title: Changes in ductus venosus flow profile in twin-twin transfusion syndrome: role in risk stratification.
abstract: OBJECTIVE
  To evaluate changes in ductus venosus (DV) waveforms and the timing of these changes in twin-twin transfusion syndrome (TTTS), to relate these to disease severity and to assess the clinical applicability of the suggested measurements in the prediction of TTTS.
  
  
  METHODS
  DV time intervals and velocity-time integrals (VTI) normalized to cardiac cycle and total VTI, respectively, as well as velocity ratios were analyzed in 149 monochorionic diamniotic (MCDA) twin pairs. Pregnancies were assigned to the following groups: uncomplicated MCDA (n = 29); TTTS Stages I+II (n = 50); TTTS Stages III+IV (n = 49); and pre-TTTS (n = 21), of which 14 remained stable and seven progressed to TTTS. Intertwin differences were calculated as larger/recipient minus smaller/donor and related to disease severity. Receiver-operating characteristics curve analysis was used to distinguish TTTS vs uncomplicated MCDA and pre-TTTS progressing to TTTS vs non-progressing pre-TTTS. Intra- and interobserver reliability of measurement of DV parameters were evaluated using intraclass correlation coefficients (ICCs).
  
  
  RESULTS
  No intertwin differences in DV parameters were found in uncomplicated MCDA pregnancies. Diastolic VTIs and filling times were significantly shorter in recipient twins in TTTS cases and in larger pre-TTTS twins in comparison with their cotwins. Time intervals, VTIs and velocity ratios correlated significantly with Quintero stages. An intertwin difference in early filling time (eT) normalized to cardiac cycle, eT (%) ≤ -3.6%, could differentiate TTTS from uncomplicated MCDA pregnancies (82.8% sensitivity; 79.8% specificity) and eT (%) ≤ -2.8% predicted progression to TTTS (73.1% sensitivity; 67.4% specificity).
  
  
  CONCLUSIONS
  DV flow profiles and timing of waveform events are already altered in pre-TTTS and early-stage disease, reflecting abnormal ventricular filling and circulatory imbalance. Intertwin comparison of filling times and VTI may allow prediction of evolving TTTS in MCDA pregnancies. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
authors.affiliation: The Fetal Center at Children's Memorial Hermann Hospital, UTHealth 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, UTHealth 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, UTHealth McGovern Medical School, Houston, TX, USA.
authors.forename: K J
authors.initials: KJ
authors.lastname: Moise
authors.affiliation: Department of Obstetrics and Gynecology, Paracelsus Medical University Salzburg, Salzburg, Austria.
authors.forename: I
authors.initials: I
authors.lastname: Wieser
authors.affiliation: The Fetal Center at Children's Memorial Hermann Hospital, UTHealth 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, UTHealth 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, UTHealth 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, UTHealth McGovern Medical School, Houston, TX, USA.
authors.forename: H M
authors.initials: HM
authors.lastname: Gardiner
mesh_terms: D005260:Female; D005330:Fetofetal Transfusion / Q000000981:diagnostic imaging* / Q000503:physiopathology; D005865:Gestational Age; D006801:Humans; D015588:Observer Variation; D011169:Portal Vein / Q000503:physiopathology*; D011247:Pregnancy; D012372:ROC Curve; D015203:Reproducibility of Results; D014430:Twins, Monozygotic; D016216:Ultrasonography, Prenatal / Q000379:methods*
keywords: diamniotic; ductus venosus; monochorionic; twin pregnancy; twin-twin transfusion syndrome