Ann Thorac Surg 1999;67:1791-1793
© 1999 The Society of Thoracic Surgeons
Case Reports
Cardiac echinococcosis causing coronary artery disease
Ruggero De Paulis, MDa,
Francesco Seddio, MDa,
Luisa Colagrande, MDa,
Patrizio Polisca, MDa,
Luigi Chiariello, MDa
a Division of Cardiac Surgery, Tor Vergata University of Rome, Rome, Italy
Accepted for publication November 10, 1998.
Address reprint requests to Dr De Paulis, Cattedra di Cardiochirurgia, Università di Roma Tor Vergata, European Hospital, Via Portuense 700, 00149 Rome, Italy
e-mail: depauli{at}tin.it
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Abstract
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We report a case of cardiac echinococcosis in a patient who had sustained an acute myocardial infarction 1 month previously. The coronary angiographic study revealed an isolated complete intrinsic obstruction of the left anterior descending coronary artery in the area of the cyst. The cyst was surgically removed. Coronary artery bypass grafting was not performed because of distal myocardial scarring. Coronary arteriography should routinely be performed in all patients with cardiac echinococcosis.
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Introduction
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Cardiac echinococcosis is rare. The incidence reported ranges between 0.5% and 2% of all cases of echinococcosis in human. Although most patients with a cardiac hydatid cyst are asymptomatic, sudden death, valvular dysfunction, heart block, and more often, chest pain resulting from episodes of partial pericarditis have been described [1]. We report the case of a patient with a left ventricular hydatid cyst that caused an acute anterior myocardial infarction.
A 65-year-old woman was admitted to our division on December 10, 1997, for surgical treatment of a pericardial cyst diagnosed as celomic-pericardial 10 years previously. In November 1997, she had sustained an acute anterior myocardial infarction, and echocardiography confirmed the presence of a pericardial cyst. Total-body computed tomographic scan excluded the presence of other cysts.
At admission, the patient was asymptomatic for angina or dyspnea. Arterial blood pressure was 110/70 mm Hg, and heart rate was 60 beats/min. The electrocardiogram showed negative T waves on lateral leads (V4 through V6) and Q waves in leads V1 through V3. The chest roentgenogram revealed an irregular prominence of the lower left border of the cardiac silhouette (Fig 1). Results of laboratory tests were normal. The indirect hemagglutination test was negative. Two-dimensional echocardiography showed a huge multiloculated, egg-shaped cystic mass (12 x 8.5 cm) attached to the anterolateral wall of the left ventricle and compressing the left atrium (Fig 2). The anterior wall of the left ventricle was dyskinetic. Cardiac catheterization revealed abnormalities in anterior wall motion of the left ventricle. Coronary angiography disclosed a proximal complete occlusion of the anterior descending coronary artery with retrograde filling from collateral circulation. The anterior descending coronary artery was also displaced by the cyst (Fig 3); the rest of the coronary tree was normal. Thallium-201 scintigraphy revealed complete necrosis of the anteroseptal wall.
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Fig 2. Two-dimensional echocardiogram illustrating hydatid cyst compressing the left ventricle. (AD = right atrium; AS = left atrium; VD = right ventricle; VS = left ventricle.)
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Fig 3. Coronary angiogram showing displacement (arrows) of left anterior descending coronary artery by hydatid cyst.
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Removal of the cyst was performed through a median sternotomy. Standard technique of cardiopulmonary bypass with moderate hypothermia (28°C) and cardioplegic arrest was used. After sterilization with 33% hypertonic sodium chloride solution, the cyst was opened, and the numerous daughter cysts were carefully removed. The cavity was again washed with the hypertonic solution. The residual cavity was sutured in layers with 2-0 Ethibond. The left anterior descending coronary artery remained markedly displaced after cyst excision. The pathology report described a cyst wall containing calcium and associated small daughter cysts containing germinative membrane, which demonstrated the hydatid nature of the cyst.
The postoperative course was complicated by transient atrial fibrillation. Echocardiography showed mild pericardial effusion. The patient was discharged on a regimen of mebendazole, 1,000 mg daily for 2 months, as prophylaxis against cyst recurrence. After 6 months of follow-up, she is asymptomatic with no evidence of recurrence.
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Comment
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Echinococcus granulosus, the responsible agent for echinococcosis, can reach any part of the body. However, an extrapulmonary location is seldom seen, and in a recent report [2], pleural cysts were the most frequent type (73%) among extrapulmonary intrathoracic hydatid cysts. Cardiac hydatid cyst is very rare, even in regions where hydatid cysts are endemic (the Mediterranean basin, South America, Africa, and Australia). Two-dimensional echocardiography, computed tomography, and nuclear magnetic resonance imaging are useful in the diagnosis and the planning of the surgical procedure, but coronary arteriography should be considered for all patients with cardiac echinococcosis [3], not only those who are older than 40 years [4]. Anginalike pain has often been ascribed either to pericarditis [4] or to partial rupture of the cyst into the pericardial sac [1]. However, it can be true angina if there is direct compression of the coronary artery. It is likely that as it grows, the cyst triggers a process of inflammation and fibrosis that causes organic coronary lesions as a result of toxic irritation [3]. Conversely, Mechmeche and co-workers [5] found deviation, kinking, bulging, and mechanical compression of coronary vessels by hydatid cysts but no intrinsic coronary artery lesions. Capella and associates [6] reported that in their patient, the left anterior descending coronary artery was dislocated and squeezed, causing a nitroglycerin-responsive crisis of angina.
The case of our patient demonstrates that coronary compression by a hydatid cyst for a long period might cause an inflammation process leading to abrupt coronary occlusion. The patient had no history of hypertension, diabetes, or high cholesterol (total and LDL). She was not a smoker or a heavy drinker. Further, the right and circumflex coronary arteries had no evidence of even minimal arteriosclerotic disease. Therefore, we ascribed the alterations in the coronary wall leading to the myocardial infarction to the presence of the long-standing hydatid cyst.
In patients with cardiac hydatidosis, chest pain should also be considered a sign of coronary insufficiency rather than just involvement of the pericardium. This will lead to a more complete diagnostic approach and more timely and appropriate surgical treatment.
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References
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Murphy T.E., Kean B.H., Venturini A., Lillehei C.W. Echinococcus cyst of the left ventricle: report of a case with review of the pertinent literature. J Thorac Cardiovasc Surg 1971;61:443-450.[Medline]
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Rivera R., Delcan J.L. Surgical treatment of coronary insufficiency produced by cardiac echinococcosis. Chest 1980;78:849-852.[Abstract/Free Full Text]
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Kardaras F., Kardara D., Tselikos D., et al. Fifteen year surveillance of echinococcal heart disease from a referral hospital in Greece. Eur Heart J 1996;17:1265-1270.[Abstract/Free Full Text]
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Mechmeche R., Bousnina A., Ismail B. Apport de l’angio-coronarographie dans le diagnostic des kystes hydatiques du coeur. Arch Mal Coeur 1983;76:305-312.
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Capella G., Zolezzi F., Villani R., et al. Echinococcosi cardiaca destra con compressione coronarica. Descrizione di un caso clinico. G Ital Cardiol 1986;16:696-701.[Medline]
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Abstract
Introduction
