Acquired right ventricular outflow tract obstruction in the recipient twin in twin-twin transfusion syndrome

Lougheed, Jane; Sinclair, Brian; Fung, Karen Y.; Bigras, Jean‐Luc; Ryan, Greg; Smallhorn, Jeffrey F.; Hornberger, Lisa K.

doi:10.1016/s0735-1097(01)01549-2

Cited by 121 publications

(113 citation statements)

References 13 publications

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“…In rare cases, this hypertrophy could lead to severe acquired RV outflow tract obstruction. 35 The results of the probability studies show that various levels of differences between the recipient and donor twins for LVMPIs and LVSF could identify twins with TTTS with a sensitivity between 80% and 90% but a relatively poor specificity. TTTS could be diagnosed, however, with a sensitivity of 75% and a false-positive rate of 9% when a combination of the following 2 cutoff values is applied: ⌬LVMPI 0.09 and ⌬RVMPI 0.05.…”

Section: Discussionmentioning

confidence: 97%

Early Intertwin Differences in Myocardial Performance During the Twin-to-Twin Transfusion Syndrome

et al. 2004

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Background-In the twin-to-twin transfusion syndrome (TTTS), pressure rather than volume overload is increasingly considered as a key factor in the pathogenesis of the cardiomyopathy of the recipient twin. If this is the case, cardiac dysfunction should be among the first signs observed with TTTS. The objective of this study was to determine whether intertwin differences in myocardial function are modified early in the course of TTTS and whether they can help to differentiate this condition from intrauterine growth restriction (IUGR). Methods and Results-Eight variables were analyzed on the first fetal echocardiography on 21 pairs of twins with TTTS and 11 with IUGR. No difference was found between the 2 groups for the cardiothoracic ratio, pulsatility indices in the umbilical and middle cerebral arteries, and peak velocity of the middle cerebral artery. Significant difference was found for ventricular septal thickness, but with no association with the conditions under study. With TTTS, left ventricular shortening fraction was consistently greater in the donor twins, and myocardial performance indices (MPIs) were elevated in the recipient twins. This increase in MPI was caused by a lengthening of the isovolumic periods compared with those of the donor twin: left ventricular and right ventricular isovolumic periods 0.105Ϯ0.047 and 0.097Ϯ0.026 seconds, respectively, for the recipient twins versus 0.0561Ϯ0.46 and 0.065Ϯ0.03 seconds, respectively, for the donor twins (PϽ0.001). These changes in the isovolumic periods were mainly due to significant prolongation of isovolumic relaxation times. A change in left ventricular MPI Ն0.09 combined with a change in right ventricular MPI Ն0.05 would identify a TTTS with a sensitivity of 75% and a false-positive rate of 9%. Conclusions-The observed diastolic function impairment goes along with the pressure-overload pathogenic concept proposed in TTTS. Assessment of intertwin difference in MPI is a valuable tool for early differential diagnosis between TTTS and isolated IUGR.

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Section: Discussionmentioning

confidence: 97%

Early Intertwin Differences in Myocardial Performance During the Twin-to-Twin Transfusion Syndrome

et al. 2004

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“…These conditions lead to cardiomegaly and atrio-ventricular valve regurgitation. Occasionally, some cases of a severely affected recipient can develop into acquired pulmonary stenosis/atresia with an intact ventricular septum [5,7].…”

Section: Preparation For Fetoscopic Laser Surgerymentioning

confidence: 99%

Fetoscopic Laser Photocoagulation for the Treatment of Twin-Twin Transfusion Syndrome in Monochorionic Twin Pregnancies

Murakoshi¹

2012

TOMDJ

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Fetoscopic laser surgery for severe twin-twin transfusion syndrome (TTTS) has become the optimal treatment choice since the release of the Eurofetus randomized clinical trial. These techniques have been adopted throughout the globe, and many institutions have instituted or will soon institute fetoscopic laser surgery procedures; however, laser surgery has a steep learning curve because of the following: challenging placental location, complex and unexpected communicating anastomoses, residual anastomoses after surgery, or discolored amniotic fluid. We have been performing laser surgery since 2002 in Japan; to date, we have compiled a series of 170 cases. Our data indicates a 78% of overall survival with 5% neonatal morbidity, 63% of survival of both twins, and 93% survival of at least one twin. The recurrent TTTS rate was 1% and the residual vessel rate was 3%.To improve the learning curve of laser surgery, the employment of various techniques is recommended to achieve a successful surgical outcome: (1) Mapping: before laser ablation, a very thorough mapping of vascular anastomoses should be done, and should be repeated after ablation; (2) Sequential order: obliteration of arterio-venous anastomoses from donor to recipient should be done first to avoid donor hypotension and/or anemia; (3) Trocar (cannula) assisted technique: Trocar assisted technique: Using gentle indent the trocar to the placenta by withdrawing the scope shortly, then anastomoses could be ablated easily; (4) Line method: to avoid residual anastomoses, the laser should draw a virtual line at the hemodynamic equator; The operator must be careful not to miss small anastomoses.These techniques can help achieve a successful outcome for fetoscopic laser surgery and improve the outcome for cases of severe TTTS.

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“…We now know that critical outflow tract obstruction in the absence of severe atrioventricular valve insufficiency in the mid trimester fetus is often associated with the evolution of a hypoplastic ventricle and great artery ipsilateral to the obstruction [83][84][85][86][87][88][89]. We have also learned that functional abnormalities involving only one ventricle may also be associated with abnormal growth and progressive hypoplasia of the affected ventricle and may contribute as an etiology to such conditions as hypoplastic left heart syndrome ( Figure 8) [90,91]. Ventricular outflow obstruction may progress as a primary lesion in isolation or be associated with more complex congenital heart disease such as tetralogy of Fallot.…”

Section: Natural History Of Cardiac Disease In the Mid And Third Trimmentioning

confidence: 99%

“…Ventricular outflow obstruction may progress as a primary lesion in isolation or be associated with more complex congenital heart disease such as tetralogy of Fallot. It may also evolve secondary to altered flow as is true for pulmonary outflow obstruction in Ebstein anomaly [27] and in the recipient twin in twintwin transfusion syndrome [91]. Atrioventricular and semilunar valve regurgitation and stenosis may progress and lead to more severe secondary disease including a dilated and dysfunctional ventricle, and the evolution of fetal heart failure [27][28][29][30]34] Although most structural fetal heart lesions either remain unchanged or progress, rarely there is resolution of cardiovascular pathology including progressive diminution and even closure of ventricular septal defects [90] or normalization of discrepant ventricles and great arteries detected earlier in gestation [60].…”

Section: Natural History Of Cardiac Disease In the Mid And Third Trimmentioning

confidence: 99%

“…Furthermore, delivery of the twins at a viable age is also associated with the resolution of the cardiovascular pathology of the recipient over days to weeks. Interestingly when left untreated 10-11% of the recipient twins evolve pulmonary outflow obstruction [91] decreasing to an incidence of 2% among treated pregnancies [116], and this is believed to occur at least in part due to greater involvement of the right ventricle. The exact etiology of the recipient cardiovascular pathology is not as yet known, however, it has been speculated that increased levels of circulating vasoactive peptides and mitogens expressed by the placenta in response to the donor arterial blood could contribute [117,118] In contrast to the recipient, left heart obstruction in the form of coarctation of the aorta has been reported among the smaller donor twins [119].…”

Section: High Output Statesmentioning

confidence: 99%

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Fetal Echocardiography and Prenatal Cardiovascular Interventions – An Update (2012)

Hornberger

Moon‐Grady²,

Tworetzky³

2012

J Clin Exp Cardiolog

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Fetal echocardiography has evolved considerably over the past 1-2 decades into an exciting field that bridges maternal-fetal medicine with neonatology and pediatric cardiology. With significant advances in imaging technology and experience in prenatal diagnosis, details of the cardiac pathology can now be defined much as it is postnatally; however, unique aspects of the fetal circulation limit our ability to consistently define lesion severity and to predict the evolution of cardiac defects after birth. Serial assessment has provided an understanding of the antenatal natural history of fetal heart disease, which has led to improved counseling and perinatal/neonatal management strategies. More recently, this field has focused on improving our evaluation of fetal arrhythmias, exploring the pathophysiology of fetal heart failure, detecting heart defects at earlier gestational ages, identifying novel interventions to alter the development and progression of severe disease, and investigating strategies to optimize prenatal and neonatal care in an effort to improve perinatal outcome of affected pregnancies. In this paper we will review the current state of the art of fetal/perinatal cardiology and the advances that have occurred in the field largely over the past decade.

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Acquired right ventricular outflow tract obstruction in the recipient twin in twin-twin transfusion syndrome

Abstract: Right ventricular outflow tract obstruction may occur in the recipient twin of at least 9% of pregnancies complicated by TTTS. Right ventricular outflow tract obstruction progression is common in utero and may worsen neonatal outcome.

Cited by 121 publications

References 13 publications

Early Intertwin Differences in Myocardial Performance During the Twin-to-Twin Transfusion Syndrome

Early Intertwin Differences in Myocardial Performance During the Twin-to-Twin Transfusion Syndrome

Fetoscopic Laser Photocoagulation for the Treatment of Twin-Twin Transfusion Syndrome in Monochorionic Twin Pregnancies

Fetal Echocardiography and Prenatal Cardiovascular Interventions – An Update (2012)

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