Changes in ductus venosus flow profile in twin–twin transfusion syndrome: role in risk stratification

Objectives: 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.