Postnatal Myocardial Function in Monochorionic Diamniotic Twins with Twin-to-Twin Transfusion Syndrome following Selective Laser Photocoagulation of the Communicating Placental Vessels

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Monochorionic diamniotic (MCDA) twins are at risk for developing twin-to-twin transfusion syndrome (TTTS) throughout pregnancy. This may lead to myocardial dysfunction in the recipient and/or donor twin that persists beyond delivery. Selective laser photocoagulation of the communicating placental vessels (SLPCV) attempts to mitigate the cardiovascular outcomes. The objective of this study was to characterize early postnatal myocardial performance in MCDA twins with TTTS with and without SLPCV. A prospective study was performed of four MCDA twin groups: (1) uncomplicated MCDA twins, (2) MCDA twins with selective fetal growth restriction, (3) MCDA twins with TTTS following SLPCV (TTTS with SLPCV), and (4) MCDA twins with TTTS who did not undergo SLPCV (TTTS without SLPCV). Fifty-four twin pairs were enrolled: 23 uncomplicated MCDA twin pairs, 15 pairs with selective fetal growth restriction, seven TTTS pairs with SLPCV, and seven TTTS pairs without SLPCV. In each group, twin pairs were divided by birth weight into donor (smaller) and recipient (larger) and compared. Echocardiography was performed on day 1, day 2, and between days 5 and 7 of age, and myocardial performance was characterized by speckle-tracking echocardiography-derived left ventricular and right ventricular longitudinal strain (LS) and systolic strain rate (LSR). Longitudinal strain and longitudinal systolic strain rate are expressed as absolute values. Compared with all recipient groups, recipient TTTS without SLPCV infants had lower left ventricular LS (16±3% vs 22%-24%, P<.01) and right ventricular LS (15±5% vs 21%-24%, P<.01) on day 1 that persisted throughout the first week of age. Left ventricular LSR (1.7±0.3 vs 2.3±0.3sec-1, P<.05) and right ventricular LSR (1.5±0.4 vs 1.7±0.5sec-1, P<.05) were both lower in the recipient compared with the donor twin in the TTTS without SLPCV group. LS and LSR measurements were similar among all four donor twin groups. Biventricular performance is diminished in recipient MCDA twins with TTTS who are not treated with SLPCV, highlighting the need for close monitoring of their hemodynamic status during the early neonatal period.