Early postnatal cardiac manifestations are associated with perinatal brain injury in preterm infants with twin to twin transfusion syndrome

Abstract

Altered hemodynamics associated with twin to twin transfusion syndrome (TTTS) can be manifested in the fetal and neonatal heart. This study evaluated the association between cardiac manifestations immediately after birth and brain injury in preterm infants with TTTS. Medical records of preterm infants who were born at <35 weeks of gestation with TTTS and admitted to the neonatal intensive care unit at Seoul National University Children’s Hospital between January 2011 and January 2018 were reviewed. TTTS was prenatally diagnosed and staged according to the Quintero criteria. Echocardiographic findings, brain ultrasound and MRI imaging findings were analyzed. Fifty-three infants were enrolled in this study. Thirty-two infants (60.3%) were treated by fetoscopic laser coagulation. Brain injury developed in 15 infants (28.3%). Hypotension within the first week and immediate postnatal cardiac manifestations were more prevalent in the brain injury group. In the multivariate analysis, acute kidney injury and cardiac manifestations, such as ventricular dysfunction and tricuspid regurgitation, were statistically associated with brain injury in the study population. Immediate postnatal cardiac manifestations, such as ventricular dysfunction and tricuspid regurgitation, can serve as surrogate markers for perinatal hemodynamic disturbance, which are associated with early neonatal brain injury in preterm infants with TTTS.

Neonatal Hemodynamic Characteristics of the Recipient Twin of Twin-To-Twin Transfusion Syndrome Not Treated with Fetoscopic Laser Surgery

“…Ventricular hypertrophy was also observed in both groups but occurred significantly earlier in the CF group than in the HighBP group (100% at day 0 versus 60%, respectively; p = 0.023) ( Supplementary Figure S1 ). The median age at onset of left ventricular dysfunction in the CF group was 14 h of life [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 ]. One patient (7%) in the CF group did not receive any inotropic treatment and recovered with antihypertensive treatment only.…”

“…Due to the hemodynamic imbalance and associated prematurity, neonates with TTTS not treated with FSLC are at high risk for neonatal mortality, neonatal morbidity including necrotizing enterocolitis, severe brain injury, polycythemia, and long term neurodevelopmental delay [ 10 , 11 , 12 , 13 ]. However, the immediate postnatal cardiac and hemodynamic impairments in untreated born recipients are poorly described and remain a challenge for neonatologists.…”

Perinatal and neonatal outcomes for fetoscopic laser ablation for the treatment of twin twin transfusion syndrome at a single center

“…TTTS occurs in the presence of inter-twin vascular anastomoses on the monochorionic placenta, causing an imbalance of blood flow between fetuses and leading to anemia and anhydramnios in one fetus ("Donor") and polycythemia and polyhydramnios in another ("Recipient") [1]. These in utero hemodynamic disturbances increases risk of brain injury and congenital heart disease, such as ventricular dysfunction and cardiomyopathy, which may lead to heart failure [1][2][3]. Other morbidities associated with TTTS include prematurity, intraventricular hemorrhage (IVH), renal failure, hydrops fetalis, polycythemia/ and hyperviscosity syndrome in the recipient fetus and anemia in the donor fetus and long-term neurodevelopmental impairment [2][3][4][5].…”

“…These in utero hemodynamic disturbances increases risk of brain injury and congenital heart disease, such as ventricular dysfunction and cardiomyopathy, which may lead to heart failure [1][2][3]. Other morbidities associated with TTTS include prematurity, intraventricular hemorrhage (IVH), renal failure, hydrops fetalis, polycythemia/ and hyperviscosity syndrome in the recipient fetus and anemia in the donor fetus and long-term neurodevelopmental impairment [2][3][4][5]. In utero cardiac manifestations such as ventricular dysfunction and cardiomyopathy, are associated with increased risk of fetal demise and brain injury [3].…”

“…Other morbidities associated with TTTS include prematurity, intraventricular hemorrhage (IVH), renal failure, hydrops fetalis, polycythemia/ and hyperviscosity syndrome in the recipient fetus and anemia in the donor fetus and long-term neurodevelopmental impairment [ 2 – 5 ]. In utero cardiac manifestations such as ventricular dysfunction and cardiomyopathy, are associated with increased risk of fetal demise and brain injury [ 3 ].…”