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Hydatid cyst is a parasitic infection caused by the parasite Echinococcus granulosus. Although the disease most commonly presents with liver and lung involvement, it may rarely present with cardiac involvement in 0.5-2% of cases. Here, the management of a giant univesicular echinococcal cyst of 69×75 mm in size, almost completely occupying the intraventricular cavity of a Syrian migrant who was previously operated for hepatic hydatid cyst and applied to the outpatient clinic with the complaint of dyspnea, will be presented. To the best of our knowledge, this case is the largest intracardiac univesicular cyst presented in the literature so far. Hydatid cyst disease is a zoonotic parasitic infectious disease caused by accidental ingestion of food contaminated with the eggs of the parasite Echinoccus granulosus. The disease often presents with liver (50-70%) and lung(5-30%)involvement. Cardiac involvement is very rare and accounts for a total of 0.5-2% of all patients. The most common sites of cardiac involvement are left ventricular free wall and right ventricle and interventricular septum. In cardiac involvement, symptomatic features vary from patient to patient, depending on the location and size of the cyst. Cardiac hydatid cyst is currently treated surgically and can lead to fatal outcomes if not surgically intervened. Case report A 42-year-old Syrian migrant woman applied to the cardiology outpatient clinic with the complaint of dyspnea. She stated that her shortness of breath had gradually increased in the last year. On physical examination, blood pressure was 100/70 mm Hg, heart rate was 113 bpm, and saturation was 96%. On auscultation, there was a 2/6° systolic murmur in the mitral focus. The ECG was in normal sinus rhythm and there were non-specific ST-T changes. In her medical history, it was learned that the patient had been operated for hydatid liver cyst 5 years ago and she did not have a regular medication. Transthoracic echocardiography revealed a 69x75 mm hypoechoic cystic mass that filled almost the entire left ventricular cavity(Figure 1a-b). The left ventricular cavity was enlarged and left ventricular contraction was restricted due to the cystic mass, and the effective opening of the mitral valves during diastole was prevented by the cyst(Video 1). Thoracoabdominal Computed Tomography(Figure 1c) and cardiac magnetic resonance(Figure 1d-1e) imaging confirmed the presence of hydatid cyst in the left ventricular cavity (Figure, furthermore, multiple cystic lesions were found in the hepatic lodge on tomography. An enzyme-linked immunosorbent assay(ELISA) was positive for echinococcus antibodies. The patient was started on albendazole treatment and was referred Faculty of Medicine, Department of Cardiovascular Surgery. OPERATİON TECNİQUE Median sternotomy was performed under general anesthesia. Aortic and two-stage (unicaval) venous cannulations were performed. Cardiac arrest was achieved with anterograde Del Nido cardioplegia, followed by cross-clamping. Mild hypothermia(32-34 °C) was maintained in the operation. In open exploration, hydatid cyst was seen in the left ventricular region. The cystic material was aspirated (Figure 2a), then a short incision was made from the anterior wall of the left ventricle and the cyst was removed from the posterolateral wall to which the cyst was attached (Figure 2b-2e). The cavity formed by removal of the cyst mass was irrigated with hypertonic saline solution. There was no connection with the left ventricular cavity. The cyst cavity was closed between Teflon felt strips attached with two layers of horizontal mattress sutures using 2-0 Ethibond® (Ethicon, Johnson & Johnson Medical N.V., Belgium), in a Cooley-like aneurysmectomy(Figure 2d) like our previous cases. In the histopathological examination, the excised material was compatible with a univesicular echinococcal cyst. In control echocardiography, it was observed that left ventricular functions were mildly depressed (Left ventricular ejection fraction: 45%) and mitral regurgitation persisted (Video 2). Presumably, dysfunction of the subvalvular structures by the cyst resulted in post-operative persistence of mitral regurgitation. The patient was consulted to gastroenterology in terms of hepatic cysts and was discharged uneventfully on the 9th postoperative day with albendazole treatment. DISCUSSION Hydatid cyst is an endemic parasitic infection seen mainly in sheep farming countries such as Mediterranean countries, Middle East and South America. Animals such as cats and dogs are the main carriers and humans are intermediate hosts. Ingested parasitic larvae enter the systemic circulation via the portal venous system. The most common involvement in hydatid disease is liver (50-70%) and lung to lung (5-30%), followed by skeletal muscles (5%), bones (3%), kidneys (2%), spleen (1%) and brain (1%). Cardiac involvement is very rare and cardiac involvement is seen in 0.5-2% of cases. The larvae usually reach the left side of the heart via the coronary circulation, and in the presence of parasitic involvement, the inflammatory response produces an adventitial pericystic layer. The left ventricle is the most frequently involved cardiac structure (55-60%) due to rich coronary blood supply. Afterwards, right ventricle (10-15%), pericardium (7%), pulmonary artery (6-7%), left atrium (6-8%), right atrium (3-4%), and interventricular septum (4-7%) involvement is seen. Cardiac hydatid disease may be asymptomatic, but it often presents with non-specific symptoms such as shortness of breath, chest pain and palpitations depending on its location and size. Patients with cardiac cysts are usually diagnosed or suspected on transthoracic echocardiography during their outpatient examination. Cardiac magnetic resonance imaging and computed tomography provide more extensive information for the localization and extent of cardiac cysts. The diagnosis is confirmed by histopathological and serological tests. Cyst excision is the gold standard in the treatment of the disease, and albendazole therapy is typically prescribed for at least four days preoperatively and for 4 to 12 weeks postoperatively. Cardiac cysts must be treated surgically because they can be fatal if left untreated. We recommend cyst fluid aspiration as the initial treatment of surgery in large cardiac cysts, because the introduction of cyst fluid into the circulation means both the risk of anaphylaxis and the systemic spread of possible daughter vesicles in the cyst to the whole body. Normothermic cardiopulmonary bypass can be used safely in patients with cardiac hydatid disease. It would be beneficial to use a hypertonic saline solution perioperatively as a protoscolitic agent, since it has few side effects. In cases with extensive cystic lesions, capitonnage similar to ventricular aneurysm repair may be beneficial in preserving ventricular functions. CONCLUSIONS Cardiac hydatid cyst is a rare but important manifestation of echinococcal paarsitic infection. In these patients, early diagnosis and surgical intervention are vital to prevent major complications. In our case, the patient presenting with a cardiac cyst that covers almost the entire ventricular cavity had stable vital signs apart from only dyspnea, probably because the growth progression of the cyst was chronic, and hemodynamic compensation took time to adapt to the process. Good management of perioperative procedures is important for prognosis. The case we present is also a case that demonstrates this approach. [ABSTRACT FROM AUTHOR] |
