title: Diastolic dysfunction and cerebrovascular redistribution precede overt recipient twin cardiomyopathy in early-stage twin-twin transfusion syndrome.
abstract: 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Fetal Heart Program, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
authors.forename: Jodie K
authors.initials: JK
authors.lastname: Votava-Smith
authors.affiliation: Fetal Care Center of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
authors.forename: Mounira
authors.initials: M
authors.lastname: Habli
authors.affiliation: Fetal Heart Program, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
authors.forename: James F
authors.initials: JF
authors.lastname: Cnota
authors.affiliation: Fetal Heart Program, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
authors.forename: Allison
authors.initials: A
authors.lastname: Divanovic
authors.affiliation: Fetal Care Center of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
authors.forename: William
authors.initials: W
authors.lastname: Polzin
authors.affiliation: Fetal Care Center of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
authors.forename: Foong-Yen
authors.initials: FY
authors.lastname: Lim
authors.affiliation: Fetal Heart Program, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio. Electronic address: erik.michelfelder@cchmc.org.
authors.forename: Erik C
authors.initials: EC
authors.lastname: Michelfelder
mesh_terms: D000328:Adult; D009202:Cardiomyopathies / Q000000981:diagnostic imaging / Q000196:embryology*; D002560:Cerebrovascular Circulation / Q000502:physiology*; D003971:Diastole; D015150:Echocardiography, Doppler; D005260:Female; D005315:Fetal Diseases / Q000000981:diagnostic imaging* / Q000503:physiopathology; D005318:Fetal Heart / Q000000981:diagnostic imaging*; D005330:Fetofetal Transfusion / Q000000981:diagnostic imaging / Q000196:embryology* / Q000503:physiopathology; D005500:Follow-Up Studies; D005865:Gestational Age; D006801:Humans; D011247:Pregnancy; D012189:Retrospective Studies; D016216:Ultrasonography, Prenatal / Q000379:methods*
keywords: Cardiomyopathy; Cerebroplacental redistribution; Diastolic function; Fetal echocardiography; Twin-twin transfusion syndrome