Cardiac, Aortic, and Pulmonary Artery Hydatid Cyst

The report emphasizes the importance of surgery for such cardiac hydatid cysts whenever discovered to prevent fatal and unexpected death. Although cardiac hydatid cyst is a rare disease, early diagnosis and treatment is of great importance because of frequent fatal complications. CT scan is excellent modality for diagnosis. Surgical excision is the best treatment modality for cardiac hydatid cysts located in the pericardium. Here are two videos showing different cases.

Video 1: LV wall hydrated cyst not invading into the LV cavity

Video 2: Large pericardial cyst

Introduction:

Hydatid cysts caused by Echinococcus granulosus are usually located in the liver and lungs; cardiac involvement is quite rare. The incidence of cardiac echinococcosis is <2% of the total echinococcosis incidence, even in countries endemic for echinococcosis [1]. The anatomical site of location in the heart most commonly includes the left ventricle; cysts are rarely located in the right ventricle, interventricular septum, and atrium [2]. Isolated pericardial hydatid cysts are quite rare [3, 4]. Both the disease and its surgical treatment carry a high complication rate including rupture leading to cardiac tamponade, anaphylaxis and also death [5].
History:

A 50-year-old female, a known case of hypertension, presented with epigastric pain radiating to chest from last one year with on/off fever and her symptoms were more pronounced on exertion and relieved on rest. She had associated bilateral weakness of upper limbs along with on/off diarrhea and nausea/vomiting.

She had a history of multiple hydatid cysts in liver, right lung, pararenal and pelvic involvement for which she had multiple exploratory laparotomies during which right hemi colectomy and colostomy done.

On current admission, she was afebrile with Hb of 11.9g/dl and WBC count of 14.21 10 ^ 3/ul and stable vital signs. Cardiovascular system examination was unremarkable.

On two-dimensional transthoracic echocardiography, good LV systolic function. CT chest with contrast showed multiple cysts inside the pericardium adjacent to the apex of heart, largest one is 5.8 x 7.6 cm in size and 12x8 mm in the right upper lobe. Multiple abdominal cysts also noted on CT scan.

Case report:

We decided to treat the patient’s thoracic disease surgically as patient had already taken oral Albendazole for long time. The patient underwent a median sternotomy and chest cavity was entered. Pericardium was freed circumferentially and opened (Figure 2). Multiple cyst cavities with many daughter vesicles were found inside the pericardium surrounding the heart which included one at SVC level, one anterior on left ventricle and other large one lateral to LV (Both not invading into the LV muscle), one anterior to ascending aorta (Figure 3) and one anterior to PA. Off pump beating heart complete enucleation of all cyst cavities was done step by step containing multiple daughter cysts inside. After emptying the cavities completely, H2O2 soaked gauze pieces were used as scolicidal agent and then thorough wash done with warmed normal saline. Hemostasis secured. Sternum closed with steel wires, muscle and skin closed in layers. No postoperative complications noted. The patient w as discharged on 200 mg of oral Albendazole twice daily to prevent recurrence.

Discussion:

Echinococcus disease in humans is caused by the larval development of taenia echinococcus, a cestode tapeworm. Dogs are typically the definitive host of taenia echinococcus, but humans can become incidentally infected through contact with dogs via a fecal-oral route. The liver is the organ most frequently involved in echinococcus disease, followed by the lung. Cardiac hydatidosis is extremely rare, more commonly the liver and lungs are affected. Cardiac involvement is seen only in 0.2%–3% of cases, making early diagnosis and treatment important [6]. The most affected sites in the heart are the left and right ventricles and the interventricular septum [7]. The pericardium and left and right atria are the least affected [7].
The diagnosis of echinococcosis in heart can be divided into two steps: detection of the cyst and its identification as echinococcus. It is based on serological reactions, echocardiography, X-ray, computerized tomography, and/or magnetic resonance imaging.

Depending on the location and the direction of least resistance, primary hydatid cysts of the heart have a marked tendency to rupture either into the lumen of a cardiac chamber or into the pericardial sac [6]. The most dangerous complication of cardiac echinococcosis is cyst perforation. After cyst perforation three quarters of the patients die from septic shock or embolic complications. Early surgical removal of a hydatid cyst is the treatment of choice. Off-pump resection of epicedial cysts is advocated by some, but the majority use cardiopulmonary bypass regardless of the cyst’s location. The two main principles of the surgery are to: avoid handling the heart before cross-clamping, and completely excise the germinal layer. As for the residual cavity, some prefer to let it heal by secondary intent to avoid complications. However, this approach risks leaving a potential space behind; therefore, the authors obliterated the cavity with sutures.

Conclusion:
The report emphasizes the importance of surgery for such cardiac hydatid cysts whenever discovered to prevent fatal and unexpected death. Although cardiac hydatid cyst is a rare disease, early diagnosis and treatment is of great importance because of frequent fatal complications. CT scan is excellent modality for diagnosis. Surgical excision is the best treatment modality for cardiac hydatid cysts located in the pericardium.

References

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6. Jorge dighiero, Eduardo joaquin canabal, Cesar v. aguirre, jacobo hazan, and josé o. horjales. Echinococcus Disease of the Heart Circulation. 1958;17:127-132, doi:10.1161/01.CIR.17.1.127

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