LTR/LRA in the group of right heart obstructive disease is the biggest(0.98 + 0.06). The area ratio of tricuspid regurgitation and right atrium(ATR/ARA) for comparison:There were significant differences between each group of pathological and physiological tricuspid regurgitation. The ratio of ATR/ARA in the group of right heart obstructive disease is the biggest(0.63±0.22). Analysis Z-Scores of tricuspid ring in each group : in addition to right heart obstructive disease group, there were significant difference betweenpathological and physiological tricuspid regurgitation.The Z-Scores in tricuspid valve structure abnormal group is the most obvious(4.21±1.92), Z-Scores in cardiomyopathy group and right heart volume overload group were 2.92 ± 1.22,1.83 ± 1.61.Right heart obstructive disease group and normal regurgitation group showed no significant difference(P=0.17). The diameter ratio of right atrial and left atrial(DRA/DLA) for comparison:The right atrium increased significantly in tricuspid structure abnormal group(1.75±0.32)and right ventricular volume overload group(1.68±0.33). The diameter ratio of right atrial and left atrial(DRA/DLA) showed no significant difference between physiological regurgitation group and cardiomyopathy group(P=0.19). The diameter ratio offetal right ventricular transverse diameter and left ventricular diameter ratio(DRV/DLV) for comparison:There were significant differences between each group of pathological and physiological tricuspid regurgitation in DRV/DLV ratio. The ratio of DRV/DLV in the group of Right ventricular volume overload is the biggest(1.53±0.28).The ratio of TRV/TLV、TRV/TIVS inright ventricular obstructes group is up to 1.60±0.35,1.32±0.20.No significant differences in the other parameters.Conclusions: 1fetal physiological tricuspid regurgitation characteristics: velocity generally less than 2m/s, the root of reflux beam width less than 3mm,, the ratio of reflux beam length and right atrial diameter is less than 50%, the ratio of regurgitant jet area and right atrial area is less than 25%, the ratio of reflux time and heart systolic time is less than 50%; tricuspid valve ring size, the ratio of right ventricular and left ventricular, the thickness septal and right ventricular wall have no change. 2The time ratio of tricuspid regurgitation and ventricular systolic(TTR/TS)≥50% has the highest accuracy as a diagnosis indexfor the diagnosis of pathological tricuspid regurgitation. The combined application of various parameters may improve the accuracy. 3Pathological tricuspid regurgitation in types of congenital heart disease. When fetal congenital heart with right ventricular obstruction, tricuspid regurgitation was pansystolic high-speed,shows a long and large area and a widely root of refluxbeam.when right heart obstruction severely, such as right ventricular dysplasia, ventricular septal and right ventricular wall was significantly thickened and right ventricular cavity was reduced. When fetal right ventricular volume overload, most fetuses showed increased right heart and tricuspid ring. The peak velocity of tricuspid regurgitation and the root width, length and reflux area of regurgitation beam changed greatly due to right heart volumetric load.There was no obvious change in the thickness of the left and right ventricular wall and interventricular septum. When fetal tricuspid structural abnormalities, The root of reflux beam width significantly broadened. regurgitant jet root located in right ventricular rather than tricuspid annulus level is important characteristics of the Ebstein malformation. The wall of atrialized right ventricle is thin and the ratio of TRV/TLV、 TRV/TIVS decreased.When tricuspid valve dysplasias,two-dimensional ultrasound can display the leaflet thickening.When tricuspid leaflet hascleft,the reflux beamoriginated fromthe leaflet rather than tricuspid orifice,thetricuspid regurgitation was pansystolic high-speed. Tricuspid regurgitation varied from the type of fetal cardiomyopathy.In hypertrophic cardiomyopathy, two-dimensional ultrasonic shows the left and right ventricular wall and muscular septal thicken, and ventricular septal thickening is obvious, so TRV/TIVS decreased.in dilatation heart, much performance is all increase, the Z-Scores of tricuspid ring increases, in addition some patients can be found that tricuspid valve leaflet opening range small, slow heart rate and pericardial effusion. Tricuspid regurgitation and related parameters can better evaluate the right heart load, tricuspid structural abnormalities and cardiac insufficiency caused by cardiomyopathy, tricuspid regurgitation has great help to determining the type of congenital heart disease.