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Restoration of atrioventricular conduction after surgical removal of a hydatid cyst of the interventricular septum
The Journal of
14 4
Brief communications
hold use, the incidence of these accidents has declined. However, with early intensive care, patients with severe upper gastrointestinal and respiratory bums survive to the stage of total obliteration of the esophagus and hypopharynx:" This is more likely to occur in the patient with total gastric necrosis." There are several important differences between this case and those previouslyreported: (1) The stomach had been excised; (2) there was significant damage to the larynx, which would have made competence of the laryngeal inlet during swallowing difficult and dangerous or impossible; (3) the only site at which colon could be anastomosed to the pharynx was above the level of the cords; (4) the patient had surgical procedures to the larynx, including skin grafting to restore the airway sufficiently to permit closure of the tracheostomy. There were several options: (1) permanent tracheostomy with colopharyngostomy (with loss of natural phonation), (2) pharyngoplasty with pedicled skin or free bowel graft" and a hook-up below the diaphragm, (3) permanent tube feeding, (4) a trial of colon anastomosis to the supralaryngeal pharynx with assessment of deglutition, and (5) colon bypass from the mouth. It was easy to offer the patient swallowing without phonation or to leave him with phonation and tube feeding, but it was not easy to offer phonation and predictably safe swallowing. We expected the patient to take a long time "learning" to swallow, but having learned in the preceding 4 years not to allow saliva or even mouthwash to enter his throat, he found eating and swallowing through the new stoma to be remarkably easy. The excellent functional and acceptable cosmetic result of this operation make us strongly recommend the operation to restore swallowing in the group of patients with corrosive bums producing pharyngoesophageal obliteration. REFERENCES
2
3 4
5
Haupt GJ, Templeton JW III, Armadeo JA: Retrosternal placement of ascending colon for esophageal substitution. JAMA 167:832, 1958 Hong PW, Seel OJ, Dietrick RB: The use of colon in the repair of benign structure of the esophagus. Pacif Med Surg 75: 148, 1967 Davis MV: Early and late management of caustic burns of the esophagus. Ann Surg 22:308, 1956 Ogura JH, Roper CL, Burford TH: Complete functional restitution of the food passages in stenosing caustic burns. J THORAC CARDIOVASC SURG 42:340, 1961 Kirsh MM, Ritter F: Caustic ingestion and subsequent damage to the oropharyngeal and digestive passages. Ann Thorac Surg 21:74, 1976
Thoracic and Cardiovascular Surgery
6 Gupta S: Total obliteration of esophagus and hypopharynx due to corrosives. A new technique of reconstruction. J THORAC CARDIOVASC SURG 60:264, 1970 7 Thomas AN, Dedo HH, Lim RC Jr, Steele M: Pharyngoesophageal caustic stricture. Treatment by pharyngogastrostomy compared to colon interposition combined with free bowel graft. Ann J Surg 132: 195, 1976 8 Jurkiewicz MJ: Vascularized interstitial graft for reconstruction of the cervical esophagus and pharynx. Plast Reconstr Surg 36:509, 1965 9 Haller JA Jr, Andrews HG, White 11, Tamer MA, Cleveland WW: Pathology and management of acute corrosive burns of the esophagus. J Pediatr Surg 6:578, 1971 10 Fatti L, Marchand P, Crawshaw GR: The treatment of caustic strictures of the esophagus. Surg Gynecol Obstet 102:195,1956 II Daly JF: The early management of corrosive burns of the esophagus. Surg Clin North Am 34:343, 1954 12 Gryboski W, Page R, Rush BF Jr: Management of total gastric necrosis following lye ingestion. Ann Surg 161:469, 1965 13 Peters LR, McKee OM, Berry BE: Pharyngo-esophageal reconstruction with revascularized jejunal transplants. Am J Surg 121:675, 1971
Restoration of atrioventricular conduction after surgical removal of a hydatid cyst of the interventricular septum Gianmaria Ottino, M.D., Massimo Villani, M.D., Ruggero De Paulis, M.D., Gualtiero Trucco, M.D., and Alberto Viara, M.D., Torino, Italy From the Department of Cardiac Surgery, University of Torino, and the Department of Cardiology, Ospedale San Giovanni Battista, Torino, Italy.
A young man withsyncope and complete heart block wasfound to have an echinococcal cyst in the interventricular septum. The block disappeared after surgical removal of the cyst.
Surgical treatment of hydatidosis of the heart has been reported in 135 cases according to Shakibi and associates,1 who reviewed the world literature in 1977. In a small number of cases the cyst was located in the interventricular septum. The first reported removal of such a hydatid cyst dates back to 1962.2 Address for reprints: Gianmaria Ottino, M.D., Department of Cardiac Surgery, University of Torino, C.so Polonia 14, 10126 Torino, Italy.
Volume 93 Number 1 January 1987
Brief communications 1 4 5
Fig. 1. A two-dimensional echocardiogram in the four-chamber apical view shows a rounded cyst-like mass (C) in the upper interventricular septum. LA. left atrium. LV, Left ventricle. RV, Right ventricle. RA, Right atrium.
Fig. 2. Left, A round translucent mass (C) is seen protruding from the septal side of the left ventricular outflow tract during left ventriculography in the left anterior oblique projection. Right, A similar mass protruding in the right ventricular cavity is seen during right ventriculography in the same projection. Ao, Aorta. C. Cyst. IYS, Interventricular septum. LV, Left ventricle. PA, Pulmonary artery. RV, Right ventricle.
We recently operated on a patient with a septal echinococcal cyst and complete atrioventricular (AV) block. One year after the operation the patient is well and the conduction defect has disappeared. Case report. A 31-year-old-man was admitted to our hospital because of dizziness of recent onset. The patient had been exposed to echinococcus, as he had been raising cattle
and sheep. Physical examination demonstrated a Grade 3/6 ejection systolic murmur. The heart rate was 50 beats/min and the blood pressure 115/85 mm Hg. An electrocardiogram showed a third-degree AY block with a ventricular rate of 50 beats/min. The chest x-ray film revealed no abnormalities. Echocardiography showed a round cystlike structure in the interventricular septum, bulging toward both the pulmonary infundibulum and the left outflow tract (Fig. 1). Because of the exposure to echinococcus associated with his profession
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The Journalof Thoracic and Cardiovascular Surgery
Brief communications
Fig. 3. Surgical exposure of the ventricular septal hydatid cyst via a right transverse ventriculotomy. The white wall of the cyst protrudes through the myocardial tissue in the right infundibulum. (Patient's head is toward the bottom of the photograph.) and the echocardiographic appearance, a diagnosis of hydatic cyst of the interventricular septum was made and confirmed by the intradermal Casoni skin test. Cardiac catheterization and angiography further demonstrated a 35 mm Hg gradient between the body and the outflow tract of the right ventricle and confirmed the presence of a round structure obstructing the right infundibulum and protruding into the left ventricular outflow tract (Fig. 2). While in the hospital the patient fainted twice within a few hours; therefore, a transvenous electrode catheter was introduced percutaneously for temporary pacing, and surgical treatment was advised. A transverse right ventriculotomy was performed. The cyst, which was large enough to protrude from the surface of the right ventricular outflow tract, was located in the infundibular and muscular septum, anterior to the membranous portion of the interventricular septum. It was ovoid, with a long axis of 8 em, its surface was a brilliant white, and it was partly covered by ventricular septal myocardium (Fig. 3). After the septal area was surrounded with sponges soaked in 0.2% formalin solution, the cyst was first drained with a needle and then was injected with a hypertonic saline solution (NaCl 36%) to kill the parasite. The cyst was then easily dissected away. The empty cavity left in the septum was excluded with 3-0 Ethibond mattress sutures and the septal continuity was kept intact. A few days after the operation the block disappeared. One year later the patient is doing well and his electrocardiogram shows regular sinus rhythm with normal AV conduction.
Discussion. Hydatidosis of the heart is uncommon: 0.5% to 3% of all cases of echinococcosis. Among these rare instances about 9% of the patients have had a cyst in the interventricular septum. The clinical picture is not specific, because cardiac hydatidosis can mimic various cardiac diseases even in the case of septal localization."
Often the first symptoms are related to the rupture of the cyst and pulmonary embolization. 1,5,6 Even if the diagnosis is not clinically suspected, a routine echocardiographic investigation can lead to a correct conclusion. Echocardiography and computed tomographic scanning, have been reported to be the best noninvasive diagnostic methods." 8 We concur with this opinion: Angiography and cardiac catheterization gave us very little additional information. The occurrence of AV block and syncopal attacks in patients with hydatic cyst of the interventricular septum has been reported so far in five cases, to our knowledge." 9.10 Only the patient described by Ben Ismail and associates" was operated on but required implantation of a permanent pacemaker for chronic heart block. Eight other patients with ventricular septal echinococcosis have had a successful operation. 1,3, 5, 6.10-13 Surgical treatment is mandatory because of the risk of embolization and AV block. Although the interventricular septum can be perforated during the surgical maneuvers,' every effort should be made to spare it as the conduction defect can be reversible. We acknowledge the helpful advice of Dr. F. Orzan in reviewing the manuscript. REFERENCES Shakibi JG, Safavian MH, Azar H, Siassi B. Surgical treatment of echinococcal cyst of the heart: report of two cases and review of the world literature. J THORAC CARDIOVASC SURG
1977;74:941-6.
Volume 93 Number 1
Brief communications 1 4 7
January 1987
2 Artucio H, Roglia JL, Oi Bello R, et al. Hydatid cyst of the interventricular septum of the heart with rupture into the right ventricle. J THORAC CARDIOVASC SURG 1962; 44:110-4. 3 Baud F, Gandjbakhch I, Pavie A, Marchand P, Cabrol C. Kyste hydatique du septum interventriculaire. Traitement chirurgical. A propos d'un cas. Ann Chir 1983;37:56971. 4 Ben Ismail M, Fourati M, Bousnina A, Zouari F, Lacronique J. Le kyste hydatique du coeur. A propos de 9 cas. Arch Mal Coeur 1977;2:119-27. 5 Bazelly B, Oonzeau-Gouge GP, Vanetti A, Oaumet P. Echinococcose pulmonaire metastatique, secondaire a une localisation cardiaque primitive situee dans Ie septum interventriculaire. A propos d'un cas opere avec succes, Chirurgie 1982;4:271-3. 6 Hoyer J, Malmejac C, Oelaye A, Houel J. Beitrag zur echinococcose des herzens an hand von sieben eigenen beobachtungen. Thoraxchirurgie 1974;22:197-206. 7 Ganau A, Andreoni G, Piga G, et al. L'ecocardiografia bidimensionale nello studio di una cisti di echinococco
8
9
10
11
12 13
miocardio-pericardica. Boll Soc Ital Cardiol 1978;23:2028. Malouf J, Saksouk FA, Alam S, Rizk GK, Oagher I. Hydatid cyst of the heart: diagnosis by two-dimensional echocardiography and computed tomography. Am Heart J 1985;109:605-7. Gavrilescu S, Gavrilescu M, Streian C, Luca C. Complete atrioventricular block due to cardiac echinococcosis. Cardiology 1979;64:215-21. Di Bello R, Urioste HA, Rubio R: Hydatid cyst of the ventricular septum of the heart: a study based on two personal cases and forty-one observations in the literature. Am J Cardiol 1964;14:237-41. Oi Bello R, Sadi I, Esteves S. Abnormal precordial pulsation in cardiac echinococcosis. J THORAC CARDlOVASC SURG 1967;53:366-70. Urquia M, Garrido J, de los Arcos E. Hydatidosis del septo interventricular. Rev Clin Esp 1975;138:521-7. Malmejac C, Hovel J, Metros P, Pons R. Le kiste hydatique du coeur (a propos de 7 observations). Chirurgie 1970;96:261-7.
14 4
Brief communications
hold use, the incidence of these accidents has declined. However, with early intensive care, patients with severe upper gastrointestinal and respiratory bums survive to the stage of total obliteration of the esophagus and hypopharynx:" This is more likely to occur in the patient with total gastric necrosis." There are several important differences between this case and those previouslyreported: (1) The stomach had been excised; (2) there was significant damage to the larynx, which would have made competence of the laryngeal inlet during swallowing difficult and dangerous or impossible; (3) the only site at which colon could be anastomosed to the pharynx was above the level of the cords; (4) the patient had surgical procedures to the larynx, including skin grafting to restore the airway sufficiently to permit closure of the tracheostomy. There were several options: (1) permanent tracheostomy with colopharyngostomy (with loss of natural phonation), (2) pharyngoplasty with pedicled skin or free bowel graft" and a hook-up below the diaphragm, (3) permanent tube feeding, (4) a trial of colon anastomosis to the supralaryngeal pharynx with assessment of deglutition, and (5) colon bypass from the mouth. It was easy to offer the patient swallowing without phonation or to leave him with phonation and tube feeding, but it was not easy to offer phonation and predictably safe swallowing. We expected the patient to take a long time "learning" to swallow, but having learned in the preceding 4 years not to allow saliva or even mouthwash to enter his throat, he found eating and swallowing through the new stoma to be remarkably easy. The excellent functional and acceptable cosmetic result of this operation make us strongly recommend the operation to restore swallowing in the group of patients with corrosive bums producing pharyngoesophageal obliteration. REFERENCES
2
3 4
5
Haupt GJ, Templeton JW III, Armadeo JA: Retrosternal placement of ascending colon for esophageal substitution. JAMA 167:832, 1958 Hong PW, Seel OJ, Dietrick RB: The use of colon in the repair of benign structure of the esophagus. Pacif Med Surg 75: 148, 1967 Davis MV: Early and late management of caustic burns of the esophagus. Ann Surg 22:308, 1956 Ogura JH, Roper CL, Burford TH: Complete functional restitution of the food passages in stenosing caustic burns. J THORAC CARDIOVASC SURG 42:340, 1961 Kirsh MM, Ritter F: Caustic ingestion and subsequent damage to the oropharyngeal and digestive passages. Ann Thorac Surg 21:74, 1976
Thoracic and Cardiovascular Surgery
6 Gupta S: Total obliteration of esophagus and hypopharynx due to corrosives. A new technique of reconstruction. J THORAC CARDIOVASC SURG 60:264, 1970 7 Thomas AN, Dedo HH, Lim RC Jr, Steele M: Pharyngoesophageal caustic stricture. Treatment by pharyngogastrostomy compared to colon interposition combined with free bowel graft. Ann J Surg 132: 195, 1976 8 Jurkiewicz MJ: Vascularized interstitial graft for reconstruction of the cervical esophagus and pharynx. Plast Reconstr Surg 36:509, 1965 9 Haller JA Jr, Andrews HG, White 11, Tamer MA, Cleveland WW: Pathology and management of acute corrosive burns of the esophagus. J Pediatr Surg 6:578, 1971 10 Fatti L, Marchand P, Crawshaw GR: The treatment of caustic strictures of the esophagus. Surg Gynecol Obstet 102:195,1956 II Daly JF: The early management of corrosive burns of the esophagus. Surg Clin North Am 34:343, 1954 12 Gryboski W, Page R, Rush BF Jr: Management of total gastric necrosis following lye ingestion. Ann Surg 161:469, 1965 13 Peters LR, McKee OM, Berry BE: Pharyngo-esophageal reconstruction with revascularized jejunal transplants. Am J Surg 121:675, 1971
Restoration of atrioventricular conduction after surgical removal of a hydatid cyst of the interventricular septum Gianmaria Ottino, M.D., Massimo Villani, M.D., Ruggero De Paulis, M.D., Gualtiero Trucco, M.D., and Alberto Viara, M.D., Torino, Italy From the Department of Cardiac Surgery, University of Torino, and the Department of Cardiology, Ospedale San Giovanni Battista, Torino, Italy.
A young man withsyncope and complete heart block wasfound to have an echinococcal cyst in the interventricular septum. The block disappeared after surgical removal of the cyst.
Surgical treatment of hydatidosis of the heart has been reported in 135 cases according to Shakibi and associates,1 who reviewed the world literature in 1977. In a small number of cases the cyst was located in the interventricular septum. The first reported removal of such a hydatid cyst dates back to 1962.2 Address for reprints: Gianmaria Ottino, M.D., Department of Cardiac Surgery, University of Torino, C.so Polonia 14, 10126 Torino, Italy.
Volume 93 Number 1 January 1987
Brief communications 1 4 5
Fig. 1. A two-dimensional echocardiogram in the four-chamber apical view shows a rounded cyst-like mass (C) in the upper interventricular septum. LA. left atrium. LV, Left ventricle. RV, Right ventricle. RA, Right atrium.
Fig. 2. Left, A round translucent mass (C) is seen protruding from the septal side of the left ventricular outflow tract during left ventriculography in the left anterior oblique projection. Right, A similar mass protruding in the right ventricular cavity is seen during right ventriculography in the same projection. Ao, Aorta. C. Cyst. IYS, Interventricular septum. LV, Left ventricle. PA, Pulmonary artery. RV, Right ventricle.
We recently operated on a patient with a septal echinococcal cyst and complete atrioventricular (AV) block. One year after the operation the patient is well and the conduction defect has disappeared. Case report. A 31-year-old-man was admitted to our hospital because of dizziness of recent onset. The patient had been exposed to echinococcus, as he had been raising cattle
and sheep. Physical examination demonstrated a Grade 3/6 ejection systolic murmur. The heart rate was 50 beats/min and the blood pressure 115/85 mm Hg. An electrocardiogram showed a third-degree AY block with a ventricular rate of 50 beats/min. The chest x-ray film revealed no abnormalities. Echocardiography showed a round cystlike structure in the interventricular septum, bulging toward both the pulmonary infundibulum and the left outflow tract (Fig. 1). Because of the exposure to echinococcus associated with his profession
14 6
The Journalof Thoracic and Cardiovascular Surgery
Brief communications
Fig. 3. Surgical exposure of the ventricular septal hydatid cyst via a right transverse ventriculotomy. The white wall of the cyst protrudes through the myocardial tissue in the right infundibulum. (Patient's head is toward the bottom of the photograph.) and the echocardiographic appearance, a diagnosis of hydatic cyst of the interventricular septum was made and confirmed by the intradermal Casoni skin test. Cardiac catheterization and angiography further demonstrated a 35 mm Hg gradient between the body and the outflow tract of the right ventricle and confirmed the presence of a round structure obstructing the right infundibulum and protruding into the left ventricular outflow tract (Fig. 2). While in the hospital the patient fainted twice within a few hours; therefore, a transvenous electrode catheter was introduced percutaneously for temporary pacing, and surgical treatment was advised. A transverse right ventriculotomy was performed. The cyst, which was large enough to protrude from the surface of the right ventricular outflow tract, was located in the infundibular and muscular septum, anterior to the membranous portion of the interventricular septum. It was ovoid, with a long axis of 8 em, its surface was a brilliant white, and it was partly covered by ventricular septal myocardium (Fig. 3). After the septal area was surrounded with sponges soaked in 0.2% formalin solution, the cyst was first drained with a needle and then was injected with a hypertonic saline solution (NaCl 36%) to kill the parasite. The cyst was then easily dissected away. The empty cavity left in the septum was excluded with 3-0 Ethibond mattress sutures and the septal continuity was kept intact. A few days after the operation the block disappeared. One year later the patient is doing well and his electrocardiogram shows regular sinus rhythm with normal AV conduction.
Discussion. Hydatidosis of the heart is uncommon: 0.5% to 3% of all cases of echinococcosis. Among these rare instances about 9% of the patients have had a cyst in the interventricular septum. The clinical picture is not specific, because cardiac hydatidosis can mimic various cardiac diseases even in the case of septal localization."
Often the first symptoms are related to the rupture of the cyst and pulmonary embolization. 1,5,6 Even if the diagnosis is not clinically suspected, a routine echocardiographic investigation can lead to a correct conclusion. Echocardiography and computed tomographic scanning, have been reported to be the best noninvasive diagnostic methods." 8 We concur with this opinion: Angiography and cardiac catheterization gave us very little additional information. The occurrence of AV block and syncopal attacks in patients with hydatic cyst of the interventricular septum has been reported so far in five cases, to our knowledge." 9.10 Only the patient described by Ben Ismail and associates" was operated on but required implantation of a permanent pacemaker for chronic heart block. Eight other patients with ventricular septal echinococcosis have had a successful operation. 1,3, 5, 6.10-13 Surgical treatment is mandatory because of the risk of embolization and AV block. Although the interventricular septum can be perforated during the surgical maneuvers,' every effort should be made to spare it as the conduction defect can be reversible. We acknowledge the helpful advice of Dr. F. Orzan in reviewing the manuscript. REFERENCES Shakibi JG, Safavian MH, Azar H, Siassi B. Surgical treatment of echinococcal cyst of the heart: report of two cases and review of the world literature. J THORAC CARDIOVASC SURG
1977;74:941-6.
Volume 93 Number 1
Brief communications 1 4 7
January 1987
2 Artucio H, Roglia JL, Oi Bello R, et al. Hydatid cyst of the interventricular septum of the heart with rupture into the right ventricle. J THORAC CARDIOVASC SURG 1962; 44:110-4. 3 Baud F, Gandjbakhch I, Pavie A, Marchand P, Cabrol C. Kyste hydatique du septum interventriculaire. Traitement chirurgical. A propos d'un cas. Ann Chir 1983;37:56971. 4 Ben Ismail M, Fourati M, Bousnina A, Zouari F, Lacronique J. Le kyste hydatique du coeur. A propos de 9 cas. Arch Mal Coeur 1977;2:119-27. 5 Bazelly B, Oonzeau-Gouge GP, Vanetti A, Oaumet P. Echinococcose pulmonaire metastatique, secondaire a une localisation cardiaque primitive situee dans Ie septum interventriculaire. A propos d'un cas opere avec succes, Chirurgie 1982;4:271-3. 6 Hoyer J, Malmejac C, Oelaye A, Houel J. Beitrag zur echinococcose des herzens an hand von sieben eigenen beobachtungen. Thoraxchirurgie 1974;22:197-206. 7 Ganau A, Andreoni G, Piga G, et al. L'ecocardiografia bidimensionale nello studio di una cisti di echinococco
8
9
10
11
12 13
miocardio-pericardica. Boll Soc Ital Cardiol 1978;23:2028. Malouf J, Saksouk FA, Alam S, Rizk GK, Oagher I. Hydatid cyst of the heart: diagnosis by two-dimensional echocardiography and computed tomography. Am Heart J 1985;109:605-7. Gavrilescu S, Gavrilescu M, Streian C, Luca C. Complete atrioventricular block due to cardiac echinococcosis. Cardiology 1979;64:215-21. Di Bello R, Urioste HA, Rubio R: Hydatid cyst of the ventricular septum of the heart: a study based on two personal cases and forty-one observations in the literature. Am J Cardiol 1964;14:237-41. Oi Bello R, Sadi I, Esteves S. Abnormal precordial pulsation in cardiac echinococcosis. J THORAC CARDlOVASC SURG 1967;53:366-70. Urquia M, Garrido J, de los Arcos E. Hydatidosis del septo interventricular. Rev Clin Esp 1975;138:521-7. Malmejac C, Hovel J, Metros P, Pons R. Le kiste hydatique du coeur (a propos de 7 observations). Chirurgie 1970;96:261-7.