Diagnosis and Management of Cardiac Hydatid Cyst:

Tiirk Kardiyol Dem Arş 2000; 28: 131-133

CASEREPORT

Role of Transesophageal Echocardiography in

Diagnosis and Management of Cardiac Hydatid Cyst:

Report of two cases and review of the literature

Uz. Dr. Tufan TÜKEK, Uz. Dr. ŞerefDEMİREL, Prof. Dr. Dursun ATILGAN, Prof. Dr. Ertan ONURSAL*, Prof. Dr. Ferruh KORKUT

Cardiovascular Disease Resem·ch Center, *Department ofCardiothoracic Surgery, Istanbul Medical Faculty Istanbul, Turkey

KARDiAK

KİST

H

İDATİK

TANI VE TEDAVi- SiNDE TRANSÖZOFAGEAL EKOKARDiYO-

GRAFiNİN ÖNEMİ: İKİ

VAKA NEDENi

İLE

LiTERATÜRÜN GÖZDEN

GEÇİRİLMESİ

ÖZET

Burada nadir göriilen 2 kardiak kist hidatik olgusu sunulmakra, transözofajiyal ekokardiyof;raf inin (TEE) tam ve tedavideki ro/ii

tartıştlnıaktadtr.

Ilk vakada,

sağ

atrial kist hidatik operasyonu Strasmda TEE yardmu ile vena kavalann kaniile edilmesi ve kistin cerrahi olarak çtkan/mast bildirildi.

İkinci

vakada,

aralamıda

TEE' nin de

bulunduğu de{:işik göriintiilenıe

yöntemleri ile

değerlendirilen,

çok saytda dejeneratif perikardial kist

hidatiği

olan bir hasta sunuldu. Sonuç olarak, TEE kardiak kist hidatik tant ve cerrahi tedavisinde kullamlan fayda!t bir yömemdir.

Anahtar kelime/er: K ard

i

yak ki st ltidatik, transözofajiyal ekokardiyogra fi

Cardiac hydatid cyst is rare, and the most common involveme nts are left ventricular wall and septum

(ıl.

Surgical exeisi on is the treatment of c hoice for cardiac hydatid cyst because of its possible fatal complications

(2).

A lthough the diagnostic value of transthoracic echocardiography (TTE) is we ll established, there are very few reports of the use of transesophageal echocardiography (TEE) as an aid to d iagnosis and/or treatment

(3-5).

In this report, we present 2 unus ual cases of ca rdiac hydatid cyst and d iscuss the role o f TEE in th e diagnosis and treatm ent.

REPORT of CASES

Case

ı.

A 26-year-old woma n w ith history of hydatid cyst in the liver was acimineel for palpitation and dyspnea on

Alındığı tarih: 4 Ekim, revizyon 24 Ekim 1999 . ..

Address for correspondence: Tufan Tükek, MD, Istanbul Univer- sitesi, İstanbul Tıp Fakültesi Kalp Damar Araştınna

ve

Uygulama Merkezi

Tlf: (O 212) 534 00 00-17 68 Faks:+ (0 212) 534 09 34

mild exertion. The ca rdiac findings, ECG and chest fil m were unremarkable. It was de monstrated with TTE a large, single, trabecu

latecl hyclati

cl cyst (5 x 4.5 cm)

in

the rig

ht

atrium (Fig.

1

a).

In orcler

to rule out the presence of the smaller cysts in the heart anel g reat blood vessels anel to ele te rmine the re lationship between the cyst and cardiac structures, TEE with omniplane probe was performed. The cyst was located o

n

the right atrial free wall , causing no obstruction to superior or inferior vena c avae and to the tricuspid valve. No other ey st was detected in the heart and great blood vessels, and interatria

l septum was also intacı

(Fig.

1

b). Du e to concerns for cyst pe rforat ion during cannulation of right atrium a nd during cys t expos ure, surgical treatment u nder TEE guidance was recommended.

The cannulation was done from superior and inferior vena cavae. The cyst, which included many daughter cysts, was exposeel under TEE guidance with atrial inc ision anel was totally removeel together with a part of the right atrial free wall because of its tig ht attachment. Rcconstruction was

nıacle

using parietal per icardium. TEE was repeated be fore closure of the

tlıorax

to rule out resicl ual cysts (Fi g.

l e). The patient was dischargeel with albendazole the rapy a week later. At her

1.5

years fo llow-up she was doing well.

Case 2. A 5 !-year-old

wonıan

was adm

itteel w ith elyspnca

on milcl exertion, a nd abdom ina l discomfort. She had undergone surgery for pericardia

l hydatid cyst 6 years ago.

On physical examination, prominent edema of the le gs and large ascites we re no ticeel. Jugula

r

veins werc distenclecl to 6 cm at 45 clegrccs, and thcre were rales at both lowcr lung fie lds. The ECG revealed atrial fibrillation, anel c hcst roentgenogram displayed an enlargecl carcliac si lhouette.

Because of her poor echogenicity, we were not able to

nıake

an aclequate TTE

exanıination.

Transesophagea l echocarcliography ele mo nstrateel a si

ngle pericardial

cyst

( 1.5

x

1.5

cm) at the a pex that protruded int o the interventricular septum and four-chamber d ilatation with moclerate left ventricular dysfunction (Fig. 2). Computeel

tonıograplıy

(CT) only

confirnıcd

the TEE findings (Fig.

3a). Aelditionally , magnetic resonance imaging (MR I) revealcd multiple clegenerativc pericardial cysts locatcd in the diaphragmatic anel apical regions of the heart (Fig. 3b).

Ncither CT nor MRI d isplaycd

anotlıer

organ

iııvolvemcnt.

Wc belie ved that the patient was not a surgical candieiate and dicl not undergo surgery. The paticnt was treatecl medically

witlı

digoxin, furoscm ide, aldactone , and albendazole, and ACE inh ibitor.

131

Tiirk Kardiyol Dem Arş 2000:28: 131-133

a b c

Fig I. a) Transthoracic echocardiographic apical four-chambcr view of the heart (case 1) shows the hydatid cyst in the right atrium. HC = hydatid cyst; LA = lcft atrium; LV = lcft vcntricle; RA = right atrium; RV = right ventriclc. b) Preopenıtivc transesophagcal cchocardiogram showing the cyst in the right atrium (case 1). HC = hydatid cyst;LA = Jcft atrium; RA= right atrium; RV = right ventriclc;

TV = tricuspid valve. c) lntraoperative transesophageal echocardiogranı after removal of the ey st, but just be fo re closure of the chesı (case 1 ). AO = aorı: LA= Jcfı atrium: LV= left ventricle: RA = right atrium: RV = right venıricle.

Fig 2. Transcsophageal echocardiogram (casc 2) slıows the singlc pericardial hyadatid cyst. ; HC = lıydatid cyst: LA = Jeft atrium:

LV= Jeft ventricle; RA= righı atrium; RV = riglıt venıriclc.

DISCUSSION

Cardiac in volvem ent of hydatid cyst is rare and usually occ urs in

1%

of patients inf ested with Echinococcus Granulosus. The most

comınan

location of the cardiac hydatid cyst are the left ventricul ar free w all (52% ), inte rventricular septum ( 42% ), and less freq uently the right ventricle (3 1% ), pericardium (10%) , or the a trium

(1,6).

In a review of the lite rature, we we re able to find 9 cases of right atrial hydatid cyst

(4,7-14).

Four (45%) of the cases died of mass ive

pulnıonary

hyda tid

eınbolism,

one 3

nıonths

a fter s urgery, 2 others before operation. The case of Kardaras e t al.

(ll)

died of massive pulmonary

eınbolisın

due to rupture of the fragile cyst during cannulation fo r total cardiopulmonary bypass. Due to these reports it

132

was thought bes t for the patients to be assessed for obstruction of superior and inferior vena cavae with TEE a nd the cannulation a nd cyst exposure monitored during surgery. In o ur first patient, the cys t was s uccess fully

reınoved

unde r the TEE guidance, and no compl ication did occur.

Although C T and MRI provide valuabl e information , TTE has been accepted to be the

iınaging

procedu re of choice for the diagnosis of cardiac hydatid cyst, but the diagnostic valu e ofTEE in this entity is not known. To our knowledge, there are o nly 3 cases of cardiac hyda tid cys t in the

literatuı·e

in which TEE has been used in the d iagnos is or surgical

nıanagenıent.

The first casc, reported by Urbanyl et al.

(3),

was a cyst localized at the interventricular septum and perfo rated into the pericardium. The second case, re ported by Ambrosi e t al.

(4),

w as a cyst in the inferior vena ca va, which mimicked a ca rdi ac thrombus with ri ght atri al exte ns ion. The third report detailed a case of a large s ingle hydatid cyst in the left ventricle in which an adequate paras terna l s ho rt-ax is view was not possible to obtain during TTE, and the cystic

involveınent

of the a nterolatera l papill ary

ınuscle

was only demonstrated in transgastric view duri ng the TEE examinatio n

(5).

It was previously re ported th at pericard ial hydatid cyst can induce myocardial dys functio n and present as right s ided heart failure !ike our second case

(15).

Alt hough TEE and compu ted

toınography denıonstrated

a typ ica l cys tic image in the

T. Tiikek er al.: Role ofTransesoplıageal Eclıocardiograplıy in Diagnosis and Manageme/1{ of Cardiac Hydatid Cyst:

Report of two ca ses and reı•iew of tlıe literature

Fig 3. Computeel tomographic axial image (case 2). Arrow points to the cyst. and spin-echo magııetic resonance imaging, coronal seetion (case 2). Arrows show the multiple degenerative pericardial cysts.

peri cardium in

ıhe

seco nd case, the m ul tiple degenerative cysts were on ly noticedon M RI.

The cardiac hydatid cyst, w hich is rare but usua lly

associaıed

w ith fatal complica tions, can be diagnosed by several imagi ng modalities.

Alıhough tlıere

are limited

mımber

of reports, we

ılıink

that TEE is helpful for

boıh

the diagnosis and successful s urg ical treatment. Magne tic resonance imaging may also provide addiri onal information that can not be obtained on the TEE examination.

REFERENCES

1. Bashour TT, Alali ARK, Mason DT, Saalouke M:

Ec hin ococco s is o f th e heart: elinical and

eclıocardiographic

features in 19 patients. Am

Hearı 1

ı

996;

ı

32:

ı

028-30

2. Perez-Gomez F, Duran H, Tamames S, Perotte JL, lllaner A: Cardiac echinococcosis. C linical picture and

conıplications.

Br Heart J 1 973;35: 1326-31

3. Urbanyl B, Rieckmann C, Hellberg K, Krakau M, Liebau G, Mayer A, et al: Myocardia l echinococcos is with pcrforation into the pericarclium. J Carcliovasc Surg

ı

99

ı

;32:534-8

4. Amb

rosi

P, Mesena T, Habib G , Boulain L, Lambert M, Simeoni JB , et al: Right

inıra-

atrial cxtcnsion of hydatid cyst

nıimicking

carcliac

tlıroınbosis

(in

Frenclı]. Arclı

Mal Coeur Vaiss 1992;85:909-1 2 S. Atilgan D, Demirel S, Akkaya V, Korkut F: Left ventricular

lıydatid

cyst: an unusual l ocation of

Eclıinococcus

Granulo sus

witlı

multipl e orga n

involvcıııcnt.

J Am Soc

Eclıocardiogr

1996;9:212-5 6. O liver JM, Sotillo JF,

Doıninguez

FJ, de Sa EL, C alvo L, Salvador A, et a

l:

T wo-climcnsional echocardiographic feat ures of echinococcus of the

lıeart

and

greaı

blood vessels: elinical and surgical

inıplications.

Circu lation 1 988;78:327-37

7. M

iralles A, Bracaınonte

L, Pavie A, Bors V, Rabago G, Gandjibakhch I , e t al: Cardiac

eclıinococcosis.

Surgical treatment and results. J

Tlıorac

Cardiovasc Surg 1 994;

ı

07:1 84-90

8. G ilsa nz V,

Caınpo

C , C ue R, Estella J , Estrada RV, Perez-Oteiza C, et al: Recurrent pulmona ry emboli sm due to

lıydatid

cyst o f

lıeart.

Study of 3 cases, one with

internıittent

tricuspid val ve

obstnıction

(atrial

pseudonıyxoma).

Br Heart J 1 977;39:553-8

9. De Castro S, Santilli M,

Brandiınarte

C, Gualdi G, Migliau G: Ro le of non invasive diagnosis in cardiac echinococcosis:

pulınonary

embol ization from right atrial localization [in h al ian]. Cardiologia 1 991 ;36:8 17-21 10. Rey M, Alfonso F, Torrecilla EG, Mc Kenna WJ , Balaguer J , Alvarez L, et al: Diagnostic value of two- dimensional echocardiography in carcliac hydatid d

isease.

EurHeartJ 1 99 1 ;12:1300-7

ll. Karelaras F, Kardara D, Tselikos D, Tsoukas A, Exadactylos N, Anagnostopou

lou M,

et al: Fifteen year surveillance of echinococcal

hearı

disease from a referral hospital in G reece. E ur Heart J 1 996; 1 7: 1 265-70

12. Ege E, Soysal O, Gulculer M,

Ozdeınir

H, Pac M:

Carcliac hyclatid cyst causing

ınassive

pul monary emboli sm. Thorac Cardiovasc Surg 1 997;45:249-50 13. Jeridi G, Boughzala E, Hajri S, Hediji A,

Aınmar

H: Complicated hydatid cyst of the right atrium

siınulating nıyxonıa

of the tricuspid valve (in French]. Ann Cardiol Angeiol 1 997;46:

ı59-62

14. Kabhani SS, Jokhadar M, Sundouk A, Nabhani F, Baba B, Shafik Al

:

Surgical

ınanagemen ı

of cardiac

eclıinococcosis.

Report of four cases. J Card

iovasc Su

rg

ı

992;33:505- 1 o

IS. Al Naaman YD,

AI-Oıneri

MM: Card io-pericardial echinococcosis causing myocardial insufficiency, right- sided hea rt failure and constrictivc pericarclitis. Report of four cascs and review of t he

litcraıurc. 1 Cardiovasc Surg

ı

970; ll :303-9

133