Speckle Tracking-Derived Myocardial Tissue Deformation Imaging in Twin-Twin Transfusion Syndrome: Differences in Strain and Strain Rate between Donor and Recipient Twins

Abstract

Objectives: Twin-twin transfusion syndrome (TTTS) is a complex disorder with altered cardiovascular loading conditions that affects both donors and recipients. Myocardial tissue deformation analysis using vector velocity imaging is an angle-independent, speckle-tracking technique which can assess myocardial mechanics and may provide insight into cardiac dysfunction in TTTS. Methods: Digital dynamic two-dimensional four-chamber views were interrogated offline. Images were acquired utilizing standard video frame rates (30 frames/s). The global longitudinal strain, systolic strain rate, and diastolic strain rate were measured in the left (LV) and right ventricles (RV) of 25 fetal pairs with TTTS and compared to 25 gestational age-matched normal controls. Pulsatility indices for the umbilical artery and middle cerebral artery were measured. Results: The gestational age at evaluation was 20.5 ± 1.3 weeks. The donor LV systolic strain rate was higher, while the donor RV diastolic strain rate was significantly lower, than control values. The recipient longitudinal strain, systolic strain rate, and diastolic strain rate were significantly lower for both LV and RV in comparison to controls. The donor umbilical artery pulsatility index was higher than control values (1.92 ± 0.45 vs. 1.41 ± 0.25, p < 0.001), while the donor middle cerebral artery pulsatility index was lower (1.46 ± 0.28 vs. 1.87 ± 0.21). Recipient umbilical artery and middle cerebral artery pulsatility indices were no different than control values. Conclusions: In TTTS, both the donor and the recipient exhibit abnormalities of myocardial tissue deformation with ventricle-specific changes evident based on loading conditions. Donor LV systolic function is hyperdynamic due to hypovolemia and selective ejection into a low-resistance cerebrovascular circuit while the donor RV selectively ejects into a high-resistance placental circuit. Recipient RV and LV are both globally depressed with systolic and diastolic dysfunction. Further prospective validation of our findings using high frame rate analysis is indicated.

Treatment of premature infants with pulmonary hypertension and right ventricular dysfunction with milrinone: a case series

“…Recipient RV and LV are both globally depressed with systolic and diastolic dysfunction as estimated by speckle-tracking echocardiography. 15 The RV of the recipient fetus is known to be vulnerable to altered loading conditions. Interestingly, those changes are not detectable using conventional imaging methods such as fractional shortening.…”

Intertwin cardiac status at 10-year follow-up after intrauterine laser coagulation therapy of severe twin–twin transfusion syndrome: comparison of donor, recipient and normal values

“…The recipient faces increased preload and afterload. In contrast, the donor shows mild cardiac involvement before LC,11 but may be affected by unequal placental sharing, which lead to growth discordance and intrauterine growth restriction 17. Epidemiological studies provide evidence that prenatal haemodynamic or placental alterations are associated with increased cardiovascular risk in adults, and cardiovascular system programming takes place in utero 4 15 16.…”

“…Besides functional cardiac impairment, right ventricular outflow tract obstruction (RVOTO) has been reported in recipients and is attributed to increased loading of the fetal right ventricle (RV) 8–10. In contrast, the smaller donor shows less cardiac pathology but manifests moderate right ventricular diastolic impairment due to increased placental resistance and poor renal perfusion 11. Cardiovascular changes occur early in pregnancy and progress with increasing gestational age, potentially causing significant impact on the development of the cardiovascular system 4 6…”

Two‐Dimensional Speckle Tracking of the Fetal Heart

“…[44][45][46][47][48][49][50][51][52][53][54][55][56] Figure 14. Transverse and longitudinal strain using the 17-segment model.…”

“…Deformation analysis has been evaluated in fetuses with twin-twin transfusion syndrome, intrauterine growth restriction, maternal diabetes, as well as other fetal conditions. [44][45][46][47][48][49][50][51][52][53][54][55][56] The problem with its adaptation by the ultrasound community of noncardiologists is that the software used for analysis was initially only available on dedicated cardiovascular ultrasound machines that were not generally available to the broader medical community (Table 1). With changes in imaging technology and the availability of machine-independent software, it is now possible to obtain DICOM clips from virtually any ultrasound machine used for fetal imaging and to analyze deformation of the fetal heart with machine-independent software (Table 1).…”