Interventions and Perinatal Outcomes Associated With Recipient Twin Cardiomyopathy in the Setting of Twin‐To‐Twin Transfusion Syndrome: A Systematic Review

ABSTRACT

Objective
To determine (1) Whether the presence and severity of recipient twin cardiomyopathy in the setting of twin‐to‐twin transfusion syndrome are associated with worse perinatal outcomes when compared to recipient twins without evidence of cardiomyopathy and (2) The optimal management strategy to reduce the likelihood of adverse perinatal outcomes when recipient twin cardiomyopathy is present.


Methods
We included observational studies and randomized controlled trials of monochorionic‐diamniotic twin gestations affected by twin‐to‐twin transfusion syndrome, which reported the relationship between recipient twin cardiomyopathy and adverse perinatal outcomes. PubMed, CINAHAL, Scopus, Embase, and the Cochrane Central Register of Controlled Trials were queried from January 2004 to December 2025. The primary outcome was single and dual twin survival at 6 months of life. The secondary outcomes were the frequency of live birth of one or both twins; gestational age at the time of delivery; latency from diagnosis of twin‐to‐twin transfusion syndrome to delivery; birthweight of living twins; newborn length(s) of stay; need for neonatal intensive care unit admission; single and dual twin survival at 0 and 1 month of life; postnatal recipient twin cardiomyopathy (inclusive of right ventricular outflow tract obstruction); and frequency of neonatal complications at 6 months of life. Assessment of bias was performed using the Cochrane Risk‐of‐Bias and Newcastle‐Ottawa tools.


Results
Of 207 abstracts available, 13 met the inclusion criteria. None of the studies reported the primary outcome defined by the systematic review, but did report on multiple secondary outcomes. Most manuscripts (10/13) used the Myocardial Performance Index to define recipient twin cardiomyopathy. One manuscript reported on the use of calcium channel blockers in addition to selective fetoscopic photocoagulation, and its relationship with adverse perinatal outcomes. Most studies exhibited a low risk of bias. Three out of 10 manuscripts using the Myocardial Performance Index demonstrated a relationship between the presence and severity of recipient twin cardiomyopathy and adverse perinatal outcomes. Two manuscripts demonstrated that the use of calcium channel blockers perioperatively may be associated with a reduced frequency of adverse perinatal outcomes.


Conclusion
A small number of studies have assessed recipient twin cardiomyopathy's role in the risk of adverse perinatal outcomes or whether unique forms of treatment may improve the risk of perinatal outcomes. Further, studies suffer from a lack of long‐term neonatal follow‐up. Future studies should investigate whether other markers of recipient twin cardiac compromise are associated with adverse perinatal outcomes.