Twenty-five years of fetal echocardiography in conjoined twins: lessons learned

The aim of this study was to determine the accuracy of prenatal echocardiography in the diagnosis of intracardiac malformations and the degree of cardiac fusion in conjoined twins presenting to a single center over a 25-year period.

The study group included 53 sets of conjoined twins from 1987 to 2012, including 38 thoracopagus, six parapagus, six omphalo-ischiopagus, two omphalopagus, and one cephalopagus. Twins were classified according to the degree of cardiac fusion: separate hearts and pericardium (group A, n = 10), separated hearts and common pericardium (group B, n = 2), fused atria and separated ventricles (group C, n = 2), and fused atria and ventricles (group D, n = 39). Postmortem examination was possible in 68 individual cases (98 deaths [69.3%]).

Cardiac defects were diagnosed in 47 sets of twins (88.6%). In 10 (18.8%), only one fetus was affected, and in 37 (69.8%), both fetuses were affected (n = 84/106 [79.2%]). There was a high predominance of right-sided lesions (63.0% [53 fetuses in 84 affected]) including pulmonary atresia or stenosis (35.7%), tricuspid atresia (11.9%), and hypoplastic or small right ventricle (21.4%). Autopsy findings added information to fetal echocardiographic findings in nine sets of twins (25.7%). Three pairs classified antenatally in groups A, B, and D were confirmed by autopsy in groups B, C, and C, respectively.

This study demonstrates that specialized fetal echocardiography is not a perfect diagnostic tool but is sensitive enough to establish prognosis in the counseling process. Because of complexity, such evaluations should be performed only at tertiary centers by specialists who are familiar with the peculiarities of this rare malformation. The predominance of right-sided lesions is not only an interesting finding, but this information has essential importance in terms of shortening examination times, allowing a more focused analysis of the fetal heart.