Cardiac Manifestations of Twin–to–Twin Transfusion Syndrome

Manning, Nicky; Archer, Nick

doi:10.1017/thg.2016.20

Cited by 28 publications

(26 citation statements)

References 66 publications

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“…Because most studies on this topic focus on recipients with preintervention RVOTO and lack longitudinal prospective follow‐up on all recipients, detection of these late‐onset cases is rarely described before . Initial mild RVOTO after birth is however important, as it may progress to severe RVOTO with need for intervention in infancy . The total incidence of postnatal RVOTO found in this study is slightly higher than in prior large cohort studies, which found an incidence of 2.1% to 4% .…”

Section: Commentscontrasting

confidence: 55%

“…Several pathways of RVOTO development have been suggested, such as the underdevelopment of the pulmonary valve due to decreased forward flow across the PV, caused by right ventricular hypertrophy, the effect of endothelial damage caused by shear stress, which eventually results in valve dysplasia and damage of the valve due to exposure to abnormal concentrations of vasoactive mediators such as endothelin‐1, renin, and angiotensin II . The decreased flow across the PV may be explained by impaired cardiac function at the time of TTTS .…”

Section: Commentsmentioning

confidence: 99%

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

et al. 2018

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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.

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Section: Commentscontrasting

confidence: 55%

Section: Commentsmentioning

confidence: 99%

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

et al. 2018

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“…Recent reports have indicated that the aforementioned cardiovascular disorders can remain even after FLP treatment, and there are frequently observed right side cardiac anomalies in the recipient, appeared as pulmonary artery stenosis and functional atresia 7,32,33 . The authors have also experienced cases where functional pulmonary valve atresia developed after birth, similar to reports that described a right-side circular shunt where the ductus arteriosus flow also had a left-to-right shunt due to the presence of pulmonary artery regurgitation and tricuspid regurgitation from the fetal stage 34,35 . As described, cardiovascular complications can remain even after curative therapy for TTTS.…”

Section: Cardiovascular Complications Of Fetoscopic Lasersupporting

confidence: 70%

Fetal and Neonatal Circulatory Disorders in Twin to Twin Transfusion Syndrome (The Secondary Publication)

Yoda

2019

J Nippon Med Sch

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Twin to twin transfusion syndrome (TTTS) is a major complication of monochorionic diamniotic (MD) twins, and its onset is known to be associated with placental vascular anastomoses and blood flow imbalance. In a typical case of TTTS, the recipient develops polyhydramnios, weight gain, cardiomegaly and hydrops fetalis in the uterus. In contrast, the donor develops oligohydramnios and intrauterine growth restriction. Recently, the significance of the renin-angiotensin-aldosterone system (RAAS) that transfers from the donor to the recipient has attracted interest in the fetal circulation of TTTS. The donor has decreased renal blood flow due to decreased circulating blood volume. For this reason, the secretion of RAAS hormones is augmented in the fetal kidneys of the donor. In TTTS, these RAAS hormones from the donor transfer to the recipient through the anastomosed vessels. In addition to excess preload, the recipient heart is exposed to excess afterload due to systemic vasoconstriction through RAAS hormones. Commonly occurring complications in the recipient include myocardial hypertrophy, atrioventricular valve regurgitation, and pulmonary valve stenosis or pulmonary atresia. Fetoscopic laser photocoagulation (FLP) has been introduced recently because neither mortality nor neurological morbidity have been satisfactorily improved with conventional treatment. FLP is a curative method that may improve the prognosis of TTTS. In Japan, this procedure has been performed frequently, and positive neurological outcomes have been achieved. (J Nippon Med Sch 2019; 86: 192 200)

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“…Although fetal functional and/or structural cardiac abnormalities improve after successful laser surgery, they can persist beyond birth and sometimes require intervention. Cardiovascular complications are primarily seen in the recipient twin and include hypertension, cardiomyopathy, right ventricular outflow tract obstruction (which affects about 4% of recipients at birth) and persistent pulmonary hypertension of the newborn [56,57]. However, donors may be at increased risk for aortic coarctation, possibly due to reduced flow caused by hypovolemia [58].…”

Section: Neonatal Outcomementioning

confidence: 99%

Twin-twin transfusion syndrome in the era of fetoscopic laser surgery: antenatal management, neonatal outcome and beyond

Spruijt

Lopriore

Steggerda

et al. 2020

Expert Review of Hematology

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Introduction: Twin-twin transfusion syndrome (TTTS) is a devastating complication of monochorionic twin pregnancy and remains a major challenge for worldwide fetal medicine specialists. In TTTS, intertwin transfusion through vascular anastomoses in the shared placenta leads to severe hemodynamic imbalance. This review summarizes the current knowledge of TTTS. Areas covered: The most recent insights concerning the management of TTTS, as well as fetal and neonatal complications are described. Relevant articles were selected based on a Pubmed search using the keywords below. Understanding of the underlying pathophysiology has improved greatly as a result of placental injection studies. Advancements in antenatal management have led to increased perinatal survival and a decreased incidence of neonatal complications, including brain injury and neurodevelopmental impairment. Expert opinion: Further opportunities for improvement comprise technological innovations in laser procedures and the prevention of preterm rupture of membranes with subsequent prematurity. A noninvasive treatment such as high-intensity focused ultrasound (HIFU) seems to hold promise for the future treatment of TTTS. Fetal MRI studies are important to improve our understanding of fetal brain injury and should relate their findings to long-term neurodevelopment. International collaboration and centralization of care are of paramount importance to ensure the best care for our patients.

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Cardiac Manifestations of Twin–to–Twin Transfusion Syndrome

Cited by 28 publications

References 66 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

Fetal and Neonatal Circulatory Disorders in Twin to Twin Transfusion Syndrome (The Secondary Publication)

Twin-twin transfusion syndrome in the era of fetoscopic laser surgery: antenatal management, neonatal outcome and beyond

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