Asian Cardiovasc Thorac Ann 2001;9:320-321
© 2001 Asia Publishing EXchange Pte Ltd
Infected Myocardial Hydatid Cyst Imitating Pericardial Cyst
Ufuk Özergin, MD,
Kadir Durgut, MD,
Niyazi Görmü
, MD,
Güven Sadi Sunam, MD1,
Tahir Yüksek, MD
Department of Cardiovascular Surgery
1 Department of Thoracic Surgery University of Selcuk School of Medicine Konya, Turkey
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For reprint information contact: Ufuk Özergin, MD Tel: 90 332 323 2600 Fax: 90 332 323 2643 email: ozergin{at}selcuk.edu.tr Department of Cardiovascular Surgery, University of Selcuk School of Medicine, Akyoku, Konya 42080, Turkey.
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ABSTRACT
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Pericardial hydatid cyst was diagnosed by 2-dimensional echocardiography and magnetic resonance imaging in a 25-year-old female. At operation, an infected myocardial hydatid cyst was found on the lateral wall of the left ventricle.
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INTRODUCTION
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Hydatid disease is still common in our country, although cardiac hydatid cyst is extremely rare. The infection occurs mostly in sheep-raising areas of the world.1,2 This case of infected myocardial hydatid cyst was incorrectly diagnosed by 2-dimensional echocardiography and magnetic resonance imaging (MRI).
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CASE REPORT
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A 25-year-old female, previously in good health, was admitted with exertional dyspnea, cough, and palpitations for 4 months. On physical examination, her blood pressure was 100/70 mm Hg and her heart rate was 120 beats•min-1. Chest radiography indicated that the lungs were normal but the cardiothoracic ratio was increased with an enlarge-ment on the left border of the heart. Two-dimensional echocardiography and MRI revealed a pericardial cystic lesion adjacent to the lateral side of the left ventricle (Figures 1 and 2
). The lesion was suspected to be a hydatid cyst because the patient came from a region where echinococcosis is still endemic. A left thoracotomy was performed and the pericardium was opened from the posterolateral side. A 2 x 3 x 1.5-cm hydatid cyst was found on the anterolateral side of the left ventricle, which was located inside the myocardium, with no relationship to the pericardium. Puncture and aspiration of the cystic contents revealed infected cystic fluid but no involvement of the cardiac chambers. There was a distance of 0.3 cm between the epicardium and the outer layer of the cyst, and 0.5 cm between the cardiac chamber and the upper part of the cyst. All of the daughter cysts were removed, the cystic cavity was sterilized with hypertonic saline solution, and the epicardium was closed with Teflon-pledgeted sutures to prevent ventricular rupture. Cardio-pulmonary bypass was not needed. Culture of the aspirated cystic fluid was negative. The postoperative course was uneventful. Albendazole treatment (15 mg•kg-1) was given to prevent recurrence. Postoperative transthoracic 2-dimensional echocardiography revealed a cavitation image that was thought to be due to growth of the cyst inside the myocardium over many years (Figure 3). There were no complications or recurrence during 1 year of follow-up.
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Figure 1. Preoperative transthoracic 2-dimensional echocardiography of the patient showing a pericardial cystic image (PER CYST). LA = left atrium, LV = left ventricle, RA = right atrium, RV = right ventricle.
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Figure 3. Postoperative 2-dimensional echocardiography revealing the persisting cystic cavity inside the pericardium.
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DISCUSSION
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In humans, cardiac echinococcosis accounts for only 0.5% to 2% of all cases of hydatid disease.3 Pericardial cysts constitute 7% of all mediastinal tumors.4 The most frequent locations of hydatid cysts are the liver (65%) and lungs (25%), but they can be seen in almost any site in humans. A myocardial cyst forms in 1 to 5 years by migration of the embryo to the myocardium via the coronary circulation. The cyst consists of an outermost protective membrane (the pericystic layer), a laminated membrane, and a germinal layer containing fluid.5 Continual growth of the cyst has a progressive effect on the heart, leading to hemodynamic dysfunction. A viable cardiac hydatid cyst may cause various complications such as rupture into the heart chambers or pericardium, conduction defects, ventricular outflow tract obstruction, myocardial ischemia due to coronary vessel compression, or systemic and pulmonary embolization.5,6
There are no specific symptoms of cardiac echinococcosis. The finding of a cystic lesion on chest radiography or 2-dimensional echocardiography in a patient from an endemic area should raise the suspicion of cardiac hydatid disease.6,7 Although the standard electrocardiogram is also not specific for cardiac hydatid cyst, the presence of Q waves and T-negative waves in the inferior leads can indicate myocardial necrosis. Two-dimensional echocardiography and MRI are the most informative and effective noninvasive techniques for identifying and locating a hydatid cyst.7 However, both methods failed to define the location of the cyst in this case. Surgery remains the treatment of choice, and median sternotomy is the preferred incision. Medical therapy with albendazole as a supplement to surgical treatment has been advocated for reducing the incidence of recurrence.8 Infection of myocardial cystic contents is uncommon because of the sterile nature of the mediastinum. Hydatid cysts of the heart can be aborted and become amorphous masses of putty-like debris, some fill with thrombi after being aborted, and a few remain without alteration. This patient fell into the first category, with negative findings in cultures of the aspirated fluid.
This case is reported because of the diagnostic problems encountered. However, echocardiography and MRI remain the best techniques for diagnosing and locating cardiac hydatid cysts. We performed a left anterolateral thora-cotomy on the basis of the echocardiography and MRI findings indicating a pericardial cyst adjacent to the lateral side of the left ventricle. For this reason, it is recommended that a median sternotomy with cardiopulmonary bypass on standby should be employed, even when a pericardial cyst has been diagnosed.
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REFERENCES
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ABSTRACT
INTRODUCTION
