Asian Cardiovasc Thorac Ann 2007;15:278-279
© 2007 Asia Publishing EXchange Ltd
Cardiac and Pericardial Echinococcosis: Report of 15 Cases
Vakeli Murat, MD,
Zhongxi Qian, MD,
Shuiyuan Guo, MD,
Jun Qiao, MD
Department of Cardiac Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
For reprint information contact: Vakeli Murat, MD, Tel: 86 991 436 2601, Fax: 86 991 436 2601, Email: muratvakeli{at}hotmail.com, Department of Cardiac Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang 830054, China.
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ABSTRACT
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Between 1978 and 2002, 15 patients (mean age, 23.0 ± 8.5 years) with cardiac and pericardial echinococcosis were treated surgically. The cysts were located in the right atrium in 3 patients, on the anterior myocardium in 7, and pericardially in 5. The 3 patients with right atrial cysts were operated on using cardiopulmonary bypass. There were 4 recurrences requiring re-operation after a mean of 12 months. All other patients received mebendazole treatment and exhibited no recurrence during follow-up. One late death due to chronic right heart failure occurred after 10 months of follow-up. The serologic test is an effective method of diagnosis in undeveloped and developing countries.
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INTRODUCTION
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As the clinical signs and symptoms of cardiac hydatid cyst are nonspecific and highly varied, this disease may be difficult to diagnose. Echinococcosis is a serious health issue in some geographical regions of the world. Cardiac involvement is rare, and early diagnosis and prompt surgical intervention are critical. Although hydatid disease is common in China, surgical treatment of cardiac echinococcosis has been reported rarely.1–5 We reviewed our surgical experience in treating this disease.
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PATIENTS AND METHODS
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During a 24-year period between 1978 and 2002, 15 patients with cardiac or pericardial echinococcosis were treated surgically. There were 9 males and 6 females, their mean age was 23.0 ± 8.5 years, with a range of 8 to 36 years. The cysts were located in the right atrium in 3 patients, on the left anterior myocardium in 7, and in the pericardium in 5. Other systemic organs were not involved. The serologic test was positive in 12 cases and negative in 3. On the basis of our surgical experience of treatment of pulmonary echinococcosis (100 cases per year), a correct preoperative diagnosis was established in 12 patients.
Surgical treatment included removal of cysts, resection of the redundant pericyst, freeing of dense adhesions, and a partial pericardiectomy. Cysts were extirpated intact when feasible. Otherwise, they were punctured and suctioned out, and the germinative membrane and daughter cysts were removed. Our approach was by midline sternotomy in 10 cases, with arrangements for possible use of extracorporeal bypass. Cardiopulmonary bypass was not required in 7 patients with myocardial involvement because of superficial location and ease of removal. Extirpation of 3 right atrial cysts was carried out under total cardiopulmonary bypass. After removal of the cysts, the pericyst in the myocardium was always left open.
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RESULTS
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The 15 patients were followed up from 10 months to 22 years. There were 4 recurrences of myocardial cysts after a mean of 12 months; these patients underwent re-operation. All other patients received mebendazole 50 mg·kg–1 orally 4-times daily for 3 months. One late death due to chronic right heart failure occurred in a patient who had a myocardial hydatid cyst after 10 months of follow-up.
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DISCUSSION
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The surgical pathology and treatment of cardiac echinococcosis have been reviewed by a number of authors.1–4 Hydatidosis occurs in humans (intermediate host) when the ova of Echinococcus granulosus from canine (definitive host) feces are accidentally swallowed. The larvae hatch in the duodenum and are carried to the liver, lungs, and systemic circulation. Less than 10% of the larvae reach various organs through the systemic circulation.5 Cardiac involvement can occur from the systemic or pulmonary circulation or as direct extension from adjacent structures.6 It can occur in any part of the heart and the manifestations depend on the size, location, and integrity of the cyst. The left ventricle is the most common site (75%), followed by the right ventricle (15%), interventricular septum (5%–9%), left atrium (8%), pericardium (8%), pulmonary artery (7%), and right atrium (3%–4%).7 Echocardiography, computed tomography, and magnetic resonance imaging are valuable diagnostic tools. Although the symptoms associated with echinococcosis are nonspecific, it may be indicated by an abnormal cardiac silhouette on a chest radiograph, or by echocardiographic findings of cardiac chamber deformation. There have been few serious consequences encountered from obstruction of the cardiac valves by a cyst, or from compression of the conduction system or great veins.8–11 There have been major surgical implications from rupture, with systemic or pulmonary embolization, pericardial dissemination, purulent inflammation, and sepsis.11,12 In treating the disease surgically, these problems account for a greater mortality than death from anaphylaxis and heart failure.1,2 If there is no purulent infection, pericardial rupture and dissemination can be treated successfully by surgery.13
The enucleation of cysts is performed on a beating heart or with the use of cardiopulmonary bypass when necessary. Puncture and evacuation, supplemented with standard precautionary measures to prevent dissemination, appears to be equally satisfactory. This applies particularly to patients with secondary cardiac and pericardial echinococcosis, packed within dense, chronic, fibrous, and constrictive pericardial inflammation or scars. A multiplicity of cysts or intracardiac location does not preclude effective surgical correction. In the majority of cases, postoperative complications have not been significant. Recurrence is rare but severe if not treated early. An early mortality rate of approximately 10% has been reported.9 There were 4 recurrences of myocardial cysts in our patients, which might have been associated with incomplete removal. Although our patients received mebendazole treatment preoperatively, the outcome of preoperative mebendazole treatment needs larger numbers to reach a conclusion on efficacy.
In view of the progressive and dangerous complications in its natural course, surgical treatment of cardiac echinococcosis is urgent. The definitive treatment is surgical extraction of the cyst. As the clinical picture varies according to the number, size, and location of cysts, as well as complications, cardiac echinococcosis should be included in the differential diagnosis to achieve correct treatment. Echocardiography is of paramount value in diagnosis and planning the management of successful surgery. The serologic test is an effective method of diagnosis in undeveloped and developing countries.
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REFERENCES
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- Di Bello R, Rubio R, Dighiero J, Zubiaurre L, Cortes R. Pseudo-aneurysmatic form of cardiac echinococcosis. Report of a new case and review of the literature. J Thorac Cardiovasc Surg 1963;45:657–61.[Medline]
- Di Bello R, Abo JC, Cortes R, Zubiaurre L, Folle LE, Urioste HA, et al. Hydatid cyst of the left ventricle of the heart: mitral insufficiency after surgical treatment. J Thorac Cardiovasc Surg 1965;49:854–9.[Medline]
- Di Bello R, Menendez H. Intracardiac rupture of hydatid cysts of the heart. A study based on three personal observations and 101 cases in the world literature. Circulation 1963;27:366–74.[Abstract/Free Full Text]
- Halliday JH, Jose AD, Nicks R. Constrictive pericarditis following rupture of a ventricular hydatid cyst. Br Heart J 1963;25:821–4.[Free Full Text]
- Trehan V, Shah P, Yusuf J, Mukhopadhyay S, Nair GM, Arora R. Thromboembolism: a rare complication of cardiac hydatidosis. Indian Heart J 2002;54:199–201.[Medline]
- Ozer N, Aytemir K, Kuru G, Atalar E, Ozer Y, Ovunc K, et al. Hydatid cyst of the heart as a rare cause of embolization: report of 5 cases and review of published reports. J Am Soc Echocardiogr 2001;14:299–302.[Medline]
- Kaplan M, Demirtas M, Cimen S, Ozler A. Cardiac hydatid cysts with intracavitary expansion. Ann Thorac Surg 2001;71:1587–90.[Abstract/Free Full Text]
- Heyat J, Mokhtari H, Hajaliloo J, Shakibi JG. Surgical treatment of echinococcal cyst of the heart. Report of a case and review of the world literature. J Thorac Cardiovasc Surg 1971;61:755–64.[Medline]
- Perez-Gomez F, Duran H, Tamames S, Perrote JL, Blanes A. Cardiac echinococcosis: clinical picture and complications. Br Heart J 1973;35:1326–31.[Free Full Text]
- Gula G, Luisi VS, Machado F, Yacoub M. Hydatid cyst of the heart. Clinical and surgical implications. Thorac Cardiovasc Surg 1979;27:393–6.[Medline]
- Gavrilescu S, Gavrilescu M, Streian C, Luca C. Complete atrio-ventricular block due to cardiac echinococcosis. Cardiology 1979;64:215–21.[Medline]
- al-Naaman YD, Samarrai AA, al-Omeri MM. Hydatid disease of the heart. A report of four cases. J Cardiovasc Surg (Torino) 1973;14:95–101.[Medline]
- Shojaee S, Hutchins GM. Echinococcosis complicated by purulent pericarditis. Chest 1978;73:512–4.[Medline]
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ABSTRACT
INTRODUCTION
