Diastolic cardiac pathology and clinical twin-twin transfusion syndrome in monochorionic/diamniotic twins

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.

Reply

“…Consequently, assuming that there were no differences in fetal heart rate between the two groups, the total relaxation time would be expected to be shorter, despite the increase in IRT, resulting in an overall prolongation of systole and shortening of diastole. This is supported by a study showing that recipient fetuses in TTTS have a significantly shorter right ventricular filling time compared with normal cases 3 . It is likely that impaired fetal cardiac function includes a spectrum of changes in functional ultrasound measurements which may have different trends depending on the underlying condition.…”

Diagnosis and Treatment of Fetal Cardiac Disease

“…Diastolic dysfunction may be less well tolerated by the fetal circulation than systolic dysfunction, as suggested in a retrospective study of fetal cardiomyopathies in which diastolic dysfunction was associated with an 8-fold increased risk of fetal mortality relative to other parameters of fetal heart function in a multiple logistic regression analysis. 168 Short-duration, monophasic ventricular inflow Doppler flow patterns have been observed in fetal cardiomyopathies, the recipient in TTTS, ductus arteriosus constriction, and severe semilunar valve stenosis, 161,168,173,174,[235][236][237] and have been shown to be predictive of progressive ventricular hypoplasia in the presence of severe semilunar valve obstruction. 235,236 Doppler interrogation of blood flow in the inferior vena cava or hepatic veins, ductus venosus, and umbilical vein can also be used in the assessment of functional pathology of the fetal heart.…”

“…The diastolic filling time may be an early cardiac finding of TTTS, distinguishing TTTS from other causes of fetal growth or amniotic fluid discordance. 237,304,499 These imaging techniques may provide clinicians with advanced tools to differentiate TTTS from other disease processes and may be reasonable to perform as part of the assessment of monochorionic twin gestations.…”

Re-Thinking Elective Single Embryo Transfer: Increased Risk of Monochorionic Twinning - A Systematic Review

“…TTTS also lends consequences to the cardiovascular status of the fetuses with progressive decompensation as disease status progresses. The recipient twin develops cardiomyopathy and abnormal diastolic and systolic function [70][71][72][73] . Interestingly, MCDA twins conceived after eSET splitting may experience less TTTS [74] .…”