Long term cardiac follow up of severe twin to twin transfusion syndrome after intrauterine laser coagulation

Abstract

Objective: To assess long term changes in cardiac morphology and function in survivors of severe twin to twin transfusion syndrome (TTTS) after intrauterine laser coagulation of placental anastomoses. Design: Prospective follow up of fetuses with severe TTTS treated by laser coagulation of intrauterine placental anastomoses. Fetal echocardiography and Doppler studies of feto-placental haemodynamic function were performed at the time of laser coagulation (median gestational age of 21.7 weeks). Postnatal cardiac follow up included a detailed echocardiographic study of systolic and diastolic cardiac function at a median age of 21.1 months. Setting: Paediatric cardiology unit. Patients: 89 survivors from 73 consecutive pregnancies with severe TTTS. Results: Before laser treatment, 28 of 51 (54.9%) recipient twins had typical signs of cardiac dysfunction due to volume overload and 9 of 38 (23.7%) donors had absent or reversed end diastolic flow in the umbilical artery. Echocardiography was normal in 87.6% of the survivors (34 of 38 donors, 44 of 51 recipients). The prevalence of congenital heart disease and particularly of pulmonary stenosis, which was recorded only in recipients, was increased in comparison with the general population (congenital heart disease, 10 of 89 (11.2%) v 0.3%; pulmonary stenosis, 4 of 51 (7.8%) v 0.03%). Findings before laser treatment were not correlated with the development of structural heart disease. Conclusions: Despite the high rate and severity of prenatal cardiac overload in recipients, the majority of cases of TTTS are normalised after laser treatment. However, given the increased prevalence of congenital heart disease and in particular pulmonary stenosis, intrauterine and postnatal follow up is warranted.

Diagnosis and Treatment of Fetal Cardiac Disease

“…TTTS has been associated with polyhydramnios and myocardial changes, including acquired right ventricular outflow tract obstruction, which occurs in ≈10% of recipient twin fetuses. 84 Atrial septal defects have also been reported postnatally in either twin. 84,133 The incidence of pulmonary stenosis may be lower if the pregnancy is successfully treated with invasive laser photocoagulation of the intertwin anastomosis.…”

“…84,133 The incidence of pulmonary stenosis may be lower if the pregnancy is successfully treated with invasive laser photocoagulation of the intertwin anastomosis. 84,133,134 Fetal echocardiogram is recommended in all monochorionic twin gestations.…”

“…162,[503][504][505] Despite successful fetoscopic laser therapy, a significant proportion of right ventricular outflow tract abnormalities documented in utero persist after birth. 84 Changes in venous Doppler flow patterns in the hepatic veins, ductus venosus, and umbilical vein consistent with elevated fetal central venous pressure can manifest, particularly in the recipient twin of TTTS. Quantitative methods to assess cardiac function have been used to characterize changes in TTTS, including Doppler MPI, 239,499,501 an index of global systolic and diastolic function.…”

Increased Prevalence of Congenital Heart Defects in Monozygotic and Dizygotic Twins

“…8,[29][30][31] However, an increased congenital heart defect risk was also found in the non-TTTS monochorionic twins. Overall, VSDs were found to be the most frequent in this sample of monochorionic/diamniotic twin gestations, whereas pulmonary stenosis and atrial septal defects were significantly more prevalent in pregnancies complicated by TTTS.…”

Invasive Procedures in Monochorionic Twins

“…137 Eighty seven percent recipient twins who survived after laser treatment for severe TTTS, were reported to have normal cardiac function at about 2 years after delivery. 138 Other complications that have been documented with laser treatment involve amniotic fluid leakage into the maternal peritoneal cavity, vaginal bleeding, placental abruption and chorioamnionitis. 64,79 The instruments used for laser photocoagulation are of larger diameter than the spinal needle that are usually preferred for amnioreduction or even septostomy and even that factor is enough to increase the risk of complications.…”