General Obstetrics and Gynecology: Obstetrics
Prenatal cardiovascular manifestations in the twin-to-twin transfusion syndrome recipients and the impact of therapeutic amnioreduction

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Objective

We evaluated the cardiovascular pathologic condition in the recipient twin in twin-to-twin transfusion syndrome and the influence of amnioreduction.

Study design

Fetal echocardiograms and medical records of 54 pregnancies that were complicated by twin-to-twin transfusion syndrome were reviewed. Recipient twin right and left ventricular wall thickness, diameters, systolic and diastolic function, valve regurgitation, and structural cardiac defects were assessed at examination and after amnioreduction.

Results

At examination (n = 28 pregnancies), cardiomegaly because of right ventricular and/or left ventricular hypertrophy was observed in 58% of recipient twins, and biventricular hypertrophy was observed in 33% of recipient twins, without ventricular dilation. Biventricular diastolic dysfunction was present in two thirds of recipient twins, and right ventricular systolic dysfunction and significant atrioventricular valve regurgitation was observed in one third of recipient twins. Serial assessment (n = 21 pregnancies) revealed progressive biventricular hypertrophy and right ventricular systolic and biventricular diastolic dysfunction in most recipient twins. Steeper progression of hypertrophy, diastolic dysfunction, and structural or functional right ventricular outflow disease (20% incidence) were associated with an increased perinatal mortality rate.

Conclusion

In twin-to-twin transfusion syndrome, the recipient twin has progressive biventricular hypertrophy with predominant right ventricular systolic and biventricular diastolic dysfunction. Despite amnioreduction, the cardiovascular disease persists and even progresses in many recipient twins.

Section snippets

Methods

From 1993 to 2001, 78 patients with TTTS were seen in our institutions, 61 of whom were referred for fetal echocardiography as part of their routine assessment; 54 of these patients were included in the analysis (Table I). The diagnosis of TTTS was based on a monochorionic-diamniotic twin pregnancy (single placenta, thin dividing membrane, same gender) that was complicated by a “polyhydramnios (>8 cm depth of amniotic fluid)-oligohydramnios (<2 cm depth of amniotic fluid)” sequence, with the

Results

Fifty-four patients with TTTS were included: 50 pairs of twins and 4 sets of triplets. GA at diagnosis of TTTS was 21 ± 3 weeks. More than one half of the patients were in Quintero stage III. Figure 1 summarizes the case, including the interventions where performed. Amnioreduction was the treatment of choice until 1999; laser was the treatment of choice thereafter, especially for advanced (stage III or IV) or when the diagnosis was made at <22 weeks of gestation.22

Comment

In TTTS, cardiovascular disease occurs in most recipient twins19, 20, 21, 32 and is a major cause of death.33, 34 The recipient's cardiovascular disease also contributes significantly to the donor's morbidity and death. Knowledge of the influence of TTTS on ventricular systolic and diastolic function in the recipient contributes to our understanding of pathophysiologic conditions and may ultimately assist in the identification of the most effective invasive or noninvasive therapies.

Most

Acknowledgments

We thank our obstetric and pediatric colleagues who referred patients and provided prenatal and postnatal follow-up both locally and in other Canadian provinces.

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    Supported in part by The Physician's Services Incorporated Foundation, grant no. 78390 and by the Foundation “Saint Luc,” Cliniques Universitaires Saint Luc, Catholic University of Louvain, Brussels, Belgium.

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