Case of Identical Twins Exhibiting Different Type of Brugada Type ECG

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We report a rare case of identical twins that exhibited different types of Brugada type ECG. Forty-one year-old identical twins were referred to our hospital for further evaluation of ECG abnormality. Both of the twins exhibited Brugada type ECG. However, the pattern was different. Twin-A exhibited saddle-back type ST elevation in precordial leads and ventricular pre-excitation suggestive of anteroseptal accessory pathway. During Treadmill exercise testing, ventricular pre-excitation was present only when the heart rate was below 120 bpm. The ST level reduced when ventricular pre-excitation abruptly disappeared, and recovered as ventricular pre-excitation recovered. On the other hand, twin-B exhibited spontaneous coved type ST elevation for 4 mm in precordial leads and no ventricular pre-excitation. Echocardiogram showed no structural abnormality for both. Because both are asymptomatic and had no familial history of cardiac sudden death, they had no further evaluation and were put on regular follow-up. In each follow-up visit, the ECG for twin-A and B always show saddle back and coved type ST elevation, respectively. This is the first report of identical twins with Brugada type ECG. Even in identical twins, the degree and type of ST elevation may differ. Further, ventricular pre-excitation may modify ST elevation in Brugada type ECG.