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

Introduction

Altough hydatid cysts are usually seen in undeveloped Asian countries, it is also an important health problem in developed countries. Cardiac hydatid cysts are rarely seen (0.5-2.5%). Among cardiac cysts, pericardial localisation is mostly seen while cardiac septal localisation is rare (₁,₂). The cysts are seen in people especially unprotectively in touch with the dogs. As the scolexes arrive the myocard cyst formation begins. The symptoms develop as the cysts grow and they differ depending on their localisation.

Case Report

A 19 years old asymphtomatic 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 two dimentional echocardiography there was a cyst like lesion in interventricular septum with a diameter of 5.8 cm. and LVEF was measured as 66% (Figure-I).

Figure 1

Figure I: Echocardiographic imaging of the cyst

The existing lesion was towards the right ventricular area. With these findings Echinococcus hemaglutination test was carried out. Following the positive serological test result 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 2

Figure II: MRI imaging of the cyst

The patient was prepared for the urgent cardiac operation by using standart canulation technique. After the cross clamp was placed to the aorta and pulmonary artery, cristalloid cardioplegia was given and the tapes of vena cavas were squeezed. Right atriotomy was done. Two normal suction tip was placed in the right atrial base. Before opening the cyst a compression gauze that was soaked with NaCl 20% was placed in right ventricular cavity surroinding the cyst that was bulging through the right ventricular cavity with a gentle surgical blade incision. The calcificated pericystic layer was thinnered. 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. Five minutes later this solution was aspirated through the same place at one time. With a gentle cut an incision line of pericystic layer was extended in a shape of 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 postoperative 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 echinococcus cysts are mostly symptomatic (₁). These symptoms include angina that is because of the pressure over the coronary artery, dyspnea, and palpitation. In asyptomatic cases mortality rates are rather high due to acute 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). Right after the positive serological test result, starting albendazol therapy shortens the postoperative medical treatment period and prevents various organ involments. While taking out cardiac echinococcous cyst to provide a complet recovery and to prevent recurrances surgical intervention is necessary for the extra cardiac echinococcus cysts that are revealed by total body computed tomography.

Pulmonary embolus risk is very high during and after the operation especially for the cysts placed in the right cardiac chambers (₃). To avoid pulmonary artery embolus we prefer total cardiopulmonary by pass in which the cross clamp is placed to the aorta and also pulmonary artery. Before opening the cyst a compression gauze that was soaked with NaCl 20% was placed in right ventricular cavity to prevent contamination of the cardiac area with the cyst content. In many centers to maintain this protection after cystectomy 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 pouch cavity. The cysts that are placed in interventricular septum cause extensive weakness, edema and calcificiation in myocardium. 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 suture of the cavity will decrease cardiac performance by causing retraction in interventrucular section hindering septal motility. In this patient, one month after the operation the echocardiography revealed that the cyst cavity was closed. We believe that this conclution is achieved with high left ventriculary pressure compressing 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