Surgery for Cardiac Hydatid Cyst with Right Intraventricular Extension

Cardiac hydatid cysts are very rarely encountered, with a frequency of 0.01 percent to 2 percent of all cases of human hydatidosis. This video discusses the surgical management of a case of cardiac hydatid cyst.

The Patient

The patient is a 37-year-old male. He presented with complains of chest pain and shortness of breath for two months. He has no significant past and family history. On general examination he was essentially normal and his routine blood investigations were within normal limits.

A chest X-ray showed cardiomegaly so an echocardiogram was done. It revealed that a multiloculated cystic mass was present in the pericardial cavity, which was compressing the left ventricle and doubtful extension into the right ventricular cavity.

A CT was performed, which revealed a large, well encapsulated multiloculated cystic mass. The mass was seen to be infiltrating the myocardium of left ventricle, interventricular septum, and anterior wall of the right ventricle. There was a lobulation extension of the mass into the right ventricular cavity, which was seen as a filling defect within the contrast filled right ventricular chamber.

For accurate delineation of cardiac extension of the mass, a cardiac MRI was done. It showed a large, well defined multiseptated cystic lesion measuring 11 x 6.6 x 8 cm in the pericardial space. It was causing compression and mass effect on both the ventricles. It was also extending into the anterior interventricular septum and seen to bulge into the right ventricular cavity.

As a result, a diagnosis of cardiac hydatid cyst causing compression of both ventricles and an extension into the right ventricular cavity was made. The patient was started on tablet albendazole preoperatively and was scheduled for cardiac hydatid cyst excision on pump, in view of right intraventricular extension.

The Surgery

Under general anesthesia, after painting and draping, a median sternotomy was performed. The pericardium was adherent to the right atrium, aorta, and right ventricle. There was a cystic lesion over the left and right ventricle in the intrapericardial space. The pericardial adhesions were released over the aorta and right atrium. Then, the patient was heparinized for adequate activated clotting time (ACT). Cardiopulmonary bypass was initiated via aortic, SVC, and IVC cannulation and hypertonic saline soaked sponges were packed around the cyst. 

The procedure was performed on-pump with a beating heart under transesophageal echocardiogram (TEE) guidance. The pericardium and pericyst were incised, and the daughter cysts were expelled out with each heartbeat and completely sucked out using a wall suction. The pericyst was partially released from the adjacent left pleura and diaphragm and washed with scolicidal agent. An intraoperative TEE still showed a lobulated cyst in the right ventricular cavity, so the heart was arrested using antegrade cardioplegia after cross-clamping the aorta. The right atrium was opened, and there was a cyst near the medial papillary muscle, which was then excised. 

After the excision, there was a communication noted between the right ventricle and the pericyst via the interventricular septum. The opening of the communication was closed on the right ventricular side with pledgeted Prolene sutures. The heart was filled with blood, and there was no filling of the pericyst, so the right atrium was closed. The excessive pericyst was excised, and the remaining pericyst was closed in a double-breasted fashion over the left ventricle. 

The patient was then weaned off bypass smoothly. Intraoperative TEE showed no residual intraventricular cyst and hemostasis was achieved. Protamine was started, sequential decannulation was done, and the chest closed in routine fashion. 

The patient did well in the postoperative period and was discharged on postoperative day seven. He continued to do well at his last follow- up. He is on tablet albendazole to prevent recurrence of hydatid cyst.

References

1. Firouzi A, Neshati Pir Borj M, Alizadeh Ghavidel A. Cardiac hydatid cyst: A rare presentation of echinococcal infection. J Cardiovasc Thorac Res. 2019;11(1):75-77.
2. Echinococcus Disease of the Heart JORGE DIGHIERO, EDUARDO JOAQUIN CANABAL, CESAR V. AGUIRRE, JACOBO HAZAN, and JOSÉ O. HORJALES. Circulation. 1958;17:127-132, doi:10.1161/01.CIR.17.1.127
3. Alshehri HZ, Lawand S, Omar AH, Koudieh MS. Surgical approach to huge cardiac hydatid cyst of the interventricular septum. Asian Cardiovasc Thorac Ann. 2014 Nov;22(9):1093-5.
4. Kabbani SS, Jokhadar M, Sundouk A, Nabhani F, Baba B, Shafik AI. Surgical management of cardiac eshinococcosis, report of four cases. J Cardiovasc Surg (Torino) 1992;33:505–10.

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