美国医学超声协会胎儿超声心动图操作指南-中文

美国医学超声协会胎儿超声心动图操作指南-中文 美国医学超声协会胎儿超声心动图操作指南 I 简介 先天性心脏病是导致胎儿死亡的主要原因，死亡率约为 6‰。准确的产前诊断能够改善婴儿的预后，尤其在需要前列腺素来维持动脉导管通畅的病例中更为重要。胎儿超声心动图普遍认为是产前评价胎儿心脏畸形的最详 细的检查手段。其检查手段是在“基本”和“基本扩展”胎儿成像指南基础上延伸而出的，即胎儿心脏四腔心和流出道切面。胎儿超声心动图只有在有确切的原因的 情况下，并且最大限度的减少由于采集诊断信息而暴露在超声下的时间的情况下进行。有时，额外或特殊的检查手段比如彩色多普勒是必须的。但并不是所有的畸形 都能够检出，以下指南将最大限度的探查大部分临床严重的先心病。 II人员的资质及责任 参照AIUM官方文件《医师培训指南、诊断超声检查评估与解释、AIUM超声实践指南》 III指征 胎儿超声心动图指征基于先心病的亲代及胎儿危险因素。然而，大多数病例并没有明确的已知的高位因素。胎儿超声心动图的普通指征是(也不局限与此): 母体指征 自身免疫抗体，抗Ro(SSA)/抗La(SSB) 家族遗传疾病(如:马凡综合症) 先心病家族史 试管婴儿 代谢性疾病(如:糖尿病和苯丙酮尿症) 至畸源接触(如:类视黄醇和锂) 胎儿指征 心脏显像异常 心脏心率心律异常 胎儿染色体异常 心外畸形 胎儿水肿 颈项透明层增厚 单绒毛膜双胎 无法解释的羊水过多 IV检查申请 书面或电子申请超声心动图检查应提供详细的信息以更好的完成检查。 检查申请必须由临床医生或其他有资格的健康中心出具，并提供相关临床资料，并且因遵守相关法律和当地健康结构规定。 V 检查说明 以下部分为胎儿超声心动图详细或选择性推荐。 A(综述 胎 儿超声心动图通常在孕18到22周进行。有些先心病可能在更早孕周发现。最佳的图像是胎儿心尖向前或朝向孕妇腹壁。由于声影(如:孕妇肥胖或胎儿俯卧体 位)使得全面的检查十分困难，特别是在晚孕期更是如此。所以由于心脏显像欠佳多次观察是必要的。检查者可以通过调节各种参数来获得最好的图像，比如焦点、 频率、增益、图像放大、时间分辨率、谐波成像及多普勒相关参数(比如:血流速度、壁滤波、帧频)。 B(心脏图像参数: 基本要求:胎儿超声心动图是对心脏结构及功能的全面评价。检查方法包括三个节段的:心房、心室、大动脉及其连接。节段分析法包括以下连接及关系: 心房位置 房室连接 心室与动脉流出到的连接 每个节段的异常都需要对其他伴随异常进行评价比如:心脏位置、心房异构、主动脉骑跨、房间隔缺损、室间隔缺损、心肌肥厚、体循环或肺静脉的异常连接、卵圆孔关闭、心室比例失调、动脉缩窄及二三尖瓣发育异常。 C(灰阶图像(推荐) 关键切面的获取有助于诊断信息的获得。应该获得以下切面: 四腔心 左室流出道 右室流出道 三血管及气管切面 短轴切面(心室及流出道) 主动脉弓 导管弓 上腔静脉 下腔静脉 D 多普勒检查(心脏血流异常时推荐) 使用光谱、连续、彩色和或能量多普勒来评价下列结构的血流或心律异常: 肺静脉 卵圆孔 房室瓣 房室间隔 主、肺动脉瓣 动脉导管 主动脉弓 E(M型超声心动图(心率或心律异常时推荐) M 型超声心动图显示一个薄的取样容积内结构随时间的变化。较高的时间分辨率有助于心室收缩的评价。能够分辨房性、室性心律失常，及它们之间的关系。其他方法如:脉冲多普勒或者组织多普勒也被用来评价胎儿心律失常。 F.心脏生物学测量(在结构异常时推荐) 胎儿心脏测量的正常范围根据不同孕周或胎儿大小而不同，数据已经以百分位数和z积分的形式公布。每个个体的测量应使用M型或二维图像，包括以下参数: 主动脉及肺动脉瓣环水平内径 主动脉弓及峡部内径 舒末期心室内径，紧贴房室瓣下 心室自由壁及室间隔的厚度，紧贴房室瓣下 额外测量按需要而定，包括: 心室收缩内径 心房的横径 肺动脉分支内径 G.补充切面(可选) 其他附属成像模式，比如3或4维超声，已经应用于心脏结构异常和定量胎儿血流参数(比如心输出量)的应用。多普勒超声和斑点追踪技术被用来描述心室的应变和心肌指数的测量。 VI(及存档 充足的存档对高质量病例管理是必要的。胎儿超声 心动图检查和说明应该永久存储。所用的图像包括正常和异常的都应该存档。异常时应该同时附有测量数据。图形应标注病人信息、仪器信息、检查日期、以及图像 左右方向。正式报告(最终报告)应收录在病人的医疗档案中。超声的检查应有临床适应症，并且遵守相关法律及当地健康结构的规定。报告应符合AIUM超声检 查标准。 VII(仪器要求 胎儿超声心动图检查应该使用实时探头扫查。因此 应使用扇形、凸阵及经 阴道探头。尽量将探头频率调至最佳，值得注意分辨率与扫查深度是相互制约的。 对目前设备而言，经腹壁探查时经常使用频率为 3.5MHz或更高，而经阴道扫查 时频率为5MHz或更高。超声声影及母体体型肥胖均可限制高频探头的使用，从 而限制了心脏高分辨率解剖信息的获得。 VIII(质量控制及提高、安全性、感染控制、患者教育 质量控制及提高、安全性、感染控制的执行应符合AIUM超声实践标准及指 南。 仪器的工作辐射监控应符合AIUM超声实践标准及指南。 IX.ALARA 原则 每次检查的益处及风险应同时评估。在控制声能输出及扫查时间时应遵守 ALARA原则(低声能、短时间)。更详细内容见AIUM发布的医学超声安全。 American Institute of Ultrasound in Medicine (AIUM) and the International Society of Ultrasound in Obstetrics and Gynecology outlined recent guidelines for sonographic evaluation of the fetal heart. The International Society of Ultrasound in Obstetrics and Gynecology guidelines include the “basic”cardiac examination that relies on a 4-chambe r view.There are key features of this sonographic view that will be emphasized in this article. This society also included the “extended basic” examination that includes the right and left ventricular out- flow tracts (RVOTand LVOT, respectively). It is important to include imaging that demonstrates the relationship of the LVOT and the RVOT to detect conotruncal abnormalities. 美国超声医学协会(AIUM)和国际妇产科超声协会最近针对胎儿心脏超声检查出 台了一项指南。国际妇产科超声协会指南包括了基于四腔心切面的最基本的心脏 检查，其中重点强调了在此超声切面上的几个关键征象，同时指南还包括了“进 一步”的检查，包括对左右心室流出道(RVOT和LVOT)的检查，明确两者的关 系对于发现圆锥动脉干畸形非常重要。 Depending on technical factors, such as maternal body habitus, fetal age, or fetal position, demonstrating the relationship of the RVOT and the LVOT may be problematic. Alternatives to routine 2-dimensional (2-D) imaging of out-flow tracts include the use of 3-D imaging technologies including the use of dynamic multiplanar imaging. Even with advanced imaging and the ability to reconstruct images in different planes, the examiner must be familiar with routine cardiac views or failure of detection of CHD may still occur. Thus, understanding basic cardiac views is necessary to detecting CHD even with more advanced imaging. We will concentrate on a method to best understand these basic views, such as the 4-chamber or outflow tract views, as a springboard to more advanced cardiac imaging. An alternative to these views is a comprehensive examination of the fetal heart, which may be obtained using 4 to 5 short-axis views of the heart. These 5 planes include (1) the stomach; (2) the 4-chamber view of the heart; (3) the 5-chamber view of the heart; (4) the pulmonary artery (PA) bifurcation; and (5) the alignment of the 3 vessels, which are the PA, aorta, and superior vena cava (SVC). 由于一些技术上的原因，比如母体的体质、胎龄或者胎儿体位等因素的影响，有 时显示ROVT和LOVT的关系比较的困难。除了可以通过常规二维图像来显示流出 道外，还可以应用三维影像技术包括使用多维动态图像技术来显示流出道。即便 是具备了先进的影像技术和不同平面图像重建的技能，检查者还必须要掌握常规 的心脏切面，否则仍有可能无法发现先天性心脏病。因此，即便是有了很多先进 的影像技术，但如果要发现先天性心脏病仍然需要掌握基本的心脏切面。我们概 括了一种最好的方法来理解这些基本的切面比如四腔心切面和流出道切面，这种 方法可以作为其他先进的心脏影像技术的跳板。除了这些切面之外，我们还需要 对胎儿心脏进行其他的广泛细致的检查，我们可以通过4到5个短轴切面来获取， 包括胃泡、四腔心切面、五腔心切面、肺动脉分叉以及三血管排列(肺动脉、主 动脉和上腔静脉)。 A useful mnemonic to help In the basic evaluation of the fetal heart is PASSSS. Each letter is meant to serve as a memory aid as follows :position, axis, size, symmetry, septum, and squeeze. If each of these cardiac features is evaluated and considered normal, the examiner can evaluate the 4-chamber view of the fetal heart PASSSS as normal (Table 1). 在胎儿心脏的基础的检查中我们可以通过PASSSS这个词来进行记忆，每个字母 可作为一个检查的要点:位置、轴向、大小、对称轴、间隔和节律。如果检查者 能够发现心脏的每一个征象并认为正常，那么他可以认为在胎儿四腔心切面上它 是正常的。 TABLE 1. The PASSSS Mnemonic for the 4-Chamber Vessel 四腔心切面的PASSSS 记忆法 Position Determine correct situs 位置 确定位置是否正常，有无反位 Axis Determine that the interventricular septum is 40 to 45 degrees 轴: 确定室间隔的角度在40-45度 Size Make sure that the heart is approximately one third of the fetal thorax 大小:确定心脏的大小是胎儿胸腔的三分之一左右 Symmetry Generally, the diameters of the right and left ventricles have a 1:1 ratio 对称性:通常情况下，左右心室的直径为1:1 Septum Check the entire septum for possible ductal defects 间隔:检查 整个间隔明确是否存在可能的缺损 Sinus rhythm Check cardiac rate and rhythm 窦性节律:检查心律和心率。 In evaluating the fetal heart, the fetal presentation should ,rst be documented. Then, the examiner must determine if the fetus’ left side is up or down. Lastly, the stomach side and its relationship to the heart side should be assessed. Simply put, situs solitus is the normal relationship, with the stomach on the left and the left atrium on the left side of the fetus. Situs inversus is the exact mirror image of situs solitus, with the stomach on the left but the left atrium on the right. Situs ambiguous is an anatomically indeterminate type of visceral situs, which is part of the heterotaxy syndromes. 胎儿心脏检查时首先我们要明 确胎儿的胎位，然后必须要确定胎儿的左侧是在上还是在下，最后要明确胃泡在 哪边以及胃泡和心脏的位置关系。简单的说，心房正位是正常的关系，胃泡和左 心房位于胎儿的左侧。心房反位是心房正位的镜像面，胃泡位于左侧但左心房位 于右侧。心脏不定位是一种解剖学上的心房位置不明确的类型，它属于器官变异 综合症的一部分。 After determining the situs (or position), a 4-chamber view of the heart is obtained (Table 2). This is done by identifying the fetal thoracic spine, and a scan is obtained transverse to the thorax. Anatomically, the right ventricle is posterior to the sternum, and the left ventricle is to the left of the right ventricle or at the same side as the stomach. Identifying features unique to the right ventricle include its retrosternal location, lower insertion of the tricuspid valve compared with the mitral valve, and a thicker moderator band. The flap of the foramen ovale opens from the right atrium into the left atrium. 在明确了心房的位置之后我们可以来看一下四腔心切面(表2)。我们可以通过 辨认胎儿胸椎然后对胸腔进行横切面扫面获得四腔心切面。从解剖学上来说，右 心室位于胸骨的后方，左心室在右心室的左侧或者和胃泡同在一侧。右心室独有 的征象包括与胸骨的关系、三尖瓣的附着点比二尖瓣低以及粗大的调节束。卵圆 孔瓣从右心房向左心房开放。 TABLE 2. Identi,cation of Right and Left Ventricles From the 4-Chamber View View Right Ventricle Left Ventricle Position within thorax Right ventricle retrosternal Left border, same side as the stomach Flap of foramen ovale Present within the left atrium Insertion of AV valve leaflets on interventricular sternum Tricuspid valve inserted lower than the mitral valve Mitral valve inserted higher than the tricuspid valve Muscle Thicker moderator band Veins SVC + IVC Pulmonary veins IVC indicates inferior vena cava. Modi,ed from DeVore and Polanko. 四腔心切面上鉴别左右心室 切面 右心室 左心室 胸腔内的位置 右心室位于胸骨后方 左心室位于左边和胃泡同处一侧 卵圆瓣 ---- 出现在左房内 三尖瓣的附着点低于二尖瓣 二尖瓣的附着点高于房室瓣在室间隔上的附着点 三尖瓣 肌层 可见调节束 --- 上下腔静脉 肺静脉 静脉 Axis 心轴 Once a 4-chamber view of the heart is obtained, a line is drawn from the spine to the anterior sternum. The interventricular septum intersects that line at 40 to 45 degrees. Shipp et al 13 found a normal cardiac axis of 43 degrees, with an SD of 7 degrees (Fig.. 1). Abnormal cardiac axis can be an indicator of extracardiac intrathoracic abnormalities, displacing the heart. Examples include pulmonary cystic adenomatoid malformation, diaphragmatic hernia, or intrathoracic pulmonary sequestration. Axis deviation is also seen in intracardiac abnormalities. Examples include Ebstein anomaly and tetralogy of Fallot. 在获取了四腔心切面后我们可以从脊柱到前面的胸骨画一条线，室间隔与之成 40-45?的角。Shipping等人发现正常心轴为43?，SD为7?(图1)。心轴异 常可能表明存在心外的胸腔内异常挤压心脏，比如肺脏的囊性腺瘤样畸形、膈疝 或者胸腔隔离肺。心轴的偏转也可以是由于心内的异常导致，比如Ebstein畸形 和Fallot四联征。 FIGURE 1. Four-chamber view of the heart. The 4-chamber view of the heart in the transaxial plane shows the spine noted posteriorly. A line is drawn from the spine to the anterior sternum. The interventricular septum intersects that line at approximately 45 degrees. Note that the RA lies to the right side of the spinal sternal line. The heart can be noted to occupy approximately one third of the fetal thorax. RA indicates right atrium. 图1 四腔心切面。在心脏轴向的四腔心切面上我们可以看到脊柱位于后方，从 脊柱到前方的胸骨画一条线，室间隔与此线大约呈45?。我们可以看到RA位于 脊柱胸骨线的右侧，心脏大约占整个胎儿胸腔的三分之一。 Size 大小 This is to assess the size of the fetal heart in relation to the fetal thorax. The cardiac area is approximately one third of the thoracic area (Fig. 1). Simply put, approximately 3 fetal hearts can normally ,t into the fetal thorax. A small heart can be attributed to extrinsic mass compressing the heart. There are many causes for fetal cardiomegaly. Intrinsic cardiac anomalies include Ebstein anomaly, cardiomyopathies, or cardiac tumors, most commonly rhabdomyomas. 胎儿心脏的大小要看和胸腔的关系，心脏的面积大约是胸腔面积的三分之一(图 1)。简单的说，正常情况下一个胸腔大约能放置三个心脏。心脏过小可能是由 于心外的肿块挤压心脏，而心脏增大的原因很多，心内的异常有Ebstein畸形、 心肌病变或者心脏肿瘤(最常见的是横纹肌瘤)。 Symmetry 对称性 This refers to the symmetric size of the ventricles. Generally, the diameters of the right and left ventricles maintain about a 1:1 ratio (Fig. 2). With the diameter of the right ventricle slightly larger than that of the left ventricle, real-time examination can be used as a rough estimate of ventricular chamber size. Most common anomalies are the hypoplasia of either the left or right side of the heart. Hypoplastic left heart syndrome is composed of ,ndings including underdevelopment of the aorta, the aortic valve, the left ventricle, or the mitral valve. Right ventricle hypoplasia can be attributed to 1 of 2 anomalies: pulmonary atresia or tricuspid atresia with or without an intact ventricular septum. There are multiple other etiologies of chamber discrepancy beyond the scope of this review. 对称性是指心室大小对称，通常情况下，左右心室的直径保持大约1:1的比例(图 2)。当右室直径比左室略大的话，实时检查可以大体的估测心室的腔径。最常见 的异常是心脏左侧或右侧的发育不良，左心发育不全综合症包括有主动脉、主动 脉瓣膜、左心室或二尖瓣的发育不全。右心发育不全可能是由于1-2种异常导致: 肺动脉闭锁或三尖瓣闭锁合并或不合并室间隔完整。除此之外，还有很多种其他 的原因导致腔径的不对称。 FIGURE 2. Four-chamber view of the heart. Note that the diameter of the RV is approximately equal to that of the LV at the AV valve level. RV indicates right ventricle; LV, left ventricle. 四腔心切面。在房室瓣水平RV的直径与LV大约是相等的 Septum 间隔 Evaluation for a septal defect is best performed on the 4-chamber heart view that is obtained perpendicular to the interventricular septum. This allows adequate visualization of the membranous portion of this septum, which can suffer from drop-out artifact if imaging is performed parallel to the interventricular septum. There are 3 basic types of septal defects. Ventricular septal defects (VSDs) can be small or large. The smaller ones are hard to detect and can occur in perimembranous location just below the aortic valve. Color Doppler may be helpful with this diagnosis. Atrial septal defects can be quite dif,cult to detect because of the normal foramen ovale. The atrioventricular (AV) canal defects result from the absence of the endocardial cushion. In this situation, the normal lower insertion of the tricuspid valve compared with the mitral valve is not observed, but rather there is a “T” con,guration with the residual mitral and tricuspid valve inserting at the same level but with no interventricular septum (Fig.3). Color ,ow imaging allows easier recognition of ventricular defects. 检查室间隔时最好选取与室间隔垂直的四腔心切面，这样能非常清楚的看到室间 隔的膜部，可以避免因声束与室间隔平行时出现的衰减伪像。间隔缺损有三种基 本类型。室间隔缺损大小不一，较小的缺损难以发现，可发生在主动脉瓣下的膜 周部。彩色多普勒有助于明确诊断。房间隔缺损非常难以发现，因为存在正常的 卵圆孔。房室通道是由于心内膜垫缺损导致的，发生这种情况时我们看不到正常 情况下的三尖瓣附着点低于二尖瓣，而是残存的二尖瓣和三尖瓣附着点在同一水 平呈T型结构，但不与室间隔相连接(图3)。彩色血流图像可以很容易的看到 室间隔的缺损。 FIGURE 3. Valve insertion. This diagram illustrates that the tricuspid valve lies closer to the apex than does the mitral valve. In an AV canal, these valves form a ‘‘T,’’ along with lack of the interventricular septum. 瓣膜附着点。示意图显示三尖瓣距离心尖要比二尖瓣近。当出现房室通道时，瓣 膜与缺损的室间隔呈T型。 Squeeze 节律 This refers to assessing the normal fetal cardiac rhythm. The normal fetal cardiac rhythm is regular, with a 1:1 atrial-ventricular relationship. The heart rate increases rapidly in early gestation until it reaches the peak rate of 175 beats/min (SD, 20 beats/min) at approximately 8 weeks. Then, the heart rate gradually decreases to 140 beats/min (SD, 20 beats/min) at 20 weeks and 130 beats/min (SD, 20 beats/min) toward term. Fetal rhythm abnormalities include (1) irregularity of the cardiac rhythm, (2) abnormally slow or fast heart rate, or (3) combination of the two. M-mode ultrasound is most commonly used to document fetal cardiac rate and rhythm. M-mode line placement becomes important to simultaneously assess the atrial and ventricular walls to record the sequence of their systolic wall motions. The M-mode beam direction is placed through the atrial and ventricular walls immediately above and below the AV junction. At this location, the M-modes of the atrium and the ventricle are displayed together, allowing assessment of atrial contraction and conduction to the ventricles. In brief, most common causes of fetal arrhythmias include premature atrial contractions and brief sinus tachycardia/bradycardia. Less common arrhythmias include complete AV block and supraventricular tachycardia. Fetal rhythm abnormalities affect at least 2% of pregnancies and are a common reason for referral to fetal cardiologists. 这里指的是检查胎儿心律是否正常。正常的胎儿心律是规整的，房室比例为1:1。 妊娠的早期心率会快速增高，8周的时候可以达到175bpm(SD，20bpm)，到20 周的时候逐渐的降到140bpm(SD，20bpm)，足妊时为135bpm(SD，20bpm)。 胎儿心律异常包括(1)心律不规整，(2)异常过缓或过速，或者(3)两者都 存在。M型超声对于发现胎儿心律和心率异常非常有用，要注意M取样线放置的 位置保证能同时监测心房和心室壁在收缩期的室壁运动的顺序。M型超声的取样 线要在紧邻房室交界处的上方和下方并同时经过心房和心室壁，这样的话心房 和心室的M波形才能同时显示出来从而能观察到心房的收缩和向心室的传导。简 单的说，胎儿心律失常最常见的病因包括房性期前收缩和短暂的窦性心动过速和 心动过缓，少见的情况还包括房室阻滞和室上性心动过速。胎儿心律失常至少出 现在2%的妊娠中，也是常见的进行胎儿心脏检查的原因。 chamberThe PASSSS mnemonic is helpful as a basic evaluation of the 4- heart view. PASSSS记忆法对于四腔心切面的基本检查有帮助。 道切面 OUTFLOW VIEWS 流出 To improve sensitivity of CHD, long-axis views of the out,ow tracts a re obtained, with the interventricular septum perpendicular to the transducer beam. The left ventricular long-axis view of the fetal heart is obtained by rotating the transducer approximately 45 degrees from the 4-chamber view to angle from the fetal abdominal left upper quadrant toward the right shoulder (Fig. 4). This view will demonstrate the aorta originating from the left ventricle. 我们还可以通过观察流出道的长轴切面来提高CHD的检出率，在这个切面上，室 间隔与探头的声束方向是垂直的。在四腔心切面上将探头旋转45度使得探头从 胎儿上腹部指向右肩就可以获得左室长轴切面(图4)。在此切面上可以显示起 源于左心室的主动脉。 This view is also useful in the visualization of the membranous portion of the interventricular septum. Once the aortic out,ow tract is id enti,ed, the transducer is “rocked” slightly. This view should demo nstrate the main PA exiting the right ventricle. The main PA and the ascending aorta should be perpendicular to each other, or demonstrated to “crisscross”, to exclude conotruncal anomalies such as transposition of the great arteries. When demonstrating the longaxis views of the out,ow tracts, it is necessary to con,rm crisscrossing of the v essels (Fig. 4). If this proves dif,cult, de,ning the anatomic featur es of the vessels is important. The aorta should be traced originating from the left ventricle to the proximal arch, with demonstration of the takeoffs of the great vessels to the head and neck. Similarly, the main PA should be demonstrated to arise from the right ventricle; it must be noted to bifurcate. 通过这个切面有助于显示室间隔的膜部。当我们看到主动脉流出道时将探头轻轻 一动就可以显示出与右心室相连的主肺动脉。主肺动脉和升主动脉相互垂直或者 十字交叉”就可以排除动脉圆锥的异常，比如大动脉转位。当显示出流出说呈“ 道的长轴切面时我们需要确定血管的十字交叉情况(图4)。如果有困难，那么 我们可以根据血管的解剖特性来确定。主动脉与左心室相连然后延伸为主动脉 弓，其分支走向头颈部。同时，主肺动脉起源于右心室，并且一定可以看到分叉。 FIGURE 4. A-E, Out,ow tracts apex perpendicular to the ultrasound beam. A, Interventricular septum perpendicular to the ultrasound beam. B, Normal 4 chambers of the heart, with the interventricular septum perpendicular to the ultrasound beam. C, After performing a 4-chamber view of the heart, the transducer is placed at an angle between the left upper quadrant of the abdomen and the right shoulder. D, By changing from the 4-chamber view of the heart to a more oblique scan plane, the aorta is noted exiting the LV, which was noted exiting to the aorta (arrow). E, The transducer is rotated as the PA is seen to exit from the RV (arrow) and cross-perpendicular to the LVOT. 图4. A-E，流出道与声束垂直。A，室间隔与声束垂直。B，正常的四腔心切面， 室间隔与声束垂直。C，在四腔心切面检查之后将探头由左上腹指向右肩部。D， 从四腔心切面转变到倾斜的扫描平面上可以看到左心室与主动脉相互通联(箭 头)。E，旋转探头可以看到起源于右心室的肺动脉(箭头)与左室流出道呈是 十字交叉。 When the apex of the heart is “up” or pointed parallel to the ultrasound beam, then it may be more dif,cult to identify the out,ow tracts to crisscross. In this situation, the LVOT is again obtained, but often short-axis view must be obtained to identify the RVOT. In this view, the aorta lies centrally, and the right ventricle and PA "wrap around" the aorta. It is important in this view to identify that the vessel originating from the right ventricle is the PA by noting that it bifurcates (Fig. 5). 如果心尖上翘或者是与声束平行的话就更难以确定流出道是否相互交叉排列，在 这种情况下可以看到左室流出道，但常常是在短轴切面上才能看到右室流出道。 在此切面上，主动脉位于中央，而右心室和肺动脉“环绕”在其周围，重要的是 我们可以从此切面上通过观察与右室相连的血管是否分叉来确定是否为肺动脉 (图5)。 In a review of transposition of the great vessels (TGA) ,ndings, McGahan et al described the "baby bird’s beak" sign. This occurs when the main PA arising from the left ventricle is noted to bifurcate and thus is the PA. If the crisscrossing of the main PA and aorta is not demonstrated, then this view may be useful. When the main PA originating from the left ventricle is noted to bifurcate, the left branch makes a sharp angle with the main PA and ductus arteriosus, reminiscent of a baby bird’s head with an open beak. This is a critical clue that there is TGA. McGahan等人在对大动脉转位(TGA)的回顾中提出了“小鸟嘴征”，这种情况 发生时肺动脉起源于左心室并且分叉所以可以确定它是肺动脉，如果我们不能发 现主肺动脉和主动脉的十字交叉，那么可以通过这个切面来观察。当我们看到主 肺动脉起源于左心室并且分叉时，左肺动脉与主肺动脉和动脉导管成锐角，构成 了小鸟头部和张开的鸟嘴。这种征象强烈提示为TGA。 FIGURE 5. Out,ow tracts-apex up. A, Interventricular septum is parallel to the ultrasound beam. B, The 4-chamber view of the heart with the apex up. Note that the tricuspid valve is closer to the apex (arrow) compared with the mitral valve, as illustrated in Figure 3. C, This long-axis view demonstrates the retrosternal location of the RV and the AO originating from LV. This view is also helpful to detect membranous VSDs. D, With the apex of the heart again pointed toward the transducer, the transducer is angled at almost 90 degrees from the long-axis plane. In this view, the circular aorta is noted centrally. The RV gives rise to the main PA. AO indicates aorta. 图5. 流出道-心尖上翘。A，室间隔与声束平行。B，四腔心切面显示心尖上翘， 我们可以看到就像图3中所看到的三尖瓣(箭头)比二尖瓣更靠近心尖。C，长 轴切面显示右心室位于胸骨后方，主动脉起源于左心室。此切面还有助于发现室 间隔膜部缺损。D，在心尖指向探头的情况下，探头从左室长轴面调整90?。在 这个切面上，圆形的主动脉位于中央，右心室延伸为主肺动脉。 COMPREHENSIVE 5 SHORT-AXIS VIEWS 更进一步的5个短轴切面 A comprehensive examination of the fetal heart using 5 short-axis views has been advocated. These are best obtained with the interventricular septum parallel to the transducer beam. These are 5 transverse planes (Figs. 6, 7). (1) The most caudal view begins with the fetal stomach, which is needed to assess the situs. (2) The 4-chamber view of the heart is then obtained. (3) The 5-chamber heart view demonstrates the aorta centrally, with the pulmonary anterior and perpendicular to the aorta. The borders of the central aorta should be clearly identi,ed. (4) The main PA should be demonstrated to bifurcate and then follows (5) the so-called 3-vessel view. 为了更进一步的对胎儿心脏进行检查我们推荐应用5个短轴切面，这些切面最好 是在室间隔与声束平行的情况下采用，这5个切面都是横断面(图6、7)。(1) 是位于最尾端的胎儿胃部切面，通过它可以确定内脏位置;(2)是四腔心切面; (3)是五腔心切面，它可以显示主动脉位于中央，肺动脉位于其前方并且与之 垂直，可以清晰的显示圆形主动脉的边界;(4)显示分叉的主肺动脉;(5)所 谓的三血管平面。 These 5 short-axis views are helpful in the detection of conotruncal abnormalities when the crisscrossing of the aorta and main PA is not de,nitely demonstrated using the routine out,ow tract views. In the 3 -vessel view, the main PA continues to the descending aorta through the ductus arteriosus; the 3 vessels that are seen are the main PA, the ascending aorta, and the SVC. These are aligned in the stated order in a straight line from the left anterior aspect to the right posterior aspect of the thorax. They also decrease in size, with the main PA being the largest and the SVC being the smallest (Fig. 7). When having this view, it is important to note that the right ventricle is left sided, with the PA “crossing” and ending on the left side of the fetus and to the left of the aorta. The left ventricle starts on the left side, with the aorta passing under the PA to lie between the left-sided PA and the right-sided SVC in the 3-vessel view. Thus, the aorta and PA are also observed to cross in these 5 short-axis views. In transposition, it is important in the 3-vessel view to note that the PA arises from the left ventricle and that the central aorta arises from the right ventricle. Thus, these vessels do not cross in transposition. 当使用常规的流出道切面不能显示肺动脉和主动脉呈现的十字交叉时通过这5 个短轴切面可以确定是否存在圆锥动脉干畸形。在三血管平面上，主肺动脉通过 动脉导管与降主动脉相连，我们所看到的三根血管分别是主肺动脉、升主动脉和 上腔静脉，它们在胸腔内从左上到右下依次成直线排列，其内径大小也是逐渐的 降低，最大的是主肺动脉，而上腔静脉内径最小(图7)。在这个切面上，重要 的一点是我们应该看到RV是位于左侧，分叉的PA也是消失于胎儿的左侧，并且 是位于Ao的左侧。在三血管切面上，LV始于左侧，Ao在PA的后方走形于左侧 PA和右侧的SVC之间。因此在这5个短轴切面上，Ao 和PA也会死呈交叉状态。 当发生大动脉转位时，很重要的一点就是在三血管切面上，PA起源于LV，而位 于中央的Ao则是起源于RV，因此这两条血管是没有交叉的。 FIGURE 6. The 5 short-axis views for optimal fetal heart screening. The image shows the trachea, heart and great vessels, liver, and stomach, with the 5 planes of insonation superimposed. Polygons show the angle of the transducer and are assigned to the relevant gray-scale images. (I) The most caudal plane, showing the fetal stomach and a cross-section of the AO, SP, and LI. (II) The 4-chamber view of the fetal heart, showing the RV and LV and atria (RA and LA), FO, and PV to the right and left sides of the AO. (III) The 5-chamber view, showing the AO, LVs, RVs, and atria (LA and RA) and a cross-section of the descending aorta (AO with arrow). (IV) The slightly more cephalad view showing the MPA and the bifurcation of LPA and RPA and cross-sections of the ascending and descending aorta (AO and AO with arrow, respectively). (V) The 3 vessel tracked plane of insonation showing the P, ((P)Ao), DA, ((D)Ao), SVC, and T. AO indicates aorta; LA, left atrium; DA, ductus arteriosus; (I) AO, abdominal aorta; SP, spine; LI, liver; LT, left; RT, right; (II) FO, foramen ovale; PV, pulmonary veins; AO, aorta; (III) AO, aortic root; MPA, main PA; LPA, left PA; RPA, right PA; (V) P, pulmonary trunk; ((P)Ao), proximal aorta; ((D)Ao), distal aorta; T, trachea. Adapted from Yagel et al. 胎儿心脏检查最佳的5个短轴切面。图像中显示了气管、心脏和大动脉、图6. 肝脏和胃，以及5个超声检查时的扫查平面。多边形指示的是指定的相关灰阶图 像检查时探头的角度。(I)最尾端的平面，显示的是胎儿胃泡以及腹主动脉、脾 脏和肝脏的横断面。(II)胎儿的四腔心切面，显示的是RV和LV以及心房(RA 和LA)、卵圆孔和Ao左右侧的肺静脉。(III)五腔心切面，显示的是主动脉根 部、LV、RV、心房(RA和LA)以及降主动脉的横断面。(IV)稍稍移向头端的切 面，显示的是主肺动脉和左右肺动脉的分叉，以及升主动脉和降主动脉的横断面。 (V)三血管平面显示肺动脉干、近端主动脉、动脉导管和远端主动脉、上腔静 脉以及气管。 FIGURE 7. Five normal short-axis cardiac views. A, This is after obtaining a view of the stomach (ST) to determine the situs. B, The 4-chamber view of the heart is obtained. C, The transducer is moved cephalad to obtain a 5-chamber view of the heart, with the aorta noted centrally. Note that although the RV is right sided, the arrows indicate that the PA will cross the aorta to lie on the left side on more cephalad views. D, With a continual motion, the aorta is noted centrally, with bifurcation of the PA. The top of the right atrium with a junction of the SVC is shown on the other side of the aorta. E, A cephalad position shows the 3 vessels (PA, AO, and SVC). AO indicates aorta. Adapted from McGahan et al. 图7. 5个正常的心脏短轴切面。A，经胃泡的切面可以明确内脏的位置;B，四 腔心切面;C，探头向头侧移动后显示的五腔心切面，主动脉位于中央。尽管RV 是在右侧，但如箭头所指示的，与Ao十字交叉的PA其实在更为接近头侧的切面 上是位于左侧;D，探头接着向头侧移动，我们就可以看到位于中央的Ao和分叉 的PA，而与RA顶端相连的SVC则是位于Ao的另一侧;E，显示三条血管(PA， Ao和SVC)。 Examples of Abnormalities 心脏异常的诊断示例 This section will be a brief review of abnormalities that can be appreciated using the 4-chamber view of the heart, the classic out,ow tract views, and the 5 short-axis views of the heart. 在这一部分我们主要来看一下能通过四腔心切面、典型的流出道切面和5个短轴 切面而能鉴别的心脏异常。 Four-chamber views were viewed as PASSSS, and when using the mnemonic to help understand the basic heart, cardiac features are evaluated considering position, axis, size, symmetry, septum, and squeeze. Examples of abnormalities include the following. 四腔心切面上我们可以使用PASSSS记忆法来理解心脏的基本结构，包括心脏的 位置、轴向、大小、对称性、间隔以及节律。 The PASSSS Mnemonic PASSSS记忆法 The heart should be on the same side as the fetal stomach. Abnormal position of the heart within the thorax may be secondary to situs inversus. In addition, the heart may be more midline with situs ambiguous. In this situation, it is important to check the cardiac axis and the position of the liver in the abdomen. In addition, masses within the thorax may displace the heart into abnormal position. In Figure 8, a large left congenital diaphragmatic hernia displaced the heart into the right thorax. There was also an endocardial canal in this fetus with trisomy 21 (Fig. 8). 正常情况下，心脏和胎儿胃泡位于同一侧。心脏在胸腔内位置的异常可以是继发 于内脏反位，另外在内脏不定位时心脏可能会位于中间位，在这时我们需要重点 观察心脏的轴向和肝脏在腹腔内的位置。此外，胸腔内的肿瘤也可以将心脏挤压 到异常位置。在图8中，一个巨大的左侧的先天性隔疝将心脏挤压到右侧胸腔， 这个胎儿还存在心内通道和21三体(图8)。 FIGURE 8. Congenital diaphragmatic hernia. Note that the heart is displaced to the right of the midline (solid line) from the congenital diaphragmatic hernia. Also note the "T’’ appearance to the mitral valve and the tricuspid valve insertion (arrows) in this case with AV canal defect. 图8.先天性隔疝。心脏被挤压到中线(图中的实线)的右侧，同时我们也可以 看到这例房室管缺损的病例中二尖瓣和三尖瓣的附着点呈“T”型(箭头)。 Axis 轴向 As the 4-chamber view of the heart is obtained, the interventricular septum should intersect at approximately 45 degrees at a line drawn from the spine to the sternum. In the example of hypoplastic left side of the heart, the interventricular septum intersects the line drawn from the spine to the sternum at approximately 90 degrees (Fig. 9). This example also demonstrates asymmetry of the size of the left ventricle and the atrium as compared with that of the right ventricle and the atrium. These 2 clues are helpful in the diagnosis of the hypoplastic left heart syndrome (Fig. 9). 在四腔心切面上，室间隔与脊柱胸骨线呈45?角，而左心发育不良的病例中室 间隔与脊柱胸骨线成角可接近90?(图9)，并且在这样的病例中左心室和左心 房的大小与右心室和右心房的大小是不对称的，这两个征象有助于诊断左心发育 不良综合征(图9)。 On other views, it was noted that the aortic out,ow was much smaller ed in the hypoplastic left side than that of the PA, which is identi, of the heart. 在其他的切面上我们也可以看到主动脉流出道要比肺动脉流出道小很多，这也可 以鉴别左心发育不良。 FIGURE 9. Hypoplastic left heart syndrome. A, Diagram demonstrating the hypoplastic left side of the heart, which may involve the very small LV and the abnormal aortic valve and ((P)Ao). B, Four-chamber view of the heart demonstrating discrepancy in size of the RV compared with that of the very small LV. Also note the abnormal axis of interventricular septum (arrows). 图9.左心发育不良综合征。A，左心发育不良的示意图，显示左心室缩小，主动 脉瓣和主动脉根部异常。B，四腔心切面显示左右心室不对称，左心室非常小， 同时也可以看到室间隔轴向异常(箭头)。 Size 大小 In general, the fetal heart can normally fit into the fetal thorax. In this example of the left ventricular aneurysm with surrounding pericardial effusion, the heart and the effusion occupy nearly half of the fetal thorax (Fig. 10). 通常情况下，胎儿的心脏与胎儿胸前的比例正常匹配，当出现左室室壁瘤合并心 )。 包积液时，心脏和积液几乎会占据整个胸前的一半(图10 Thus, observation of the pericardial effusion and the large heart-effusion complex would be initial clues for diagnosis. Color flow was helpful in demonstrating the defect in the apex of the left ventricle corresponding to the left ventricular aneurysm (Fig. 10). 因此，心包积液以及心脏增大合并积液的出现时诊断的最初线索，彩色血流有助 于发现左心室心尖部的缺损，这与左室室壁瘤相符(图10)。 FIGURE 10. Left ventricular aneurysm. A, There is a pericardial effusion surrounding the heart (arrow). Note the defect in the apex of the LV (open arrow). B, The color flow demonstrates blood flow from the LV into this aneurysm of the LV. 4CH indicates 4-chamber view. Adapted from El Kady et al. 图10. 左室室壁瘤。A，心脏周围存在心包积液(箭头)，可以在左室心尖部发 现有缺损(开放的箭头);B，彩色血流显示血流从左室进入左室室壁瘤内。 Symmetry 对称性 Symmetry refers to the size of the ventricles. Generally, the diameters of the right and the left ventricles are approximately a 1:1 ratio. As noted in Figure 9, in the hypoplastic left side of the heart, the left ventricle was much smaller than the right ventricle. Alternatively, in Figure 11 showing tricuspid atresia, there is marked discrepancy in size, with the right ventricle being much smaller than the left ventricle. In this example of tricuspid atresia, there is an association with VSD, identi,ed with color ,ow (Fig. 11). 对称性是指的心室的大小。通常情况下，左右心室直径的比例约为1:1。就如 我们在图9中所看到的一样，心脏左侧发育不全，左心室比右心室要小很多。同 样，在图11中显示的是由于三尖瓣闭锁导致左右心室明显的比例失衡，右心室 比左心室小很多。在这例三尖瓣闭锁中还存在室间隔缺损，彩色血流可以证实(图 11)。 FIGURE 11. A-C, Tricuspid atresia with VSD. A, Corresponding line drawing of tricuspid with VSD. B, The color Doppler ultrasound again demonstrates small RV as compared with LV. The color Doppler demonstrates the VSD. C, This 4-chamber view of the heart demonstrates a small RV as compared with the larger LV. Also note the small VSD (arrow). 图11.A-C 三尖瓣闭锁合并室间隔缺损。A，示意图;B，彩色多普勒超声显示右 心室比左心室小，同时也发现有VSD;C，四腔心切面显示右心室比左心室小， 同时也存在小的VSD(箭头)。 In Figure 12, there is some discrepancy in the size of the lumen of the right ventricle as compared with the size of the lumen of the left ventricle. This is an example of cardiac rhabdomyoma with associated thickening of the left ventricular wall. Usually, the right ventricle moderator band is thickened as compared with structures within the left ventricle. However, in this example, there is asymmetry in the lumen of the left ventricle as compared with the lumen of the right ventricle because of the associated cardiac rhabdomyoma. This is often associated with tuberous sclerosis. 在图12中左右心室的内径存在一些比例失调，这是一例心脏横纹肌瘤的病例， 左心室室壁增厚。通常情况下，右心室的调节束与左心室的结构相比比较的厚， 然而在这个病例中，因为存在心脏横纹肌瘤从而导致左右心室内径比例失调，这 种病变经常合并有结节性硬化。 FIGURE 12. Rhabdomyoma of the heart. Four-chamber view of the heart demonstrates a well-circumscribed mass arising from the interventricular septum and protruding into the LV (arrow) corresponding to cardiac rhabdomyoma in this fetus with tuberous sclerosis. Note the thickening of the LV wall (curved arrow). 图12 心脏横纹肌瘤。 四腔心切面显示肿块边界清晰，来源于室间隔并且向左 心室内凸起(箭头)，符合心脏横纹肌瘤，胎儿还存在结节性硬化症。我们还可 以看到左心室室壁增厚(弯曲箭头)。 Septum 间隔 The evaluation of septal defects can be done best on the 4-chamber view of the heart. However, the interventricular septum may also be visualized on the LVOT. In Figure 13, there is a small VSD, which is much more dif,cult to appreciate on real-time images than with the use of color ,ow. This is an isolated VSD. Often, VSDs may be associated with more complex cardiac anomalies, as identi,ed in Figure 11 showing tricuspid atresia with associated VSD. 检查间隔缺损时最好是在四腔心切面，然而在左室流出道也可以显示室间隔。图 13中我们可以看到一个较小的VSD，在实时状态下要比彩色血流模式下难以发 现，这是一个单发的VSD。通常，室间隔缺损会合并有其他心脏异常，就像图11 中所显示的三尖瓣闭锁合并VSD。 Use of the PASSSS mnemonic is helpful for the basic examination of the 4-chamber view of the heart and may be helpful for the detection of complex cardiac anomalies, as outlined earlier. 运用PASSSS记忆法在进行基本的四腔心检查时很有用处，并且对于复杂心脏畸 形有很有帮助，如上所述。 FIGURE 13. A and B, Small VSD. A, Real-time image showing small VSD (curved arrow). B, This is better identi,ed using color Doppler (curved arrow). 图13. 小型室间隔缺损。 A，实时状态显示较小的VSD(弯曲箭头);B，在彩色 多普勒模式下能更好的显示(弯曲箭头)。 Out,ow Tract Views 流出道切面 Using a routine out,ow tract views, conotruncal anomalies may be detected. In Figure 14, TGA is identi,ed because the aorta and the PA are parallel. On routine fetal cardiac examination, the PA should be noted to cross the aorta, and if this is not observed, then this may be a clue for conotruncal abnormalities (Fig. 14). Furthermore, when using out,ow track views, it is imperative that the vessel originating from the right ventricle is noted to bifurcate to ensure that this is the PA. In Figure 15, the vessel originating from the left ventricle is noted to bifurcate. This is the PA originating from the left ventricle as associated with TGA. As this view resembles the open mouth of a baby bird’s beak, this has been called the baby bird’s beak view. It is critical to note both the crisscross relationship of the PA and the aorta and the PA bifurcation. 通过常规流出道切面有时就可以发现圆锥动脉干畸形，在图14中由于主动脉和 肺动脉平行排列我们可以确定是TGA。常规胎儿心脏检查时我们应该注意到肺动 脉与主动脉是交叉走行，如果看不到这种走行就可能提示是圆锥动脉干畸形(图 14)。此外，在进行流出道切面检查时务必要观察从右心室起源的血管是不是存 在分叉从而确定是否为肺动脉。在图15中，起源于左心室的血管存在分叉，说 明肺动脉起源于左心室，符合TGA。由于这个切面看上去像是一个小鸟张开的嘴， 因此被称为小鸟嘴切面。在流出道切面上我们一定要注意肺动脉与主动脉的交叉 关系以及肺动脉的分成情况。 In situations in which this relationship cannot be demonstrated because of technical factors, then 5 short-axis views of the heart should be obtained (Fig. 7). In the 5 short-axis views of the heart, the right ventricle is noted to originate from the right side of the heart, with the pulmonary crossing the aorta to the left side of the thorax. The PA is also noted to bifurcate in the 5 short-axis views. In the 3-vessel view, the PA is larger, and the aorta lies centrally between the PA and the SVC. 如果由于技术上的原因不能显示两者的关系的话，我们应该找到心脏的5个短轴 切面(图7)。在这5个短轴切面上，我们应该注意到右心室位于心脏的右侧， 肺动脉与主动脉交叉向胸腔的左侧走行，在这5个短轴切面上也应该注意到肺动 脉的分叉。在三血管平面上，肺动脉比主动脉大，而主动脉则位于肺动脉和上腔 静脉中间。 Another example of an abnormal outflow tract could include truncal arteriosus. There are different types of truncal arteriosus, but most commonly, the trunk overrides the interventricular septum with an associated VSD, as seen in Figure 16. Other complex cardiac abnormalities may be identified in outflow tract views including tetralogy of Fallot and similar overriding aorta with associated VSD and small pulmonary outflow tract (Fig. 17). 另一个流出道异常包括动脉干，它有多种类型，但最常见的是动脉干骑跨室间隔 合并室间隔缺损(图16)。在流出道切面上还可以发现其他的复杂性心脏畸形， 包括法四、类似的主动脉骑跨合并室间隔缺损和肺流出道缩窄(图17)。 FIGURE 14. A and B, Transposition of the great arteries. A, Diagram shows transposition of the great vessels, with the aorta originating from the RV and the PA originating from the LV. B, An out,ow view show s the parallel course of the aorta and the PA rather than the normal perpendicular course of these vessels. AO, aorta. Adapted from 14A courtesy of Dr Gregory DeVore. 图14 A和B，大动脉转位。A，大动脉转位的示意图，主动脉与RV相连，肺动 脉与LV相连。B，流出道切面显示主动脉和肺动脉平行走行而不是正常的垂直走 行。 FIGURE 15. Transposition of the great arteries. A, This scan shows the PA originating from the LV. B, The PA bifurcation is shown, and the left branch of PA makes a sharp angle with the main PA and DA, reminiscent of a baby bird’s head with an open beak. Normally, the aorta exiting the LV should be traced to the aortic arch. The SP is to the left of the image, and the left side of the fetus is toward the transducer. Adapted from McGahan et al. 图15 大动脉转位。A，图像显示肺动脉与LV相连;B，图像显示肺动脉分叉， 左肺动脉与主肺动脉和降主动脉呈锐角，呈现为小鸟的头部和张开的嘴。正常情 况下，主动脉与LV相连并延续为主动脉弓。脾脏位于图像左侧，胎儿的左侧朝 向探头。 FIGURE 16. Truncus arteriosus. A, Diagram of truncus arteriosus with VSD. B, A single large vessel (T) is identi,ed arising from the base of the heart. It overrides the VSD (arrow). 图16 动脉干畸形。A，动脉干畸形合并VSD的示意图;B，图像显示有一条大血 管(T)起源于心脏底部，骑跨缺损的室间隔(箭头)。 FIGURE 17. Tetralogy of Fallot. The long-axis view of the heart demonstrates a large aorta (AO) overriding the VSD (arrow). The PA is small. 图17 法四。心脏长轴切面显示扩张的主动脉(Ao)骑跨缺损的室间隔(箭头)， 肺动脉缩窄。 FIGURE 18. Three-dimensional multiplanar imaging. Three-dimensional images of the heart are obtained as reconstructed images from the data set, with the cursor placed on the ((P)Ao). (Special thanks to Beryl Benacerraf, MD). 图18 三维多平米图像。光标置于主动脉近端时心脏的三维重建图像。 More Advanced Cardiac Imaging 进一步的心脏超声检查 More advanced cardiac imaging can include 3-D or 4-D multiplanar imaging. This technology enables the physician or the examiner to have an unlimited number of 2-D images from the single acquisition. Thus, not only 4-chamber and 5-chamber views but also other cardiac views maybe obtained in different planes. The data set images are usually dis played as 3 simultaneous images onto a single display (Fig. 18). To best use this technology, one must be familiar with the basic extended cardiac examination and the 5 short-axis views of the heart. 心脏的进一步的超声检查包括三位和四维多平面检查，这种技术可以让临床医生 或检查者通过一次的采集获取无限数量的二维图像，因此通过这种技术不仅可以 获取四腔心和五腔心切面，而且还可以获取其他的心脏切面，通常在一个显示界 面上显示3个同时的图像(图18)。为了能最大限度的应用这种技术，我们必 须熟悉基本的心脏检查和5个短轴切面。 dimensional/4-D rendered images can be displayed surface-renderThree- ed images of the heart. The examiner can display the surface anatomy of the heart. This technology may be useful to detect conotruncal abnormalities, as in Figure 19A showing a normal examination compared with TGA (Fig. 19B). 三维/四维图像重建可以显示重建的心脏外形，检查者可以显示心脏畸形的外观， 这种技术可以用来发现圆锥动脉干畸形，就象图19A显示的正常心脏和图19B 显示的大动脉转位。 FIGURE 19. Power Doppler. A, Four-dimensional power Doppler showing normal crisscross of the aorta (AO) and the PA (arrow). B, Four-dimensional power Doppler showing parallel AO and PA in the transposition of the great arteries. (Special thanks to Gregory Devore, MD). 图19 能量多普勒。A，四维能量多普勒显示正常的主动脉和肺动脉交叉(箭头B， 四维能量多普勒显示大动脉转位时的主动脉和肺动脉平行走行。