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J Thorac Cardiovasc Surg 2009;137:e14-e16
© 2009 The American Association for Thoracic Surgery
Brief Communication |
Department of Cardiothoracic Surgery, Kasr El Aini Hospital, Cairo University, Cairo, Egypt
Received for publication April 2, 2008; accepted for publication April 16, 2008. * Address for reprints: T. Mohsen, MD, FRCS, Kasr El Aini Hospital, Cairo University Cardiothoracic Surgery, Villa 23 street 262 New Maadi, Cairo11431 Egypt. (Email: tmohsen_2000{at}yahoo.com).
Echinococcosis has a low endemicity in Egypt. However, in some governorates it presents a public health concern with an incidence ranging from 0.8 to 2.6 per 100,000.1
Cardiac infestation is very uncommon, accounting for 0.5% to 2% of all hydatid infestations.2 We present 2 cases of hydatid cysts of the interventricular septum in early childhood.
PATIENT 1. A 5-year-old boy had had progressive dyspnea over the past 4 months and easy fatigability. The results of routine examinations were within normal limits. Echocardiography revealed an interventricular cyst 2.1 x 2.3 cm.
PATIENT 2. A 4-year-old boy had palpitations and progressive dyspnea over the past 6 months, with two episodes of ventricular tachyarrhythmias. Results of routine examination and laboratory studies were within normal limits. Echocardiography revealed a large cyst, 3 x 3 cm, in the interventricular septum.
Magnetic resonant imaging, done for both patients. confirmed the diagnosis and showed concomitant hepatic infestation in the second patient (
Figure 1).
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Standard median sternotomy was used, with cardiopulmonary bypass and warm blood cardioplegic arrest. The interventricular septum was reached through the tricuspid valve. A bulge was noted in both cases near the outflow tract of the right ventricle. The cysts were first aspirated and the covering layer of the septal myocardium was dissected until the cysts' walls were reached. They could then be removed (
Figure 2). In the first patient a ventricular septal defect was created, and this was closed with a Dacron patch. In the second patient the remaining cavity was suture closed. Both patients had uneventful postoperative recoveries and were discharged on days 7 and 10 postoperatively. Three months later the second patient underwent laparotomy for removal of hepatic cysts.
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In this report, we present 2 particularly interesting cases of hydatid cyst of the interventricular septum at a rare age of presentation. Moreover, 1 of these patients had multivesicular cysts. Because the cyst takes 1 to 5 years to grow, the usual presentation of hydatid disease of the heart occurs at or over 20 years of age.3,4 Echinococcosis is a human parasitic disease most commonly caused by the larval stage of Echinococcus granulosus. As a rule, lung cysts and heart echinococcosis occur less often than hepatic cysts. The most frequent location in the heart is the ventricular myocardium.5 Cardiac echinococcal cysts rarely involve the interventricular septum. Presentation varies according to the location in the septum; therefore, compression involving the atrioventricular conduction pathway may lead to variable arrhythmias or obstruction to the ventricular outflow tract. However, the most dangerous complication is cyst perforation, which has a frequency between 25% and 40%. After cyst perforation, three quarters of the patients die of septic shock or embolic complications.
Diagnosis of cardiac hydatid cyst is simple, reliable, and sensitive when transthoracic echocardiography is used.5 However, computed tomographic scan and magnetic resonance imaging are complementary tools to rule out mutivesicular cysts.
In this report, we used standard median sternotomy with cardiopulmonary bypass. The septum was reached through the tricuspid valve, and initially the content was aspirated and a crystal rock fluid was obtained. Sterilization before enucleation with different agents has been mentioned in the literature. In this report, we did not use any sterilizing agent but depended on complete enucleation of the cyst; in 1 case, we had to create a ventricular septal defect to achieve this. Albendazole was routinely given for 6 months after the operation.
In conclusion, cardiac echinococcosis is a rare disease. We report 2 cases of cardiac echinococcosis in childhood, 1 of which was multivesicular. Follow-up extends for 9 years without recurrence.
References
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