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Masaoka S, Yamamoto Y, Takano M, Nagasaki S, Takahashi K, Nakata M, Itakura A. Sensitive detection of hemodynamic changes after fetoscopic laser photocoagulation by assessing intraventricular pressure difference in fetuses with twin-to-twin transfusion syndrome. J Perinat Med 2024; 0:jpm-2024-0147. [PMID: 39118408 DOI: 10.1515/jpm-2024-0147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 07/20/2024] [Indexed: 08/10/2024]
Abstract
OBJECTIVES To assess the hemodynamics of twin-to-twin transfusion syndrome (TTTS), we measured the intraventricular pressure difference (IVPD), a sensitive marker of myocardial diastolic function, using fetal echocardiography. METHODS We included 28 monochorionic diamniotic (MD) twins diagnosed with TTTS who underwent fetoscopic laser photocoagulation (FLP) between 2018 and 2022. Color M-mode Doppler images of both cardiac ventricles were obtained before and after FLP. According to this evaluation, the IVPDs were divided into three groups; those with total, basal, and mid-apical IVPD. RESULTS Of the 28 twins, 21 were available for analysis (including eight, eight, three, and two cases in stages Quintero Ⅰ, Ⅱ, Ⅲd, and Ⅲr, respectively). Comparing the pre and postFLP results, significant increases in total and mid-apical IVPD in the left ventricle (LV) of recipient twins were noted (total and mid-apical IVPD: p=0.026 and 0.013, respectively). In the LV of the donor twins, all IVPDs were significantly increased after FLP (total, basal, and mid-apical IVPD: p=0.003, 0.001, and 0.022, respectively). In addition, comparisons between the donor and recipient groups did not show significant differences in either ventricle before FLP. CONCLUSIONS IVPD detected subtle hemodynamics changes, such as volume overload and diastolic dysfunction in TTTS before and after FLP. Therefore, IVPD may be a useful marker for monitoring myocardial diastolic function in TTTS.
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Affiliation(s)
- Shun Masaoka
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Yuka Yamamoto
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Mayumi Takano
- Department of Obstetrics and Gynecology, Faculty of Medicine, Toho University, Ota-ku, Tokyo, Japan
| | - Sumito Nagasaki
- Department of Obstetrics and Gynecology, Faculty of Medicine, Toho University, Ota-ku, Tokyo, Japan
| | - Ken Takahashi
- Department of Pediatrics, Juntendo University Urayasu Hospital, Urayasu, Chiba, Japan
| | - Masahiko Nakata
- Department of Obstetrics and Gynecology, Faculty of Medicine, Toho University, Ota-ku, Tokyo, Japan
| | - Atsuo Itakura
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
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Jiang Y, Qiao X, Liao H, Luo H. Evaluation of the efficacy of intrauterine treatments of twin-to-twin transfusion syndrome using myocardial performance index. Quant Imaging Med Surg 2024; 14:5621-5629. [PMID: 39144042 PMCID: PMC11320544 DOI: 10.21037/qims-23-1669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 06/25/2024] [Indexed: 08/16/2024]
Abstract
Background Prognosis of twin-to-twin transfusion syndrome (TTTS) varies depending on the Quintero stage and fetal cardiac function. The purpose of our study was to evaluate fetal cardiac function before and after different intrauterine treatments of TTTS through myocardial performance index (MPI). Methods In this retrospective study, data were collected from August 2016 to December 2022. Totals of 68 cases of TTTS and 68 monochorionic diamniotic (MCDA) twins without TTTS were included. MPI was collected and compared between TTTS and MCDA twins without TTTS before intrauterine treatments. TTTS cases were divided into 3 groups according to different intrauterine treatments: (I) amnioreduction (34 cases), (II) fetoscopic laser photocoagulation (FLPC; 20 cases), and (III) selective reduction (14 cases). The MPI of the left ventricle (LV) and right ventricle (RV) in each surviving fetus were measured 48 hours before and after treatments by pulse Doppler ultrasound. One-way analysis of variance (ANOVA) was employed to assess whether there were statistical differences in LV-MPI and RV-MPI among the donors, recipients, and the control group. Paired t-test analysis was used to compare whether there were differences in MPI before and after intrauterine treatments. Results The MPIs of the LV and RV in the recipients were significantly higher than those in the MCDA twins without TTTS (P<0.05). After the amnioreduction treatment of TTTS, no significant differences were observed in the MPI of either the LV or the RV before and after treatment. At 48 hours after FLPC treatment, the value of the LV-MPI in donors was 0.25±0.08, and the value of the RV-MPI in recipients was 0.58±0.17. Both of them were significantly lower than those before the treatment (P<0.05). In the selective reduction group, the value of the RV-MPI in surviving recipients significantly decreased compared to that before treatment (P<0.05). Conclusions MPI is an effective indicator to evaluate fetal cardiac function of TTTS and assess the efficacy of intrauterine treatments of TTTS.
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Affiliation(s)
- Yu Jiang
- Department of Ultrasound, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Xiaoyong Qiao
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
- Department of Reproductive Medicine, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Hua Liao
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
- Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Hong Luo
- Department of Ultrasound, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
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Mustafa HJ, Jawwad M, Iqbal Mansoor A, Pagani G, D'Antonio F, Khalil A. Right ventricular outflow tract obstruction in twin-to-twin transfusion syndrome undergoing laser surgery: A systematic review and meta-analysis. Acta Obstet Gynecol Scand 2024; 103:1513-1521. [PMID: 38482999 PMCID: PMC11266639 DOI: 10.1111/aogs.14825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 11/24/2023] [Accepted: 02/01/2024] [Indexed: 07/25/2024]
Abstract
INTRODUCTION We aimed to investigate the incidence, prenatal factors and outcomes of twin-to-twin transfusion (TTTS) with right ventricular outflow tract obstruction (RVOTO). MATERIAL AND METHODS A systematic search was conducted to identify relevant studies published until February 2023 in English using the databases PubMed, Scopus and Web of Science. Studies reporting on pregnancies with TTTS and RVOTO were included. The random-effect model pooled the mean differences or odds ratios (OR) and the corresponding 95% confidence intervals. Heterogeneity was assessed using the I2 value. RESULTS A total of 17 studies encompassing 4332 TTTS pregnancies, of which 225 cases had RVOTO, were included. Incidence of RVOTO at time of TTTS diagnosis was 6%. In all, 134/197 (68%) had functional pulmonary stenosis and 62/197 (32%) had functional pulmonary atresia. Of these, 27% resolved following laser and 55% persisted after birth. Of those persisting, 27% required cardiac valve procedures. Prenatal associations were TTTS stage III (53% vs 39% in no-RVOTO), stage IV TTTS (28% in RVOTO vs 12% in no-RVOTO) and ductus venosus reversed a-wave (60% in RVOTO vs 19% in no-RVOTO). Gestational age at laser and gestational age at delivery were comparable between groups. Survival outcomes were also comparable between groups, including fetal demise of 26%, neonatal death of 12% and 6-month survival of 82% in RVOTO group. Findings were similar when subgroup analysis was done for studies including head-to-head analysis. CONCLUSIONS RVOT occurs in about 6% of the recipient twins with TTTS, especially in stages III and IV and those with reversed ductus venosus a-wave. The findings from this systematic review support the need for a thorough cardiac assessment of pregnancies complicated by TTTS, both before and after laser, to maximize perinatal outcome, and the importance of early diagnosis of TTTS and timely management.
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Affiliation(s)
- Hiba J. Mustafa
- Division of Maternal‐Fetal MedicineIndiana University School of MedicineIndianapolisIndianaUSA
- The Fetal Center at Riley Children's and Indiana University HealthIndianapolisIndianaUSA
| | - Muhammad Jawwad
- Department of Medicine and SurgeryDow University of Health and SciencesKarachiPakistan
| | - Ayesha Iqbal Mansoor
- Department of Medicine and SurgeryDow University of Health and SciencesKarachiPakistan
| | - Giorgio Pagani
- Maternal Fetal Medicine Unit, Department of Obstetrics and Gynecology, ASST‐Papa Giovanni XXIIIBergamoItaly
| | - Francesco D'Antonio
- Center for Fetal Care and High‐Risk Pregnancy, Department of Obstetrics and GynecologyUniversity Hospital of ChietiChietiItaly
| | - Asma Khalil
- Fetal Medicine Unit, St George's HospitalSt George's University of LondonLondonUK
- Vascular Biology Research center, Molecular and Clinical Sciences Research Institute, St George's University of LondonLondonUK
- Twins Trust center for Research and Clinical Excellence, St George's University of LondonLondonUK
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Noll ATR, Gijtenbeek M, Verweij EJTJ, Lewi L, Herling L, Haak MC. Cardiac adaptation and malformation in twin-twin transfusion syndrome and selective fetal growth restriction: A systematic review. Prenat Diagn 2024; 44:832-845. [PMID: 38643403 DOI: 10.1002/pd.6575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/04/2024] [Accepted: 04/05/2024] [Indexed: 04/22/2024]
Abstract
OBJECTIVES This systematic review explores cardiac adaptation in monochorionic (MC) twins with twin-twin transfusion syndrome (TTTS) or selective fetal growth restriction (sFGR) and assesses the risk of congenital heart defects (CHDs). METHODS Adhering to PRISMA guidelines, 63 studies were reviewed (49 on cardiac adaptation, 13 on CHD, one on both). A narrative synthesis of cardiac adaptation patterns was performed. Additionally, a meta-analysis compared the livebirth prevalence of CHD in TTTS and sFGR against uncomplicated MC twins. RESULTS In TTTS recipients, cardiac function may be impaired for diastolic, systolic, as well as global functions, while in donors, cardiac function is generally preserved. In sFGR, large twins may show hypertrophic cardiomyopathy, and small twins may show impaired systolic function. Co-occurrence of TTTS and sFGR magnifies cardiac impact but is often underreported. Meta-analysis for CHD prevalence revealed a relative risk ratio of 3.5 (95% CI: 2.5-4.9) for TTTS and 2.2 (95%CI: 1.3-3.5) for sFGR compared with uncomplicated MC twins. CONCLUSIONS This study highlights the well-documented cardiac adaptation in TTTS, contrasting with limited understanding in sFGR. Elevated CHD risks were observed in both conditions. Enhanced cardiovascular surveillance is warranted in complicated MC twin pregnancies. Future research should explore cardiac adaptation in sFGR and its long-term consequences.
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Affiliation(s)
- Anne T R Noll
- Department of Obstetrics and Gynecology, Division of Fetal Therapy, Leiden University Medical Center, Leiden, The Netherlands
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Center for Fetal Medicine, Pregnancy Care and Delivery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Manon Gijtenbeek
- Department of Obstetrics and Gynecology, Division of Fetal Therapy, Leiden University Medical Center, Leiden, The Netherlands
| | - E J T Joanne Verweij
- Department of Obstetrics and Gynecology, Division of Fetal Therapy, Leiden University Medical Center, Leiden, The Netherlands
| | - Liesbeth Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Lotta Herling
- Center for Fetal Medicine, Pregnancy Care and Delivery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Monique C Haak
- Department of Obstetrics and Gynecology, Division of Fetal Therapy, Leiden University Medical Center, Leiden, The Netherlands
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Schroeder L, Soltesz L, Leyens J, Strizek B, Berg C, Mueller A, Kipfmueller F. Vasoactive Management of Pulmonary Hypertension and Ventricular Dysfunction in Neonates Following Complicated Monochorionic Twin Pregnancies: A Single-Center Experience. CHILDREN (BASEL, SWITZERLAND) 2024; 11:548. [PMID: 38790543 PMCID: PMC11120423 DOI: 10.3390/children11050548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 04/26/2024] [Accepted: 05/01/2024] [Indexed: 05/26/2024]
Abstract
OBJECTIVES Twins resulting from a complicated monochorionic (MC) twin pregnancy are at risk for postnatal evolution of pulmonary hypertension (PH) and cardiac dysfunction (CD). Both pathologies are important contributors to short- and long-term morbidity in these infants. The aim of the present retrospective single-center cohort study was to evaluate the need for vasoactive treatment for PH and CD in these neonates. METHODOLOGY In-born neonates following a complicated MC twin pregnancy admitted to the department of neonatology of the University Children's Hospital Bonn (UKB) between October 2019 and December 2023 were screened for study inclusion. Finally, 70 neonates were included in the final analysis, with 37 neonates subclassified as recipient twins (group A) and 33 neonates as donor twins (group B). RESULTS The overall PH incidence at day of life (DOL) 1 was 17% and decreased to 6% at DOL 7 (p = 0.013), with no PH findings at DOL 28. The overall incidence of CD was 56% at DOL 1 and decreased strongly until DOL 7 (10%, p = 0.015), with no diagnosis of CD at DOL 28. The use of dobutamine, norepinephrine, and vasopressin at DOL 1 until DOL 7 did not differ between the subgroups, whereas the dosing of milrinone was significantly higher in Group B at DOL 1 (p = 0.043). Inhaled nitric oxide (iNO) was used in 16% of the cohort, and a levosimendan therapy was administered in 34% of the neonates. One-third of the cohort was treated with oral beta blockers, and in 10%, an intravenous beta blockade (landiolol) was administered. The maximum levosimendan vasoactive-inotropic score (LVISmax) increased from DOL 1 (12.4 [3/27]) to DOL 2 (14.6 [1/68], p = 0.777), with a significant decrease thereafter as measured at DOL 7 (9.5 [2/30], p = 0.011). CONCLUSION Early PH and CD are frequent diagnoses in neonates following a complicated MC twin pregnancy, and an individualized vasoactive treatment strategy is required in the management of these infants.
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Affiliation(s)
- Lukas Schroeder
- Department of Neonatology and Pediatric Intensive Care Medicine, University Children’s Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany (F.K.)
| | - Leon Soltesz
- Department of Neonatology and Pediatric Intensive Care Medicine, University Children’s Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany (F.K.)
| | - Judith Leyens
- Department of Neonatology and Pediatric Intensive Care Medicine, University Children’s Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany (F.K.)
| | - Brigitte Strizek
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Christoph Berg
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, 53127 Bonn, Germany
- Division of Prenatal Medicine and Gynecologic Sonography, Department of Obstetrics and Gynecology, University of Cologne, 50931 Cologne, Germany
| | - Andreas Mueller
- Department of Neonatology and Pediatric Intensive Care Medicine, University Children’s Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany (F.K.)
| | - Florian Kipfmueller
- Department of Neonatology and Pediatric Intensive Care Medicine, University Children’s Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany (F.K.)
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Ezazi Bojnordi T, Eslamian L, Marsoosi V, Golbabaei A, Sheikh Vatan M, Shamshirsaz AA, Eshraghi N, Ghaemi M. Doppler Finding, Cardiovascular Function Assessment, and Fetuses' Survival Following the Fetoscopic Laser in Twin-to-Twin Transfusion Syndrome. J Lasers Med Sci 2023; 14:e64. [PMID: 38318221 PMCID: PMC10843211 DOI: 10.34172/jlms.2023.64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 10/08/2023] [Indexed: 02/07/2024]
Abstract
Introduction: This study aimed to evaluate the effectiveness of selective laser photocoagulation of communicating vessels (SLPCV) on cardiac function in twins with twin-to-twin transfusion syndrome (TTTS). Methods: This retrospective cohort study evaluated 178 women with twin pregnancies complicated with TTTS and scheduled for SLPCV between 16 and 26 weeks of gestation. The severity of TTTS was determined by Quintero staging and the severity of cardiovascular disorders by the CHOP (Children's Hospital of Philadelphia) score. Patient survival was evaluated through a one-month-after-birth follow-up of fetuses. Results: The study revealed significant improvements in Doppler indices in both donors and recipients after SLPCV. The CHOP score also significantly decreased after the intervention. One-month-after-birth survival rates were 55.1% in donors and 56.7% in recipients. Some Doppler indexes of fetuses before SLPCV could predict survival until one month after birth. Conclusion: The study suggests that SLPCV can improve cardiac function in fetuses with TTTS and that some Doppler indexes can predict survival outcomes. Additionally, the severity of TTTS can be a powerful indicator of the severity of cardiovascular complications.
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Affiliation(s)
- Tahmineh Ezazi Bojnordi
- Department of Obstetrics and Gynecology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Laleh Eslamian
- Department of Obstetrics and Gynecology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Vajiheh Marsoosi
- Department of Obstetrics and Gynecology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Golbabaei
- Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehrdad Sheikh Vatan
- Department of Obstetrics and Gynecology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza A. Shamshirsaz
- Maternal Fetal Care Center, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Nasim Eshraghi
- Vali-E-Asr Reproductive Health Research Center, Family Health Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Marjan Ghaemi
- Vali-E-Asr Reproductive Health Research Center, Family Health Research Institute, Tehran University of Medical Sciences, Tehran, Iran
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Virk P, Arora R, Burt H, Finnamore C, Gadermann A, Barbic S, Doan Q. Evaluating the Psychometric Properties and Clinical Utility of a Digital Psychosocial Self-Screening Tool (HEARTSMAP-U) for Postsecondary Students: Prospective Cohort Study. JMIR Ment Health 2023; 10:e48709. [PMID: 37556180 PMCID: PMC10448294 DOI: 10.2196/48709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/08/2023] [Accepted: 06/11/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Existing screening tools for mental health issues among postsecondary students have several challenges, including a lack of standardization and codevelopment by students. HEARTSMAP-U was adapted to address these issues. OBJECTIVE This study aimed to evaluate the suitability of HEARTSMAP-U as a self-screening tool for psychosocial issues among postsecondary students by evaluating its validity evidence and clinical utility. METHODS A prospective cohort study was conducted with University of British Columbia Vancouver students to evaluate HEARTSMAP-U's predictive validity and convergent validity. Participating students completed baseline and 3-month follow-up assessments via HEARTSMAP-U and a clinician-administered interview. RESULTS In a diverse student sample (n=100), HEARTSMAP-U demonstrated high sensitivity (95%-100%) in identifying any psychiatric concerns that were flagged by a research clinician, with lower specificity (21%-25%). Strong convergent validity (r=0.54-0.68) was demonstrated when relevant domains and sections of HEARTSMAP-U were compared with those of other conceptually similar instruments. CONCLUSIONS This preliminary evaluation suggests that HEARTSMAP-U may be suitable for screening in the postsecondary educational setting. However, a larger-scale evaluation is necessary to confirm and expand on these findings.
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Affiliation(s)
- Punit Virk
- School of Population and Public Health, The University of British Columbia, Vancouver, BC, Canada
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Ravia Arora
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Heather Burt
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | | | - Anne Gadermann
- School of Population and Public Health, The University of British Columbia, Vancouver, BC, Canada
- Centre for Health Evaluation and Outcome Sciences, Providence Health, Vancouver, BC, Canada
| | - Skye Barbic
- Centre for Health Evaluation and Outcome Sciences, Providence Health, Vancouver, BC, Canada
- Department of Occupational Science and Occupational Therapy, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Quynh Doan
- School of Population and Public Health, The University of British Columbia, Vancouver, BC, Canada
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
- Department of Paediatrics, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
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8
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Highlights from the International Twins Congress 2021. MATERNAL-FETAL MEDICINE 2022. [DOI: 10.1097/fm9.0000000000000166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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9
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Takano M, Hine K, Nagasaki S, Sakuma J, Shimabukuro M, Kotaki H, Saito K, Ogata K, Yoda H, Nakata M. Different expressions of cardiac biomarkers between different types of acquired right ventricular outflow tract abnormality in monochorionic twins. Prenat Diagn 2022; 42:1448-1457. [PMID: 36081332 DOI: 10.1002/pd.6236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 08/17/2022] [Accepted: 09/05/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To investigate the differences in amniotic fluid cardiac biomarkers and clinical features among types of right ventricular outflow tract (RVOT) abnormality in monochorionic (MC) twins. METHOD This prospective study included MC twins that underwent laser surgery. Recipient or larger twins (group A) and donor or smaller twins (group B) were assessed and divided into those with a normal right ventricular outflow tract (normal RVOT), functional pulmonary atresia (fPA), or pulmonary stenosis (PS). Amniotic fluid levels of NT-proBNP (afNT-proBNP) and cardiac troponin T (afTnT) were examined during surgery. RESULTS Of 190 fetuses in group A, there were 14 RVOT abnormality cases (including 7 fPA and 7 PS). No group B fetuses showed RVOT abnormality findings. In group A, later and earlier gestational age at surgery were observed in fPA (25.1±2.8 weeks) and PS groups (17.8±0.9 weeks). All survived PS cases demonstrated progressive pulmonary valve obstruction, not observed in fPA groups. AfNT-proBNP were significantly higher in fPA and PS than in normal RVOT group (p<0.05). AfTnT was significantly higher in group A with PS than fPA and normal RVOT groups (p<0.05). CONCLUSION Among RVOT abnormality types in group A, amniotic fluid cardiac biomarkers were differently expressed, and clinical features were also differentiated. These findings provide insight into the pathophysiological influence on RVOT in MC twins. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Mayumi Takano
- Department of Obstetrics and Gynecology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Kotaro Hine
- Department of Neonatology, Toho University Faculty of Medicine, Tokyo, Japan.,Department of Neonatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Sumito Nagasaki
- Department of Obstetrics and Gynecology, Toho University Faculty of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, T, oho University Omori Medical Center, Tokyo, Japan
| | - Junya Sakuma
- Department of Obstetrics and Gynecology, Toho University Faculty of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, T, oho University Omori Medical Center, Tokyo, Japan
| | - Makiko Shimabukuro
- Department of Obstetrics and Gynecology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Hikari Kotaki
- Department of Obstetrics and Gynecology, Toho University Faculty of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, T, oho University Omori Medical Center, Tokyo, Japan
| | - Keiko Saito
- Department of Neonatology, Toho University Faculty of Medicine, Tokyo, Japan.,Department of Neonatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Kohei Ogata
- Department of Neonatology, Toho University Faculty of Medicine, Tokyo, Japan.,Department of Neonatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Hitoshi Yoda
- Department of Neonatology, Toho University Faculty of Medicine, Tokyo, Japan.,Department of Neonatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Masahiko Nakata
- Department of Obstetrics and Gynecology, Toho University Faculty of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, T, oho University Omori Medical Center, Tokyo, Japan
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10
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Faiola S, Casati D, Laoreti A, Amendolara M, Consonni D, Corti C, Mannarino S, Lanna M, Rustico M, Cetin I. Right ventricular outflow tract abnormalities in monochorionic twin pregnancies without twin-to-twin transfusion syndrome: Prenatal course and postnatal long-term outcomes. Prenat Diagn 2021; 41:1510-1517. [PMID: 34585412 DOI: 10.1002/pd.6052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 09/12/2021] [Accepted: 09/18/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVES Right ventricular outflow tract abnormalities (RVOTA) have been mostly reported in recipient twins (RT) of monochorionic/diamniotic (MC/DA) twin pregnancies with twin-to-twin transfusion syndrome (TTTS). Aim of the study was to describe RVOTA detected in MC/DA pregnancies without TTTS. METHODS Cases of RVOTA were retrieved from our database among all MC/DA pregnancies without TTTS from 2009 to 2018. RESULTS Out of 891 MC/DA twin pregnancies without TTTS, 14 (1.6%) were associated with RVOTA: 10 pulmonary stenosis (PS), one steno-insufficiency, one insufficiency and two atresia (PA). In 93% of cases (13/14), pregnancy was complicated either by amniotic fluid discrepancy (AFD) or by TAPS or mostly by selective fetal growth restriction (sFGR) (11/13: 85%), involving predominantly (10/11: 91%) the large twin, with high incidence (9/11: 82%) of sFGR and AFD coexistence. Eight out of 14 (57%) survived after the perinatal period (7 PS, 1 PA). Five (62%) underwent pulmonary balloon valvuloplasty, whereas 3 children still showed persistent mild PS at cardiac follow up after 1 year of life. CONCLUSIONS RVOTA can occur in MC/DA pregnancies without TTTS, particularly when other complications coexist. In complicated cases specialized fetal echocardiographic evaluation is recommended during pregnancy; RVOTA cases should be delivered in a tertiary level center, where cardiologists are available.
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Affiliation(s)
- Stefano Faiola
- Fetal Therapy Unit-Umberto Nicolini, Vittore Buzzi Children's Hospital, Milan, Italy.,Department of Women, Mother and Newborn, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - Daniela Casati
- Fetal Therapy Unit-Umberto Nicolini, Vittore Buzzi Children's Hospital, Milan, Italy.,Department of Women, Mother and Newborn, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - Arianna Laoreti
- Fetal Therapy Unit-Umberto Nicolini, Vittore Buzzi Children's Hospital, Milan, Italy.,Department of Women, Mother and Newborn, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - Mariella Amendolara
- Department of Women, Mother and Newborn, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - Dario Consonni
- Epidemiology Unit, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Carla Corti
- Paediatric Cardiology Unit, Vittore Buzzi Children's Hospital, Milan, Italy
| | - Savina Mannarino
- Paediatric Cardiology Unit, Vittore Buzzi Children's Hospital, Milan, Italy
| | - Mariano Lanna
- Fetal Therapy Unit-Umberto Nicolini, Vittore Buzzi Children's Hospital, Milan, Italy.,Department of Women, Mother and Newborn, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - Mariangela Rustico
- Fetal Therapy Unit-Umberto Nicolini, Vittore Buzzi Children's Hospital, Milan, Italy
| | - Irene Cetin
- Department of Women, Mother and Newborn, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
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11
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Abstract
Twin to twin transfusion syndrome (TTTS) is a common complication that typically presents in the second trimester of pregnancy in 10-15% of monochorionic twins due to net transfer of volume and hormonal substances from one twin to the other across vascular anastomoses on the placenta. Without recognition and treatment, TTTS is the greatest contributor to fetal loss prior to viability in 90-100% of advanced cases. Ultrasound diagnosis of monochorionicity is most reliable in the first trimester and sets the monitoring strategy for this type of twins. The diagnosis of TTTS is made by ultrasound with the findings of polyhydramnios due to volume overload and polyuria in one twin and oligohydramnios due to oliguria of the co-twin. Assessment of bladder filling as well as arterial and venous Doppler patterns are required for staging disease severity. Assessment of fetal cardiac function also provides additional insight into the fetal cardiovascular impacts of the disease as well as help identify fetuses that may require postnatal follow up. Fetoscopic laser ablation of the communicating vascular anastomoses between the twins is the standard treatment for TTTS. It aims to cure the condition by interrupting the link between their circulations and making them independent of one another. Contemporary outcome data after laser surgery suggests survival for both fetuses can be anticipated in up to 65% of cases and survival of a single fetus in up to 88% of cases. However, preterm birth remains a significant contributor to postnatal morbidity and mortality. Long term outcomes of TTTS survivors indicate that up to 11% of children may show signs of neurologic impairment. Strategies to minimize preterm birth after treatment and standardized reporting by laser centers are important considerations to improve overall outcomes and understand the long-term impacts of TTTS.
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Affiliation(s)
- Jena L Miller
- The Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD, USA
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12
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Wohlmuth C, Agarwal A, Stevens B, Johnson A, Moise KJ, Papanna R, Donepudi R, Bell CS, Averiss IE, Gardiner HM. Fetal ventricular strain in uncomplicated and selective growth-restricted monochorionic diamniotic twin pregnancies and cardiovascular response in pre-twin-twin transfusion syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:694-704. [PMID: 31682302 PMCID: PMC7702120 DOI: 10.1002/uog.21911] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 10/19/2019] [Accepted: 10/25/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Our primary aim was to confirm whether intertwin discordance in ventricular strain and ductus venosus (DV) time intervals predicts twin-twin transfusion syndrome (TTTS). Secondary aims were to create gestational-age ranges for ventricular strain in uncomplicated monochorionic diamniotic (MCDA) twin pregnancies without selective intrauterine growth restriction (sIUGR) and to characterize the relationship of ventricular strain with gestational age in MCDA twin pregnancies with sIUGR that did not develop TTTS. METHODS In the period 2015-2018, we enrolled 150 MCDA twin pregnancies consecutively into this prospective, blinded study of global longitudinal left and right ventricular strain. With the observer blinded to twin pairing and pregnancy outcome, videoclips of the four-chamber view, which had been recorded during ultrasound surveillance in the usual window for development of TTTS (16-26 completed gestational weeks), underwent offline measurement of strain. Uncomplicated MCDA twin pregnancies, without sIUGR, were used to test the association between strain, gestational age and estimated fetal weight using mixed-effects multilevel regression. Inter-rater reliability was tested in 208 strain measurements in 31 fetuses from pregnancies which did not develop TTTS and within-fetus variation was assessed in 16 such fetuses, in which multiple four-chamber views were taken on the same day. The effect of sIUGR on strain in otherwise uncomplicated MCDA twin pregnancy was analyzed. MCDA twin pregnancies were defined as 'pre-TTTS' when, having been referred for TTTS evaluation, they did not satisfy Quintero staging criteria, but subsequently developed TTTS requiring laser treatment. MCDA pregnancies which did not develop TTTS comprised the 'non-TTTS' group. Cardiovascular parameters measured in these cases included tissue Doppler parameters and DV early filling time as a percentage of the cardiac cycle (DVeT%). Intertwin strain and DVeT% discordance was compared between non-TTTS and pre-TTTS cases, matched for gestational age. RESULTS Paired strain data were available for intertwin comparison in 127/150 MCDA twin pregnancies, comprising 14 pre-TTTS and 113 non-TTTS pregnancies, after exclusions. Scans were collected at a median frame rate of 97 (range, 28-220) Hz. Laser therapy was performed at a median gestational age of 20.6 (range, 17.2-26.6) weeks. There were no group differences in right (RV) or left (LV) ventricular strain discordance between 68/113 non-TTTS and 13/14 pre-TTTS MCDA twin pregnancies < 20 completed gestational weeks (RV, P = 0.338; LV, P = 0.932). DVeT% discordance > 3.6% was found in eight of 13 pre-TTTS pregnancies. In non-TTTS pregnancies, the estimated variability in ventricular strain within each twin during the day was high (RV, 19.7; LV, 12.9). However, within each pair (intertwin variation), variability was low (RV, 5.5; LV, 2.9). Interclass correlation reflecting the proportion of total variability represented by the variability between twin pairs was low (RV, 0.22; LV, 0.18). Both RV (P < 0.001) and LV (P = 0.025) strain showed a negative association with gestational age. Among non-TTTS MCDA twin pregnancies, LV strain was, on average, higher by 1.83 in sIUGR compared with normally grown fetuses (P = 0.023), with no statistically significant difference in RV strain (P = 0.271). CONCLUSIONS Although ventricular strain has been reported previously as a possible predictor of developing TTTS, in this blinded, prospective study, we found no significant intergroup differences in ventricular strain in pre-TTTS compared with age-matched non-TTTS MCDA twin pregnancies. We recommend using DVeT% discordance as a more practical screening tool in MCDA twin pregnancies. This study also provides new information on the changes with gestational age, and the biological and technical variation, of global longitudinal ventricular strain in uncomplicated MCDA twin pregnancies and those with isolated sIUGR. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- C. Wohlmuth
- The Fetal CenterUTHealth McGovern Medical SchoolHoustonTXUSA
- Department of Obstetrics and GynecologyParacelsus Medical UniversitySalzburgAustria
| | - A. Agarwal
- The Fetal CenterUTHealth McGovern Medical SchoolHoustonTXUSA
| | - B. Stevens
- The Fetal CenterUTHealth McGovern Medical SchoolHoustonTXUSA
| | - A. Johnson
- The Fetal CenterUTHealth McGovern Medical SchoolHoustonTXUSA
| | - K. J. Moise
- The Fetal CenterUTHealth McGovern Medical SchoolHoustonTXUSA
| | - R. Papanna
- The Fetal CenterUTHealth McGovern Medical SchoolHoustonTXUSA
| | - R. Donepudi
- The Fetal CenterUTHealth McGovern Medical SchoolHoustonTXUSA
| | - C. S. Bell
- Center for Clinical Research & Evidence‐Based MedicineUTHealth McGovern Medical SchoolHoustonTXUSA
| | - I. E. Averiss
- The Fetal CenterUTHealth McGovern Medical SchoolHoustonTXUSA
| | - H. M. Gardiner
- The Fetal CenterUTHealth McGovern Medical SchoolHoustonTXUSA
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13
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Early postnatal cardiac follow-up of survivors of twin-twin transfusion syndrome treated with fetoscopic laser coagulation. J Perinatol 2020; 40:1375-1382. [PMID: 32152494 DOI: 10.1038/s41372-020-0645-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 02/25/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess the cardiac function and prevalence of congenital heart defects (CHD) in twin-twin transfusion syndrome (TTTS) survivors. STUDY DESIGN Prospective follow-up of TTTS pregnancies treated with laser surgery (2015-2018). Echocardiography was performed 1 day and 1 month after birth (corrected for prematurity). Results were compared with a control group of age-matched uncomplicated monochorionic twin-pairs at 1 month. RESULT Eighty-nine TTTS (168 neonates) and nine control pregnancies (18 neonates) were enrolled. CHD birth prevalence was 9.2% (8/87) in recipients and 13.6% (11/81) in donors (p = 0.37). Four of 19 (21%) were detected prenatally, all pulmonary stenosis. Donors had lower aortic peak velocities compared with recipients at day 1 (0.66 ± 0.15 m/s vs 0.71 ± 0.19 m/s, p = 0.04) and 1 month (1.04 ± 0.21 m/s vs 1.11 ± 0.18 m/s, p = 0.02), but not compared with controls. CONCLUSION CHD prevalence in TTTS survivors is high, with a low prenatal detection of minor abnormalities. Follow-up fetal echocardiograms and a postnatal echocardiogram should be offered.
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14
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McPherson E, Korlesky C, Hebbring S. Cardiac Anomalies in Liveborn and Stillborn Monochorionic Twins. Clin Med Res 2020; 18:58-67. [PMID: 31959670 PMCID: PMC7428205 DOI: 10.3121/cmr.2019.1478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 07/25/2019] [Accepted: 10/17/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Cardiovascular anomalies are more common in monochorionic twins, especially with twin-twin transfusion, compared to other twin types and to singletons. Because previous studies are based on fetal and neonatal echocardiography, more information is needed to study prevalence of cardiac anomalies in twin miscarriages, stillbirths, and children after the immediate neonatal period. METHODS With specific attention to cardiac anomalies, we reviewed the medical records of 335 selected liveborn twin pairs from the Marshfield Clinic Twin Cohort (enriched for twin-twin transfusion) and all twins (175 pairs) identified in the Wisconsin Stillbirth Service Program cohort of late miscarriages and stillbirths. RESULTS Structural cardiac defects occurred in 12% of liveborn monochorionic twin infants and 7.5% of stillborn infants with twin-twin transfusion compared to only 2% of liveborn dizygotic twins and no stillborn dizygotic infants. The most common cardiac lesion in liveborn twins was ventricular septal defect, which was usually isolated and discordant, preferentially affecting the smaller twin in monochorionic pairs. Among stillborn and miscarried monochorionic twins, the most common cardiac lesion was acardia. CONCLUSIONS Monochorionic twins, particularly those with TTT, are at increased risk for a spectrum of structural cardiac malformations which we suggest may be related to asymmetry of the inner cell mass resulting in a smaller poorly perfused twin. In severe cases, limited cardiac and circulatory development in the affected twin leads to acardia. In less severe cases, the smaller infant has deficient septal growth that sometimes results in ventricular septal defect.
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Affiliation(s)
- Elizabeth McPherson
- Center for Human Genetics, Marshfield Clinic Research Institute, Marshfield, Wisconsin USA
| | - Colin Korlesky
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Scott Hebbring
- Center for Human Genetics, Marshfield Clinic Research Institute, Marshfield, Wisconsin USA
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15
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Yoda H. Fetal and Neonatal Circulatory Disorders in Twin to Twin Transfusion Syndrome (The Secondary Publication). J NIPPON MED SCH 2020; 86:192-200. [PMID: 31484880 DOI: 10.1272/jnms.jnms.2019_86-301] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Twin to twin transfusion syndrome (TTTS) is a major complication of monochorionic diamniotic (MD) twins, and its onset is known to be associated with placental vascular anastomoses and blood flow imbalance. In a typical case of TTTS, the recipient develops polyhydramnios, weight gain, cardiomegaly and hydrops fetalis in the uterus. In contrast, the donor develops oligohydramnios and intrauterine growth restriction. Recently, the significance of the renin-angiotensin-aldosterone system (RAAS) that transfers from the donor to the recipient has attracted interest in the fetal circulation of TTTS. The donor has decreased renal blood flow due to decreased circulating blood volume. For this reason, the secretion of RAAS hormones is augmented in the fetal kidneys of the donor. In TTTS, these RAAS hormones from the donor transfer to the recipient through the anastomosed vessels. In addition to excess preload, the recipient heart is exposed to excess afterload due to systemic vasoconstriction through RAAS hormones. Commonly occurring complications in the recipient include myocardial hypertrophy, atrioventricular valve regurgitation, and pulmonary valve stenosis or pulmonary atresia. Fetoscopic laser photocoagulation (FLP) has been introduced recently because neither mortality nor neurological morbidity have been satisfactorily improved with conventional treatment. FLP is a curative method that may improve the prognosis of TTTS. In Japan, this procedure has been performed frequently, and positive neurological outcomes have been achieved.
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Affiliation(s)
- Hitoshi Yoda
- Department of Neonatology, Toho University, Faculty of Medicine
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16
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Rotar IC, Zaharie G, Staicu A, Preda A, Mureşan D. Fetal cardiovascular alterations in twin-to-twin transfusion syndrome. Med Pharm Rep 2020; 93:5-11. [PMID: 32133441 PMCID: PMC7051825 DOI: 10.15386/mpr-1481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 12/15/2019] [Accepted: 12/30/2019] [Indexed: 11/23/2022] Open
Abstract
Twin-to-twin transfusion syndrome (TTTS) is the consequence of vascular anastomoses of the shared placenta of monochorionic twin pregnancies. Both circulating inter-twin blood flow and vasoactive mediators imbalance cause hypovolemia in the donor and hypervolemia in the recipient fetus. If left untreated, TTTS has a high perinatal mortality rate and adverse long-term outcomes mainly cardiovascular and neurological. The recipient has cardiovascular changes including atrioventricular valve regurgitation, diastolic dysfunction and pulmonary stenosis/atresia. The maladaptive response to vascular changes determines a constant decreased blood flow in the donor that permanently modifies the arterial structure leading to postnatal alterations in the vascular system. Fetoscopic LASER surgery of placental vascular anastomoses may disrupt the underlying pathophysiology and improves cardiovascular function with normalization of systolic and diastolic function within weeks after treatment. The impact of cardiovascular changes is relevant for the safety of the management of a TTTS case. The improvement of the perinatal survival after intrauterine surgery leads to viable infants with the longer-term sequelae. Therefore accurate quantification of cardiovascular involvement is essential for clinicians for pregnancy management but also for patient counseling about the potential treatment options the outcome.
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Affiliation(s)
- Ioana Cristina Rotar
- 1 Department of Obstetrics and Gynecology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.,1 Clinic of Obstetrics and Gynecology, Emergency County Hospital, Cluj-Napoca, Romania
| | - Gabriela Zaharie
- Neonatal Department, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Neonatal Department, Emergency County Hospital, Cluj-Napoca, Romania
| | - Adelina Staicu
- 1 Department of Obstetrics and Gynecology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Andreia Preda
- 1 Department of Obstetrics and Gynecology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Daniel Mureşan
- 1 Department of Obstetrics and Gynecology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.,1 Clinic of Obstetrics and Gynecology, Emergency County Hospital, Cluj-Napoca, Romania
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17
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Prevalence of right ventricular outflow tract abnormalities among recipients in twin-twin transfusion syndrome after fetoscopic laser surgery in 90 consecutive cases. J Med Ultrason (2001) 2019; 47:117-121. [PMID: 31641903 DOI: 10.1007/s10396-019-00982-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 09/28/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Right ventricular outflow tract obstruction (RVOTO) is a severe complication in recipients in twin-twin transfusion syndrome (TTTS). This study investigated the prevalence of RVOTO in TTTS after laser surgery and examined the risk factors for RVOTO. METHODS This retrospective study evaluated 90 patients who had undergone laser surgery and been followed for 6 months after birth. The diagnosis of RVOTO was made based on postnatal echocardiography findings. Ultrasound and clinical records, including maternal and neonatal data, were retrieved from our database. Risk factors for developing RVOTO were compared between recipients with and without RVOTO in a statistical analysis. RESULTS Six surviving recipients were diagnosed with RVOTO. Three recipients had developed severe pulmonary stenosis (PS) that required percutaneous transluminal pulmonary valvuloplasty or balloon pulmonary angioplasty. A total of 6.7% of recipients (6/90) had RVOTO, consisting of PS and tricuspid regurgitation (TR), and 3.3% of recipients (3/90) required invasive treatment. The characteristic factors did not differ significantly between recipients with and without RVOTO. CONCLUSION This study revealed that 6.7% of recipients with TTTS had PS, and 3.3% required invasive treatment for PS. However, no significant association was noted between RVOTO development in recipients and maternal clinical data and fetal ultrasound examination findings. It is difficult to predict RVOTO development in recipients using only preoperative ultrasound and clinical information.
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18
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Takano M, Nakata M, Nagasaki S, Morita M. Asymmetrical Hemodynamic Influence of Twin-Twin Transfusion Syndrome on Fetal E/e' by the Dual Gate Doppler Method in Recipient Twins. Fetal Diagn Ther 2019; 47:261-267. [PMID: 31574521 DOI: 10.1159/000501773] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 06/26/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To assess the hemodynamic influence of twin-twin transfusion syndrome (TTTS) on diastolic function, using left ventricle (LV) and right ventricle (RV) E/e' measured in the same cardiac cycle using the dual-gate Doppler (DD) method. METHODS This study included 56 monochorionic twin pregnancies that underwent fetoscopic laser surgery (FLS) for TTTS in 2015-2018. E/e' by the DD method was measured 24 h before and 4-7 days after FLS. RESULTS Recipients showed higher LV-E/e' Z score in stage I-, II-, and III-recipients (IIIr) and higher RV-E/e' Z score in stage III-donors and IIIr than donors (p < 0.05). After FLS, LV-E/e' Z score of recipients significantly decreased due to LV-E velocity Z score decrease (p < 0.05). RV-E/e' Z score after FLS significantly decreased due to RV-e' velocity Z score increase in recipients (p < 0.05). CONCLUSIONS E/e' by the DD method helped assess cardiac changes of recipients. LV-E/e' could assess early hemodynamic changes by TTTS, and RV-E/e' can assess later influence on cardiac diastolic function. Furthermore, in recipient twins, the decrease in LV-E/e' after FLS might reflect the improvement of volume overload and the decrease in RV-E/e' might reflect the improvement of diastolic relaxation function in the RV.
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Affiliation(s)
- Mayumi Takano
- Department of Obstetrics and Gynecology, Toho University Graduate School of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Masahiko Nakata
- Department of Obstetrics and Gynecology, Toho University Graduate School of Medicine, Tokyo, Japan, .,Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan,
| | - Sumito Nagasaki
- Department of Obstetrics and Gynecology, Toho University Graduate School of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Mineto Morita
- Department of Obstetrics and Gynecology, Toho University Graduate School of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
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19
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Gijtenbeek M, Shirzada MR, Ten Harkel ADJ, Oepkes D, C Haak M. Congenital Heart Defects in Monochorionic Twins: A Systematic Review and Meta-Analysis. J Clin Med 2019; 8:E902. [PMID: 31238552 PMCID: PMC6617007 DOI: 10.3390/jcm8060902] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 06/14/2019] [Accepted: 06/18/2019] [Indexed: 12/19/2022] Open
Abstract
Monochorionic (MC) twins are at an increased risk of developing congenital heart defects (CHDs) compared to singletons and dichorionic twins. The development of acquired CHDs in this specific group of twins is associated with twin-twin transfusion syndrome (TTTS). We performed a systematic review and meta-analysis to provide an overview of the reported birth prevalence of CHDs in liveborn MC twins with and without TTTS. Twelve studies were included in this review. Compared to the reference population, MC twins were 6.3 times more likely to be born with a CHD (59.3 per 1000 liveborn twins; relative risk (RR) 6.3; 95% confidence interval (CI): 4.4-9.1), and TTTS twins had a 12-fold increased risk of having a CHD at birth (87.3 per 1000 live births; RR 12.4, 95% CI: 8.6-17.8). The increased incidence of CHDs can mainly be attributed to the risk of right ventricular outflow tract obstruction (35/1000 TTTS twin live births vs. 0.5/1000 singleton live births). We recommend an expert fetal echocardiogram in all MC twins, follow-up scans in the event of TTTS, and a postnatal cardiac evaluation in all TTTS survivors.
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Affiliation(s)
- Manon Gijtenbeek
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, PO Box 9600, NL-2300 RC Leiden, The Netherlands.
| | - Maryam R Shirzada
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, PO Box 9600, NL-2300 RC Leiden, The Netherlands.
| | - Arend D J Ten Harkel
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, PO Box 9600, NL-2300 RC Leiden, The Netherlands.
| | - Dick Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, PO Box 9600, NL-2300 RC Leiden, The Netherlands.
| | - Monique C Haak
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, PO Box 9600, NL-2300 RC Leiden, The Netherlands.
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20
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Eschbach SJ, Ten Harkel ADJ, Middeldorp JM, Klumper FJCM, Oepkes D, Lopriore E, Haak MC. Acquired right ventricular outflow tract obstruction in twin-to-twin transfusion syndrome; a prospective longitudinal study. Prenat Diagn 2018; 38:1013-1019. [PMID: 30365169 DOI: 10.1002/pd.5378] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 10/07/2018] [Accepted: 10/12/2018] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The pathophysiology of right ventricular outflow tract obstruction (RVOTO) in twin-to-twin transfusion syndrome (TTTS) recipients is incompletely understood. We aimed to investigate the development and spectrum of RVOTO in TTTS recipients. METHODS A prospective longitudinal cohort study was conducted between 2015 and 2017. Echocardiographic assessment was performed in recipients from TTTS diagnosis until the neonatal period. RESULTS Prenatal RVOTO, defined as abnormal flow velocity waveforms across the pulmonary valve (PV), was diagnosed in 12.9% (16/124) of recipients at TTTS diagnosis. Postnatal RVOTO was found in 6.7% (7/105) of surviving recipients. All recipients with severe postnatal RVOTO showed prenatal RVOTO at TTTS diagnosis. In 5.6% (6/108) of cases, prenatal RVOTO appeared only after laser therapy, and in 1.9% (2/108), this progressed to mild postnatal pulmonary stenosis. Elevated peak systolic PV velocities were more frequently associated with postnatal RVOTO compared with prenatal finding of functional pulmonary atresia. Postnatal RVOTO was associated with early manifestation of TTTS but was equally found in all Quintero stages. CONCLUSION In the spectrum of postnatal RVOTO, severe cases show prenatal RVOTO at TTTS diagnosis. However, RVOTO can develop after laser or even in the neonatal period and in all Quintero stages. A potential risk factor for postnatal RVOTO is early TTTS manifestation.
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Affiliation(s)
- Sanne J Eschbach
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, Netherlands
| | - Arend D J Ten Harkel
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Johanna M Middeldorp
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, Netherlands
| | - Frans J C M Klumper
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, Netherlands
| | - Enrico Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, Netherlands
| | - Monique C Haak
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, Netherlands
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21
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Perry H, Duffy JMN, Umadia O, Khalil A. Outcome reporting across randomized trials and observational studies evaluating treatments for twin-twin transfusion syndrome: systematic review. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 52:577-585. [PMID: 29607558 DOI: 10.1002/uog.19068] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 03/19/2018] [Accepted: 03/27/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Twin-twin transfusion syndrome (TTTS) is associated with significant mortality and morbidity. Potential treatments for the condition require robust evaluation. The aim of this study was to evaluate outcome reporting across observational studies and randomized controlled trials assessing treatments for TTTS. METHODS Cochrane Central Register of Controlled Trials, EMBASE and MEDLINE were searched from inception to August 2016. Observational studies and randomized controlled trials reporting outcome following treatment for TTTS in monochorionic-diamniotic twin pregnancy and monochorionic-triamniotic or dichorionic-triamniotic triplet pregnancy were included. Outcome reporting was systematically extracted and categorized. RESULTS Six randomized trials and 94 observational studies were included, reporting data from 20 071 maternal participants and 3199 children. Six different treatments were evaluated. Included studies reported 62 different outcomes, including six fetal, seven offspring mortality, 25 neonatal, six early childhood and 18 maternal/operative outcomes. Outcomes were reported inconsistently across trials. For example, when considering offspring mortality, 31 (31%) studies reported live birth, 31 (31%) reported intrauterine death, 49 (49%) reported neonatal mortality and 17 (17%) reported perinatal mortality. Four (4%) studies reported respiratory distress syndrome. Only 19 (19%) studies were designed for long-term follow-up and 11 (11%) of these reported cerebral palsy. CONCLUSIONS Studies evaluating treatments for TTTS have often neglected to report clinically important outcomes, especially neonatal morbidity outcomes, and most are not designed for long-term follow-up. The development of a core outcome set could help standardize outcome collection and reporting in TTTS studies. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- H Perry
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - J M N Duffy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
- Balliol College, University of Oxford, Oxford, UK
| | - O Umadia
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - A Khalil
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
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22
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Hecher K, Gardiner HM, Diemert A, Bartmann P. Long-term outcomes for monochorionic twins after laser therapy in twin-to-twin transfusion syndrome. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 2:525-535. [PMID: 30169324 DOI: 10.1016/s2352-4642(18)30127-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/09/2018] [Accepted: 04/03/2018] [Indexed: 12/28/2022]
Abstract
Twin-to-twin transfusion syndrome typically occurs in the second trimester in 10-15% of monochorionic twin pregnancies. Vascular anastomoses of monochorionic placentae are the underlying cause of the development of the syndrome. If a blood flow imbalance occurs, one fetus becomes the so-called donor twin and the other the recipient. If untreated, perinatal mortality is 80-90%. Fetoscopic laser coagulation of the vascular anastomoses destroys the cause of the syndrome and leads to dual twin survival rates of around 70% and more than 90% of pregnancies with at least one survivor. However, unequal placental sharing, intrauterine death, and severe prematurity are still limiting factors for further improvement of survival rates and decreases in long-term morbidity. Prematurity and neurodevelopmental impairment affect the donor and recipient twins, whereas cardiovascular failure and obstruction of the right ventricular outflow tract are typical complications of recipients, which can lead to long-term morbidity. In this Review, we summarise the literature on follow-up data for survivors of twin-to-twin-transfusion syndrome after laser therapy, including neurodevelopmental outcomes, cardiovascular outcomes, growth, renal function, and ischaemic events, as well as the potential effects of intrauterine programming on later life.
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Affiliation(s)
- Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Helena M Gardiner
- Fetal Center at Children's Memorial Herman Hospital, McGovern Medical School at UTHealth, University of Texas Health Sciences Center, Houston, TX, USA
| | - Anke Diemert
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Bartmann
- Children's Hospital, University Hospital Bonn, Bonn, Germany
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23
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Djaafri F, Stirnemann J, Mediouni I, Colmant C, Ville Y. Twin-twin transfusion syndrome - What we have learned from clinical trials. Semin Fetal Neonatal Med 2017; 22:367-375. [PMID: 29122542 DOI: 10.1016/j.siny.2017.08.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Monochorionic twin pregnancies are at increased risk for adverse outcome compared to dichorionic twin pregnancies and singletons. Monochorionic-specific complications include twin-twin transfusion syndrome (TTTS), twin anemia-polycythemia sequence, single intrauterine fetal demise and its consequences on the co-twin, and selective intrauterine growth restriction. Whereas the natural history of monochorionic-specific complications carries a high risk of fetal death or severe neurologic disability, a framework now exists, based on well-designed clinical trials, for optimal treatment of these entities. Fetoscopic selective laser coagulation of anastomotic vessels on the chorionic plate has been clearly demonstrated to improve survival and neurologic outcomes for Quintero stage ≥2 TTTS. However, many challenges remain unsolved, the most important of which is preterm premature rupture of membranes. Further improvement in the outcomes of monochorionic pregnancies will require improvements in the rate of premature delivery, and improved diagnosis and treatment strategies for early and late onset TTTS.
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Affiliation(s)
- Fatiha Djaafri
- Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - Julien Stirnemann
- Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France; EA7328, Faculté de Medicine Paris Descartes, Paris, France
| | - Imen Mediouni
- Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - Claire Colmant
- Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - Yves Ville
- Obstetrics and Maternal-Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France; EA7328, Faculté de Medicine Paris Descartes, Paris, France.
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24
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Pruetz JD, Votava-Smith JK, Chmait HR, Korst LM, Llanes A, Chmait RH. Recipient Twin Circular Shunt Physiology Before Fetal Laser Surgery: Survival and Risks for Postnatal Right Ventricular Outflow Tract Obstruction. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2017; 36:1595-1605. [PMID: 28370096 DOI: 10.7863/ultra.16.08038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 11/07/2016] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To evaluate risk for congenital heart disease (CHD) in recipient twins with circular shunt physiology (CSP). METHODS This prospective study enrolled twin-twin transfusion syndrome (TTTS) cases from 2006 to 2015. Fetal echocardiography (FE) was performed before laser surgery when cardiac involvement was suspected. Diagnosis of recipient twin CSP required tricuspid and pulmonary regurgitation, right ventricular dysfunction, and flow reversal in the ductus arteriosus. Outcomes were assessed at 30 days after birth. RESULTS Of the 496 TTTS pregnancies, 20 (4%) met the criteria for CSP. Among those born alive, who had documented cardiac outcomes (n = 457), patients with CSP were more likely to have CHD, specifically right ventricular outflow tract obstruction (5 of 18 [27.8%] versus 22 of 439 [5.0%], odd ratio [OR] 7.29, 95% confidence interval [CI] 2.05-24.72, P = .0025). Of the recipient twins with preoperative FE (n = 259, 52%) who were born alive and had documented cardiac outcomes (n = 242), those with CSP were still more likely to have right ventricular outflow tract obstruction (5 of 18 [27.8%] versus 14 of 224 [6.3%], OR 5.77, CI 1.54-20.92, P = .0077). With both analyses, twins with CSP had higher Quintero stage, but similar patient characteristics and 30-day mortality compared with those without CSP. Subgroup analyses of the CSP cohort identified no differences in preoperative characteristics or FE findings predictive of CHD. CONCLUSIONS Recipient twins with preoperative CSP were at increased risk for postnatal right ventricular outflow tract obstruction, but appeared to have comparable survival after fetal laser surgery despite these dramatic pathophysiological prenatal findings. Preoperative FE in TTTS remains important for prediction of postnatal CHD.
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Affiliation(s)
- Jay D Pruetz
- Division of Pediatric Cardiology, Children's Hospital Los Angeles, University of Southern California, Los Angeles, California, USA
- Department of Obstetrics & Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jodie K Votava-Smith
- Division of Pediatric Cardiology, Children's Hospital Los Angeles, University of Southern California, Los Angeles, California, USA
| | - Hikmat R Chmait
- Department of Obstetrics & Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Lisa M Korst
- Childbirth Research Associates, North Hollywood, California, USA
| | - Arlyn Llanes
- Department of Obstetrics & Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Ramen H Chmait
- Department of Obstetrics & Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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25
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Khalil A, Perry H, Duffy J, Reed K, Baschat A, Deprest J, Hecher K, Lewi L, Lopriore E, Oepkes D. Twin-Twin Transfusion Syndrome: study protocol for developing, disseminating, and implementing a core outcome set. Trials 2017; 18:325. [PMID: 28709445 PMCID: PMC5513392 DOI: 10.1186/s13063-017-2042-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 06/16/2017] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Twin-Twin Transfusion Syndrome (TTTS) is associated with an increased risk of perinatal mortality and morbidity. Several treatment interventions have been described for TTTS, including fetoscopic laser surgery, amnioreduction, septostomy, expectant management, and pregnancy termination. Over the last decade, fetoscopic laser surgery has become the primary treatment. The literature to date reports on many different outcomes, making it difficult to compare results or combine data from individual studies, limiting the value of research to guide clinical practice. With the advent and ongoing development of new therapeutic techniques, this is more important than ever. The development and use of a core outcome set has been proposed to address these issues, prioritising outcomes important to the key stakeholders, including patients. We aim to produce, disseminate, and implement a core outcome set for TTTS. METHODS An international steering group has been established to oversee the development of this core outcome set. This group includes healthcare professionals, researchers and patients. A systematic review is planned to identify previously reported outcomes following treatment for TTTS. Following completion, the identified outcomes will be evaluated by stakeholders using an international, multi-perspective online modified Delphi method to build consensus on core outcomes. This method encourages the participants towards consensus 'core' outcomes. All key stakeholders will be invited to participate. The steering group will then hold a consensus meeting to discuss results and form a core outcome set to be introduced and measured. Once core outcomes have been agreed, the next step will be to determine how they should be measured, disseminated, and implemented within an international context. DISCUSSION The development, dissemination, and implementation of a core outcome set in TTTS will enable its use in future clinical trials, systematic reviews and clinical practice guidelines. This is likely to advance the quality of research studies and their effective use in order to guide clinical practice and improve patient care, maternal, short-term perinatal outcomes and long-term neurodevelopmental outcomes. TRIAL REGISTRATION Core Outcome Measures in Effectiveness Trials (COMET), 921 Registered on July 2016. International Prospective Register of Systematic Reviews (PROSPERO), CRD42016043999 . Registered on 2 August 2016.
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Affiliation(s)
- Asma Khalil
- St George’s University of London, Blackshow Road, Tooting, London, SW17 0QT UK
| | - Helen Perry
- St George’s University of London, Blackshow Road, Tooting, London, SW17 0QT UK
| | - James Duffy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG UK
| | - Keith Reed
- Twin and Multiple Births Association (TAMBA), The Manor House, Manor Park, Church Hill, Aldershot, GU12 4JU UK
| | - Ahmet Baschat
- The Johns Hopkins Center for Fetal Therapy, 600 North Wolfe, Nelson 228, Baltimore, MD 21287 USA
| | - Jan Deprest
- Department of Obstetrics and Gynecology, University Hospitals of KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Neues Klinikum, Gebäude O10 Martinistraße 52, 20246 Hamburg, Germany
| | - Liesbeth Lewi
- Department of Obstetrics and Gynecology, University Hospitals of KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Enrico Lopriore
- Department of Pediatrics, Leiden University Medical Center, K-06-35, P.O. Box 9600, 2300RC Leiden, The Netherlands
| | - Dick Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, K-06-35, P.O. Box 9600, 2300RC Leiden, The Netherlands
| | - On behalf of the International Collaboration to Harmonise Outcomes for Twin–Twin Transfusion Syndrome (CHOOSE)
- St George’s University of London, Blackshow Road, Tooting, London, SW17 0QT UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG UK
- Twin and Multiple Births Association (TAMBA), The Manor House, Manor Park, Church Hill, Aldershot, GU12 4JU UK
- The Johns Hopkins Center for Fetal Therapy, 600 North Wolfe, Nelson 228, Baltimore, MD 21287 USA
- Department of Obstetrics and Gynecology, University Hospitals of KU Leuven, Herestraat 49, 3000 Leuven, Belgium
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Neues Klinikum, Gebäude O10 Martinistraße 52, 20246 Hamburg, Germany
- Department of Pediatrics, Leiden University Medical Center, K-06-35, P.O. Box 9600, 2300RC Leiden, The Netherlands
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, K-06-35, P.O. Box 9600, 2300RC Leiden, The Netherlands
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26
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Eschbach SJ, Boons LSTM, Van Zwet E, Middeldorp JM, Klumper FJCM, Lopriore E, Teunissen AKK, Rijlaarsdam ME, Oepkes D, Ten Harkel ADJ, Haak MC. Right ventricular outflow tract obstruction in complicated monochorionic twin pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:737-743. [PMID: 27363529 DOI: 10.1002/uog.16008] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 06/16/2016] [Accepted: 06/17/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Severe right ventricular outflow tract obstruction (RVOTO) is a potential complication in recipient twins of twin-to-twin transfusion syndrome (TTTS) that requires postnatal follow-up or treatment. We aimed to evaluate pregnancy characteristics of neonates with RVOTO from complicated monochorionic twin pregnancies, determine the incidence of RVOTO in TTTS cases and construct a prediction model for its development. METHODS This was an observational cohort study of all complicated monochorionic twin pregnancies with a postnatal diagnosis of RVOTO examined at our center. Cases were referred for evaluation of the need for fetal therapy or intervention because of TTTS, selective intrauterine growth restriction (sIUGR) or multiple congenital malformations in one of the twins. Ultrasound data were retrieved from our monochorionic twin database. Among liveborn TTTS recipients treated prenatally with laser therapy, those with RVOTO were compared with those without RVOTO (controls). We describe four additional cases with RVOTO that were not TTTS recipients. RESULTS A total of 485 twin pregnancies received laser therapy for TTTS during the study period. RVOTO was diagnosed in 3% (11/368) of liveborn TTTS recipients, of whom two showed mild Ebstein's anomaly. Before laser therapy, pericardial effusion was seen in 45% (5/11) of RVOTO cases (P < 0.01) and abnormal A-wave in the ductus venosus (DV) in 73% (8/11) (P = 0.03), significantly higher proportions than in controls. Mean gestational age at laser therapy was 17 + 3 weeks in RVOTO cases compared with 20 + 3 weeks in controls (P = 0.03). A prediction model for RVOTO was constructed incorporating these three significant variables. One TTTS donor had RVOTO after the development of transient hydrops following laser therapy. Three larger twins in pregnancies complicated by sIUGR developed RVOTO, the onset of which was detectable early in the second trimester. CONCLUSIONS RVOTO occurs in TTTS recipient twins but can also develop in TTTS donors and larger twins of pregnancies complicated by sIUGR. Abnormal flow in the DV, pericardial effusion and early gestational age at onset of TTTS are predictors of RVOTO in TTTS recipients, which suggests increased vulnerability to hemodynamic imbalances in the fetal heart in early pregnancy. These findings could guide diagnostic follow-up protocols after TTTS treatment. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- S J Eschbach
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - L S T M Boons
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - E Van Zwet
- Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - J M Middeldorp
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - F J C M Klumper
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - E Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - A K K Teunissen
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - M E Rijlaarsdam
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - D Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - A D J Ten Harkel
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - M C Haak
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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27
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Abstract
This review addresses the physiology of monochorionic diamniotic (MC/DA) twins and the potential for twin–twin transfusion syndrome (TTTS). It focuses on the underlying cardiovascular pathophysiology of TTTS and the cardiovascular impact of TTTS for both the recipient and the donor twin. It explains the principles for assessment and monitoring of these cardiovascular changes and how these may be used to guide pregnancy management. Finally, it describes the effect of treatment on the altered hemodynamics and how this can influence pregnancy and perinatal management, as well as longer-term follow-up.
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28
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Síndrome de transfusión feto-feto: resultados neonatales en un hospital de tercer nivel en la Ciudad de México. PERINATOLOGÍA Y REPRODUCCIÓN HUMANA 2016. [DOI: 10.1016/j.rprh.2016.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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29
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Best KE, Rankin J. Increased risk of congenital heart disease in twins in the North of England between 1998 and 2010. Heart 2015; 101:1807-12. [PMID: 26412859 PMCID: PMC4680160 DOI: 10.1136/heartjnl-2015-307826] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 07/10/2015] [Indexed: 01/04/2023] Open
Abstract
Objective To examine the relative risk (RR) of congenital heart disease (CHD) in twins compared with singletons, according to chorionicity. Methods Twins and singletons with CHD notified to the Northern Congenital Abnormality Survey between 1998 and 2010 were included in this population-based study. Information on chorionicity was obtained from the Northern Survey of Twins and Multiple Pregnancy. Prevalence was calculated as the number of cases occurring in live births, late miscarriages (20–23 weeks), stillbirths (≥24 weeks) and terminations of pregnancy for fetal anomaly, per 10 000 total births. The risk of CHD in twins compared with singletons was estimated using Poisson regression. Results There were 399 414 singleton births of which 2984 (0.7%) had CHD. Among 11 871 twin births, 154 (1.3%) had CHD; one twin was affected by CHD in 2.5% of twin pregnancies. Of 8605 dichorionic (DC) births and 2317 monochorionic (MC) births, 96 (1.1%) and 47 (2.0%) were associated with CHD. Compared with singletons, twins were at significantly increased risk of CHD (RR=1.73, 95% CI 1.48 to 2.04; p<0.001). MC twins were at 82% significantly increased risk of CHD compared with DC twins (RR=1.82, 95% CI 1.29 to 2.57; p<0.001). The RR of severe and mild CHD was particularly high in MC twins compared with singletons (292% increased risk, RR=3.92, 95% CI 1.25 to 12.30, p=0.02 and 207% increased risk, RR=3.07, 95% CI 2.20 to 4.28; p<0.001). Conclusions Compared with singletons, twins were at increased risk of CHD, the risk being substantially higher among MC twins. This information is important for health professionals when counselling women with twin pregnancies.
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Affiliation(s)
- K E Best
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - J Rankin
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK PHE: Regional Maternity Survey Office, Newcastle upon Tyne, UK
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30
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Stagnati V, Chalouhi GE, Essaoui M, Giuseppi A, Stirnemann JJ, Le Bidois J, Ville Y. Pulmonary stenosis in complicated monochorionic twin pregnancies: prevalence, management and outcome. Prenat Diagn 2015; 35:1085-92. [DOI: 10.1002/pd.4650] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Revised: 06/06/2015] [Accepted: 07/06/2015] [Indexed: 11/06/2022]
Affiliation(s)
- V. Stagnati
- National Referral Centre for Twin-to-Twin Transfusion Syndrome; Paris-Descartes University, Necker-Enfants-Malades Hospital, APHP; Paris France
- Obstetrics and Fetal Medicine Department; Necker-Enfants-Malades Hospital, APHP, Paris V University; Paris France
- Maternal Fetal Medicine Unit; University of Brescia, Spedali Civili di Brescia; Brescia Italy
| | - G. E. Chalouhi
- National Referral Centre for Twin-to-Twin Transfusion Syndrome; Paris-Descartes University, Necker-Enfants-Malades Hospital, APHP; Paris France
- Obstetrics and Fetal Medicine Department; Necker-Enfants-Malades Hospital, APHP, Paris V University; Paris France
| | - M. Essaoui
- National Referral Centre for Twin-to-Twin Transfusion Syndrome; Paris-Descartes University, Necker-Enfants-Malades Hospital, APHP; Paris France
- Obstetrics and Fetal Medicine Department; Necker-Enfants-Malades Hospital, APHP, Paris V University; Paris France
| | - A. Giuseppi
- Neonatology Department; Necker-Enfants-Malades Hospital, APHP, Paris V University; Paris France
| | - J. J. Stirnemann
- National Referral Centre for Twin-to-Twin Transfusion Syndrome; Paris-Descartes University, Necker-Enfants-Malades Hospital, APHP; Paris France
- Obstetrics and Fetal Medicine Department; Necker-Enfants-Malades Hospital, APHP, Paris V University; Paris France
| | - J. Le Bidois
- Pediatric Cardiology Department; Necker-Enfants-Malades Hospital, APHP, Paris V University; Paris France
| | - Y. Ville
- National Referral Centre for Twin-to-Twin Transfusion Syndrome; Paris-Descartes University, Necker-Enfants-Malades Hospital, APHP; Paris France
- Obstetrics and Fetal Medicine Department; Necker-Enfants-Malades Hospital, APHP, Paris V University; Paris France
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31
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James AT, Bee C, Corcoran JD, McNamara PJ, Franklin O, El-Khuffash AF. Treatment of premature infants with pulmonary hypertension and right ventricular dysfunction with milrinone: a case series. J Perinatol 2015; 35:268-73. [PMID: 25429380 DOI: 10.1038/jp.2014.208] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 09/22/2014] [Accepted: 10/14/2014] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Milrinone has been proposed as an effective treatment for pulmonary hypertension (PH) and right ventricular (RV) dysfunction. We aimed to determine the effect of milrinone therapy on clinical and echocardiography parameters of PH in preterm infants with elevated pulmonary pressures. STUDY DESIGN A retrospective case review was conducted on infants <32 weeks gestation who received milrinone for the treatment of PH and reduced RV function. Echocardiographic data were collected before and after treatment with milrinone, and serial clinical parameters were recorded over a 72h period. RESULT Seven infants met the inclusion criteria with a median gestation and birth weight of 27.3 weeks and 1140 g, respectively. Four infants had a diagnosis of pulmonary hypoplasia with PH, and three infants were recipients in twin-to-twin transfusion syndrome who also developed PH. Nitric oxide was used in six infants before commencement of milrinone. Milrinone was commenced at a dose of 0.33 μg kg(-1) min(-1) to 0.5 μg kg(-1) min(-1) and continued for a median duration of 70 h. Use of milrinone was associated with a fall in oxygenation index and inhaled nitric oxide dose. Following an initial fall in blood pressure over the first 6 h, there was an increase in blood pressure over the subsequent 72 h. Echocardiographic data demonstrated an increase in indicators of myocardial performance and PH. One infant died before discharge. CONCLUSION This case series suggests that milrinone may be a useful therapy for premature infants with echocardiography findings of PH and/or RH dysfunction. This data support the need for a randomised control trial to confirm its efficacy.
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Affiliation(s)
- A T James
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - C Bee
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - J D Corcoran
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - P J McNamara
- 1] Physiology and Experimental Medicine, Hospital for Sick Children, Toronto, Canada [2] Department of Neonatology, The Hospital for Sick Children, Toronto, Canada
| | - O Franklin
- Department of Paediatric Cardiology, Our Lady's Children's Hospital Crumlin, Dublin, Ireland
| | - A F El-Khuffash
- 1] Department of Neonatology, The Rotunda Hospital, Dublin, Ireland [2] Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland
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Halvorsen CP, Mohlkert LA, Norman M, Sonesson SE. Childhood cardiac outcome after intrauterine laser treatment of twin-twin transfusion syndrome is favourable. Acta Paediatr 2015; 104:252-8. [PMID: 25492400 DOI: 10.1111/apa.12895] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 11/10/2014] [Accepted: 12/10/2014] [Indexed: 11/28/2022]
Abstract
AIM Intrauterine laser treatment is used to alleviate abnormal circulatory load and cardiac morbidity affecting foetuses with twin-twin transfusion syndrome (TTTS). We conducted this childhood follow-up study to fill the gap in knowledge about final cardiac outcomes after such interventions. METHODS We investigated 19 TTTS pairs - 11 male and eight female - with a mean age of four and a half years (range 1.1-9.9) using 2D, blood flow and tissue Doppler, 3D and speckle tracking echocardiography, and compared them with 19 age-matched and gender-matched singletons. RESULTS The only observed differences in cardiac structure or function between the donors and recipients were related to diastolic ventricular filling. Recipients had a lower left ventricular ratio of early and late diastolic filling compared with their donor cotwins [1.48(0.35) versus 1.66 (0.28), p < 0.05], but not compared with singleton controls. All observations, except one, were within the reference limits. Speckle tracking could not demonstrate any group differences in systolic ventricular function, besides marginally lower ventricular strain in the donors than controls. CONCLUSION Double survivors of laser-treated TTTS showed only minor within-pair differences in diastolic cardiac function at childhood follow-up. Cardiac function in TTTS twins compared well to singleton controls, suggesting a favourable long-term outcome.
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Affiliation(s)
| | - Lilly-Ann Mohlkert
- Department of Clinical Science; Intervention and Technology; Karolinska Institutet; Stockholm Sweden
| | - Mikael Norman
- Department of Clinical Science; Intervention and Technology; Karolinska Institutet; Stockholm Sweden
| | - Sven-Erik Sonesson
- Department of Women's and Children's Health; Karolinska Institutet; Stockholm Sweden
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33
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Herberg U, Bolay J, Graeve P, Hecher K, Bartmann P, Breuer J. Intertwin cardiac status at 10-year follow-up after intrauterine laser coagulation therapy of severe twin-twin transfusion syndrome: comparison of donor, recipient and normal values. Arch Dis Child Fetal Neonatal Ed 2014; 99:F380-5. [PMID: 24972991 DOI: 10.1136/archdischild-2013-305034] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND In twin-to-twin transfusion syndrome (TTTS), genetically identical twins are exposed to different haemodynamic conditions during fetal life, which are considered to be the cause of prenatal and postnatal cardiovascular differences between the donor and the recipient. OBJECTIVE To assess intertwin differences on childhood cardiac outcome after intrauterine laser coagulation therapy (LC) of severe TTTS. DESIGN AND PATIENTS Prospective, detailed, echocardiographic follow-up of 31 twin pairs aged 9.95±0.8 years (mean±SD) with severe TTTS treated by LC, and the comparison with reference values. RESULTS Cardiac function was normal and did not show intertwin differences in twins without structural heart disease. Discordant birth weight or birth weight <3rd centile for gestational age had no influence on blood pressure and cardiac indices. Pulmonary stenosis was more common (5/62; 8.1%) than in the general population (prevalence 0.066%, relative risk 134.4, 95% CI 42.1 to 428.8, p<0.0001) and affected both donor and recipient. Intertwin differences in late diastolic right ventricular filling (peak velocities: recipient 0.51±0.11 m/s vs donor 0.45±0.10 m/s, mean difference 0.74 m/s, 95% CI 0.23 to 1.24, p=0.009) and early septal relaxation (mean myocardial velocities: recipient -8.2±1.5 cm/s vs donor -8.9±1.2 cm/s, mean difference 0.7 cm/s, 95% CI 0.02 to 1.38, p=0.044) were found only when twins with right heart disease were included. CONCLUSIONS Despite severe prenatal cardiac involvement, childhood cardiac function is normal in the majority of surviving donors and recipients after successful LC of severe TTTS. This underlines the favourable impact of intrauterine LC on postnatal cardiovascular performance.
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Affiliation(s)
- Ulrike Herberg
- Division of Pediatric Cardiology, University of Bonn, Bonn, Germany
| | - Julian Bolay
- Division of Pediatric Cardiology, University of Bonn, Bonn, Germany
| | - Pauline Graeve
- Division of Neonatology, University of Bonn, Bonn, Germany
| | - Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Bartmann
- Division of Neonatology, University of Bonn, Bonn, Germany
| | - Johannes Breuer
- Division of Pediatric Cardiology, University of Bonn, Bonn, Germany
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Michelfelder E, Tan X, Cnota J, Divanovic A, Statile C, Lim FY, Crombleholme T. Prevalence, Spectrum, and Outcome of Right Ventricular Outflow Tract Abnormalities in Twin-twin Transfusion Syndrome: A Large, Single-center Experience. CONGENIT HEART DIS 2014; 10:209-18. [DOI: 10.1111/chd.12215] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/20/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Erik Michelfelder
- Fetal Heart Program; The Heart Institute; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio USA
| | - Xiao Tan
- Fetal Heart Program; The Heart Institute; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio USA
| | - James Cnota
- Fetal Heart Program; The Heart Institute; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio USA
| | - Allison Divanovic
- Fetal Heart Program; The Heart Institute; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio USA
| | - Christopher Statile
- Fetal Heart Program; The Heart Institute; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio USA
| | - Foong-Yen Lim
- Fetal Care Center of Cincinnati; Department of Surgery; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio USA
| | - Timothy Crombleholme
- Fetal Care Center of Cincinnati; Department of Surgery; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio USA
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Gardiner HM, Matsui H, Roughton M, Greenwald SE, Diemert A, Taylor MJO, Hecher K. Cardiac function in 10-year-old twins following different fetal therapies for twin-twin transfusion syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:652-657. [PMID: 24347245 DOI: 10.1002/uog.13279] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 12/02/2013] [Accepted: 12/06/2013] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To compare cardiac function at 10 years of age in four groups of monochorionic diamniotic (MCDA) twin pairs: uncomplicated MCDA twins (n = 6) (Group 1); twins that had had twin-twin transfusion syndrome (TTTS) managed by amnioreduction (TTTS-amnio, n = 9) (Group 2) or laser photocoagulation (TTTS-laser, n = 10) (Group 3); and dichorionic diamniotic controls (DCDA, n = 6) (Group 4). METHODS Echocardiograms optimizing apical four-chamber and short-axis left ventricular views were stored for offline speckle-tracking analysis, blinded to twin type. Myocardial long-axis shortening and lengthening velocities were measured using pulsed Doppler ultrasound at the cardiac base. M-mode measurements of fractional shortening (short axis) and maximal excursion of the atrioventricular annulus (four-chamber) were recorded. Syngo Vector Velocity Imaging software tracked left ventricular myocardial motion offline to produce free wall strain, strain rate and rotation. Intertwin pair and group differences were investigated using ANOVA. RESULTS Cardiac measurements were within the normal ranges for 10-year-olds. No significant within-twin-pair and intergroup differences were found in current size, heart rates, strain or strain rate. Compared to DCDA controls, TTTS twins showed less cardiac rotation (TTTS-laser, P < 0.001 and TTTS-amnio, P = 0.054) with significant intertwin reduction in the ex-recipient (TTTS-amnio, P = 0.006) and larger MCDA twins (P = 0.027) compared with their cotwins. A similar pattern was seen in left ventricular early diastolic mitral valve tissue velocity (MVE') in all monochorionic groups, but only achieving significance in TTTS-amnio twins (P = 0.037). Intrapair differences in rotation and MVE' were significantly different following treatment at Quintero stages III or IV. CONCLUSIONS Within-twin-pair patterns of left ventricular rotation and diastolic function differ at 10 years of age in ex-recipients of TTTS twins treated with amnioreduction compared with those treated by laser photocoagulation and controls. .
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Affiliation(s)
- H M Gardiner
- Faculty of Medicine, Imperial College, Queen Charlotte's and Chelsea Hospital, London, UK; Royal Brompton NHS Foundation Trust Hospital, London, UK
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Donofrio MT, Moon-Grady AJ, Hornberger LK, Copel JA, Sklansky MS, Abuhamad A, Cuneo BF, Huhta JC, Jonas RA, Krishnan A, Lacey S, Lee W, Michelfelder EC, Rempel GR, Silverman NH, Spray TL, Strasburger JF, Tworetzky W, Rychik J. Diagnosis and treatment of fetal cardiac disease: a scientific statement from the American Heart Association. Circulation 2014; 129:2183-242. [PMID: 24763516 DOI: 10.1161/01.cir.0000437597.44550.5d] [Citation(s) in RCA: 732] [Impact Index Per Article: 73.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The goal of this statement is to review available literature and to put forth a scientific statement on the current practice of fetal cardiac medicine, including the diagnosis and management of fetal cardiovascular disease. METHODS AND RESULTS A writing group appointed by the American Heart Association reviewed the available literature pertaining to topics relevant to fetal cardiac medicine, including the diagnosis of congenital heart disease and arrhythmias, assessment of cardiac function and the cardiovascular system, and available treatment options. The American College of Cardiology/American Heart Association classification of recommendations and level of evidence for practice guidelines were applied to the current practice of fetal cardiac medicine. Recommendations relating to the specifics of fetal diagnosis, including the timing of referral for study, indications for referral, and experience suggested for performance and interpretation of studies, are presented. The components of a fetal echocardiogram are described in detail, including descriptions of the assessment of cardiac anatomy, cardiac function, and rhythm. Complementary modalities for fetal cardiac assessment are reviewed, including the use of advanced ultrasound techniques, fetal magnetic resonance imaging, and fetal magnetocardiography and electrocardiography for rhythm assessment. Models for parental counseling and a discussion of parental stress and depression assessments are reviewed. Available fetal therapies, including medical management for arrhythmias or heart failure and closed or open intervention for diseases affecting the cardiovascular system such as twin-twin transfusion syndrome, lung masses, and vascular tumors, are highlighted. Catheter-based intervention strategies to prevent the progression of disease in utero are also discussed. Recommendations for delivery planning strategies for fetuses with congenital heart disease including models based on classification of disease severity and delivery room treatment will be highlighted. Outcome assessment is reviewed to show the benefit of prenatal diagnosis and management as they affect outcome for babies with congenital heart disease. CONCLUSIONS Fetal cardiac medicine has evolved considerably over the past 2 decades, predominantly in response to advances in imaging technology and innovations in therapies. The diagnosis of cardiac disease in the fetus is mostly made with ultrasound; however, new technologies, including 3- and 4-dimensional echocardiography, magnetic resonance imaging, and fetal electrocardiography and magnetocardiography, are available. Medical and interventional treatments for select diseases and strategies for delivery room care enable stabilization of high-risk fetuses and contribute to improved outcomes. This statement highlights what is currently known and recommended on the basis of evidence and experience in the rapidly advancing and highly specialized field of fetal cardiac care.
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Diehl W, Diemert A, Hecher K. Twin–twin transfusion syndrome: Treatment and outcome. Best Pract Res Clin Obstet Gynaecol 2014; 28:227-38. [DOI: 10.1016/j.bpobgyn.2013.12.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Revised: 11/07/2013] [Accepted: 12/02/2013] [Indexed: 11/26/2022]
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Petousis S, Margioula-Siarkou C, Kalogiannidis I, Prapas N. Twin Pregnancy and Antenatal Examination: An Overview. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2013. [DOI: 10.1007/s13669-013-0057-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Van Mieghem T, Hodges R, Jaeggi E, Ryan G. Functional echocardiography in the fetus with non-cardiac disease. Prenat Diagn 2013; 34:23-32. [DOI: 10.1002/pd.4254] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 09/23/2013] [Accepted: 10/07/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Tim Van Mieghem
- Fetal Medicine Unit, Mount Sinai Hospital; University of Toronto; Toronto Canada
| | - Ryan Hodges
- Fetal Medicine Unit, Mount Sinai Hospital; University of Toronto; Toronto Canada
| | - Edgar Jaeggi
- Fetal Cardiac Program, Pediatric Cardiology, Hospital for Sick Children; University of Toronto; Toronto Canada
| | - Greg Ryan
- Fetal Medicine Unit, Mount Sinai Hospital; University of Toronto; Toronto Canada
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Van Mieghem T, Martin AM, Weber R, Barrea C, Windrim R, Hornberger LK, Jaeggi E, Ryan G. Fetal cardiac function in recipient twins undergoing fetoscopic laser ablation of placental anastomoses for Stage IV twin-twin transfusion syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 42:64-69. [PMID: 23495173 DOI: 10.1002/uog.12454] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/27/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVE Cardiac dysfunction is common in the recipient fetus of twin-twin transfusion syndrome (TTTS). In this study, we aimed to document the severity of fetal cardiac dysfunction in Stage IV TTTS (fetal hydrops) and assess evolution of cardiac function longitudinally after fetoscopic laser surgery. METHODS We reviewed obstetric ultrasound examination data, pre- and postoperative echocardiograms and neonatal outcomes for 22 cases of Stage IV TTTS undergoing fetoscopic laser ablation of placental anastomoses between 1998 and 2011. Myocardial performance index, atrioventricular valve flow patterns, ventricular shortening fraction, ventricular hypertrophy, outflow tract obstruction and venous Doppler waveforms were assessed. RESULTS Nineteen fetuses (86.4%) had ascites, eight (36.4%) had pleural effusions, nine (40.9%) had a pericardial effusion and 12 (54.5%) had subcutaneous edema at presentation. Preoperatively, cardiac function was grossly abnormal in all. Eight fetuses (36.4%) had functional pulmonary atresia and one (4.5%) had functional aortic atresia. Seventy-seven percent of recipient fetuses survived until birth. Postoperative echocardiographic follow-up (mean, 26 days) showed that indices of fetal cardiac function improved considerably, but never completely normalized. Six of the eight fetuses with functional pulmonary atresia (75.0%), as well as the fetus with functional aortic atresia, survived to birth. In all cases, the functional atresia resolved within 48 h of laser ablation therapy and none had structural valve anomalies at birth. All fetal effusions resolved after the laser. CONCLUSIONS Fetoscopic laser ablation of placental anastomoses reverses cardiac dysfunction and valvulopathy, even in the most severe cases of TTTS. However, recovery takes longer than in early stage disease.
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Affiliation(s)
- T Van Mieghem
- Fetal Medicine Unit, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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41
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Hui L, Wick HC, Moise KJ, Johnson A, Luks F, Haeri S, Johnson KL, Bianchi DW. Global gene expression analysis of amniotic fluid cell-free RNA from recipient twins with twin-twin transfusion syndrome. Prenat Diagn 2013; 33:873-83. [PMID: 23640821 DOI: 10.1002/pd.4150] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2013] [Revised: 04/23/2013] [Accepted: 04/25/2013] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The objective of this study was to understand the biological pathways involved in twin-twin transfusion syndrome (TTTS) by performing global gene expression analysis of amniotic fluid (AF) cell-free RNA. METHODS A prospective whole transcriptome microarray study analyzing cell-free RNA in AF from TTTS recipient twins and singleton controls was carried out. Significantly differentially regulated genes in TTTS cases (N = 8) versus matched controls (N = 8) were identified and pathways analyses performed. Significant gene expression differences between stage II TTTS recipients (N = 5) and stage III TTTS recipients with abnormal Doppler measurements (N = 5) were also analyzed. RESULTS Analysis of paired data from TTTS cases and controls revealed differential expression of 801 genes, which were significantly enriched for neurological disease and cardiovascular system pathways. We also identified cardiovascular genes and pathways associated with the presence of critically abnormal Doppler measurements in stage III TTTS recipients. CONCLUSIONS This study provides the first transcriptome-wide data on the impact of TTTS on fetal development. Our results show that gene expression involving neurological and cardiovascular pathways are altered in recipient fetuses prior to surgical treatment. This has relevance for the origins of long-term complications seen in survivors and for the development of future fetal biomarkers.
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Affiliation(s)
- Lisa Hui
- Mother Infant Research Institute, Tufts Medical Center, Boston, MA, USA.
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Abstract
OBJECTIVE To determine the prevalence of congenital heart defects (CHDs) in a large, unselected cohort of monochorionic (MC) twins. STUDY DESIGN We completed a chart review of all MC twin pregnancies in the Kaiser Permanente Northern California population from 1996 to 2003. CHDs were identified by diagnostic codes and confirmed by postnatal echocardiograms. Follow-up was obtained through one year of age. RESULT A total of 926 liveborn MC twins met inclusion criteria. The prevalence of CHDs was 7.5%, 11.6 times the general population rate (CI 9.2 to 14.5). Septal defects were most common. 20% of infants with heart defects had twin-to-twin transfusion syndrome (TTTS) versus 8% of infants without defects (P<0.01); this association remained significant when controlling for potential confounders. CONCLUSION The prevalence of CHDs in this large cohort of MC twins was significantly higher than the general population rate, with TTTS an added risk factor.
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Khalek N, Johnson MP, Bebbington MW. Fetoscopic laser therapy for twin-to-twin transfusion syndrome. Semin Pediatr Surg 2013; 22:18-23. [PMID: 23395141 DOI: 10.1053/j.sempedsurg.2012.10.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Twin-to-twin transfusion syndrome (TTTS) is a unique and complicated phenomenon occurring in 10-15% of monochorionic gestations. The chronic unbalanced distribution of blood volume across placental anastomoses between the donor and recipient fetuses leads to multisystem organ impairment including maladaptive changes in both fetuses. Fetoscopic selective laser photocoagulation (SLPC) is now established as the primary treatment modality for advanced stages of TTTS. SLPC is also associated with a risk reduction in fetal demise and long-term neurological impairment.
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Affiliation(s)
- Nahla Khalek
- The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.
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Wagner S, Repke JT, Ural SH. Overview and Long-term Outcomes of Patients Born With Twin-to-Twin Transfusion Syndrome. REVIEWS IN OBSTETRICS & GYNECOLOGY 2013; 6:149-154. [PMID: 24826204 PMCID: PMC4002191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Twin-to-twin transfusion syndrome (TTTS) results from a disproportionate blood supply between two (or more) fetuses that share a single placenta. Multiple complications can occur as a result of the syndrome, including intrauterine growth restriction in the donor twin, cardiomyopathies in recipients, and neurodevelopmental morbidities in survivors. Studies indicate that patients with TTTS have higher incidences of congenital heart disease compared with the unaffected population, and even when compared with uncomplicated monochorionic diamniotic twins. If managed properly, TTTS can result in a positive outcome for most patients.
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Affiliation(s)
- Stephen Wagner
- Department of Obstetrics and Gynecology, Penn State Milton S. Hershey Medical Center Hershey, PA
| | - John T Repke
- Department of Obstetrics and Gynecology, Penn State Milton S. Hershey Medical Center Hershey, PA
| | - Serdar H Ural
- Department of Obstetrics and Gynecology, Penn State Milton S. Hershey Medical Center Hershey, PA
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Abstract
OBJECTIVE We sought to review the natural history, pathophysiology, diagnosis, and treatment options for twin-twin transfusion syndrome (TTTS). METHODS A systematic review was performed using MEDLINE database, PubMed, EMBASE, and Cochrane Library. The search was restricted to English-language articles published from 1966 through July 2012. Priority was given to articles reporting original research, in particular randomized controlled trials, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Evidence reports and guidelines published by organizations or institutions such as the National Institutes of Health, Agency for Health Research and Quality, American College of Obstetricians and Gynecologists, and Society for Maternal-Fetal Medicine were also reviewed, and additional studies were located by reviewing bibliographies of identified articles. Consistent with US Preventive Task Force guidelines, references were evaluated for quality based on the highest level of evidence, and recommendations were graded accordingly. RESULTS AND RECOMMENDATIONS TTTS is a serious condition that can complicate 8-10% of twin pregnancies with monochorionic diamniotic (MCDA) placentation. The diagnosis of TTTS requires 2 criteria: (1) the presence of a MCDA pregnancy; and (2) the presence of oligohydramnios (defined as a maximal vertical pocket of <2 cm) in one sac, and of polyhydramnios (a maximal vertical pocket of >8 cm) in the other sac. The Quintero staging system appears to be a useful tool for describing the severity of TTTS in a standardized fashion. Serial sonographic evaluation should be considered for all twins with MCDA placentation, usually beginning at around 16 weeks and continuing about every 2 weeks until delivery. Screening for congenital heart disease is warranted in all monochorionic twins, in particular those complicated by TTTS. Extensive counseling should be provided to patients with pregnancies complicated by TTTS including natural history of the disease, as well as management options and their risks and benefits. The natural history of stage I TTTS is that more than three-fourths of cases remain stable or regress without invasive intervention, with perinatal survival of about 86%. Therefore, many patients with stage I TTTS may often be managed expectantly. The natural history of advanced (eg, stage ≥III) TTTS is bleak, with a reported perinatal loss rate of 70-100%, particularly when it presents <26 weeks. Fetoscopic laser photocoagulation of placental anastomoses is considered by most experts to be the best available approach for stages II, III, and IV TTTS in continuing pregnancies at <26 weeks, but the metaanalysis data show no significant survival benefit, and the long-term neurologic outcomes in the Eurofetus trial were not different than in nonlaser-treated controls. Even laser-treated TTTS is associated with a perinatal mortality rate of 30-50%, and a 5-20% chance of long-term neurologic handicap. Steroids for fetal maturation should be considered at 24 0/7 to 33 6/7 weeks, particularly in pregnancies complicated by stage ≥III TTTS, and those undergoing invasive interventions.
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Gembruch U, Geipel A, Müller A, Bartmann P, Berg C. Intrauterine minimalinvasive Therapie. Monatsschr Kinderheilkd 2012. [DOI: 10.1007/s00112-012-2729-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kowitt B, Tucker R, Watson-Smith D, Muratore CS, O'Brien BM, Vohr BR, Carr SR, Luks FI. Long-term morbidity after fetal endoscopic surgery for severe twin-to-twin transfusion syndrome. J Pediatr Surg 2012; 47:51-6. [PMID: 22244392 DOI: 10.1016/j.jpedsurg.2011.10.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2011] [Accepted: 10/06/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND/PURPOSE Severe twin-to-twin transfusion syndrome (TTTS) leads to 80% to 100% dual mortality. Endoscopic laser coagulation of connecting vessels improves outcome to 80% survival of at least 1 twin. There is limited long-term follow-up of surviving TTTS patients. The aim of this study was to analyze gestational age-stratified, long-term morbidity in these patients. METHODS A retrospective case-control study of TTTS surviving patients (38 patients, 72% follow-up rate) from one center. Perinatal and pediatric records were reviewed, and outcomes were compared with published reports and gestational age-matched controls. RESULTS Forty percent (15/38) had at least 1 major sequela, all but 6 of which were fully resolved at a median follow-up of 4.4 years. There were no permanent cardiac, genitourinary, renal, or respiratory sequelae. All major complications were in patients born <29 weeks. There were no significant differences in complications between this cohort of patients and gestational age (GA)-matched control patients. CONCLUSIONS The long-term morbidity of monochorionic twins after fetal laser surgery for severe TTTS is 13%. At a median follow-up of more than 4 years, these children fare no worse than gestational age-matched, non-operated twins and singletons. The degree of prematurity at birth is the best predictor of temporary or permanent sequela in this group of patients.
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Affiliation(s)
- Benjamin Kowitt
- Division of Pediatric Surgery, Hasbro Children's Hospital, Alpert Medical School of Brown University, Providence, RI 02905, USA
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Diastolic Cardiac Pathology and Clinical Twin-Twin Transfusion Syndrome in Monochorionic/Diamniotic Twins. Am J Obstet Gynecol 2011; 205:279.e1-279.e11. [PMID: 21909155 DOI: 10.1016/j.ajog.2011.06.045] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE: to identify differences in echocardiographic profiles of monochorionic/diamniotic pregnancies with early or mild twin-twin transfusion syndrome (TTTS), compared to monochorionic/diamniotic twins affected only by discordant growth or discordant fluid. STUDY DESIGN: retrospective evaluation of sonograms and echocardiograms of twin pregnancies referred for suspected TTTS. RESULTS: 112 monochorionic/diamniotic pairs were studied. 41 did not have/develop TTTS, 61 had Stage I/II TTTS. Ten developed TTTS after initially not meeting criteria. TTTS recipients had a higher rate of venous Doppler or tricuspid inflow abnormalities than purported "recipients" in non-TTTS pregnancies (86% vs. 37%, P<0.001). TTTS recipients had shorter tricuspid inflow duration/RR intervals than non-TTTS fetuses (32+/-6% versus 37+/-4%, P<0.001). Logistic regression and recursive partitioning identified shorter tricuspid inflow duration, longer isovolumic relaxation, and ductus venosus abnormality associated with TTTS. CONCLUSION: Diastolic pathology, specifically shorter tricuspid inflow duration, may be considered a hallmark of TTTS distinguishing these pregnancies from other monochorionic/diamniotic twin complications.
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Pruetz JD, Sklansky M, Detterich J, Korst LM, Llanes A, Chmait RH. Twin-twin transfusion syndrome treated with laser surgery: postnatal prevalence of congenital heart disease in surviving recipients and donors. Prenat Diagn 2011; 31:973-7. [DOI: 10.1002/pd.2818] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Revised: 05/26/2011] [Accepted: 06/01/2011] [Indexed: 11/12/2022]
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Maschke C, Diemert A, Hecher K, Bartmann P. Long-term outcome after intrauterine laser treatment for twin-twin transfusion syndrome. Prenat Diagn 2011; 31:647-53. [PMID: 21660996 DOI: 10.1002/pd.2797] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Revised: 05/04/2011] [Accepted: 05/04/2011] [Indexed: 11/08/2022]
Abstract
Twin-twin transfusion syndrome (TTTS) is a severe complication occurring in about 10% of monochorionic twin pregnancies. The chronic unbalanced transfusion of blood across placental vascular communications from the donor to the recipient twin may lead to impairment of various organ systems in the affected twins. In Hamburg, Germany, since 1995 patients with TTTS were treated with fetoscopic laser coagulation as the first causal therapeutic strategy. All survivors after laser surgery were followed up in the University Children's Hospital in Bonn, Germany. In this article, we summarize long-term follow-up studies from our German study population and compare our results with data from the literature.
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Affiliation(s)
- Cornelia Maschke
- Department of Neonatology, University Childrens' Hospital, Bonn, Germany.
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