Hepatic arterial buffer response: activation in donor fetuses and the effect of laser ablation of intertwin anastomosis

Abstract

Objectives: Hepatic arterial buffer response (HABR) is an important defence mechanism for maintaining liver blood flow. It is suspected that HABR is active in monochorionic diamniotic twins (MCDA) with twin-to-twin transfusion syndrome (TTTS) where donor compensates a setting of volume depletion and the recipient an overload. The present study investigates whether in TTTS, HABR is active in donor and/or recipient individually and try to determine if the activation of HABR is a direct response to TTTS.

Methods: Hepatic artery (HA) peak systolic velocity (PSV) was measured in normal MCDA fetuses and TTTS. Correlation with relevant fetal Dopplers and characteristics were determined. Z-scores for HA-PSV (HAV-Z) were calculated and its association with TTTS in donors and recipients were determined as well as changes in HAV-Z after laser treatment.

Results: In this study 118 MCDA were included, 61.9 % normal and 38.1 % TTTS. Of the TTTS 22 required laser treatment. A total of 382 scans were performed in normal group and 155 in TTTS. Our data demonstrates that in donors HAV-Z was 2.4 Z-scores higher compared to normal fetuses (β=2.429 95 % CI 1.887, 2.971; p<0.001) and after laser treatment HAV-Z reduced (β=-1.829 95 % CI -2.593, -1.064; p<0.001). There was no significant difference between recipients and normal (β=-0.092 95 % CI -0.633, 0.449; p=0.738).

Conclusions: HABR is active in TTTS, promoting an increased hepatic blood flow in donors. The activation is direct response to TTTS as shown by the reduction in HAV-Z after laser. This finding provides important insights into the pathophysiology of TTTS.

Keywords: fetal Doppler; fetal therapy; hepatic arterial buffer response; hepatic artery; monochorionic twin pregnancy; twin to twin transfusion syndrome.