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A Hydatid Cyst of the Interventricular Septum Diagnosed Incidentally by Multislice Computed Tomography
Case Reports
347 CASE REPORTS
Heart, Lung and Circulation 2008;17:330–351
A Hydatid Cyst of the Interventricular Septum Diagnosed Incidentally by Multislice Computed Tomography M. Timur Selcuk, MD a,∗ , Hatice Selcuk, MD a , Omac Tufekcioglu, MD a , Kazim Baser, MD a , Nilgun Isiksalan Ozbulbul, MD b , Levent Birincioglu, MD c and Sule Korkmaz, MD a a
Department of Cardiology, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey Department of Radiology, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey b
c
Cardiac involvement of the hydatid disease is uncommon. In this report a case of 54-year-old patient with a hydatid cyst in the interventricular septum was presented. The cyst was detected incidentally by cardiac multislice computed tomography and transthoracic echocardiographic appearances of the cyst raised the suspicion of cardiac echinococcosis. The patient was referred to surgery immediately for the removal of the cyst in order to prevent the potentially life threatening complications. The postoperative period was uneventful and she was discharged on albendazole therapy. (Heart, Lung and Circulation 2008;17:330–351) © 2007 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved. Keywords. Cardiac cyst; Hydatid cyst; Computed tomography
Introduction
C
ystic hydatid disease is a parasitic infection caused by echinococcus granulosus which is still endemic in sheep- raising countries.1 Although the liver (55–70%) and lung (20–30%) are the most common sites for cyst formation, the incidence of cardiac involvement is very low with a ratio of 0.02–2% of all hydatid infestations.2 Here we report a case of hydatid cyst localised in the interventricular septum (IVS) that was presented with angina and detected incidentally by cardiac multislice computed tomography (MSCT).
Case Report A 54-year-old woman admitted to our institution with the complaints of chest pain and dyspnea on exertion. Clinical examination was unremarkable except for a 1/6 grade systolic murmur at apex. Electrocardiography and chest roentgenogram did not show any pathological finding. Coronary angiography was planned in view of the clinical suspicion of coronary artery disease. As she had refused to undergo an invasive procedure, a cardiac multislice computed tomography (MSCT) was performed. Coronary Received 2 September 2006; received in revised form 27 October 2006; accepted 30 December 2006; available online 1 March 2007 ∗
Corresponding author at: Ayvali M. 5.C. 92.S. No: 2/8, 06020 Ankara, Turkey. Tel.: +90 3123316570; fax: +90 3123316570. E-mail address: [email protected] (M.T. Selcuk).
arteries were found to be normal and a cystic like structure 5.1 cm × 3.9 cm × 3.8 cm in size was detected in the IVS on cardiac MSCT (Fig. 1). A subsequent transthoracic echocardiography (TTE) revealed a round shaped, multicystic lesion in the IVS protruding into both of the ventricles without creating a pressure gradient. It was consisting of an internal (germinal) and an outer (cuticula) layer suggesting a hydatid cyst (Fig. 2). The patient was started on albendazole and referred to surgery for the resection of the cyst. She was operated on under cardiopulmonary bypass and cardioplegia. By transaortic approach, cyst content was aspired, irrigated with hypertonic saline solution and then removed (Fig. 3). Her postoperative period was uneventful and she was discharged without symptoms.
Discussion Cardiac cyst hydatid is an uncommon form of the echinococcal disease. The cysts tend to occur most commonly at the left ventricular free wall because of its thickness and rich blood supply.3 The IVS is the next more frequent site of cyst involvement, followed by the atria, right ventricle and pericardium.4 The presenting symptoms of the cardiac hydatid cysts depend on the location, size and the complications of the cyst. Although most of the patients with cardiac involvement remain asymptomatic, a patient with a cardiac hydatid cyst may present with a variety of symptoms such
© 2007 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved.
1443-9506/04/$30.00 doi:10.1016/j.hlc.2006.12.011
348
Case Reports
CASE REPORTS
Heart, Lung and Circulation 2008;17:330–351
Figure 1. Three-dimensional-volume rendering technique of a retrospective electrocardiography gated multislice computed tomography shows a cystic mass in the interventricular septum. It appeared to be situated just below the aortic root and extended to the base of the heart. LA, indicates left atrium; RA, right atrium; RV, right ventricle; LV, left ventricle; Ao, aorta; C, cyst.
Figure 2. An apical four chamber view of the cyst (left side) located in the interventricular septum protruding into both of the ventricles. A subcostal echocardiographic image of the cyst (right side) showing the internal (germinal) and outer (cuticula) layers. LA, indicates left atrium; RA, right atrium; RV, right ventricle; LV, left ventricle; C, cyst.
Figure 3. Multiple hydatid cysts removed on surgery.
as angina, arrhythmias, valvular dysfunction or pericardial reaction.5 The rupture of a hydatid cyst may result in serious complications including cardiac tamponade, systemic and pulmonary embolism, anaphylactic shock or sudden death.4 A fluid- filled mass with a well defined outer wall and initial septations are the typical appearances of a hydatid cyst on transthoracic echocardiography.6 Nevertheless, computed tomography and magnetic resonance examinations can be helpful for the identification of the cystic structures and their relation with surrounding cardiac and non-cardiac structures.7 In the present case, cyst located in IVS resulted in angina probably due to the compression of the coronary arteries and a cardiac cyst was diagnosed during the evaluation of coronary artery disease. As the diagnosis of cardiac echinococcosis is usually difficult because of the variable and non-specific presenting symptoms, a cardiac cyst in a patient from an endemic or sheep forming area should raise the suspicion of cardiac echinococcosis. Owing to the potentially life threatening consequences, patients with
cardiac echinococcosis should be diagnosed and undergo surgery without delay.
References 1. Miralles A, Bracamonte L, Pavie A, Bors V, Rabago G, Gandjbakhch I, Cabrol C. Cardiac echinococcosis. Surgical treatment and results. J Thorac Cardiovasc Surg 1994;107:184–90. 2. Alehan D, Celiker A, Aydingoz U. Cardiac hydatid cyst in a child: diagnostic value of echocardiography and magnetic resonance imaging. Acta Paediatr Jpn 1995;37:645–7. 3. Chadly A, Krimi S, Mghirbi T. Cardiac hydatid cyst rupture as cause of death. Am J Forensic Med Pathol 2004;25:262–4. 4. Marci M, Ponari A, Finazzo F, Battaglia A. Echocardiographically diagnosed cardiac echinococcus complicated by
Case Reports
349
embolic intraventricular thrombus. J Am Soc Echocardiogr 1998;11:1158–60. 5. Karabay O, Onen A, Yildiz F, Yilmaz E, Erdal CA, Sanli A, Kilci G, Algin I, Itil O, Acikel U. The case of a cyst hydatid localized within the interatrial septum. Jpn Heart J 2004;45:703–7. 6. Oliver JM, Sotillo JF, Dominguez FJ, Lopez de Sa E, Calvo L, Salvador A, Paniagua JM. Two-dimensional echocardiographic features of echinococcosis of the heart and great blood vessels. Clinical and surgical implications. Circulation 1988;78: 327–37. 7. Desnos M, Brochet E, Cristofini P, Cosnard G, Keddari M, Mostefai M, Gay J. Polyvisceral echinococcosis with cardiac involvement imaged by two-dimensional echocardiography, computed tomography and nuclear magnetic resonance imaging. Am J Cardiol 1987;59:383–4.
Papillary Fibroelastoma of Aortic Valve: Diagnosis and Surgical Management Pankaj Saxena, MCh, DNB ∗ , Andrew Lee, MBBS, Igor E. Konstantinov, MD, PhD and Mark A.J. Newman, FRACS Department of Cardiothoracic Surgery, Sir Charles Gairdner Hospital, Nedlands, WA 6009, Australia
Papillary fibroelastoma (PFE) is a rare and benign cardiac tumour that mainly affects the valves. This tumour has the potential to cause serious life threatening thromboembolic complications. Herein, we describe successful excision of an aortic valve papillary fibroelastoma. The importance of valve sparing tumour resection is emphasised. (Heart, Lung and Circulation 2008;17:330–351) © 2006 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved. Keywords. Papillary fibroelastoma; Thromboembolism; Aortic valve
P
rimary cardiac tumours are rare. Papillary fibroelastoma (PFE) is the third most common primary cardiac tumour following myxomas and lipomas and the commonest tumour of the cardiac valves.1–3 This is a benign tumour. This tumour has the potential to result in thromboembolic phenomena to the brain or coronary circulation.
Case Report A 68-year-old woman presented to her general practitioner with a three-month history of episodic dizziness, palpitations, pre-syncope and one episode of amaurosis fugax. There were no focal neurological symptoms during these episodes. Past medical history was unremarkable, apart from curative excision of a superficial malignant melanoma from the left leg. Physical examination was normal. She underwent 24 h Holter electrocardiography Received 15 March 2006; received in revised form 11 October 2006; accepted 19 October 2006; available online 8 March 2007 ∗ Corresponding author. Tel.: +61 8 9346 3333; fax: +61 8 934 62 344. E-mail address: [email protected] (P. Saxena).
(ECG) monitoring. This demonstrated two isolated brief episodes of atrial fibrillation. The patient subsequently underwent echocardiography, which demonstrated a mobile mass attached by a thin stalk to the aortic valve. Trans-oesophageal echo demonstrated a 1.5–2 cm long pedunculated mobile mass involving the non-coronary cusp of aortic valve. The valve was tricuspid in structure. There was no aortic insufficiency. All other cardiac chambers were normal in structure and function of left ventricle was normal. Exercise stress test was performed which was negative. Her coronary angiogram was normal. As a part of the pre-operative work up in the setting of ischaemic cerebral symptoms, she underwent carotid Doppler, computed tomographic (CT) scan and magnetic resonance imaging (MRI) scan of the brain. These investigations were normal. She was then referred for urgent surgical resection. The patient underwent resection of a 15 mm long tumour mass, which was 2 mm in diameter. Myocardial protection was achieved with cold blood cardioplegia delivered in antegrade and retrograde fashion with systemic hypothermia to 28 ◦ C. Terminal warm cardioplegia was delivered in retrograde manner. Aortic cross clamp
© 2006 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved.
1443-9506/04/$30.00 doi:10.1016/j.hlc.2006.10.016
CASE REPORTS
Heart, Lung and Circulation 2008;17:330–351
347 CASE REPORTS
Heart, Lung and Circulation 2008;17:330–351
A Hydatid Cyst of the Interventricular Septum Diagnosed Incidentally by Multislice Computed Tomography M. Timur Selcuk, MD a,∗ , Hatice Selcuk, MD a , Omac Tufekcioglu, MD a , Kazim Baser, MD a , Nilgun Isiksalan Ozbulbul, MD b , Levent Birincioglu, MD c and Sule Korkmaz, MD a a
Department of Cardiology, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey Department of Radiology, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey b
c
Cardiac involvement of the hydatid disease is uncommon. In this report a case of 54-year-old patient with a hydatid cyst in the interventricular septum was presented. The cyst was detected incidentally by cardiac multislice computed tomography and transthoracic echocardiographic appearances of the cyst raised the suspicion of cardiac echinococcosis. The patient was referred to surgery immediately for the removal of the cyst in order to prevent the potentially life threatening complications. The postoperative period was uneventful and she was discharged on albendazole therapy. (Heart, Lung and Circulation 2008;17:330–351) © 2007 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved. Keywords. Cardiac cyst; Hydatid cyst; Computed tomography
Introduction
C
ystic hydatid disease is a parasitic infection caused by echinococcus granulosus which is still endemic in sheep- raising countries.1 Although the liver (55–70%) and lung (20–30%) are the most common sites for cyst formation, the incidence of cardiac involvement is very low with a ratio of 0.02–2% of all hydatid infestations.2 Here we report a case of hydatid cyst localised in the interventricular septum (IVS) that was presented with angina and detected incidentally by cardiac multislice computed tomography (MSCT).
Case Report A 54-year-old woman admitted to our institution with the complaints of chest pain and dyspnea on exertion. Clinical examination was unremarkable except for a 1/6 grade systolic murmur at apex. Electrocardiography and chest roentgenogram did not show any pathological finding. Coronary angiography was planned in view of the clinical suspicion of coronary artery disease. As she had refused to undergo an invasive procedure, a cardiac multislice computed tomography (MSCT) was performed. Coronary Received 2 September 2006; received in revised form 27 October 2006; accepted 30 December 2006; available online 1 March 2007 ∗
Corresponding author at: Ayvali M. 5.C. 92.S. No: 2/8, 06020 Ankara, Turkey. Tel.: +90 3123316570; fax: +90 3123316570. E-mail address: [email protected] (M.T. Selcuk).
arteries were found to be normal and a cystic like structure 5.1 cm × 3.9 cm × 3.8 cm in size was detected in the IVS on cardiac MSCT (Fig. 1). A subsequent transthoracic echocardiography (TTE) revealed a round shaped, multicystic lesion in the IVS protruding into both of the ventricles without creating a pressure gradient. It was consisting of an internal (germinal) and an outer (cuticula) layer suggesting a hydatid cyst (Fig. 2). The patient was started on albendazole and referred to surgery for the resection of the cyst. She was operated on under cardiopulmonary bypass and cardioplegia. By transaortic approach, cyst content was aspired, irrigated with hypertonic saline solution and then removed (Fig. 3). Her postoperative period was uneventful and she was discharged without symptoms.
Discussion Cardiac cyst hydatid is an uncommon form of the echinococcal disease. The cysts tend to occur most commonly at the left ventricular free wall because of its thickness and rich blood supply.3 The IVS is the next more frequent site of cyst involvement, followed by the atria, right ventricle and pericardium.4 The presenting symptoms of the cardiac hydatid cysts depend on the location, size and the complications of the cyst. Although most of the patients with cardiac involvement remain asymptomatic, a patient with a cardiac hydatid cyst may present with a variety of symptoms such
© 2007 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved.
1443-9506/04/$30.00 doi:10.1016/j.hlc.2006.12.011
348
Case Reports
CASE REPORTS
Heart, Lung and Circulation 2008;17:330–351
Figure 1. Three-dimensional-volume rendering technique of a retrospective electrocardiography gated multislice computed tomography shows a cystic mass in the interventricular septum. It appeared to be situated just below the aortic root and extended to the base of the heart. LA, indicates left atrium; RA, right atrium; RV, right ventricle; LV, left ventricle; Ao, aorta; C, cyst.
Figure 2. An apical four chamber view of the cyst (left side) located in the interventricular septum protruding into both of the ventricles. A subcostal echocardiographic image of the cyst (right side) showing the internal (germinal) and outer (cuticula) layers. LA, indicates left atrium; RA, right atrium; RV, right ventricle; LV, left ventricle; C, cyst.
Figure 3. Multiple hydatid cysts removed on surgery.
as angina, arrhythmias, valvular dysfunction or pericardial reaction.5 The rupture of a hydatid cyst may result in serious complications including cardiac tamponade, systemic and pulmonary embolism, anaphylactic shock or sudden death.4 A fluid- filled mass with a well defined outer wall and initial septations are the typical appearances of a hydatid cyst on transthoracic echocardiography.6 Nevertheless, computed tomography and magnetic resonance examinations can be helpful for the identification of the cystic structures and their relation with surrounding cardiac and non-cardiac structures.7 In the present case, cyst located in IVS resulted in angina probably due to the compression of the coronary arteries and a cardiac cyst was diagnosed during the evaluation of coronary artery disease. As the diagnosis of cardiac echinococcosis is usually difficult because of the variable and non-specific presenting symptoms, a cardiac cyst in a patient from an endemic or sheep forming area should raise the suspicion of cardiac echinococcosis. Owing to the potentially life threatening consequences, patients with
cardiac echinococcosis should be diagnosed and undergo surgery without delay.
References 1. Miralles A, Bracamonte L, Pavie A, Bors V, Rabago G, Gandjbakhch I, Cabrol C. Cardiac echinococcosis. Surgical treatment and results. J Thorac Cardiovasc Surg 1994;107:184–90. 2. Alehan D, Celiker A, Aydingoz U. Cardiac hydatid cyst in a child: diagnostic value of echocardiography and magnetic resonance imaging. Acta Paediatr Jpn 1995;37:645–7. 3. Chadly A, Krimi S, Mghirbi T. Cardiac hydatid cyst rupture as cause of death. Am J Forensic Med Pathol 2004;25:262–4. 4. Marci M, Ponari A, Finazzo F, Battaglia A. Echocardiographically diagnosed cardiac echinococcus complicated by
Case Reports
349
embolic intraventricular thrombus. J Am Soc Echocardiogr 1998;11:1158–60. 5. Karabay O, Onen A, Yildiz F, Yilmaz E, Erdal CA, Sanli A, Kilci G, Algin I, Itil O, Acikel U. The case of a cyst hydatid localized within the interatrial septum. Jpn Heart J 2004;45:703–7. 6. Oliver JM, Sotillo JF, Dominguez FJ, Lopez de Sa E, Calvo L, Salvador A, Paniagua JM. Two-dimensional echocardiographic features of echinococcosis of the heart and great blood vessels. Clinical and surgical implications. Circulation 1988;78: 327–37. 7. Desnos M, Brochet E, Cristofini P, Cosnard G, Keddari M, Mostefai M, Gay J. Polyvisceral echinococcosis with cardiac involvement imaged by two-dimensional echocardiography, computed tomography and nuclear magnetic resonance imaging. Am J Cardiol 1987;59:383–4.
Papillary Fibroelastoma of Aortic Valve: Diagnosis and Surgical Management Pankaj Saxena, MCh, DNB ∗ , Andrew Lee, MBBS, Igor E. Konstantinov, MD, PhD and Mark A.J. Newman, FRACS Department of Cardiothoracic Surgery, Sir Charles Gairdner Hospital, Nedlands, WA 6009, Australia
Papillary fibroelastoma (PFE) is a rare and benign cardiac tumour that mainly affects the valves. This tumour has the potential to cause serious life threatening thromboembolic complications. Herein, we describe successful excision of an aortic valve papillary fibroelastoma. The importance of valve sparing tumour resection is emphasised. (Heart, Lung and Circulation 2008;17:330–351) © 2006 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved. Keywords. Papillary fibroelastoma; Thromboembolism; Aortic valve
P
rimary cardiac tumours are rare. Papillary fibroelastoma (PFE) is the third most common primary cardiac tumour following myxomas and lipomas and the commonest tumour of the cardiac valves.1–3 This is a benign tumour. This tumour has the potential to result in thromboembolic phenomena to the brain or coronary circulation.
Case Report A 68-year-old woman presented to her general practitioner with a three-month history of episodic dizziness, palpitations, pre-syncope and one episode of amaurosis fugax. There were no focal neurological symptoms during these episodes. Past medical history was unremarkable, apart from curative excision of a superficial malignant melanoma from the left leg. Physical examination was normal. She underwent 24 h Holter electrocardiography Received 15 March 2006; received in revised form 11 October 2006; accepted 19 October 2006; available online 8 March 2007 ∗ Corresponding author. Tel.: +61 8 9346 3333; fax: +61 8 934 62 344. E-mail address: [email protected] (P. Saxena).
(ECG) monitoring. This demonstrated two isolated brief episodes of atrial fibrillation. The patient subsequently underwent echocardiography, which demonstrated a mobile mass attached by a thin stalk to the aortic valve. Trans-oesophageal echo demonstrated a 1.5–2 cm long pedunculated mobile mass involving the non-coronary cusp of aortic valve. The valve was tricuspid in structure. There was no aortic insufficiency. All other cardiac chambers were normal in structure and function of left ventricle was normal. Exercise stress test was performed which was negative. Her coronary angiogram was normal. As a part of the pre-operative work up in the setting of ischaemic cerebral symptoms, she underwent carotid Doppler, computed tomographic (CT) scan and magnetic resonance imaging (MRI) scan of the brain. These investigations were normal. She was then referred for urgent surgical resection. The patient underwent resection of a 15 mm long tumour mass, which was 2 mm in diameter. Myocardial protection was achieved with cold blood cardioplegia delivered in antegrade and retrograde fashion with systemic hypothermia to 28 ◦ C. Terminal warm cardioplegia was delivered in retrograde manner. Aortic cross clamp
© 2006 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved.
1443-9506/04/$30.00 doi:10.1016/j.hlc.2006.10.016
CASE REPORTS
Heart, Lung and Circulation 2008;17:330–351