Ann Thorac Surg 1998;66:2110-2111
© 1998 The Society of Thoracic Surgeons
Case Reports
Hydatid cyst of the interventricular septum in a 3.5-year-old child
Luis C. Maroto, MDa,
Yolanda Carrascal, MDa,
Maria J. López, MDa,
Alberto Forteza, MDa,
Ana Pérez, MDb,
Claudio Zavanella, MDa
a Pediatric Cardiac Surgery Unit, Hospital Materno-Infantil 12 de Octubre, Madrid, Spain
b Department of Pediatrics, Hospital Materno-Infantil 12 de Octubre, Madrid, Spain
Accepted for publication June 4, 1998.
Address reprint requests to Dr Maroto, Servicio de Cirugía Cardíaca, Hospital 12 de Octubre, Ctra. de Andalucia Km 5.400, 28041 Madrid, Spain
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Abstract
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An asymptomatic cardiac cyst located in the interventricular septum was diagnosed in a 3.5-year-old child by echocardiographic findings. Surgical ablation was done and hystopathologic analysis confirmed a hydatid cyst. The patient was discharged without symptoms.
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Introduction
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Cardiac echinococcosis is not frequent, accounting for 0.5% to 2% of all hydatid infestations [1–7]. Because of the slow growth of the cysts (approximately 1 cm per year) they rarely present in early childhood [2,3,8–10]. We present the case of a hydatid cyst of the interventricular septum in an asymptomatic 3.5-year-old child.
A 3.5-year-old boy was admitted to the Pediatric Cardiac Unit of our hospital for evaluation of an asymptomatic systolic murmur. Results of chest x-ray and routine blood tests were normal. Electrocardiographic analysis disclosed a right bundle branch block. Two-dimensional echocardiography showed a 3 x 2-cm cystic formation in the interventricular septum (Fig 1) bulging into the right ventricle. There were no echocardiographic signs of obstruction (only a mild acceleration in the right ventricular outflow tract). Results of serologic tests for hydatid disease were negative, and no other visceral localization of the disease was found. He underwent surgical removal of the cyst with the aid of cardiopulmonary bypass, without certain knowledge of its nature. Under moderate hypothermic cold crystaloid cardioplegic arrest and through the tricuspid valve, the interventricular septum was exposed and a large bulging mass was observed under the septal leaflet of the tricuspid valve. The mass was first punctured and its content aspired. The myocardium was then opened and the cyst removed (Fig 2), which produced a large cavity inside the septum. The cavity was sutured closed, and the opening into the right ventricle was closed with a polypropylene running suture. Recovery was uneventful and the child was discharged without symptoms. Histologic study of the cystic wall revealed its hydatic condition. Eighteen months postoperatively he remains asymptomatic without echocardiographic signs of recurrence.
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Fig 1. Transthoracic echocardiography. Arrow indicates the cyst. AI = left atrium; AO = aorta; VD = right ventricle; VI = left ventricle.
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Comment
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Echinococcosis is a human parasitic disease most commonly caused by the larval stage of Echinococcus granulosus. Cardiac echinococcosis is an infrequent complication (0.5% to 2%) of hydatid disease with invasion of the myocardium through the coronary circulation. Distribution of the cysts within the heart is related to vascular supply of the different myocardial areas, with a higher incidence in the left ventricle [2–4]. Cardiac echinococcal cysts rarely involve the interventricular septum [5]; when they do they can cause symptoms related to compression of the atrioventricular conduction pathway and obstruction of the right or left ventricular outflow tract. Other cardiovascular manifestations of cardiac echinococcosis are arrythmia, angina, valvular dysfunction, pericardial reaction, pulmonary or systemic embolism, pulmonary hypertension, or anaphylactic reactions [7]. This case is of particular interest because of the rarity of the cysts in childhood [6]. The cyst is formed over 1 to 5 years, so it tends to manifest in individuals over age 20 years. Some groups have previously published their experience with 3- to 13-year-old patients [8–10].
The main diagnostic tools and preoperative work-up include serologic tests and cardiac imaging by echocardiography, computed tomography, and magnetic resonance imaging. Echocardiography, the diagnostic method of choice, is noninvasive, easily performed, and has a high sensitivity in detecting intracardiac echinococcal cysts [4,7]. Hydatidosis must always be kept in mind when an intracardiac cystic image is detected even in early childhood as shown in the present report. Surgical excision using cardiopulmonary bypass is the treatment of choice [1,2,6]. Supplemental medical treatment is not used widely [2]. When a hydatid cyst is going to be removed it is usually sterilized before enucleation by injection or instillation of 2% formalin, 0.5% silver nitrate solution, 30% hypertonic saline solution, 1% iodine solution, or 5% cetimide solution. Di Bello and colleagues [8] consider that a dessicating agent is not a prerequisite before complete enucleation of the cyst. The remaining question is whether an unidentified intracardiac nonsolid mass should be evacuated before removal. In the present case, magnetic resonance imaging failed to identify its contents, its true nature was yet unknown, and it was also unknown whether a membrane was present. At the time, it was considered safer to first evacuate the mass before opening the septum to avoid taking the chance of an unknown fluid spilling into the ventricular cavity.
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References
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Oliver J.M., Sotillo J.F., Domínguez F.J., et al. Two-dimensional echocardiographic features of echinococcosis of the heart and great blood vessels. Clinical and surgical implications. Circulation 1988;78:327-337.[Abstract/Free Full Text]
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Abstract
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