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Chapter 12.2 - Twin reversed arterial perfusion (TRAP) sequence

In-Utero treatment

from Section 2 - Fetal disease

Published online by Cambridge University Press:  05 February 2013

By
Diana L. Farmer  and
Katrine M. Løfberg
Edited by
Mark D. Kilby ,
Anthony Johnson  and
Dick Oepkes
Mark D. Kilby
Affiliation:
Department of Fetal Medicine, University of Birmingham
Anthony Johnson
Affiliation:
Baylor College of Medicine, Texas
Dick Oepkes
Affiliation:
Department of Obstetrics, Leiden University Medical Center
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Summary

Background

Twin reversed arterial perfusion (TRAP) sequence or acardiac twinning is a rare congenital anomaly unique to monozygotic multiple gestations. Existence of TRAP requires two conditions: (1) pump or forward flow failure in the acardiac twin and (2) a set of arterioarterial and venovenous placental anastomoses connecting the acardiac and “pump” twins’ circulatory systems. It is considered the most severe malformation of twinning seen in humans. Other historical though less commonly used terms include chorioangiopagus parasiticus and acardiac monster. Incidence is estimated to be 1:35000 pregnancies or 1% of all monochorionic pregnancies [1, 2], though it may be higher given that some cases of TRAP may go undiagnosed due to early pregnancy loss or reabsorption of the acardiac twin [3].

Pathophysiology

In TRAP, one twin, the acardiac, has a non-functioning (pseudoacardius) or absent (holoacardius) heart. This twin is hemodynamically dependent on the structurally normal donor or “pump” twin. Blood is shunted from the “pump” twin, bypassing the placenta, in a retrograde fashion through anomalous arterioarterial anastomoses and perfuses the acardiac twin [4]. The blood reaching the acardiac twin is poorly oxygenated and nutrient deplete. Once in the acardiac’s circulatory system, blood flows passively through the iliac arteries, first perfusing the lower body and extremities. The further deoxygenated blood then perfuses the caudal structures and subsequently flows via the acardiac’s umbilical vein back to the “pump” twin through direct venovenous anastomoses (see Figure 12.2.1). Thus, blood returning to the “pump” twin is a mix of oxygenated blood from the placenta and deoxygenated blood from the acardiac twin.

Keywords

trace fetal vesselstwin reversed arterial perfusionumbilical cordplacentaMRIcolor Doppler sonography
Type
Chapter
Information
Fetal Therapy
Scientific Basis and Critical Appraisal of Clinical Benefits
 , pp. 193 - 199
Publisher: Cambridge University Press
Print publication year: 2012

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References

Gillim, DL, Hendricks, CH. Holoacardius: review of the literature and case report. Obstet Gynecol 1953;2:647–52.Google Scholar
Moore, TR, Gale, S, Benirschke, K. Perinatal outcome of forty-nine pregnancies complicated by acardiac twinning. Am J Obstet Gynecol 1990;163:907–12.Google Scholar
Bonilla-Musoles, F, Machado, LE, Raga, F, et al. Fetus acardius: two- and three-dimensional ultrasonographic diagnoses. J Ultrasound Med 2001;20:1117–27.Google Scholar
Pretorius, DH, Leopold, GR, Moore, TR, et al. Acardiac twin. Report of Doppler sonography. J Ultrasound Med 1988;7:413–16.Google Scholar
Tan, TYT, Sepulveda, W. Acardiac twin: a systematic review of minimally invasive treatment modalities. Ultrasound Obstet Gynecol 2003;22:409–19.Google Scholar
Van Gemert, MJC, Umur, A, van den Wijngaard, JPHM, et al. Increasing cardiac output and decreasing oxygenation sequence in pump twins of acardiac twin pregnancies. Phys Med Biol 2005;50:N33–42.Google Scholar
Napolitani, FD, Schreiber, I. The acardiac monster: a review of the world literature and presentation of two cases. Am J Obstet Gynecol 1960;80:582–9.Google Scholar
Wong, AE, Sepulveda, W. Acardiac anomaly: current issues in prenatal assessment and treatment. Prenat Diagn 2005;25:769–806.Google Scholar
Weber, MA, Sebire, NJ. Genetics and developmental pathology of twinning. Semin Fetal & Neonatal Med 2010;15:313–18.Google Scholar
Ersch, J, Stallmach, T. Cardiac regression sequence: reversal of blood flow is diagnostic but not causative in an acardiac fetus. Early Hum Dev 1998;52:81–5.Google Scholar
Benirschke, K. The monozygotic twinning process, the twin-twin transfusion syndrome and acardiac twins. Placenta 2009;30:923–8.Google Scholar
Nikkels, PGJ, Hack, KEA, van Gemert, MJC. Pathology of twin placentas with special attention to monochorionic twin placentas. J Clin Pathol 2008;61:1247–53.Google Scholar
Coulam, CB. First trimester diagnosis of acardiac twins. Obstet Gynecol 1996;88:729.Google Scholar
Wesley, AJ, Thomas, JT, Petersen, S, et al. An acardiac twin with documented heart beat at 6+5 weeks and TRAP diagnosed at 8+5 weeks: insights into possible pathophysiology. Prenat Diagn 2011;31:413–14.Google Scholar
Lehr, C, DiRe, J. Rare occurrence of a holocardious acephalic monster: sonographic evidence and pathologic findings. J Clin Ultrasound 1978;6:259–61.Google Scholar
Bornstein, E, Monteagudo, A, Dong, R, et al. Detection of twin reversed arterial perfusion sequence at the time of first-trimester screening: the added value of 3-dimensional volume and color Doppler sonography. J Ultrasound Med 2008;27:1105–9.Google Scholar
Guimaraes, CV, Kline-Fath, BM, Linam, LE, et al. MRI findings in multifetal pregnancies complicated by twin reversed arterial perfusion sequence (TRAP). Pediatr Radiol 2011;41:694–701.Google Scholar
Hata, N, Wada, T, Kashima, K, et al. Non-gated fetal MRI of umbilical blood flow in an acardiac twin. Pediatr Radiol 2005;35:826–9.Google Scholar
Healey, MG. Acardia: predictive risk factors for the co-twin’s survival. Teratology 1994;50:205–13.Google Scholar
Lewi, L, Valencia, C, Gonzalez, E, et al. The outcome of twin reversed arterial perfusion sequence diagnosed in the first trimester. Am J Obstet Gynecol 2010;203:213.e1–4.Google Scholar
Brassard, M, Fouron, JC, Leduc, L, et al. Prognostic markers in twin pregnancies with an acardiac fetus. Obstet Gynecol 1999;94:409–14.Google Scholar
Dashe, JS, Fernandez, CO, Twickler, DM. Utility of Doppler velocimetry in predicting outcome in twin reversed-arterial perfusion sequence. Am J Obstet Gynecol 2001;185:135–9.Google Scholar
Kinsel-Ziter, ML, Cnota, JF, Crombleholme, TM, et al. Twin-reversed arterial perfusion sequence: pre-and postoperative cardiovascular findings in the ‘pump’ twin. Ultrasound Obstet Gynecol 2009;34:550–5.Google Scholar
Platt, LD, DeVore, GR, Bieniarz, A, et al. Antenatal diagnosis of acephalus acardia: a proposed management scheme. Am J Obstet Gynecol 1983;146:857–9.Google Scholar
Robie, GF, Payne, GG, Morgan, MA. Selective delivery of an acardiac, acephalic twin. N Engl J Med 1989;320:512–13.Google Scholar
Tan, TYT, Sepulveda, W. Acardiac twin: a systematic review of minimally invasive treatment modalities. Ultrasound Obstet Gynecol 2003;22:409–19.Google Scholar
Hamada, H, Okane, M, Koresawa, M, et al. Fetal therapy in utero by blockage of the umbilical blood flow of acardiac monster in twin pregnancy. Nippon Sanka Fujinka Gakkai Zasshi 1989;41:1803–9.Google Scholar
Porreco, RP, Barton, SM, Haverkamp, AD. Occlusion of umbilical artery in acardiac, acephalic twin. Lancet 1991;337:326–7.Google Scholar
Holzgreve, W, Tercanli, S, Krings, W, et al. A simpler technique for umbilical cord blockade of an acardiac twin. N Engl J Med 1994;331:57–8.Google Scholar
Deprest, JA, Audibert, F, Van Schoubroeck, D, et al. Bipolar coagulation of the umbilical cord in complicated monochorionic twin pregnancy. Am J Obstet Gynecol 2000; 182:340–5.Google Scholar
Gul, A, Gungorduk, K, Yildirim, G, et al. Fetal therapy in twin reverse arterial perfusion sequence pregnancies with alcohol ablation or bipolar cord coagulation. Arch Gynecol Obstet 2009;279:517–20.Google Scholar
He, Z, Fang, Q, Yang, Y, et al. Fetal reduction by bipolar cord coagulation in managing complicated monochorionic multiple pregnancies: preliminary experience in China. Chin Med J 2010;123:549–54.Google Scholar
Rodeck, C, Deans, A, Jauniaux, E. Thermocoagulation for the early treatment of pregnancy with an acardiac twin. N Engl J Med 1998;339:1293–5.Google Scholar
Robyr, R, Yamamoto, M, Ville, Y. Selective feticide in complicated monochorionic twin pregnancies using ultrasound-guided bipolar coagulation. BJOG 2005;112:1344–8.Google Scholar
McCurdy, CM, Childers, JM, Seeds, JW. Ligation of the umbilical cord of an acardiac-acephalus twin with an endoscopic intrauterine technique. Obstet Gynecol 1993;82:708–11.Google Scholar
Quintero, RA, Chmait, RH, Murakoshi, T, et al. Surgical management of twin reversed arterial perfusion sequence. Am J Obstet Gynecol 2006;194:982–91.Google Scholar
Hecher, K, Lewi, L, Gratacos, E, et al. Twin reversed arterial perfusion: fetoscopic laser coagulation of placental anastomoses or the umbilical cord. Ultrasound Obstet Gynecol 2006;28:688–91.Google Scholar
Ville, Y, Hyett, JA, Vandenbussche, FPHA, et al. Endoscopic laser coagulation of umbilical cord vessels in twin reversed arterial perfusion sequence. Ultrasound Obstet Gynecol 1994;4:396–8.Google Scholar
Sepulveda, W, Bower, S, Hassan, J, et al. Ablation of acardiac twin by alcohol injection into the intra-abdominal umbilical artery. Obstet Gynecol 1995;86:680–1.Google Scholar
Chang, PJ, Liou, JD, Hsieh, CC, et al. Monopolar thermocoagulation in the management of acardiac twins. Fetal Diagn Ther 2004;19:271–4.Google Scholar
Holmes, A, Jauniaux, E, Rodeck, C. Monopolar thermocoagulation in acardiac twinning. BJOG 2001;108:1000–2.Google Scholar
Sepulveda, W, Hasbun, J, Dezerega, V, Devoto, JC, Alcalde, JL. Successful sonographically guided laser ablation of a large acardiac twin at 26 weeks’ gestation. J Ultrasound Med 2004;23:1663–6.Google Scholar
Jolly, M, Taylor, M, Rose, G, et al. Interstitial laser: a new surgical technique for twin reversed arterial perfusion sequence in early pregnancy. BJOG 2001;108:1098–102.Google Scholar
O’Donaghue, K, Barigye, O, Pasquini, L, et al. Interstitial laser therapy for fetal reduction in monochorionic multiple pregnancy: loss rate and association with aplasia cutis congenital. Prenat Diagn 2008;28:535–43.Google Scholar
Soothill, P, Sohan, K, Carroll, S, et al. Ultrasound-guided, intra-abdominal laser to treat acardiac pregnancies. BJOG 2002;109:352–4.Google Scholar
Weisz, B, Peltz, R, Chayen, B, et al. Tailored management of twin reversed arterial perfusion (TRAP) sequence. Ultrasound Obstet Gynecol 2004;23:451–5.Google Scholar
Hirose, M, Murata, A, Kita, N, et al. Successful intrauterine treatment with radiofrequency ablation in a case of acardiac twin pregnancy complicated with a hydropic pump twin. Ultrasound Obstet Gynecol 2004;23:509–12.Google Scholar
Lee, H, Wagner, A, Sy, E, et al. Efficacy of radiofrequency ablation for twin-reversed arterial perfusion sequence. Am J Obstet Gynecol 2007;196:459.e1–e4.Google Scholar
Livingston, JC, Lim, FY, Polzin, W, et al. Intrafetal radiofrequency ablation for twin reversed arterial perfusion (TRAP): a single-center experience. Am J Obstet Gynecol 2007;197:399.e1–e3.Google Scholar
Tsao, KJ, Feldstein, A, Albanese, CT, et al. Selective reduction of acardiac twin by radiofrequency ablation. Am J Obstet Gynecol 2002;187:635–40.Google Scholar
Sullivan, AE, Varner, MW, Ball, RH, et al. The management of acardiac twins: a conservative approach. Am J Obstet Gynecol 2003;189:1310–13.Google Scholar
Jelin, E, Hirose, S, Rand, L, et al. Perinatal outcome of conservative management versus fetal intervention for twin reversed arterial perfusion sequence with a small acardiac twin. Fetal Diagn Ther 2010;7:138–41.Google Scholar

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