Diastolic Dysfunction and Cerebrovascular Redistribution Precede Overt Recipient Twin Cardiomyopathy in Early-Stage Twin-Twin Transfusion Syndrome

Background Indications for intervention in early-stage (Quintero I and II) twin-twin transfusion syndrome (TTTS) are not standardized. Fetal echocardiography can be used to guide the management of early-stage patients. The aim of this study was to identify early cardiovascular findings that may precede progression to overt recipient twin (RT) cardiomyopathy in early-stage TTTS. Methods This was a retrospective review of pregnancies evaluated from 2004 to 2010. Subjects were included when initial evaluation identified Quintero I or II TTTS without evidence of "overt" RT cardiomyopathy, defined on the basis of atrioventricular valve regurgitation, ventricular hypertrophy, and abnormal Doppler myocardial performance indices. Patients elected management with observation or amnioreduction. Pregnancies were grouped by whether the RT developed overt cardiomyopathy. Initial values, including myocardial performance index, diastolic filling time corrected for heart rate (Doppler inflow duration/cardiac cycle length), pulsatility indices of the ductus venosus, umbilical artery, and middle cerebral artery, and cerebroplacental ratio (middle cerebral artery PI/umbilical artery PI), were compared. Results Of 174 pregnancies evaluated with early-stage TTTS, 45 (26%) did not show evidence of RT cardiomyopathy. Follow-up echocardiography identified cardiomyopathy in 20 of 45 RTs (44%). Those RTs with subsequent cardiomyopathy had shorter diastolic filling times corrected for heart rate, higher ductus venosus PIs, lower middle cerebral artery PIs, and lower cerebroplacental ratios on initial echocardiography. Conclusion Diastolic dysfunction and cerebroplacental redistribution precede findings of overt cardiomyopathy in RTs with early-stage TTTS. Assessment of these parameters may allow earlier identification of RTs with cardiac disease and help guide management. Prospective studies are needed to assess the role of echocardiography in patient selection for the treatment of early-stage TTTS.