|Year : 2016 | Volume
| Issue : 1 | Page : 58-60
Isolated myocardial hydatid cyst: Managed with total curative excision
Santosh Kumar Sinha, Dibbendhu Khanra, Shalini Garg, Mohammed Asif
LPS Institute of Cardiology, GSVM Medical College, Kanpur, Uttar Pradesh, India
|Date of Web Publication||26-May-2016|
LPS Institute of Cardiology, GSVM Medical College, Kanpur, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Hydatid disease is still prevalent in developing countries, and isolated cardiac hydatid cysts are the rarest presentation. We report a 40-year-old nondiabetic, nonhypertensive female who presented with low-grade fever for 2 months shortness of breath and orthopnea for 2 weeks. Transthoracic echocardiography revealed a large, round cystic lesion with multiple daughter cysts without any obvious intraluminal detached membranes with mass effect on the left ventricular outflow tract. After total excision, residual tissue was closed with Teflon patch. Germinative membrane and hundreds of daughter cysts were seen. Following total excision of the cyst from myocardium, myocardial cavity was washed thoroughly with 10% Betadine solution. Pathological examination confirmed the diagnosis of hydatid cyst. Preoperatively started albendazole was continued for 4 weeks even after the operation. On follow-up after 4 weeks, the patient is doing well and cardiac imaging showed normal contours of the heart.
Keywords: Computerized tomography, echocardiography, hydatid cyst, left ventricle
|How to cite this article:|
Sinha SK, Khanra D, Garg S, Asif M. Isolated myocardial hydatid cyst: Managed with total curative excision. J Pract Cardiovasc Sci 2016;2:58-60
|How to cite this URL:|
Sinha SK, Khanra D, Garg S, Asif M. Isolated myocardial hydatid cyst: Managed with total curative excision. J Pract Cardiovasc Sci [serial online] 2016 [cited 2019 Jul 22];2:58-60. Available from: http://www.j-pcs.org/text.asp?2016/2/1/58/182983
| Introduction|| |
Hydatid disease, caused by Echinococcusgranulosus, is still prevalent in developing countries, and isolated cardiac hydatid cyst is the rarest presentation involving 0.5–2% of the human population worldwide.
| Case Report|| |
We report a 40-year-old nondiabetic, nonhypertensive female who presented to cardiology outpatient department with low-grade fever for 2 months, non-exertional shortness of breath for 1 month, orthopnea for 2 weeks, and cough without expectoration for 10 days. There was no history of chest pain or pedal edema or any previous ischemic heart disease. On examination, the patient was febrile (oral temperature 101°F), and the apex beat was localized on the left sixth intercostal space 1 cm lateral to the midclavicular line. Rest of the clinical examination was unremarkable. Blood parameters were normal except an absolute eosinophil count of 1350 cells/dL. Electrocardiogram (ECG) and chest radiograph were within normal limits. Transthoracic echocardiography (TTE) revealed a large, round cystic lesion with multiple daughter cysts [Figure 1]a,[Figure 1]b,[Figure 1]c,[Figure 1]d without any obvious intraluminal detached membranes (WHO stage CE2, USG classification) with mass effect on the left ventricular (LV) outflow tract [Figure 1]a and [Figure 1]b without any valvular dysfunction. Color Doppler imaging confirmed the lack of blood flow within the cystic space [Figure 1]b and [Figure 1]d. There was neither evidence of significant LV outflow tract gradient nor any evidence of diastolic dysfunction either. Contrast-enhanced computed tomography (CECT) of the thorax revealed 5 cm × 6 cm cystic mass inside left ventricle [Figure 1]e,[Figure 1]f,[Figure 1]g, extending into left atrium (LA) (Gharbi Stage 3) with involvement of the terminal end of left pulmonary vein [Figure 1]g, small arrow], and compressing LV outflow tract [Figure 1]g, large arrow]. There were no other cysts in lungs or liver. Serologic test was positive for echinococcal infection. The differentials considered were myocardial aneurysm, congenital cyst, pleuropericardial cyst, myocardial abscess, cystic tumors such as myxomas or fibromas and pericardial hematomas. Albendazole was started on admission and surgery was planned. Median sternotomy and aorto-bicaval cannulation was performed. The cystic mass appeared to be limited in LV myocardium and also extending into LA. After total excision, residual tissue was closed with Teflon patch. Germinative membrane and hundreds of daughter cysts were seen. Following total excision of the cyst from myocardium, the myocardial cavity was washed thoroughly with 10% Betadine solution. Pathological examination confirmed the diagnosis of hydatid cyst both macroscopically and microscopically. Preoperatively started albendazole was continued for 4 weeks even after the operation. On follow-up after 4 weeks, the patient is doing well and cardiac imaging showed normal contours of the heart.
|Figure 1: Transthoracic echocardiography (a-d) and contrast-enhanced computerized tomography (e-g) showing large cystic structure in left ventricular causing outflow tract obstruction (large arrow, g) and extending into left atrium and terminal part of pulmonary vein (small arrow, g) (CYST = Cystic structure, LA = Left atrium, RA = Right atrium, LV = Left ventricle, RV = Right ventricle).|
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| Discussion|| |
According to Polat et al., 50–60% of the cardiac hydatid cysts are LV, 10–20% are septal (interventricular), 5–15% are localized to the right ventricle, 10–15% are pericardial, and 5–8% are left atrial in origin. The embryos reach right atrium from the intestine through the liver and azygos vein, access into the left ventricle and coronary arteries. Scolices may reach the heart by following the same way as mature hepatic cysts or via the rupture of a lung cyst into the pulmonary vein. Precordial pain is the one of the common symptoms and is most often vague and does not resemble angina pectoris. Clinical development depends on the size, location, and integrity of the cyst, but in some cases it is asymptomatic. There is no characteristic ECG change in cardiac hydatid but nonspecific repolarization changes, atrioventricular and intraventricular block, and complex premature ventricular contractions may be seen. Atypical presentations range from fever, hemoptysis, cough, anaphylactic shock, syncope, arrhythmia and conduction disturbances to acute myocardial infarction, precordial pain, valvular dysfunction, pulmonary hypertension, pulmonary and systemic embolism, hemiplegia, and loss of consciousness, even sudden cardiac death.
Rupture of cardiac hydatid cyst presenting with anaphylactic shock is one of the most dreaded complications reported in literature. Serology for Echinococcus has low sensitivity with false negative results up to 50%. TTE is widely used for diagnosis, as was used in this case, because of its availability, ease of use and high sensitivity in the diagnosis of intracardiac cysts. However, the signs of a hydatid cyst revealed by ultrasonography depend essentially on the stage of the disease without consideration of the affected organ. A detached membrane is the only diagnostic sign; partition of the cyst is only suggestive of the diagnosis. CECT of thorax is good to detect calcified cysts but may miss small lesions, and cardiac motion artifacts limit its diagnostic ability. In this case, the lesion was quite big and easily detected by CECT. Cardiac magnetic resonance imaging (MRI) provides more detailed information regarding location and extension but was not done in this case as the diagnosis was already stamped by eosinophilia, positive serology, suggestive TTE and CECT findings. The WHO recommends minimum 2 years or longer duration of antihelminthic treatment in all patients of cardiac hydatid cyst irrespective of symptoms. Surgery is often undertaken in symptomatic or hemodynamically unstable patients though associated with perioperative mortality up to 20%. Aspiration to be done without spillage and cystectomy to be performed without leaving no parts of membrane followed by washing of cavity with scolicidal agents such as 2% formalin, 0.5% silver nitrate solution, 30% hypertonic saline solution, 1% iodine solution, or 5% cetrimide solution.
In a tropical country like India, one should keep the diagnosis of cardiac hydatid in mind when a patient presents with vague cardiac symptoms irrespective of normal ECG and chest radiograph. TTE and cardiac CT or MRI will help to clinch the diagnosis and treatment is surgical along with long-term albendazole therapy.
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Conflicts of interest
There are no conflicts of interest.
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