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Fetal magnetic resonance imaging, ultrasound, and echocardiography findings in twin reversed arterial perfusion sequence

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Abstract

Background

Twin reversed arterial perfusion (TRAP) sequence is a rare complication of monochorionic multiple gestation pregnancies, in which the pump twin provides hemodynamic support to a nonviable co-twin (acardius). Fetal magnetic resonance imaging (MRI) is used to detect pump twin abnormalities, particularly brain ischemia, prior to fetal intervention to interrupt umbilical blood flow to the acardius.

Objective

To summarize the imaging findings of TRAP sequence pregnancies in a large series.

Materials and methods

A single-center retrospective review was performed of all TRAP sequence pregnancies referred for fetal MRI (2004–2021). Fetal MRI, ultrasound, and echocardiography data were collected.

Results

Eighty-eight TRAP sequence pregnancies with MRI were included (mean gestational age, 19.8±2.8 weeks). Demise of the pump twin was noted in two pregnancies at the time of MRI. By MRI, 12% (10/86) of live pump twins had abnormalities, including 3% (3/86) with brain abnormalities and 9% (8/86) with extra-cranial abnormalities. By echocardiography, 7% (6/86) of pump twins had structural cardiac abnormalities. Three acardius morphological subtypes were identified by MRI: acephalus (55%, 48/88), anceps (39%, 34/88), and amorphous (7%, 6/88). The mean ultrasound acardius to pump twin ratio A/P ratio, calculated for each twin pair as the ratio of the acardius trunk (and head, if present) plus limb volume to the pump twin estimated fetal weight) differed among the three acardius subtypes (P=.03). The mean A/P ratio moderately correlated with pump twin cardiothoracic ratio and combined cardiac output (Pearson’s r=0.45 and 0.48, respectively, both P<.001).

Conclusion

Fetal MRI of TRAP sequence pregnancies found anomalies in a substantial number of pump twins. The three acardius subtypes differed in A/P ratio, which moderately correlated with the pump twin cardiothoracic ratio and combined cardiac output.

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Data availability

The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request.

References

  1. Van Allen MI, Smith DW, Shepard TH (1983) Twin reversed arterial perfusion (TRAP) sequence: a study of 14 twin pregnancies with acardius. Semin Perinatol 7:285–293

    PubMed  Google Scholar 

  2. Steffensen TS, Gilbert-Barness E, Spellacy W, Quintero RA (2008) Placental pathology in trap sequence: clinical and pathogenetic implications. Fetal Pediatr Pathol 27:13–29

    Article  CAS  PubMed  Google Scholar 

  3. Wong AE, Sepulveda W (2005) Acardiac anomaly: current issues in prenatal assessment and treatment. Prenat Diagn 25:796–806

    Article  PubMed  Google Scholar 

  4. Schwarzler P, Ville Y, Moscosco G et al (1999) Diagnosis of twin reversed arterial perfusion sequence in the first trimester by transvaginal color doppler ultrasound. Ultrasound Obstet Gynecol 13:143–146

    Article  CAS  PubMed  Google Scholar 

  5. Pretorius DH, Leopold GR, Moore TR et al (1988) Acardiac twin. Report of Doppler sonography. J Ultrasound Med 7:413–416

    Article  CAS  PubMed  Google Scholar 

  6. van Gemert MJC, Ross MG, van den Wijngaard J, Nikkels PGJ (2022) Hypothesized pathogenesis of acardius acephalus, acormus, amorphus, anceps, acardiac edema, single umbilical artery, and pump twin risk prediction. Birth Defects Res 114:149–164

    Article  PubMed  Google Scholar 

  7. Guimaraes CV, Kline-Fath BM, Linam LE et al (2011) MRI findings in multifetal pregnancies complicated by twin reversed arterial perfusion sequence (TRAP). Pediatr Radiol 41:694–701

    Article  PubMed  Google Scholar 

  8. Napolitani FD, Schreiber I (1960) The acardiac monster. A review of the world literature and presentation of 2 cases. Am J Obstet Gynecol 80:582–589

    Article  CAS  PubMed  Google Scholar 

  9. van Gemert MJ, van den Wijngaard JP, Vandenbussche FP (2015) Twin reversed arterial perfusion sequence is more common than generally accepted. Birth Defects Res Clin Mol Teratol 103:641–643

    Article  Google Scholar 

  10. Quintero RA, Reich H, Puder KS et al (1994) Brief report: umbilical-cord ligation of an acardiac twin by fetoscopy at 19 weeks of gestation. N Engl J Med 330:469–471

    Article  CAS  PubMed  Google Scholar 

  11. Tsao K, Feldstein VA, Albanese CT et al (2002) Selective reduction of acardiac twin by radiofrequency ablation. Am J Obstet Gynecol 187:635–640

    Article  PubMed  Google Scholar 

  12. Tan TY, Sepulveda W (2003) Acardiac twin: a systematic review of minimally invasive treatment modalities. Ultrasound Obstet Gynecol 22:409–419

    Article  CAS  PubMed  Google Scholar 

  13. Mone F, Devaseelan P, Ong S (2016) Intervention versus a conservative approach in the management of TRAP sequence: a systematic review. J Perinat Med 44:619–629

    Article  PubMed  Google Scholar 

  14. Murrell Z, Lim F-Y, Habli M et al (2011) 443: double barrel placental cord insertions (DBPCI): marker for high risk placental vascular configuration impacting survival with selective fetoscopic laser photocoagulation (SFLP) in twin-to-twin transfusion syndrome. Am J Obstet Gynecol 204:S178–S179

    Article  Google Scholar 

  15. (2018) AIUM-ACR-ACOG-SMFM-SRU practice parameter for the performance of standard diagnostic obstetric ultrasound examinations. J Ultrasound Med 37:E13–E24

  16. Kennedy AM, Woodward PJ (2019) A radiologist’s guide to the performance and interpretation of obstetric Doppler US. Radiographics 39:893–910

    Article  PubMed  Google Scholar 

  17. Klaritsch P, Deprest J, Van Mieghem T et al (2009) Reference ranges for middle cerebral artery peak systolic velocity in monochorionic diamniotic twins: a longitudinal study. Ultrasound Obstet Gynecol 34:149–154

    Article  CAS  PubMed  Google Scholar 

  18. Oliver ER, Coleman BG, Goff DA et al (2013) Twin reversed arterial perfusion sequence: a new method of parabiotic twin mass estimation correlated with pump twin compromise. J Ultrasound Med 32:2115–2123

    Article  PubMed  Google Scholar 

  19. Moore TR, Gale S, Benirschke K (1990) Perinatal outcome of forty-nine pregnancies complicated by acardiac twinning. Am J Obstet Gynecol 163:907–912

    Article  CAS  PubMed  Google Scholar 

  20. Ozawa K, Wada S, Muromoto J et al (2021) Long-term neurodevelopmental outcomes of the pump twin in twin reversed arterial perfusion sequence treated by radiofrequency ablation. Prenat Diagn 41:1575–1581

    Article  PubMed  PubMed Central  Google Scholar 

  21. Buntinx IM, Bourgeois N, Buytaert PM, Dumon JE (1991) Acardiac amorphous twin with prune belly sequence in the co-twin. Am J Med Genet 39:453–457

    Article  CAS  PubMed  Google Scholar 

  22. Schinzel AA, Smith DW, Miller JR (1979) Monozygotic twinning and structural defects. J Pediatr 95:921–930

    Article  CAS  PubMed  Google Scholar 

  23. Sato T, Kaneko K, Konuma S et al (1984) Acardiac anomalies: review of 88 cases in Japan. Asia Ocean J Obstet Gynaecol 10:45–52

    Article  CAS  Google Scholar 

  24. Fisher KE, Welsh AW, Henry A (2016) Uncommon complications of monochorionic twin pregnancies: twin reversed arterial perfusion sequence. Australas J Ultrasound Med 19:133–141

    Article  PubMed  PubMed Central  Google Scholar 

  25. Herrera TT, Rueda K, Espinosa H, Britton GB (2020) Intestinal volvulus in the pump twin of a twin reversed arterial perfusion (TRAP) sequence after laser therapy at 18 weeks: a case report. J Med Case Rep 14:123

    Article  PubMed  PubMed Central  Google Scholar 

  26. Habbal OA, Kenue RK, Venugopalan P (2005) Acardia syndrome coexisting with gastroschisis in the co-twin. Clin Dysmorphol 14:45–47

    Article  CAS  PubMed  Google Scholar 

  27. Athwal S, Millard K, Lakhoo K (2010) Twin reversed arterial perfusion (TRAP) sequence in association with VACTERL association: a case report. J Med Case Rep 4:411

    Article  PubMed  PubMed Central  Google Scholar 

  28. Chen CY, Wu YC, Chen CL, Yang ML (2007) Acardiac syndrome coexisting with complex skeletal dysplasia in the co-twin: 3D sonographic findings. J Clin Ultrasound 35:387–389

    Article  PubMed  Google Scholar 

  29. Fuchs KM, van der Veer AL, Miller RA, Simpson L (2010) P23.12: fetal skeletal malformations among pump twins in monochorionic gestations complicated by TRAP sequence. Ultrasound Obstet Gynecol 36:258–259

    Article  Google Scholar 

  30. Healey MG (1994) Acardia: predictive risk factors for the co-twin’s survival. Teratology 50:205–213

    Article  CAS  PubMed  Google Scholar 

  31. Moore CA, Buehler BA, McManus BM et al (1987) Acephalus-acardia in twins with aneuploidy. Am J Med Genet Suppl 3:139–143

    Article  CAS  PubMed  Google Scholar 

  32. Rehder H, Schoner K, Kluge B et al (2012) Klinefelter twins presenting with discordant aneuploidies, acardia, forked umbilical cord and with different gonadal sex despite monozygosity. Prenat Diagn 32:173–179

    Article  PubMed  Google Scholar 

  33. Livingston JC, Lim FY, Polzin W et al (2007) Intrafetal radiofrequency ablation for twin reversed arterial perfusion (TRAP): a single-center experience. Am J Obstet Gynecol 197:399e391-399e393

    Article  Google Scholar 

  34. Lee H, Bebbington M, Crombleholme TM, North American Fetal Therapy N (2013) The North American Fetal Therapy Network Registry data on outcomes of radiofrequency ablation for twin-reversed arterial perfusion sequence. Fetal Diagn Ther 33:224–229

    Article  PubMed  Google Scholar 

  35. Sugibayashi R, Ozawa K, Sumie M et al (2016) Forty cases of twin reversed arterial perfusion sequence treated with radio frequency ablation using the multistep coagulation method: a single-center experience. Prenat Diagn 36:437–443

    Article  PubMed  Google Scholar 

  36. Kinsel-Ziter ML, Cnota JF, Crombleholme TM, Michelfelder EC (2009) Twin-reversed arterial perfusion sequence: pre- and postoperative cardiovascular findings in the ‘pump’ twin. Ultrasound Obstet Gynecol 34:550–555

    Article  CAS  PubMed  Google Scholar 

  37. Brock CO, Johnson A (2022) Twin reverse arterial perfusion: timing of intervention. Best Pract Res Clin Obstet Gynaecol 84:127–142

    Article  PubMed  Google Scholar 

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Funding

No funding was received to assist with preparation of the manuscript

Author information

Author notes

  1. Julie E. Walcutt

    Present address: Division of Radiology, Children’s Nebraska, 8200 Dodge Street, Omaha, NE, 68114, USA

Authors and Affiliations

  1. Department of Radiology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA

    Julie E. Walcutt, Beth M. Kline-Fath & Usha D. Nagaraj

  2. Department of Radiology, University of Nebraska Medical Center, Omaha, NE, USA

    Julie E. Walcutt

  3. Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA

    Beth M. Kline-Fath & Usha D. Nagaraj

  4. Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA

    Bin Zhang

  5. Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA

    Bin Zhang & Allison A. Divanovic

  6. Department of Surgery, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA

    Foong-Yen Lim & Mounira A. Habli

  7. Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA

    Foong-Yen Lim

  8. Department of Obstetrics and Gynecology, TriHealth Good Samaritan Hospital, Cincinnati, OH, USA

    Mounira A. Habli

  9. Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA

    Allison A. Divanovic

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Contributions

U.D.N. and B.M.K. conceived and supported the study, and U.D.N. supervised the study.

J.E.W. collected the data, performed basic data analysis, and drafted the initial manuscript.

J.E.W. and U.D.N. interpreted the images.

B.Z. performed the statistical analysis.

F.Y.L., M.A.H., and A.A.D. edited the manuscript and provided clinical insights.

All authors reviewed and approved the manuscript.

Corresponding author

Correspondence to Julie E. Walcutt.

Ethics declarations

Ethics approval

This HIPAA-compliant study was granted exemption by the Cincinnati Children’s Hospital Medical Center Institutional Review Board (IRB ID# 2021 − 0403) in view of the retrospective nature of the study; all reported imaging and procedures were performed as a part of routine care.

Consent

The requirement for informed consent was waived by the Cincinnati Children’s Hospital Medical Center Institutional Review Board due to the limited risks and potential privacy intrusion of obtaining consent.

Conflicts of interests

None

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Electronic supplementary material

Supplementary Table 1

(DOCX 36 kb)

Supplementary Fig. 1

Double barrel placental cord insertion in TRAP sequence. FIESTA MRI coronal to the uterus of a 16 weeks, 5 days gestational age monochorionic diamniotic twin pregnancy shows double barrel cord insertions (white straight arrows) of pump twin and anceps acardius. TRAP = twin reversed arterial perfusion. FIESTA = fast imaging employing steady-state acquisition. MRI = magnetic resonance imaging (PNG 2336 kb)

Supplementary Fig. 2

Ultrasound images of anceps acardius in a TRAP sequence pregnancy imaged at 16 weeks, 2 days gestational age, demonstrating measurement of the acardius volume for calculation of the acardius/pump twin ratio, which is calculated by adding the volume of the acardius trunk (and head, if present) with the volume of the acardius limb(s) and dividing this total acardius volume by the estimated fetal weight of the pump twin. a Ultrasound image coronal to the acardius body depicts measurement of the acardius trunk (and head) length. b Ultrasound image axial to the acardius body depicts measurement of the axial dimensions of the acardius trunk. c Ultrasound image sagittal to the acardius lower limb depicts measurement of the acardius limb length. d Ultrasound image axial to the acardius lower limb depicts measurement of the axial dimension of the acardius limb. In this TRAP sequence pregnancy, the acardius/pump twin ratio was 47%. TRAP = twin reversed arterial perfusion (ZIP 9.41 mb)

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Walcutt, J.E., Kline-Fath, B.M., Zhang, B. et al. Fetal magnetic resonance imaging, ultrasound, and echocardiography findings in twin reversed arterial perfusion sequence. Pediatr Radiol 54, 702–714 (2024). https://doi.org/10.1007/s00247-024-05879-8

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