Twin-twin transfusion syndrome

General Obstetrics and Gynecology: Obstetrics
Prenatal cardiovascular manifestations in the twin-to-twin transfusion syndrome recipients and the impact of therapeutic amnioreduction

Catherine Barrea, MD – a-, Fawaz Alkazaleh, MD -b-, Greg Ryan, MB -b-, Brian W. McCrindle, MD -a-, Anita Roberts, BSc -a-, Jean-Luc Bigras, MD -a-, Jon Barrett, MD -c-, Gareth P. Seaward, MB -b- , Jeffrey F. Smallhorn, MB, BS -a-, Lisa K. Hornberger, MD -a*.

Abstract

Objective
We evaluated the cardiovascular pathologic condition in the recipient twin in twin-to-twin transfusion syndrome and the influence of amnioreduction.

Study design Fetal echocardiograms and medical records of 54 pregnancies that were complicated by twin-to-twin transfusion syndrome were reviewed. Recipient twin right and left ventricular wall thickness, diameters, systolic and diastolic function, valve regurgitation, and structural cardiac defects were assessed at examination and after amnioreduction.

Results At examination (n=28 pregnancies), cardiomegaly because of right ventricular and/or left ventricular hypertrophy was observed in 58% of recipient twins, and biventricular hypertrophy was observed in 33% of recipient twins, without ventricular dilation. Biventricular diastolic dysfunction was present in two thirds of recipient twins, and right ventricular systolic dysfunction and significant atrioventricular valve regurgitation was observed in one third of recipient twins. Serial assessment (n=21 pregnancies) revealed progressive biventricular hypertrophy and right ventricular systolic and biventricular diastolic dysfunction in most recipient twins. Steeper progression of hypertrophy, diastolic dysfunction, and structural or functional right ventricular outflow disease (20% incidence) were associated with an increased perinatal mortality rate.

Conclusion In twin-to-twin transfusion syndrome, the recipient twin has progressive biventricular hypertrophy with predominant right ventricular systolic and biventricular diastolic dysfunction. Despite amnioreduction, the cardiovascular disease persists and even progresses in many recipient twins.

Publishing and Reprint Information

aDepartment of Pediatrics, Division of Cardiology, Fetal Cardiac Program, The Hospital for Sick Children
bDivision of Maternal-Fetal Medicine, Mount Sinai Hospital
cWomen’s College Hospital, University of Toronto, Ontario, Canada
Supported in part by The Physician’s Services Incorporated Foundation, grant no. 78390 and by the Foundation “Saint Luc,” Cliniques Universitaires Saint Luc, Catholic University of Louvain, Brussels, Belgium.
*Reprint requests: Lisa K. Hornberger, MD, UCSF Medical Center, Fetal Cardiovascular Program, Pediatric Echocardiography Laboratory, 505 Parnassus Ave, Room M-306, San Francisco, CA 94143.
Email address: lhornberger@pedcard.ucsf.edu (Lisa K. Hornberger)

The American Journal of Obstetrics and Gynecology
March 2005 • Volume 192 • Number 3