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Timeliness, a Critical Factor in Treating TTTS

dure to treat the anatomic basis for the syndrome. Until now, the only major study comparing these two treatments for TTTS was the Eurofetus trial, which compared laser and amnioreduction as primary therapies. That study, published in The New England Journal of Medicine in 2004, found that, at six months, there was better survival among twins using laser vs. amnioreduction.

The NIH-funded study, which began in 2002, required participants to have more severe disease and to have already failed an initial amnioreduction. But when the Eurofetus results were published, everyone thought that laser was superior and stopped referring patients. The American investigators asked that the trial be stopped. Unbeknownst to investigators at that time, the trial oversight committee found significant differences between the two treatment modalities and recommended that the trial be stopped, which it was in May of 2005.

The trial had uncovered higher mortality among recipient twins who received laser treatment. But overall, survival of one or both twins of the same pregnancy was no different between the two treatments. In addition, there was no difference between survival rates of donor twins and recipient twins. How is this possible?

"It turns out that in amnioreduction, there were significant numbers of treatment failures, so patients were dropping out in the amnioreduction arm because they were failing therapy, whereas they were dying in the laser therapy," says Dr. Crombleholme. Statistically, these patients are considered to have had the same outcome: a treatment failure. So, ultimately, there was no significant difference in survival of one or both twins between the two treatments."

What Dr. Crombleholme and his colleagues did find were two predictors of success. One was the stage of severity of TTTS. The other was the echocardiographic finding of heart failure. Fetal echocardiography, which is not done routinely in TTTS in most c
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