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Asian Cardiovasc Thorac Ann 1999;7:161-163
© 1999 Asia Publishing EXchange Pte Ltd

CASE STUDY

Ruptured Hydatid Cyst of the Right Ventricular Outflow Tract

Durgaprasad Rajasekhar, DM, Padmanabhan Manoj, MCh,1, Dronamraju Dilip, FRCS,1

Department of Cardiology
1 Department of Cardiovascular and Thoracic Surgery Sri Venkateswara Institute of Medical Sciences Tirupati, Andhra Pradesh, India
For reprint information contact: Durgaprasad Rajasekhar, DM Tel: 91 8574 51222 ext. 2369 Fax: 91 8574 28803 Department of Cardiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh 517507, India.

   Abstract
TOP
 Abstract
Introduction
 Case Report
 Discussion
 References
 
A 12-year-old boy who presented with recurrent syncope was diagnosed to have a hydatid cyst of the right ventricular outflow tract. He underwent emergency surgery for cyst rupture but died due to pulmonary embolism and right heart failure.


   Introduction
TOP
 Abstract
 Introduction
Case Report
 Discussion
 References
 
Cardiac involvement by hydatid disease is rare with a prevalence of 0.02% to 2%. 1 While the left ventricle and the interventricular septum are the most common sites of cardiac involvement, the right ventricle is involved in 5% to 15% of cases of cardiac hydatidosis. 2 We report the case of a 12-year-old boy with recurrent syncope who was diagnosed with hydatid cyst of the right ventricular outflow tract.


   Case Report
TOP
 Abstract
 Introduction
 Case Report
Discussion
 References
 
A 12-year-old boy was admitted with complaints of dyspnea on exertion and recurrent syncope of 10 days duration. Clinical examination revealed resting tachycardia (pulse rate, 110 beats•min –1 ) and normal blood pressure (100/70 mm Hg). Cardiovascular system examination showed a systolic thrill in the pulmonary area. Heart sounds were normal. A 3/6 grade ejection systolic murmur and a short early diastolic murmur were audible in the pulmonary area. Preliminary blood investigations showed eosinophilia with a total eosinophil count of 2200 per mm 3 . An electrocardiogram revealed sinus tachycardia. A chest radiograph ( Figure 1 Go ) showed radiopacity in the region of the main pulmonary artery. Echocardiography demonstrated a large cystic mass in the region of the right ventricular outflow tract protruding into the chamber and a Doppler study indicated a right ventricular outflow peak systolic gradient of 30 mm Hg. There was mild pulmonary valve regurgitation. A computed tomography scan showed a large loculated cystic swelling in the region of the right ventricular outflow tract ( Figure 2 Go ). Ultrasonography of the abdomen did not reveal any additional cysts in the liver. Elevated right ventricular systolic pressure (60 mm Hg) was found on cardiac catheterization. No attempt was made to enter the pulmonary artery in view of the cyst located in the right ventricular outflow tract. Right ventricular angiography showed a large mobile cystic mass in the region of the right ventricular outflow tract obstructing the pulmonary valve during each period of systole ( Figure 3 Go ). A diagnosis was made of hydatid cyst of the right ventricular outflow tract producing obstruction.



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  		Figure 1. Posteroanterior chest radiograph of the patient showing a mass in the region of the main pulmonary artery. The right pulmonary artery is also dilated.

 


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  		Figure 2. Contrast-enhanced computed tomographic scan of the patient showing a loculated cystic swelling in the region of the right ventricular outflow tract. A daughter cyst can also be seen near the right hilum.

 


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  		Figure 3. Right ventricular angiogram in right lateral view showing a large cystic filling defect in the right ventricular outflow tract, obstructing the pulmonary valve. The main left and right pulmonary arteries are dilated.

 
Two days later while awaiting surgery, the patient suddenly collapsed in the ward. Rupture of the cyst with consequent pulmonary embolism was suspected. Immediate supportive measures were undertaken and the patient was rushed to the operating room for emergency surgery. While he was being moved onto the operating table, he suffered a cardiac arrest and cardiorespiratory resuscitation was performed. After a median sternotomy, the aorta and inferior vena cava were cannulated, the patient was heparinized, and cardiopulmonary bypass was instituted. The superior vena cava was cannulated through the right atrial appendage, the aorta was cross-clamped, and cardioplegic solution was instilled. The right ventricular outflow tract was opened through a vertical incision 3 cm long. The right ventricular cavity was filled with multiple grayish-white cysts measuring 5 to 20 mm in diameter, characteristic of a ruptured hydatid cyst ( Figure 4 Go ). Some daughter cysts were ruptured and a few were intact. All the cysts were removed (approximately 50). A Fogarty embolectomy catheter was passed into the right and left pulmonary arteries and 5 cysts were retrieved with gentle squeezing of the lung, confirming the clinical suspicion of pulmonary embolism. The fibrous membrane was adherent to the ventricular cavity and was removed by blunt and sharp dissection. The right ventricular outflow tract was closed in two layers with 4/0 polypropylene suture. The patient showed signs of acute right ventricular failure and could not be weaned off cardiopulmonary bypass in spite of all supportive measures.



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  		Figure 4. Some of the cysts removed from the right ventricle, ranging in size from 5 to 20 mm.

 

   Discussion
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 Abstract
 Introduction
 Case Report
 Discussion
References
 
Humans can become infected with Echinococcus granulosus by eating contaminated food or by direct contact with infected dogs. Hatched embryos migrate through the intestinal mucosa and invade the liver. 2 Some larvae bypass the liver and reach the right heart and lung via the inferior vena cava. 3 They can also reach other organs via the systemic circulation or enter the heart via lymphatics draining through the thoracic duct into the superior vena cava.

Interesting aspects of this case are the young age of the patient, the presenting symptom of syncope, the unusual site and size of the cyst, and the documented catastrophic event of cyst rupture. While hydatid cyst has been previously described in the pediatric age group, the size of this cyst in a 12-year-old boy is unusual. 4 The symptom of recurrent syncope was probably related to right ventricular outflow tract obstruction, cyst leakage, and recurrent pulmonary embolism.

The risk of sudden cardiac death is 20% in cases of cardiac hydatidosis. 5 Right ventricular hydatid cysts have been described previously, including a ruptured right ventricular hydatid cyst. 6 – 8 Pulmonary embolism and right heart failure are serious complications of such a rupture and both features were present in this case. Certain measures are recommended to prevent preoperative cyst rupture and pulmonary embolism. These include direct caval cannulation and minimal handling of the heart. Aortopulmonary cross-clamping will also minimize the chances of pulmonary embolism.


   References
TOP
 Abstract
 Introduction
 Case Report
 Discussion
 References
 

  1. Von Sinner WN, Linjw S, Al Watban J. Mediastinal hydatid disease. Report of 3 cases. Can Assoc Radiol J 1990; 41 :79 –82.[Medline]

  2. Cantoni S, Frola C, Gatta R, Loria F, Terzi MI, Vallebona A, et al. Hydatid cyst of the interventricular septum of the heart. MR findings. AJR 1993; 161 :753 –4.[Free Full Text]

  3. Kotoulas GK, Magoufis GL, Gouliamos AD, Athanassopoulou AK, Roussakis AC, Koulocheri DP, et al. Evaluation of hydatid disease of the heart with magnetic resonance imaging. Cardiovasc Intervent Radiol 1996; 19 :187 –9.[Medline]

  4. Kontopoulos AG, Avramides MJ, Athyros VG. Diagnosis, treatment and long-term follow-up of a patient with hydatid cyst of left ventricle. Br Heart J 1994; 72 :592 .[Free Full Text]

  5. Bolourian AA. Total resection of interatrial septal echinococcosis. Asian Cardiovasc Thorac Ann 1998; 6 :66 –7.[Abstract/Free Full Text]

  6. Ruiz-Nodar JM, Iturralde E, Aguilar R, Caniego JL, Martinez de la Concha L, Martinez Ebal L, et al. Rupture of cardiac hydatid cyst located in the right ventricle. Rev Esp Cardiol 1995; 48 :563 –5.[Medline]

  7. Pasaoglu I, Dogan R, Hazen E, Oram A, Bozor AY. Right ventricular hydatid cyst causing recurrent pulmonary embolism. Eur J Cardio-thorac Surg 1993; 6 :161 –3.[Abstract]

  8. Simic O, Strathausen S, Attarbaschi, Bacte J. Echinococcal hydatid cyst in the right ventricle. Dtsch Med Wochenschr 1996;121:1325–8.[Medline]





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