Parasitic omphalopagus complicated by omphalocele and congenital heart disease

Case report: Epigastric heteropagus twins and literature review

Epigastric heteropagus twins are an extremely rare congenital anomaly of conjoined twins. We present a case of epigastric heteropagus twins who were diagnosed via prenatal ultrasound imaging: the fetus (or host) was connected to the abdominal wall of the parasite (the dependent portion), and an omphalocele was present. The male infant was delivered by cesarean section at 35 + 5 weeks gestation. The parasite lacked a head and heart and presented long bones of the limbs. After abdominal computed tomography, omphalocele repair, and parasite removal were surgically performed under general anesthesia. After discharge (follow-up, 3 months), the infant is currently growing well and is healing satisfactorily. Forty-one cases of epigastric heteropagus twins were retrieved from database searches: 38 good postoperative outcomes, 2 perioperative deaths, and 1 termination. The case highlights that even when parasites are massive in size, births can present good outcomes with suitable surgical treatment.

Heteropagus twins: six cases with systematic review and embryological insights

PURPOSE

Heteropagus twinning (HT) is a rare anomaly. Six new cases along with a systematic review are described.

METHODS

Six cases of HT managed at two tertiary care teaching hospitals over the last 26 years are described. A PubMed search with words: Heteropagus AND/ OR parasitic twins from 2001 to 2021 hit 183 articles. 36 were added from non-PubMed sources. Finally, 120 cases including 114 from 69 articles and 6 new cases were analysed.

RESULTS

Of the new cases, 2/6 had an antenatal diagnosis. Five were males. 4 autosites had omphaloceles. Split notochord and 2 parasites attached to a single autosite were encountered. 5/6 autosites survived. On systematic review, the most frequent variant seen was rachipagus (n = 50) followed by omphalopagus (n = 46). Limbs were reported in 75 cases. Congenital heart disease was seen in 17/120(14.2%) autosites. Omphalocele and meningomyelocele were the most common extracardiac anomalies in autosites. Weight along with the anatomy and position of heteropagus twins was a better determinant of the mode of delivery than weight alone. Mortality was reported in 12 cases.

CONCLUSION

Autosites in HT generally carry a good prognosis, however, final outcome depends mainly on associated major cardiac anomalies. Meticulous antenatal assessment and preoperative planning are of paramount importance.

LEVEL OF EVIDENCE

IV.

Dextro-transposition of the great arteries in one twin: case reports and literature review

BACKGROUND

Dextro-transposition of the great arteries (D-TGA) is a rare congenital heart disease, as it affects only 0.02-0.05% of live births. It is the second most common cyanotic heart disease following Tetralogy of Fallot. It has a male predominance. Fetal echocardiography is an optimal method for prenatal diagnosis of fetal D-TGA. In twin pregnancies, fetal D-TGA in one twin is very rare, especially in monochorionic-diamniotic twin pregnancies. Herein, we report a case of D-TGA in one twin in two dichorionic-diamniotic twin pregnancies and one monochorionic-diamniotic twin pregnancy from January 2018 to June 2021.

CASE DESCRIPTION

One twin with D-TGA was diagnosed by fetal echocardiography in the second trimester, and the co-twin was normal in all three cases. A multidisciplinary team provided extensive counseling regarding the D-TGA twin and the co-twin, and adequate perinatal management was provided. In cases 1, 2, and 3, the mothers underwent cesarean sections at 37 weeks + 2 days, 34 weeks + 5 days, and 36 weeks + 1 day, respectively. In case 1, which involved a female D-TGA neonate with birth weight 2,410 g, an emergent atrial septostomy was performed at 20 h after birth, and the neonate underwent atrial switch operation (ASO) 24 days after birth. In case 2, involving a male D-TGA neonate with a birth weight of 2,380 g, ASO was performed 24 days after birth. In case 3, involving a female D-TGA neonate with birth weight 2,240 g, ASO was performed 19 days after birth and delayed sternal closure was performed 4 days later. All six infants showed normal development during follow-up.

CONCLUSIONS

Early antenatal diagnosis of D-TGA in one fetus of a twin pregnancy is significantly important. A multidisciplinary team should carry individual evaluation and integrated management of the D-TGA twin and co-twin during the pregnancy and perinatal period. After birth, delayed ductus arteriosus closure in the D-TGA twins should be performed when necessary and individualized timings for arterial switch operation should be considered.

Parasitic rachipagus conjoined twin: case report

A parasitic twin represents a rare developmental anomaly in which an asymmetrical, nonviable conjoined twin is attached to the host body at the time of birth. Rachipagus is among the rarest of conjoined twin subtypes and typically features a parasitic twin mass attached at the spine. Herein, the authors review the literature and describe the case of a 9-month-old girl presenting with a rachipagus parasitic twin consisting of a fully developed set of lower extremities originating from the midline upper back. After a complete workup to delineate parasite and autosite anatomy, the parasitic twin mass was successfully excised by a multidisciplinary team of surgeons, and the resulting defect was closed in a single stage.

Thoracic heteropagus conjoined twins associated to an omphalocele: Report of a case and complete review of the literature

Heteropagus twins are an extremely rare event with an incidence of 1-2 million live births that represents, sometimes, a real challenge for paediatric surgeons. The majority of cases have complete or partial duplication of the pelvis and/or lower extremities. Thoracic heteropagus conjoined twins is a rare condition in which a grossly defective foetus (the parasite) is attached to the thorax of the main foetus (the autosite). We describe a case of a parasitic heteropagus attached at the chest wall with a rare presentation of giant exomphalos on the autosite. In this situation, the separation procedure was simple after a well-done anatomic study using X-ray, ultrasonography, magnetic resonance and echocardiogram are performed.

An unusual case of heteropagus: autosite with a complex cardiac malformation

Asymmetrical form of conjoined twinning (heteropagus) is an extremely rare event with an incidence of 1-2 million live births. The incomplete component of heteropagus, namely, parasite, usually consists of rudimentary organs. Therefore, the autosite component of heteropagus can be separated successfully. A wide spectrum of associated congenital cardiac malformations, which are usually minor, has been described in autosites. However, a single-ventricle heart anomaly in the autosite has been reported in a very few cases. We report an unusual case of heteropagus with a complex cardiac malformation. To the best of our knowledge, this is the third heteropagus case in the literature with a single-ventricle heart in the autosite.

The epigastric heteropagus conjoined twins

Conjoined twins are rare and are classified as symmetrical or asymmetrical, in which a member, the host (autosite), is near normal and bears the parasite, which is incomplete, smaller, and fully dependent for growth on it. This form of conjoined twins is referred to as heteropagus and when attached to the epigastrium of the autosite is called epigastric heteropagus. Only 44 cases of epigastric heteropagus twins have been previously reported in the world literature. We hereby report the successful separation of a pair of heteropagus twins.

Heteropagus (parasitic) twins: a review

Heteropagus, or "parasitic," twins are asymmetric conjoined twins in which the tissues of a severely defective twin (parasite) are dependent on the cardiovascular system of the other, largely intact twin (autosite) for survival. The estimated incidence of heteropagus twins is approximately 1 per 1 million live births. Isolated case reports comprise most of published work on this rare congenital anomaly. In the past, review articles have focused narrowly on one particular anatomical subtype of parasitic twin and/or on the anatomicopathology observed. Here, we present the epidemiology, proposed pathoembryogenic origins, anatomical abnormalities, management, and outcomes of the wide array of heteropagus twins described in the English language literature.

A case report of an omphalopagus heteropagus (parasitic) twin

Heteropagus twin refers to a type of conjoined twin in which an incomplete smaller (parasitic) twin is attached to and dependent upon an otherwise normal host twin. The majority of cases have complete or partial duplication of the pelvis and/or lower extremities. The case depicted herein is unusual in that only isolated case reports have described an attached amorphous mass without identifiable limbs.

Congenital heart defect with associated malformations in children

BACKGROUND

Children with multisystem involvement including congenital heart defect (CHD) are a very salient problem. The purpose of this study was to evaluate the incidence of CHD associated with malformations of other systems and to assess the modalities of treatment and perioperative mortality among patients referred to the department of pediatric cardiac surgery.

METHODS

The medical records of 1856 children were reviewed retrospectively from 1997 to 2002 to establish CHD and types of associated malformations. The connections between CHD and other lesions were investigated. Furthermore, the influence of patient and perioperative variables on mortality risk was scrutinized. Univariate and multivariate analyses were used.

RESULTS

Eighty-four children (4.53%) had CHD and associated malformations. The malformations of digestive (35.7%), urinary (22.4%), and nervous (14.3%) systems were the most frequently observed associated defects. No relation was found between CHD and concomitant lesions. The results of multivariate logistic regression showed significant influence of patient age, primary cardiac procedure, and CHD type on mortality (ca 19%) in children with multiorgan lesions.

CONCLUSIONS

The treatment of children with CHD and associated multiple lesions is connected with higher mortality risk. The following factors: younger age, urgency of surgical procedure, and primary surgical procedure had negative impact on patient's outcome. However, these risks in certain cases are inevitable. The cardiac procedure preceding the surgical operation may improve the overall effect of treatment because of circulatory stabilization, provided that the condition of the patient does not preclude any intervention at all.