Recipient Twin Circular Shunt Physiology Before Fetal Laser Surgery: Survival and Risks for Postnatal Right Ventricular Outflow Tract Obstruction

Pruetz, Jay D.; Votava‐Smith, Jodie K.; Chmait, Hikmat R.; Korst, Lisa M.; Llanes, Arlyn; Chmait, Ramen H.

doi:10.7863/ultra.16.08038

Cited by 10 publications

(13 citation statements)

References 44 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…It has been suggested previously that recipients in higher Quintero stages of TTTS are more likely to develop postnatal RVOTO . In this prospective cohort, prenatal RVOTO at TTTS diagnosis seem to occur more frequently in the advanced stages of TTTS, but postnatal RVOTO was equally found in all Quintero stages.…”

Section: Commentsmentioning

confidence: 46%

“…In contrast to this, cases with pulmonary insufficiency with reversed circular shunt physiology were included in the isolated PI in our cohort (cases 4 and 6, Table ). Circular shunt physiology is a circular shunt in which blood originating in one cardiac chamber is shunted through the heart to return to the original chamber without ever crossing a capillary bed and described in recipients in a recent study of Pruetz et al In one case, fetal demise occurred, while the other case improved without echocardiographic abnormalities postnatally in this recipient. Pruetz et al stated that recipients with preoperative circular shunt physiology are at increased risk for postnatal right ventricular outflow tract obstruction.…”

Section: Commentsmentioning

confidence: 94%

“…The pathophysiology of RVOTO in TTTS is not fully understood, and risk factors for progression to postnatal RVOTO are still difficult to determine. Most studies focus on preintervention assessment of RVOTO, because systematic longitudinal echocardiographic follow‐up of all recipients after laser therapy is difficult to establish in fetal therapy centers . This impedes knowledge on the complete spectrum of RVOTO .…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Acquired right ventricular outflow tract obstruction in twin‐to‐twin transfusion syndrome; a prospective longitudinal study

et al. 2018

View full text Add to dashboard Cite

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.

show abstract

Section: Commentsmentioning

confidence: 46%

Section: Commentsmentioning

confidence: 94%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Acquired right ventricular outflow tract obstruction in twin‐to‐twin transfusion syndrome; a prospective longitudinal study

et al. 2018

View full text Add to dashboard Cite

show abstract

“…The following echocardiographic findings were used to diagnose a circular shunt: tricuspid and pulmonary regurgitation, RV dysfunction, and flow reversal in the ductus arteriosus. 9 An experienced sonologist (J.E. ), who was blinded to the study outcomes, retrospectively reviewed UA spectral Doppler images obtained before laser surgery.…”

Section: Methodsmentioning

confidence: 99%

“…[1][2][3][4][5][6][7][8] An RVOTA can persist in one-third of recipient twins surviving to birth 2 : in particular, when physiologic characteristics of a circular shunt are noted before laser surgery based on the following echocardiographic findings: tricuspid and pulmonary regurgitation, right ventricular (RV) dysfunction, and flow reversal in the ductus arteriosus. 9 Right ventricular outflow tract abnormalities have almost exclusively been reported in the recipient twin; however, these cardiac anomalies have also been described in the donor twin in a few TTTS cases 10 and in the larger twin in monochorionic diamniotic twin pregnancies complicated by selective fetal growth restriction (sFGR). 11 The conventional view is that substantial hemodynamic disturbances due to placental anastomoses may contribute to right-sided cardiac dysfunction in the recipient twin because they tend to resolve after laser photocoagulation of placental anastomoses.…”

mentioning

confidence: 99%

Umbilical Artery Doppler Patterns and Right Ventricular Outflow Abnormalities in Twin‐Twin Transfusion Syndrome

Espinoza

Furtun

Kailin

et al. 2020

J of Ultrasound Medicine

View full text Add to dashboard Cite

Objectives-To evaluate the association of abnormal Doppler velocimetric patterns in the umbilical arteries (UAs) and right ventricular outflow tract abnormalities (RVOTAs) in twin-twin transfusion syndrome (TTTS) cases. Methods-This retrospective study involved women who had laser surgery for TTTS between January 2012 and May 2018 at a single institution. The prevalence of an RVOTA in either twin was compared among TTTS cases in which both twins had positive end-diastolic flow (EDF) in the UA and those in which either twin had intermittent or persistent absent/reversed UA EDF. Nonparametric tests were used for comparisons. Logistic regression was performed to identify variables associated with an RVOTA in either twin, adjusted for moderate or severe tricuspid regurgitation, right ventricular hypertrophy, right ventricular systolic or diastolic dysfunction, the Quintero stage, and other confounders. P < .05 was considered significant. Results-A total of 126 consecutive TTTS cases were included. Right ventricular outflow tract abnormalities were seen in 8.7% (11of 126) of cases, all in recipient twins. Significant differences in the rate of RVOTAs in the recipient twin were seen between TTTS cases with intermittent absent/reversed UA EDF and those with positive UA EDF (26.9% [7 of 26] versus 3.7% [3 of 82]; P = .002]. However, no significant differences were noted among the other study groups. Intermittent absent/reversed UA EDF was associated with a significantly increased risk for an RVOTA (adjusted odds ratio, 20.6 [95% confidence interval, 3.1-138]; P = .002) after adjusting for confounders. Conclusions-Intermittent changes in vascular impedance to UA flow may contribute to the pathogenesis of acquired right-sided cardiac lesions in the recipient twin affected with TTTS.

show abstract

Novel Technique for the Measurement of Fetal Right Modified Myocardial Performance Index Using Synchronized Images of Right Ventricular Inflow and Outflow and Clinical Application to Twin‐to‐Twin Transfusion Syndrome

Kang

Kim

Lee

et al. 2021

J of Ultrasound Medicine

View full text Add to dashboard Cite

Objective To evaluate the reproducibility of the fetal right modified myocardial performance index (Mod‐MPI) obtained by synchronizing the inflow and outflow images of the right ventricle (RV) and to evaluate its feasibility through clinical application to twin‐to‐twin transfusion syndrome (TTTS). Methods We prospectively evaluated 77 normal fetuses. Two experienced operators individually measured the right Mod‐MPI using two different methods: (1) separate recording of the RV inflow and outflow using pulsed‐wave Doppler (conventional method) and (2) synchronization of RV inflow and outflow images using the MPI + ™ function based on the closure click of the pulmonary valve (new method). To evaluate the clinical utility of the new method, we measured the right Mod‐MPI in 33 TTTS fetuses using the new method before and after the fetoscopic laser coagulation (FLC). Results There was no statistical difference in Mod‐MPI values between the two methods (p = .242). For both operators, the intra‐ and interoperator reproducibility of Mod‐MPI was high with both methods (ICCs >0.950). Among the components of Mod‐MPI measured using the new method, ejection time showed the highest reproducibility, whereas isovolumetric relaxation time demonstrated the lowest reproducibility. In TTTS fetuses, the Mod‐MPI significantly decreased after FLC in recipients, and there was no difference in MPI values before and after FLC in donors. Conclusion Right Mod‐MPI measurement after the synchronization of RV inflow and outflow images is a reliable technique for evaluating fetal right cardiac function. This novel method can also independently evaluate the systolic and diastolic functions of the right heart.

show abstract

Recipient Twin Circular Shunt Physiology Before Fetal Laser Surgery: Survival and Risks for Postnatal Right Ventricular Outflow Tract Obstruction

Cited by 10 publications

References 44 publications

Acquired right ventricular outflow tract obstruction in twin‐to‐twin transfusion syndrome; a prospective longitudinal study

Acquired right ventricular outflow tract obstruction in twin‐to‐twin transfusion syndrome; a prospective longitudinal study

Umbilical Artery Doppler Patterns and Right Ventricular Outflow Abnormalities in Twin‐Twin Transfusion Syndrome

Novel Technique for the Measurement of Fetal Right Modified Myocardial Performance Index Using Synchronized Images of Right Ventricular Inflow and Outflow and Clinical Application to Twin‐to‐Twin Transfusion Syndrome

Contact Info

Product

Resources

About