Asian Cardiovasc Thorac Ann 2002;10:66-68
© 2002 Asia Publishing EXchange Pte Ltd
Surgical Treatment of Echinococcal Cysts of the Heart: Report of 3 Cases
Ahmet Özyazicio
lu, MD,
Hikmet Koçak, MD,
Münacettin Ceviz, MD,
Ahmet Yavuz Balci, MD
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Department of Cardiovascular Surgery Atatürk University Medical Faculty Aziziye Hospital Erzurum, Turkey
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Ahmet Özyaziciolu, MD Tel: 90 442 316 6333 Fax: 90 442 316 6340 email: violinahmet{at}hotmail.com Gez Mah. Yasemin Sok., Atmaca Apt. A Blok No. 5, Erzurum 25200, Turkey.
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ABSTRACT
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Three patients diagnosed with hydatid cysts of the heart underwent surgical treatment. The cysts were enucleated and the cavities were closed in 2 cases by plication and obliteration. In one case, the cystic cavity was closed with biologic glue. The outcome was satisfactory in all 3 patients. Postoperative treatment with albendazole is recommended.
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INTRODUCTION
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Hydatid cyst of the heart is an uncommon lesion.1,2 Echinococciasis is endemic to Turkey and most patients harbor the granulose species; alveolaris can also be seen in the eastern part of Turkey.3,4 Between 1992 and 1998, 3 patients underwent evaluation and treatment of cardiac echinococcosis in the cardiovascular surgery department of Atatürk University Medical Faculty, Aziziye Hospital in Erzurum, Turkey.
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CASE REPORTS
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CASE 1
A 25-year-old man was admitted with dyspnea, chest pain, and fever of 15 days' duration. Physical examination revealed crepitant rales in the basal lung fields. Chest radiography and computed tomography showed a ruptured cyst in each lung and on the anterior wall of the right ventricle. On 2-dimensional echocardiography, the cystic mass in the right ventricular wall appeared to have had a multilocular structure. Casoni and Weinberg tests were positive, whereas tests for syphilis were negative. Via a median sternotomy, the thoracic cavity was opened and the cysts in the lungs were removed by cystotomy and capitonnage. The heart was cannulated and cardio-pulmonary bypass (CPB) was established. The cystic contents were aspirated with a needle, and hypertonic saline solution (sodium chloride 10% w/v) was injected. The anterior wall of the right ventricle was opened. Approximately 10 daughter hydatid cysts of various sizes and the whole germinative membrane were removed. The wall of the right ventricle was closed with Teflon felt reinforcement. The patient was given albendazole 10 mg•kg-1•day-1 for 10 months postoperatively. During 8 years of follow-up, he had no recurrence or complication.
CASE 2
A 23-year-old man was admitted with palpitations and chest pain. On physical examination, rales were noted in the base of the left lung. Chest radiography revealed an increased cardiothoracic ratio. Routine laboratory tests were normal. The Casoni skin test was positive, and the Weinberg agglutination test was negative. Two-dimensional echocardiography showed multilocular cysts in the right apical ventricular wall and pericardial effusion. Computed tomography demonstrated round multilocular thick-walled cysts in the right apical ventricular wall and pericardial effusion. After a median sternotomy, CPB was established using standard cannulation. Approximately 26 cysts were located in the right ventricular wall and enucleation was performed (Figure 1
). The cystic cavity was cleaned with povidone-iodine and biologic glue was applied before suturing the mouth of the pouch. The patient was treated with albendazole and made an uneventful recovery. He was followed up for 5 years without incident.
CASE 3
A 42-year-old woman was admitted with abdominal pain and tachycardia. No thrill was detected on physical examination. The heart and lungs were clear on auscul-tation. Chest radiography revealed an enlarged heart. A serum echinococcal hemagglutination-inhibition test and Casoni test were positive. An electrocardiogram was normal. Echocardiography showed a cyst-like image in the left ventricular wall. Computed tomography of the chest disclosed a lobulated cystic mass in the wall of the left ventricle (Figure 2). The patient underwent surgery under CPB and cold potassium cardioplegic and ischemic arrest. The pericardium was protected with gauze pads soaked in povidone-iodine. Intact cysts were removed by needle aspiration and injection of hypertonic saline solution. Ruptured cysts were enucleated without needle puncture. The residual defect was repaired using Teflon felt reinforcement. The patient made an uneventful recovery and was treated with albendazole postoperatively. During a 2-year follow-up, there was no clinical or radiological evidence of recurrence.
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Figure 2. Computed tomography in case 3. A lobulated cystic mass can be seen in the wall of the left ventricle.
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DISCUSSION
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The reported prevalence of hydatid disease of the heart is 0.2% to 0.3% of patients with hydatidosis.5,6 There is no single clinical picture that indicates the diagnosis. In endemic areas, medical history may be very helpful. Nevertheless, a thorough clinical investigation by appro-priate methods should provide the correct preoperative diagnosis.2 Enucleation, aspiration, and cystectomy are among the specific surgical procedures for cardiac hydatids. Each operation has two phases: removal of the cyst and treatment of the residual cavity. Removal of cysts under CPB is important in preventing complications, particularly if there is a relationship between the cyst and the cardiac chamber. As cardiac cysts are usually more numerous and less firmly attached than pulmonary cysts, it is recommended that total enucleation be used for all intact cardiac cysts. However, ruptured cysts must be enucleated without needle puncture. There was no incidence of surgical rupture in these 3 cases treated by enucleation. If rupture occurs, the cavity should be filled for 5 minutes with hypertonic saline which provides reliable decontamination. The pericardial cavity should be protected with gauze pads soaked in povidone-iodine.
Biologic glue was used to close the residual cystic cavity in one case. We previously used biologic glue for treatment of multiple ventricular septal defects, and in acute aortic dissection.7 The walls of the cystic cavity were glued together before suturing the entrance. As there was no problem postoperatively, biologic glue may be considered an appropriate means of closing the cystic space.
All 3 patients were treated with albendazole in a dosage of 10 mg•kg-1•day-1 after surgery, to prevent further implantation. There was no clinical or radiological evidence of recurrence during follow-up, but serological findings did not correlate well with the radiological or clinical improvement. Results of albendazole therapy are encouraging, and the dosage used was much less than that required with mebendazole.8 Albendazole is recommended in such cases.
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REFERENCES
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Dighiero J, Canabal EJ, Hazan J, Horlales JO. Echinococcus disease of the heart. Circulation
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Morris LD, Dykes PW, Marriner S, Bogan J, Burrows F, Skeene-Smith H, et al. Albendazole — objective evidence of response in human hydatid disease. JAMA
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