An asymptomatic huge calcified intramyocardial hydatid cyst: a case report | |
DOI: 10.5606/e-cvsi.2015.299 | |
Mehmet Beşir Akpınar, Veysel Şahin, Serkan Seçici, İhsan Sami Uyar, Mehmet Ateş | |
Department of Cardiovascular Surgery, Medical Faculty of Şifa University, İzmir, Turkey | |
Keywords: Cardiac hydatid cyst; echinococcosis; myocardial calcification | |
Hydatid cyst disease is rarely asymptomatic depending on its location. A 37-year-old man presented asymptomatically and was diagnosed
with a hydatid cyst incidentally during regular check-up. Echocardiography and cardiac magnetic resonance angiography images
demonstrated a calcified solid cystic lesion (90x60 mm) on the apicoposterolateral region of the left ventricle. The cyst was localized inside
the myocardial fibers. The left ventricular cavity size was reduced due to the bulging of the mass. The cyst was evacuated with open heart
surgery and the large calcified cavity was closed carefully. |
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Hydatid cyst is an endemic infestation disease in
various regions in the world. Echinococcus granulosus,
the causative agent of cystic hydatid disease, usually
(60-70%) reaches the liver via intestinal veins or
lymphatics. If embryos bypass the liver and the lung,
they reach the systemic circulation and may affect any
organ of the body. Cardiac involvement, which is rare,
is between 0.02% and 2% of all hydatid diseases.[1,2] The embryos can reach the myocardium via coronary circulation from the left side of the heart. The most common location of cardiac hydatid cysts are the left ventricle, interventricular septum, and right ventricle.[3-5] Cardiac symptoms (mostly chest pain, shoulder pain, dyspnea, and persistent cough) usually depend on the localization and size of the cyst. The cyst may also grow between cardiac fibers without causing any symptoms. If it reaches a reasonable size, fever, palpitation, arrhythmias, and heart failure may develop. The most critical complication of a cardiac cyst is perforation with a high incidence ranging between 25% and 40%.[6] After perforation of the cyst, 75% of patients die from septic shock or embolic complications.[6] |
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CASE PRESANTATION
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A 37-year-old man presented with cardiac murmur
without any clinical sign. He was asymptomatic with
a non-specific medical history. Physical examination
revealed 3/6 systolic murmur at the second right
intercostal parasternal space. Transthoracic echocardiographic examination revealed that an intramyocardial mass involved the inferior, posterior, and free lateral walls of the left ventricle, and severe inferoposterolateral myocardial hypertrophy. The nature of the mass was solid and there were necrotic tissues inside the mass. The left ventricular end-systolic and end-diastolic diameters were reduced. The rest of the echocardiographic variables were unremarkable.
Teleradiography showed an enlarged mediastinum
and displaced cardiac apex superiorly and to the left
side of the chest. Chest X-ray also revealed a calcified
myocardial mass in the apical part of the heart (Figure 1).
A smooth-surfaced calcified cystic mass of 90x60 mm at
the left ventricular lateral wall was also seen on cardiac
magnetic resonance angiography. The mass was localized
inside the myocardial fibers. There was no contrast
intake inside the mass; the left ventricular volume was
severely decreased due to bulging of the mass (Figure
Figure 2: Cardiac magnetic resonance angiography image of
the mass (two headed arrows).
There was also an 18 mm diameter calcified cystic
mass in the liver. No other cyst was detected in the
body of the patient. His blood serology test results
were negative. Based on these findings, the patient
underwent open heart surgery.
The operation was performed through median
sternotomy. Cardiopulmonary bypass through the
aorto-bicaval cannulation was instituted. Cardiac
arrest was induced by administration of intermittent
cold blood cardioplegia. Systemic and topical cooling
with cold saline slush were also performed. The mass
was located at the apicoposterolateral wall of the heart.
The cyst was opened by performing an incision into
the apical region of the heart. 300 mL gel consistency,
white necrotic tissue, and germinative membrane
were evacuated. Samples were taken for pathological
examination and culture inoculation. The cavity
was washed thoroughly with 20% hypertonic saline
solution and a 1% iodine solution. There was no communication with the ventricular cavity. A crater
90 mm in diameter was formed due to the calcified
nature of the wall of the cavity (Figure
Figure 3: The crater of the huge cyst. The cyst was not
connected with the left ventricular cavity.
Figure 4: Postoperative X-ray. The calcified border of the
cyst can be seen (arrow).
Gross and microscopic pathological examination
confirmed the diagnosis of germinative membrane.
Preoperative albendazole treatment (10 mg/kg/day)
was continued for four weeks after surgery. |
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Cardiac hydatid cysts are often asymptomatic in the
early stages. Our case had a 90x60 mm intramyocardial
cyst and was surprisingly asymptomatic and diagnosed
incidentally during the check-up. During surgery,
we observed that the cyst was localized between the
myocardial fibers and half of the left ventricular wall
was pushed to the free edges of the mass. Ideally, an echinococcal cyst should be aspirated, evacuated, and germinative membrane should be removed. Then, the remaining capsule can be closed with capitonnage technique.[5] However, in our case, the cyst was not alive; it did not contain any fluid inside the cyst. The content of the globe was necrotic, like a gel consistency. The borders of the globe were calcified. The wide base of the cyst was consisted from a tiny wall of the left ventricle. Removing of this calcified wall would severely reduce the ventricle volume due to the huge volume of the cyst. The cavity was not able to be closed with capitonnage technique (Figure 3). As a result, we filled the cavity with pieces of absorbable gelatin sponge to support cardiac geometry and reduce the risk of rupture from the base of the cavity. The patient recovered uneventfully and is still under follow-up. |
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During surgical excision of a huge, calcified,
intramyocardial cardiac cyst hydatid with a wide
base, left ventricular muscle mass should be preserved
to avoid irreversible intraoperative left ventricular
dysfunction. Therefore, the cavity of cyst after
evacuation can be filled with gelatin sponge instead of
excision to support left ventricular free wall.
Acknowledgements
Declaration of conflicting interests
Funding |
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