title: Acquired right ventricular outflow tract obstruction in the recipient twin in twin-twin transfusion syndrome.
abstract: OBJECTIVE
  The goal of this study was to determine the prevalence and evolution of acquired right ventricular outflow tract obstruction (RVOTO) in the recipient twin in twin-twin transfusion syndrome (TTTS).
  
  
  BACKGROUND
  Twin-twin transfusion syndrome complicates 4% to 26% of diamniotic monochorionic twin gestations and is associated with high fetal morbidity and mortality. Cardiac dysfunction and biventricular hypertrophy may develop in the recipient twin with the potential for RVOTO.
  
  
  METHODS
  This was a retrospective review of a two-center experience of TTTS to describe the prevalence and evolution of acquired RVOTO in the recipient twin. Right ventricular outflow tract obstruction was diagnosed or excluded by fetal or postnatal echocardiography or clinical assessment.
  
  
  RESULTS
  Of 73 twin pregnancies with TTTS identified between 1994 to 1998, a total of seven (9.6%) were complicated by RVOTO in the recipient twin: two subvalvar/muscular, four valvar and one combined. Of 44 pregnancies with fetal echo, six had in utero RVOTO with antegrade flow diagnosed at gestational ages ranging from 19 to 27 weeks. In utero progression occurred in four cases over a period of four to eight weeks, with the development of RVOT atresia by delivery. Postnatal progression of RVOTO occurred in two cases, one of which required pulmonary balloon valvuloplasty at age two years. Postnatal regression of subvalvar RVOTO occurred in two cases in early infancy. Death related directly or indirectly to the RVOTO occurred in all four patients who developed complete RVOT obliteration.
  
  
  CONCLUSIONS
  Right ventricular outflow tract obstruction may occur in the recipient twin of at least 9% of pregnancies complicated by TTTS. Right ventricular outflow tract obstruction progression is common in utero and may worsen neonatal outcome.
authors.affiliation: Department of Pediatrics, Division of Cardiology, The Hospital for Sick Children, Toronto, Canada.
authors.forename: J
authors.initials: J
authors.lastname: Lougheed
authors.forename: B G
authors.initials: BG
authors.lastname: Sinclair
authors.forename: K
authors.initials: K
authors.lastname: Fung Kee Fung
authors.forename: J L
authors.initials: JL
authors.lastname: Bigras
authors.forename: G
authors.initials: G
authors.lastname: Ryan
authors.forename: J F
authors.initials: JF
authors.lastname: Smallhorn
authors.forename: L K
authors.initials: LK
authors.lastname: Hornberger
mesh_terms: D002170:Canada / Q000453:epidemiology; D002404:Catheterization; D002423:Cause of Death; D018450:Disease Progression; D004452:Echocardiography; D005260:Female; D005330:Fetofetal Transfusion / Q000150:complications* / Q000503:physiopathology; D005865:Gestational Age; D006439:Hemodynamics; D006801:Humans; D015994:Incidence; D007223:Infant; D007226:Infant Mortality; D007231:Infant, Newborn; D009017:Morbidity; D011247:Pregnancy; D015995:Prevalence; D011379:Prognosis; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D016216:Ultrasonography, Prenatal; D014694:Ventricular Outflow Obstruction / Q000175:diagnosis / Q000453:epidemiology* / Q000209:etiology* / Q000628:therapy