Twin and Cotwin Predictors of Fetal Demise After Laser Photocoagulation Therapy in Advanced Stage Twin-Twin
Shiraz A Maskatia1, Fu-Sheng Chou2, Betul Yilmaz3
1Betty Irene Moore Heart Center, Lucile Packard Children's Hospital, Department of Pediatrics Stanford University School of Medicine Palo Alto CA USA.
Background:
Current models to predict outcomes in advanced twin-twin transfusion syndrome are limited. We hypothesized that twin and cotwin echocardiographic factors would improve model performance for donor and recipient demise following laser photocoagulation therapy.
Methods:
We performed a multicenter retrospective cohort study of stage 3 to 4 twin-twin transfusion syndrome referred for laser photocoagulation therapy. Fetal echocardiograms were analyzed at a core laboratory. We used multivariable logistic regression models to select variables used for generalized linear mixed-effects modeling. Separate models were developed for donor and recipient demise, using both twin and cotwin variables. Models were assessed by area under the receiver operating characteristic curves.
Results:
Laser photocoagulation therapy was performed in 285 twin gestations at 20.2±2.8 weeks. Donor demise (32%) occurred more frequently than recipient demise (15%; P<0.001). Final model variables for donor demise were donor fetal weight, nifedipine administration, umbilical arterial and venous flow patterns, donor cardiac output, left ventricular myocardial performance index, recipient deepest vertical pocket, recipient chest/thoracic ratio, recipient cardiac output, and recipient ductus venosus flow pattern; and for recipient demise were nifedipine use, recipient combined cardiac output, recipient left ventricular myocardial performance index, recipient umbilical arterial flow pattern, and donor left ventricular myocardial performance index. Including cotwin variables in models for donor and recipient demise improved performance. Final model area under the receiver operating characteristic curves were 0.82 for both donor and recipient demise.
Conclusions:
This is the largest multicenter study to rigorously evaluate echocardiographic metrics associated with fetal demise in twin-twin transfusion syndrome and the first to identify intertwin parameters associated with cotwin demise.
