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cardiac and pulmonary echino

One-Stage Surgical Treatment
of Cardiac and Pulmonary Echinococcosis
Alejandro Aris, M.D., Carlos Leon, M.D., Jose 0. Bonnin, M.D.,
Constantino Serra, M.D., and Jose M. Caralps, M.D.
Q waves and negative T waves in leads I and
aVL, suggestive of myocardial necrosis of the
high lateral wall (Fig 2).
Laboratory tests were essentially normal except for mild eosinophilia and a positive serological test for hydatid cyst (latex agglutination test). The echocardiogram indicated the
presence of a mass near the base of the aorta.
The patient underwent cardiac catheterizaCardiac echinococcosis represents an infre- tion. Left ventricular end-diastolic pressure was
quent complication of hydatid disease but its 18 mm Hg. Left ventriculogram showed hyeffects can be devastating if not treated aggres- pokinesia of the lateral wall. Coronary artesively. The purpose of this article is to report riogram revealed no obstructing lesions but
the case of a young woman with previously the two branches of the left coronary artery
treated hepatic echinococcosis in whom pul- were displaced by a mass, which created a
monary and cardiac hydatid cysts developed. "cold zone" between them (Fig 3).
The patient underwent successful surgical reThe diagnosis of left ventricular hydatid cyst
moval of the cysts in a one-stage operation with and left lower lobe hydatid cysts was made, and
cardiopulmonary bypass.
the patient underwent operation. The chest was
entered through a transsternal bilateral thoraA 26-year-old woman was admitted to another cotomy, which provided ample exposure of the
hospital because of shortness of breath and car- heart and both pleural cavities. While the aorta
diac palpitations following mild exercise. The and venae cavae were being cannulated for carepisode was diagnosed as supraventricular diopulmonary bypass, a rapid supraventricular
tachycardia and was treated by electric counter- tachycardia developed. Once the patient was on
shock, which was successful. Pertinent past the pump, the pericardium was freed from the
history included two abdominal operations be- lateral, upper aspect of the left ventricle where
cause of hepatic hydatid cysts, 15 and 7 months an egg-sized mass, covered by some myocardial
previously. A routine chest roentgenogram was fibers, was bulging.
The cyst was punctured, and its contents
found to be abnormal. The diagnosis of cardiac
and pulmonary echinococcosis was suggested, were aspirated with a syringe. A creamy yellow
and the patient was transferred to our hospital material was obtained. Then the operative field
for further workup and therapy. Chest roent- was covered with gauze pads moistened with
genogram made at admission (Fig 1)revealed a 3% saline solution. The cyst was opened, and
mass at the left heart border as well as a solitary a large number of ruptured membranes of
bilocular nodule at the posterior aspect of the daughter cysts were removed. The cavity was
left lower lobe. The electrocardiogram showed emptied, and most of the fibrous pericyst was
excised. The deepest part was left untouched
From the Cardiac and Thoracic Surgery Units, Hospital de since there was only a thin layer of myocardium
la Santa Cruz y San Pablo, Barcelona, Spain.
between it and the left ventricular cavity. The
Accepted for publication June 10, 1980.
heart was defibrillated, and while the patient
Address reprint requests to Dr. Aris, Chief, Cardiac Sur- was still on the pump, the entire left lung was
gery Unit, Hospital de la Santa Cruz y San Pablo, Avda S.
retracted medially. A bilocular mass was idenAntonio M. Claret 167, Barcelona 25, Spain.
ABSTRACT The case of a 26-year-old woman with
cardiac and pulmonary echinococcosis is presented.
Surgical treatment of the intrathoracic disease was
done in a one-stage operation. Under cardiopulmonary bypass, a left ventricular hydatid cyst and a
lower lobe pulmonary cyst were removed. The patient is completely asymptomatic and is leading a
normal life two years after operation.
564 OOO3-4975/81/060564-05$01.25
@ 1980 by The Society of Thoracic Surgeons
565 Case Report: Aris et al: Cardiac and Pulmonary Echinococcosis
Fig 1. (A) Posteroanterior chest roentgenogram shows a
mass at the left heart border and a nodule at the left
lung field. (B)Lateral v i e w shows this nodule located
posteriorly (arrow).
tified in the lower lobe and excised en bloc.
Following the cystectomy, capitonnage of the
residual cavity with interrupted sutures of absorbable material was performed. Cardiopulmonary bypass was discontinued and after
careful hemostasis, the chest was closed. The
patient made an uneventful recovery and was
discharged on the tenth postoperative day.
Follow-up at regular intervals reveals that she
has not had any further arrhythmias and is
leading a normal, active life.
Pathological examination of both specimens
Fig 2 . Electrocardiogram shows Q waves and negative T
w a v e s in leads 1 and aVL, which suggest necrosis of the
high lateral wall.
aV L
566 The Annals of Thoracic Surgery Vol 31 No 6 June 1981
Fig 3 . Left c o r o n a y arteriogram in left anterior oblique
projection. The left anterior descending corona y a r t e y
is displaced upward and the circumflex corona y arte y ,
posteriorly. There is an avascular zone in between
was consistent with hydatid cyst. Necrotic material was found in both cavities but no scolices
were seen.
occurred in our patient, in whom hepatic, pulmonary, and cardiac hydatid cysts developed in
the short interval of 15 months.
The fate of a cardiac echinococcal cyst is usually rupture, either in the pericardial cavity [21,
221 or in a cardiac chamber (38% of the cases
according to Di Bello and Menendez [7]). When
the latter occurs, death of the patient by
anaphylactic shock or massive embolization to
different organs [ll, 22-24] can ensue.
Cardiac hydatid cysts rupture more frequently than do hydatid cysts in other organs,
probably because of the constant motion. Also,
rupture in the right ventricle is more frequent
than in the left (88% versus 33%) [71 because of
the thicker wall and higher pressure in the latter. Other events in the life of a cyst include
rupture inside the adventitia with formation of
daughter cysts, and interference with the conduction system of the heart, thereby inducing
arrhythmias [25]. Both were found in our patient.
Diagnosis of cardiac hydatid disease is difficult, especially in the early stages. Roentgenographic findings can be consistent with
an aneurysm 15, 261. Although several changes
in the electrocardiogram are said to be characteristic of cardiac echinococcosis [2, 8, 141 and
helpful in distinguishing it from ventricular
aneurysm, our patient showed Q waves in
some leads, indicating myocardial necrosis,
an unusual feature in cardiac hydatid disease.
Echocardiography has proved a valuable diagnostic test in detecting the location of possible
cardiac cysts [18], as it did in our patient.
Cardiac catheterization with cineangiography is the most reliable test for an accurate
diagnosis. Coronary angiography also should
be performed since coronary compression by a
growing cyst has been reported [17].In our patient, the lumen of the arteries was patent but
the cyst had displaced the two branches of the
left coronary artery, thereby creating an avascular zone between them. This angiographic
finding was described in 1976 [271 and 1979
Different reports [l-31 estimate that 0.5 to 2% of
all cases of hydatid cysts involve the heart. Most
of the cases occur in countries where the disease is endemic-Uruguay [l,4-81, Argentina
191, Iran [lo, 111, Greece [12,131, Israel [14,151,
and Spain. In the last named, more than 20
cases have been reported, most of them by surgical teams [16-201.
Implantation of the hexacanth embryo in the
myocardium usually occurs after the embryo
has passed the pulmonary capillary network
and has reached the heart by way of the coronary circulation. This explains the higher incidence of echinococcal cysts in the left ventricle
and ventricular septum, which have the richest
blood supply. Before it reaches the heart, the
embryo of the Echinococcus grunulosus has filtered through the sinusoids of the liver (the 1201.
Cardiac echinococcosis should be treated
most commonly involved organ) and the pulmonary circulation. The embryo may be im- surgically as soon as the diagnosis is estabplanted in these organs, developing an hydatid lished because of the fatal complications that
(or echinoccocal) cyst. This sequence of events can occur. Intervention involves the removal of
567 Case Report: Aris et al: Cardiac and Pulmonary Echinococcosis
the cyst (or cysts), including the adventitia.
Our patient has recovered completely and is
Needle aspiration prior to the surgical excision free from hepatic, pulmonary, and cardiac
is advisable and if clear liquid is obtained, the echinococcosis two years following the incyst should be injected with a sterilizing solu- trathoracic procedure.
tion (hypertonic saline, ether, formaldehyde)
before it is opened.
Although most of the reported patients with References
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