Right ventricular outflow tract obstruction in twin-to-twin transfusion syndrome undergoing laser surgery: A systematic review and meta-analysis

Hiba J Mustafa; Muhammad Jawwad; Ayesha Iqbal Mansoor; Giorgio Pagani; Francesco D'Antonio; Asma Khalil

doi:10.1111/aogs.14825

Right ventricular outflow tract obstruction in twin-to-twin transfusion syndrome undergoing laser surgery: A systematic review and meta-analysis

Acta Obstet Gynecol Scand. 2024 Mar 14. doi: 10.1111/aogs.14825. Online ahead of print.

Authors

Hiba J Mustafa^{1

2}, Muhammad Jawwad³, Ayesha Iqbal Mansoor³, Giorgio Pagani⁴, Francesco D'Antonio⁵, Asma Khalil^{6

7

8}

Affiliations

¹ Division of Maternal-Fetal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.
² The Fetal Center at Riley Children's and Indiana University Health, Indianapolis, Indiana, USA.
³ Department of Medicine and Surgery, Dow University of Health and Sciences, Karachi, Pakistan.
⁴ Maternal Fetal Medicine Unit, Department of Obstetrics and Gynecology, ASST-Papa Giovanni XXIII, Bergamo, Italy.
⁵ Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University Hospital of Chieti, Chieti, Italy.
⁶ Fetal Medicine Unit, St George's Hospital, St George's University of London, London, UK.
⁷ Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK.
⁸ Twins Trust Centre for Research and Clinical Excellence, St George's University of London, London, UK.

PMID: 38482999
DOI: 10.1111/aogs.14825

Abstract

Introduction: We aimed to investigate the incidence, prenatal factors and outcomes of twin-to-twin transfusion (TTTS) with right ventricular outflow tract obstruction (RVOTO).

Material and methods: A systematic search was conducted to identify relevant studies published until February 2023 in English using the databases PubMed, Scopus and Web of Science. Studies reporting on pregnancies with TTTS and RVOTO were included. The random-effect model pooled the mean differences or odds ratios (OR) and the corresponding 95% confidence intervals. Heterogeneity was assessed using the I² value.

Results: A total of 17 studies encompassing 4332 TTTS pregnancies, of which 225 cases had RVOTO, were included. Incidence of RVOTO at time of TTTS diagnosis was 6%. In all, 134/197 (68%) had functional pulmonary stenosis and 62/197 (32%) had functional pulmonary atresia. Of these, 27% resolved following laser and 55% persisted after birth. Of those persisting, 27% required cardiac valve procedures. Prenatal associations were TTTS stage III (53% vs 39% in no-RVOTO), stage IV TTTS (28% in RVOTO vs 12% in no-RVOTO) and ductus venosus reversed a-wave (60% in RVOTO vs 19% in no-RVOTO). Gestational age at laser and gestational age at delivery were comparable between groups. Survival outcomes were also comparable between groups, including fetal demise of 26%, neonatal death of 12% and 6-month survival of 82% in RVOTO group. Findings were similar when subgroup analysis was done for studies including head-to-head analysis.

Conclusions: RVOT occurs in about 6% of the recipient twins with TTTS, especially in stages III and IV and those with reversed ductus venosus a-wave. The findings from this systematic review support the need for a thorough cardiac assessment of pregnancies complicated by TTTS, both before and after laser, to maximize perinatal outcome, and the importance of early diagnosis of TTTS and timely management.

Keywords: fetoscopy; laser; meta-analysis; pulmonary atresia; pulmonary stenosis; recipient; right ventricular outflow tract; systematic review; twin-to-twin transfusion.

Publication types

Review