This article had presented on the 12^th annual meeting of the Asian society for cardiovascular surgery in Istanbul/TURKEY

Case Report

A 19 years old asymptomatic Azerbaijani male patient was hospitalized due to a cardiac mass diagnosed during a routine check up examination. Physical examination was normal. Chest radiography, complete blood count and routin biochemical evaluations revealed no pathology. On a two dimentional echocardiography there was a cyst-like lesion in interventricular septum with a diameter of 5.8 cm. The LVEF was measured as 66% (Figure-I). The existing lesion was towards the right ventricular area. With these findings an Echinococcus hemaglutination test was carried out. Following the positive serological test results albendazol treatment with a dose of 15/ mg/ kg/ per day was begun. Cardiac MR an CT revealed the exact localisation of the cyst (Figure-II).

Figure 1

Figure 1: Echocardiographic imaging of the cyst.

Figure 2

Figure 2: MRI imaging of the cyst

The patient was prepared for the urgent cardiac operation by using a standart canulation technique. After the cross clamp was placed to the aorta and pulmonary artery, cristalloid cardioplegia was given and then the tapes of the vena cavas were squeezed. Right atriotomy was done. Two normal suction tip were placed in the right atrial base. Before opening the cyst a compression gauze that was soaked with NaCl 20% and was placed in the right ventricular cavity surrounding the cyst that was bulging through the right ventricular cavity. With a gentle surgical blade incision the calcificated pericystic layer was thinned. The cyst content was taken away completely with one aspiration using a large injection having a wide needle. After this aspiration a NaCl 20% solution was injected in to the cyst. 5 minutes later this solution was aspirated through the same place at one time. With a gentle cut, the incision line in pericystic layer was extended in a shape of a cross without harming the cyst pouch. The cyst pouch was taken out of its place using a Russian forceps. The cavity was washed out with NaCl 20% once again. The inferior leg of cross insicion was extented and was left open into the right ventricular area. After the operation Albendazol therapy was continued in itensive care unit. The patient was discharged from the hospital on the 5th postoperatif day with the same medical therapy. The Echinococcus hemagglutination test and antiechinococcus Ig M level were repeated every month after dischargement. At the 5th week the Echinococcus hemaglutination test was found negative twice so that the albendazol treatment was ceased. Due to the frequency of recurrances we planned to follow up the patient with echocardiographic and serological examinations every six months for the first year and yearly after the seccond year.

Discussion

Cardiac echinococcosus cysts are mostly symptomatic (₁). These symptoms include angina due to the pressure over the coronary artery, dyspnea and palpitation. In asyptomatic cases mortality rates are rather high due to acut anaphylactic reactions and cardiogenic shock following the perforation of the cyst (₁,₃). Asyptomatic cases can also come to light with directly peripheral embolus. Among the diagnostic methods total body computed tomography and especially cardiac MR are very important to plan the surgical strategies (₂,₃). Starting albendazol therapy right after the positive serological test result are obtained shortens the postoperative medical treatment period and prevents various organ involments. Removing cardiac echinococcous cysts is necessary to provide a complet recovery and to prevent recurrances.

Pulmonary embolus risk is very high during and after the operation especially for the cysts placed in the right cardiac chambers (₃). For this reason we prefer total cardiopulmonary by pass in which the cross clamps placed to the aorta and pulmonary artery. A compression gauze that was soaked with NaCl 20% and placed in right ventricular cavity to prevent contamination of the cardiac area with the cyst content. In many centers the pouch cavity is being washed out with iodine solution (₁,₂). We prefer NaCl solution for because it is cheap, easily found, less viscous and nontoxic.

We avoid to close the puoch cavity. The cysts that are located in the interventricular septum cause extensive weakness, edema and calcificiation in myocardium and therefore, while suturation of the cyst cavity, the needle can easily cause maceration, hemorrhage and VSD. Patch plasty technique is also used commonly in many center but we believe that the residual cavity can increase the risk of abscess formation. Patch plasty or suturation of the cavity will decrease cardiac performance by causing retraction in interventrucular section that detoriored the septal motility. In this patient one month after the operation the echocardiography revealed that the cyst cavity was closed. We believe that this was achieved with high left ventriculary pressure compression over interventricular septum.

As a conclusion, early diagnosis is important. Following the diagnosis the cyst must be removed from the heart without contaminating the operation area by an experienced surgeon, aiming maximum efectiveness and minimal harm.

Correspondence to

Nezihi KUCUKARSLAN, MD GATA Haydarpasa Egitim Hastanesi. Kardiyovaskuler Cerrahi Servisi. Selimiye Mah. Tibbiye Cad. 34670 Kadikoy /Istanbul/ TURKEY Tel: +00-90-(216) 542-2675 Fax: +00-90-(216) 348-7880 E-mail: nkucukarslan@hpasa.gata.edu.tr nezihimd@hotmail.com