Randomized controlled trial of twin-twin transfusion syndrome laser surgery: the sequential trial

Area of Science:

• Perinatology
• Fetal Surgery
• Maternal-Fetal Medicine

Background:

• Twin-twin transfusion syndrome (TTTS) is a serious complication of monochorionic twin pregnancies.
• Intraoperative blood transfer during laser surgery can impact donor twin survival.
• Surgical technique variations may explain differing outcomes.

Purpose of the Study:

• To compare donor twin survival rates between sequential and selective laser occlusion techniques in TTTS.
• To evaluate the impact of ablating superficial anastomoses first versus last.
• To assess postoperative middle cerebral artery (MCA) peak systolic velocity (PSV) in donor twins.

Main Methods:

• A single-center, open-label, randomized controlled trial involving 642 TTTS patients.
• Patients were randomized to either sequential or selective laser surgery.
• A nested trial assessed the timing of superficial anastomosis ablation.

Main Results:

• Overall donor twin survival was similar between sequential (85.6%) and selective (84.2%) techniques (P=.605).
• Donor survival was significantly lower in cases with superficial anastomoses (70.6%) compared to those without (90.3%) (P<.001).
• Sequential technique resulted in lower postoperative MCA PSV in donor twins (P=.003).

Conclusions:

• Neither laser technique nor the timing of superficial anastomosis ablation significantly impacted overall donor twin survival.
• The sequential technique may offer advantages in improving donor twin MCA PSV.
• Post hoc analyses suggest tailoring laser technique choice to high-risk factors (Doppler parameters, arterioarterial anastomoses) may improve outcomes.