胎儿镜激光凝固术中静脉-静脉吻合顺序对双胎输血综合征结局的影响

原文

OBJECTIVE: To assess whether the sequence of laser occlusion of vein-to-vein placental anastomoses is associated with fetal survival after laser photocoagulation for twin-twin transfusion syndrome. STUDY DESIGN: This post hoc analysis used data from the Sequential Trial, a randomized controlled trial comparing sequential vs selective laser photocoagulation techniques. Within this trial, a nested randomization assigned patients with superficial anastomoses (ie, artery-to-artery or vein-to-vein) to ablation of these anastomoses either at the beginning or at the end of surgery. For this analysis, we compared survival in patients with vein-to-vein anastomoses with a reference group lacking superficial anastomoses. Variables associated with survival were included in multiple logistic regression models, including the nested assignment to "Ablated First" vs "Ablated Last." RESULTS: Of 642 trial patients, 64 (10%) had at least one vein-to-vein anastomosis (range, 1-3). Donor live birth was 421/466 (90.3%) in the No Superficial Anastomoses group and 48/64 (75.0%) in the vein-to-vein group (P=.001). Among the 64 patients with vein-to-vein anastomoses, 28 (43.8%) were randomized to Ablated First and 36 (56.3%) to Ablated Last. Donor survival in the No Superficial Anastomoses, Ablated First, and Ablated Last groups was 90.3%, 82.1%, and 69.4%, respectively (P<.001). Recipient survival was 94.2%, 96.4%, and 86.1% (P=.128). In adjusted models, the Ablated Last group had lower odds of donor survival (adjusted odds ratio, 0.24 [0.10-0.58]; P=.002) and recipient survival (adjusted odds ratio, 0.30 [0.10-0.92]; P=.035) compared with the No Superficial Anastomoses group. CONCLUSION: In this post hoc exploratory analysis, end-of-procedure treatment of vein-to-vein anastomoses for twin-twin transfusion syndrome was associated with lower donor and recipient survival.