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\begin{document}

\title{Right Ventricular Outflow Tract Obstruction in Twin-to-Twin Transfusion
Syndrome: A Systematic Review and Meta-analysis}



\author[1]{Hiba J. Mustafa}%
\author[2]{Muhammad Jawwad}%
\author[2]{Ayesha Iqbal Mansoor}%
\author[3]{Giorgio Pagani}%
\author[4]{Francesco DAntonio}%
\author[5]{Asma Khalil}%
\affil[1]{Indiana University School of Medicine}%
\affil[2]{Dow University of Health Sciences}%
\affil[3]{ASST Papa Giovanni XXIII}%
\affil[4]{University Hospital of Chieti}%
\affil[5]{St George's University of London Molecular and Clinical Sciences Research Institute}%


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  \date{May 27, 2024}


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\begin{abstract}
\textbf{Objective:} We aimed to investigate the incidence, prenatal
factors, and outcomes of twin-to-twin transfusion (TTTS) with right
ventricular outflow tract obstruction (RVOTO). \textbf{Search Strategy:}
A systematic search was conducted to identify relevant studies published
until February 2023 in English using the databases PubMed, Scopus, and
Web of Science \textbf{Selection Criteria:} Studies reporting on
pregnancies with TTTS and RVOTO were included. Primary outcome was
survival including fetal demise, neonatal death, and 6-months survival.
Secondary outcomes were incidence and prenatal risk factors.
\textbf{Data Collection and Analysis.} The random-effect model pooled
the mean differences or odds ratios (OR) and the corresponding 95\%
confidence intervals. Heterogeneity was assessed using the
\emph{I\textsuperscript{2}} value. \textbf{Results:} 17 studies
encompassing 4332 TTTS pregnancies of which 225 cases had RVOTO were
included. Incidence of RVOTO at time of TTTS diagnosis was 6\%. 134/197
(68\%) had functional pulmonary stenosis (PS) and 62/197 (32\%) had
functional pulmonary atresia (PA). 27\% resolved following laser and
55\% persisted after birth. Of those persisting, 27\% required cardiac
valve procedures. Risk factors were TTTS stage III (53\% vs 39\% in
no-RVOTO), stage IV TTTS (28\% in RVOTO vs 12\% in no-RVOTO), and DV
reversed a-wave (60\% in RVOTO vs 19\% in no-RVOTO). GA at laser and GA
at delivery were comparable between groups. Survival outcomes were also
comparable between groups including fetal demise of 26\%, neonatal death
of 12\%, and 6-months survival of 82\% in RVOTO group. Findings were
similar when subgroup analysis was done for studies including
head-to-head analysis. \textbf{Conclusions:} RVOT occurs in about 6\% of
the recipient twins with TTTS, especially in stages III and IV and those
with reversed DV a-wave. The findings from this systematic review
support the need of a thorough cardiac assessment of pregnancies
complicated by TTTS, both before and after laser in order to maximize
perinatal outcome and the importance of early diagnosis of TTTS and
timely management. \textbf{Tweetable abstract:} Meta-analysis shows that
the incidence of right ventricular outflow tract obstruction among TTTS
pregnancies is 6\%, among which 68\% had functional pulmonary stenosis
and 32\% had functional pulmonary atresia. Of these pregnancies, 27\%
resolved after laser therapy and 55\% persisted after birth. Of cases
persisting after birth, 27\% required cardiac valve procedures.
Significant risk factors were TTTS stage III-IV and ductus venosus
a-wave reversal. Survival outcomes including fetal demise, neonatal
death, and 6-months survival were similar compared to those without
RVOTO.%
\end{abstract}%



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\textbf{Hosted file}

\verb`RVOTO manuscript.docx`  available at \url{https://authorea.com/users/669015/articles/669971-right-ventricular-outflow-tract-obstruction-in-twin-to-twin-transfusion-syndrome-a-systematic-review-and-meta-analysis}\selectlanguage{english}
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