Download A rare localization of hydatid cyst: Right ventricular free wall cyst

Journal-Cardiovascular Surgery 2013:1(1);13-15
doi; 10.5455/jcvs.2013114
Case Report
13
A rare localization of hydatid cyst: Right ventricular free
wall cyst fistulized to the ventricular cavity
Tuğra Gençpınar1, Mehmet Güzeloğlu*2, Koray Aykut2, Gökhan Albayrak2, Eyüp Hazan1,
Department of Cardiovascular Surgery, State Hospital, Antalya
Department of Cardiovascular Surgery, Medical Park Hospital, Izmir University, Turkey
*
Corresponding Author: Department of Cardiovascular Surgery, Medical Park Hospital, Izmir University
Yeni Girne Bulvari Karsiyaka,Izmir/Turkey. Tel: +90 532 7420220 Fax:+90 232 3995070
e-mail: [email protected]
Key words: Hydatid Cyst; heart ventricle, right; pulmonary embolism
Received: 14.01.2013 Accepted: 21.01.2013 e-published: 15.02.2013
1
2
Abstract
Hydatid disease is the result of a parasitic infestation of the larva of ecchinocccus granulosus. Cardiac
cyst is a rare complication of the infection. Most frequently, the cyst is localized within the free wall of the
left ventricle and interventricular septum, where the blood supply is ample. Pericardium, right ventricle and
interatrial septum are rarely affected. Symptoms depend on localization of the cyst. Here, we report a female
patient with multiple cysts adherent to right ventricle wall were noted. The patient was successfully treated
with surgical therapy.
Introduction
Hydatic disease is the result of a parasitic infestation of
the larva of ecchinocccus granulosus. Cardiac cyst is a rare
complication of the infection and it makes up to 0.05-0.2 percent of all cyst hydatid cases. The cyst is frequently localized
within the free wall of the left ventricle and interventricular
septum, where the blood supply is ample. Pericardium, right
ventricle and interatrial septum are rarely affected (1). Symptoms depend on localization of the cyst and the clinical status
of the patient.
Here we present a young female patient with multiple cysts.
Case Report
A 29-year-old housewife was referred to our hospital. She
was diagnosed with Behçet’s disease, in another institution
to which she was presented with cough, shortness of breath,
fever and chills. She had a history of an operation for liver
hydatid disease 5 years ago. In physical examination,
dyspnea and bi-basilar rhales were evident. Chest X-ray revealed parahilar opacity (Figure 1), her electrocardiographic
exam was non-specific. We performed an echocardiography.
Pulmonary artery systolic pressure was measured as 70mmhg,
also multiple cysts adherent to right ventricle wall were noted.
A multiloculated cyst measuring 45X36X27 mm in diameter
was seen on the inferior wall of the right ventricle in cardiac
A rare localization of hydatid cyst: Right ventricular free wall cyst
fistulized to the ventricular cavity
magnetic resonance imaging (MRI). That particular cyst
seemed to be originating from right ventricular epicardium
and was extending into the pericardial space. Another smaller 1 cm cyst was also noted which was localized in the endocardium and prolapsing into the right ventricle (Figure 2).
Echinococcus antibody was positive at 1/1250 titration with
ELISA, erhytrocyte sedimentation rate and C-reactive protein
levels were within normal limits.
We performed a median sternotomy and administered NO
perioperatively. We stopped NO inhalation right after bicaval
cannulation and aortic root cold cardioplegia was secured.
Within the pericardial space, a cyst approximately of 5 cm
in diameter next to right coronary artery was observed (Figure 3a). We performed a cystectomy after securing the area
with 3% NaCl soaked gauze (Figure 3b). Exploration revealed
that the cyst had already fistulized into the right ventricle. The
fistula was repaired with a Gore Tex mesh (Figure 3c). We
performed a right ventriculotomy and excised the cyst with
careful protection of the papillary muscle (Figure 3d). The
right ventricle was washed many times with 3% NaCl solution
(Figure 3e). The surgery was completed within 31 minutes
of aortic cross clamp and 41 minutes of cardiac bypass time
(Figure 3f).
We administered post-operative albendazole treatment and
scheduled follow up with computerized tomography (CT) angiography and transthoracic echocardiography.
Gençpınar et al.
Journal-Cardiovascular Surgery 2013:1;13-15
doi; 10.5455/jcvs.2013114
Case Report
14
Figure 2. Hydatid cyst on the inferior wall of the right
ventricle detected in cardiac MRI.
Figure1. Chest X-ray of the patient.
Discussion
Hydatid disease is endemic in Mediterranean region, middle east, south Africa and Australia. Embryonated echinococcus eggs are excreted in feces of cats, dogs etc. and humans
and are accidentally infested by ingesting contaminated food.
Most of those eggs are eliminated by host defenses, those
which escape, progress to the cyst stage. Cysts grow slowly,
usually at a rate of 1 cm/year (2). When cardiac infection is
the case, cysts are encased in an adventitial pericystic coat
and they reach maturity in 1-5 years (2). The first cardiac cyst
case has been reported by Williams et al. in 1936. Ten years
after that paper, Greisinger et al. published a case series of 15
patients (3).
Cardiac hydatid infection most commonly affects the left
ventricle (%55-60) where the blood supply is ample (4). Interventricular septum, right atrial wall, right ventricle, left
atrium, pulmonary artery and pericardium are less commonly
reported. Symptoms depend on cyst localization and clinical
status of the patient. Cardiac cyst hydatic frequently presents
with pericardiac chest pain, dyspnea, cough and fever (1,2).
Anaphylaxis and shock may rarely occur. Clinical picture may
also include cardiac tamponade, arrhthymias, myocardial infarction, pericarditis, valvular dysfunction, pulmonary and
systemic emboli, congestive heart failure and sudden death.
Our patient had fever, chills, dyspnea and cough.
In diagnosis, most patients exhibit multivisceral involvement (%55-85) (5). Murmurs can be heard. Electrocardiographic findings are not specific to cardiac cyst hydatid. In
chest X-ray, calcified lobular masses and abnormal heart
shadows can be seen. Echocardiography is the most effective
examination in terms of providing a diagnosis and formulat-
A rare localization of hydatid cyst: Right ventricular free wall cyst
fistulized to the ventricular cavity
ing a plan. Tomography scans and MRI can show extracardiac involvement, if present (2). Serologic tests are positive
in 50% of the patients and false negativity must be taken into
account. We made the diagnosis with echocardiography and
soon MRI, and serologic tests were strongly positive. Casoni
skin test and Weinberg complement fixation tests are outdated
because of low sensitivity and specificity.
In terms of medical treatment, benzimidazole derivatives
are effective. They inhibit parasite spesific fumarate reductase, microtubule polymerase, oxidative phosphorylation and
glucose transport. Because of the risk of rupture into cardiac
chambers and pericardium, and sudden death, the mainstay
of the cardiac cyst treatment is urgent surgery. In cardiac cyst
hydatid, operative mortality is reported as 0,25-0,1% (6).
In conclusion, in myocardial involvement of hydatic
disease, surgical intervention is preferred because of the risk
of sudden death and possible complications. The relative low
mortality and morbidity and high effectiveness of the surgery
are also suggestive for surgical treatment. Surgical intervention is most commonly performed on-pump. Hydatid disease
is still common in our country and a variety of cases such as
this case can be encountered in clinical practice.
Acknowledgements
None
Conflicts of Interest
The authors declared no conflicts of interest with respect to
the authorship and/or publication of this article.
Gençpınar et al.
Journal-Cardiovascular Surgery 2013:1;13-15
doi; 10.5455/jcvs.2013114
Case Report
15
Figure 3. Intraoperative view of the hydatid cyst.
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