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Concordance of congenital heart defects in two pairs of monozygotic twins: pulmonary stenosis and tetralogy of Fallot
Concordancia en los defectos cardiacos congénitos, en dos pares de gemelos monocigóticos: estenosis pulmonar y tetralogía de Fallot
Carlos Alvaa, Felipe David Gómezb, Santiago Jiménez-Arteagab, Lucelli Yáñezb, Lilia Ochoac
a Director of Congenital Heart Disease Department, Hospital, Centro Médico Nacional Siglo XXI
b Staff Member of Congenital Heart Disease Department, Hospital, Centro Médico Nacional Siglo XXI
c Fellow in Human Genetics Department, Hospital, Centro Médico Nacional Siglo XXI
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction</span></p><p class="elsevierStylePara">Since Price&#39;s report in 1950&#44;<span class="elsevierStyleSup">1</span> it has been recognized that monozygotic twins provide an opportunity to study genetic contribution in the development of cardiovascular malformations&#46; The incidence of congenital heart defects among singletons is 6&#47;1000 live births&#44; compared to 17&#46;2&#47;1000 in monozygotic twins&#44; while in dizygotic twins the incidence is approximately 8&#47;1000&#46;<span class="elsevierStyleSup">2</span> When both twins are affected&#44; concordance is said to occur&#46; Concordance incidence in dizygotic twins is 5&#37;&#44; compared to 25&#37; in monozygotic twins&#46;<span class="elsevierStyleSup">3</span> In this paper&#44; two pairs of monozygotic twins with specific concordance of congenital heart defects are reported&#46; </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Case report 1 </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Monozygotic twins with pulmonary stenosis </span></p><p class="elsevierStylePara">U&#46;H&#46; and E&#46;H&#46; were13 year-old monozygotic female twins&#59; both girls had cardiac murmurs and were referred to our hospital&#46; They were completely asymptomatic and their phenotypes were very similar &#40;<span class="elsevierStyleBold">Figure 1A</span>&#41;&#46; Both of them had blood type B&#43;&#59; in a fluorescence hybridization test in situ the two girls were negative for chromosome 22q11 microdeletion&#46; Echocardiographic examination showed a severe infundibular and pulmonary valve stenosis in both of them&#46; Systolic gradient measured by Doppler was 140 mmHg in U&#46;H&#46;&#44; and 90 mmHg in E&#46;H&#46; During cardiac catheterization&#44; U&#46;H&#46; had right ventricular pressures of 120&#47;8 and 30&#47;10 in the pulmonary artery&#44; and E&#46;H&#46; had 200&#47;14&#46; Echocardiogram and selective angiogram showed severe dysplastic pulmonary valve in the right ventricle of both twins&#46;</p><p class="elsevierStylePara"><img src="293v80n01-13149368fig1.jpg" alt="Figure 1A&#46; Thirteen years-old monozygotic female twins with severe pulmonary valve stenosis&#46;"></img></p><p class="elsevierStylePara"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Figure 1A&#46;</span></span><span class="elsevierStyleItalic"> Thirteen years-old monozygotic female twins with severe pulmonary valve stenosis&#46;</span></p><p class="elsevierStylePara">In June 2006&#44; the two patients underwent cardiac surgical correction with transannular patch under cardiopulmonary bypass&#46; During surgery&#44; severe pulmonary valve stenosis with hypoplastic annulus was found in both of them&#46; In addition&#44; U&#46;H&#46; presented infundibular stenosis which was removed&#46; The patients recovered uneventfully from operation&#46; Today&#44; six years after the procedure&#44; both patients are asymptomatic with normal development and a control echocardiogram revealed a residual gradient below 20 mmHg and minimal pulmonary insufficiency&#46; </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Case report 2 </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Monozygotic twins with Tetralogy of Fallot </span></p><p class="elsevierStylePara">J&#46;T&#46; and N&#46; T&#46; were 8 year-old male monozygotic twins&#44; with almost identical phenotypes &#40;<span class="elsevierStyleBold">Figure 1B</span>&#41;&#46; Both had blood O&#43;&#59; in a fluorescence hybridization test in situ the two boys were negative for microdeletion in chromosome 22q11&#46; In both twins&#44; Tetralogy of Fallot was diagnosed by echocardiogram&#44; cardiac catheterization and angiocardiogram&#46; In the first twin a Blalock-Taussig shunt had been performed&#46; This patient had stress dyspnea and physical examination revealed cyanosis &#43;&#43;&#46; Echocardiogram demonstrated Tetralogy of Fallot with an obstructive 60 mmHg gradient in the right ventricular outflow tract&#46; </p><p class="elsevierStylePara"><img src="293v80n01-13149368fig2.jpg" alt="Figure 1B&#46; Eight years-old monozygotic male twins with tetralogy of Fallot&#46;"></img></p><p class="elsevierStylePara"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Figure 1B&#46;</span></span><span class="elsevierStyleItalic">Eight years-old monozygotic male twins with tetralogy of Fallot&#46;</span></p><p class="elsevierStylePara">Cardiac catheterization confirmed the echocardiogram diagnosis and an additional stenosis was found at the origin of the left pulmonary artery &#40;<span class="elsevierStyleBold">Figure 2a</span>&#41;&#46; The McGoon index was 1&#46;3&#46; In February 2008 surgical correction was performed with transannular patch&#44; pulmonary valve prosthesis&#44; and patches in left main coronary and pulmonary arteries&#59; the ventricular septal defect was closed too&#46; During surgery a laceration of the pulmonary artery with important bleeding occurred as a complication&#46; In the intensive care unit&#44; the patient developed pneumonia due to <span class="elsevierStyleItalic">Sthaphylocococus aureus&#44;</span> with bad and long evolution&#46; It was not possible to disconnect the patient from ventilator&#46; Fifteen days later&#44; this twin died because of septic shock&#46;</p><p class="elsevierStylePara"><img src="293v80n01-13149368fig3.jpg" alt="Figure 2A&#46; Angiogram of the main pulmonary artery in one of the twins with Tetralogy of Fallot&#46; Severe pulmonary stenosis at the origin of the left pulmonary artery is documented&#46;"></img></p><p class="elsevierStylePara"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Figure 2A&#46;</span></span><span class="elsevierStyleItalic">Angiogram of the main pulmonary artery in one of the twins with Tetralogy of Fallot&#46; Severe pulmonary stenosis at the origin of the left pulmonary artery is documented&#46;</span></p><p class="elsevierStylePara">In the second twin no previous shunt was done&#46; During physical examination cyanosis &#43;&#43; it was seen and arterial saturation was 82&#37;&#46; Echocardiography and angiocardiography showed favorable anatomy &#40;<span class="elsevierStyleBold">Figure 2B</span>&#41;&#46; The McGoon index was 2&#46;1&#46; Total surgical correction was performed in January 28&#44; 2008&#46; He recovered uneventfully&#46; Three months later&#44; an echocardiogram revealed a maximum gradient of 22 mmHg and the patient presented no symptoms&#46; </p><p class="elsevierStylePara"><img src="293v80n01-13149368fig4.jpg" alt="Figure 2B&#46; Selective right ventriculogram in the second twin with Tetralogy of Fallot&#46; Favorable anatomy is shown&#46;"></img></p><p class="elsevierStylePara"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Figure 2B&#46;</span></span><span class="elsevierStyleItalic">Selective right ventriculogram in the second twin with Tetralogy of Fallot&#46; Favorable anatomy is shown&#46;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion </span></p><p class="elsevierStylePara">Monozygotic twins are less frequent than dizygotic twins and account for approximately a third of total number of twins&#44; but incidence of congenital anomalies in monozygotic twins is about 10&#37;&#46;<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara">Congenital heart disease concordance in monozygotic twins occurs at a frequency of 25&#37;&#44; which is high when compared to other congenital disorders&#46; However&#44; in previous literature usually it is not specified whether concordance refers to either the presence of the same cardiac defect in both twins&#44; or to some cardiac malformation present in the two&#46; We will refer to specific concordance in the former concept&#46;</p><p class="elsevierStylePara">There are very few reports on specific concordance of congenital cardiac malformations&#46; After detailed search of the literature &#40;PubMed&#47;Medline&#41; only three reports of twins with tetralogy of Fallot were found&#46; In one of the reports&#44; both twins had pulmonary atresia and the same intracardiac defects&#44; with anatomic differences in large vessels&#46; Both patients were positive for microdeletion in chromosome 22q11&#46;<span class="elsevierStyleSup">5</span> In France&#44; a pair of twins had the same disorder&#44; but they were negative for microdeletion in chromosome 22q11 &#40;as in both of our cases&#41;&#59; it was reported by Laugel <span class="elsevierStyleItalic">et al</span> in 2001 V&#46;<span class="elsevierStyleSup">6</span> The first monozygotic pair of twins with Tetralogy of Fallot in India was reported by Patel AB <span class="elsevierStyleItalic">et al</span> in 2002&#46;<span class="elsevierStyleSup">7</span> In these works&#44; authors concluded that the differences found could not be explained on genetic grounds and suggested the influence of other factors in the developing embryo&#46;</p><p class="elsevierStylePara">There are two other reports of specific concordance&#46; In the first&#44; the presence of persistent truncus arteriosus in both monozygotic twins&#44; without DiGeorge phenotype syndrome and no deletion in chromosome 22q11 is described&#46;<span class="elsevierStyleSup">8</span> The second report presents a successfully operated pair of twins with ventricular septal defect&#46;<span class="elsevierStyleSup">9</span></p><p class="elsevierStylePara">This work&#44; in which we have studied two pairs of identical twins&#44; one with pulmonary valve stenosis and the other with Tetralogy of Fallot&#44; adds to the few published cases of specific concordance&#46; Just like in the previous reports&#44; both twins had the same disorder&#44; with minor differences&#44; particularly in the severity of the lesion&#46; In agreement with other authors&#44; these differences could be explained by the influence of other factors probably acquired during the first stages of embryonic development&#46; </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Acknowledgements</span></p><p class="elsevierStylePara">Authors are thankful to Hector Alva PhD for his help in the preparation of the English manuscript&#46;</p><hr></hr><p class="elsevierStylePara"><span class="elsevierStyleItalic">Corresponding author&#58;<br></br></span>Carlos Alva&#46;<br></br> Congenital Heart Disease Department&#44; Cardiology Hospital&#44; Centro M&#233;dico Nacional Siglo XXI&#44; Av&#46;Cuauht&#233;moc 330&#44; Col&#46; Doctores&#44; M&#233;xico City CP 06720&#44; M&#233;xico&#46;<br></br> Phone&#58; 5255 5585 2443&#46; <span class="elsevierStyleItalic">E mail&#58;</span><a href="mailto&#58;echoca&#64;yahoo&#46;com" class="elsevierStyleCrossRefs">echoca&#64;yahoo&#46;com</a></p><p class="elsevierStylePara"> Received&#58; December 12&#44; 2008&#59;<br></br> accepted September 23&#44; 2009&#46;</p>"
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        "resumen" => "Two pairs of twins with specific concordance in congenital heart lesions are presented&#46; We reviewed all the monozygotic twins with specific concordance in congenital heart lesions in the last 18 years&#46; Two pairs were found&#46; First&#44; a pair of 13 years-old monozygotic female twins&#59; a severe infundibular and pulmonary valve stenosis was discovered in both girls&#46; In the second pair of twins &#40;8 years-old boys&#41;&#44; Tetralogy of Fallot was diagnosed by echocardiogram&#44; cardiac catheterization and angicardiography&#46; In fluorescence hybridization test in situ all patients were negative for microdeletion in chromosome 22q11&#46; Anatomic differences between twins are not enough explained on genetic bases&#59; it’s necessary to consider the role of other factors&#44; probably acquired during the first stages of embryonic development&#46; These are the two first pairs of twins with specific concordance in congenital cardiac lesions reported in Mexico&#46;"
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        "resumen" => "Concordancia de defectos cardiacos cong&#233;nitos en dos pares de gemelos monocig&#243;ticos&#46; Se presentan dos pares de gemelos con concordancia espec&#237;fica en sus lesiones cardiacas cong&#233;nitas&#46; Se revisaron todos los gemelos monocig&#243;ticos con concordancia espec&#237;fica en sus lesiones cardiacas cong&#233;nitas en los &#250;ltimos 18 a&#241;os&#46; Se encontraron dos pares de gemelos&#46; El primer par&#44; dos gemelas monocig&#243;ticas de 13 a&#241;os de edad&#44; en ambas se encontr&#243; severa estenosis infundibular y valvular pulmonar&#46; En el segundo par&#44; dos gemelos de 8 a&#241;os de edad&#44; se diagnostic&#243; en ambos&#44; mediante ecocardiograf&#237;a&#44; cateterismo cardiaco y angiocardiograf&#237;a tetralog&#237;a de Fallot&#46; La prueba de hibridaci&#243;n por fluorescencia fue&#44; en ambos pares&#44; negativa para microdeleci&#243;n del cromosoma 22q11&#46; Las diferencias anat&#243;micas entre los gemelos estudiados&#44; no se explican suficientemente sobre bases gen&#233;ticas exclusivamente&#59; es necesario&#44; considerar la participaci&#243;n de otros factores adquiridos&#44; probablemente durante los primeros estadios del desarrollo embriol&#243;gico&#46; Estos son los dos primeros casos de gemelos con concordancia espec&#237;fica reportados en M&#233;xico&#46;"
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