title: Aortic distensibility as a surrogate for intertwin pulse pressure differences in monochorionic pregnancies with and without twin-twin transfusion syndrome.
abstract: OBJECTIVE
  Twin-twin transfusion syndrome (TTTS) complicates 10-15% of monochorionic diamniotic (MCDA) twin pregnancies. The donor response to hypovolemia allows the transfer of vasoactive mediators to the recipient, causing increased recipient afterload and hypertension. Our objective was to apply a novel speckle-tracking technique to measure the aortic fractional area change (AFAC) during the cardiac cycle in MCDA twins with and without TTTS, and identify intertwin differences in AFAC and parameters of cardiac function.
  
  
  METHODS
  High-frame rate four-chamber views of the fetal heart, including the mid-thoracic aorta, were collected prospectively in MCDA twin pairs referred to our center between June 2014 and April 2015. Using speckle-tracking software, the endovascular border of the aorta was traced manually during systole, with guidance on cardiac cycle timing by anatomical M-mode. AFAC, defined as the difference between maximum and minimum area divided by minimum area, expressed as a percentage, was calculated offline and averaged over three cardiac cycles. Tissue Doppler and displacement were used to measure long-axis cardiac function. Intra- and interclass correlation coefficients were used to test observer variability.
  
  
  RESULTS
  Fifty-one MCDA twin pregnancies were included, comprising uncomplicated MCDA (n = 14), TTTS Stages 1/2 (n = 21) and TTTS Stages 3/4 (n = 16). Median gestational age was 20.4 (range, 16.2-27.5) weeks. Mean ± SD heart rate was 142.6 ± 7.2 bpm with no significant intertwin pair differences. AFAC was significantly higher in recipients than in donors of TTTS pairs (Stages 1/2: 72.3 ± 29.9% vs 43.7 ± 19.3%, P < 0.001; Stages 3/4: 75.2 ± 29.2% vs 42.5 ± 18.4%, P = 0.002), consistent with higher recipient pulse pressure. No intertwin differences in AFAC were seen in uncomplicated MCDA pairs. Inter- and intraclass correlation coefficients for AFAC were 0.894 and 0.888. AFAC correlated significantly with combined cardiac output (r = 0.252, P = 0.011) and left and right E/E' ratio (left: r = 0.302, P = 0.004; right: r = 0.247, P = 0.030).
  
  
  CONCLUSIONS
  AFAC is a quantifiable and reproducible method to assess aortic distensibility and is a promising tool to monitor the response to prelaser therapeutic interventions in pregnancies with TTTS. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
authors.affiliation: The Fetal Center at Children's Memorial Hermann Hospital, Department of Obstetrics, Gynecology and Reproductive Sciences, UT Health - McGovern Medical School, Houston, TX, USA.|Department of Obstetrics and Gynecology, Paracelsus Medical University Salzburg, Salzburg, Austria.
authors.forename: C
authors.initials: C
authors.lastname: Wohlmuth
authors.affiliation: The Fetal Center at Children's Memorial Hermann Hospital, Department of Obstetrics, Gynecology and Reproductive Sciences, UT Health - McGovern Medical School, Houston, TX, USA.
authors.forename: F A
authors.initials: FA
authors.lastname: Osei
authors.affiliation: The Fetal Center at Children's Memorial Hermann Hospital, Department of Obstetrics, Gynecology and Reproductive Sciences, UT Health - McGovern Medical School, Houston, TX, USA.
authors.forename: K J
authors.initials: KJ
authors.lastname: Moise
authors.affiliation: The Fetal Center at Children's Memorial Hermann Hospital, Department of Obstetrics, Gynecology and Reproductive Sciences, UT Health - McGovern Medical School, Houston, TX, USA.
authors.forename: A
authors.initials: A
authors.lastname: Johnson
authors.affiliation: The Fetal Center at Children's Memorial Hermann Hospital, Department of Obstetrics, Gynecology and Reproductive Sciences, UT Health - McGovern Medical School, Houston, TX, USA.
authors.forename: R
authors.initials: R
authors.lastname: Papanna
authors.affiliation: The Fetal Center at Children's Memorial Hermann Hospital, Department of Obstetrics, Gynecology and Reproductive Sciences, UT Health - McGovern Medical School, Houston, TX, USA.
authors.forename: M
authors.initials: M
authors.lastname: Bebbington
authors.affiliation: The Fetal Center at Children's Memorial Hermann Hospital, Department of Obstetrics, Gynecology and Reproductive Sciences, UT Health - McGovern Medical School, Houston, TX, USA.
authors.forename: H M
authors.initials: HM
authors.lastname: Gardiner
mesh_terms: D000293:Adolescent; D000328:Adult; D001011:Aorta / Q000000981:diagnostic imaging / Q000196:embryology / Q000503:physiopathology*; D016022:Case-Control Studies; D015150:Echocardiography, Doppler / Q000379:methods*; D005260:Female; D005318:Fetal Heart / Q000503:physiopathology; D005330:Fetofetal Transfusion / Q000000981:diagnostic imaging* / Q000503:physiopathology; D005865:Gestational Age; D006801:Humans; D011247:Pregnancy; D059285:Pregnancy, Twin; D011446:Prospective Studies; D015203:Reproducibility of Results; D014430:Twins, Monozygotic; D016216:Ultrasonography, Prenatal / Q000379:methods*; D055815:Young Adult
keywords: TTTS; aortic distensibility; diamniotic; monochorionic; pulse pressure