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.
Highlights
Altered hemodynamics associated with twin to twin transfusion syndrome (TTTS) can be manifested in the fetal and neonatal heart
These changes can further lead to the development of structural heart disease, which may present as various cardiac manifestations before and immediately after birth
Birth weight was lower in the donor group, and small for gestational age (SGA) and acute kidney injury (AKI) were more prevalent in the recipient group (Table 1)
Summary
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. 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. Low gestational age at birth is an important risk factor for long-term neurodevelopmental impairment in TTTS treated with fetoscopic laser surgery[7]. A prospective study comparing TTTS and dichorionic twin neonates reported that only gestational age was a significant risk factor for severe cerebral lesions[8]. Functional cardiovascular changes can be manifested starting in the early stage of TTTS10 These changes can further lead to the development of structural heart disease, which may present as various cardiac manifestations before and immediately after birth. Gestational age (week) Birth weight (g) Small for gestational age Male Cesarean section Apgar score 1 minute Apgar score 5 minute Initial hemoglobin (mg/dL) Hypotension Respiratory distress syndrome Moderate to severe bronchopulmonary dysplasia Treated patent ductus arteriosus Maximum creatinine (mg/dl) Acute kidney injury Necrotizing enterocolitis Sepsis Retinopathy of prematurity operation Mortality
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