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Ann Thorac Surg 2000;70:1003-1004
© 2000 The Society of Thoracic Surgeons
lu, MDa
eref Küçüker, MDauz Ta
demir, MDa
a Department of Cardiovascular Surgery, Türkiye Yüksek 
htisas Hospital, Ankara, Turkey
To the Editor
As with clinical diversity of cardiac and pericardiac echinococcosis [1], surgical treatment options are also diverse with respect to localization and complications caused by them. However most cardiac echinococcosis seeds on the ventricular myocardial tissue due to its rich blood supply, and the treatment of these cysts may partly be standardized. During the early years of our experience, we removed the cystic region with its surrounding wall as in a ventricular aneurysmectomy operation and the residual defect was either primarily repaired or a patch was used. Later we found such a large resection unnecessary and figured that we could operate with "off pump" technique.
Cysts which are embedded in the ventricular myocardium may grow towards the endocardium or towards the adventitia by myocardial contractions. The cysts which grow towards the endocardium, because of the sheer stresses of the blood in the ventricular cavity, may rupture and their contents mix with the circulation. The cysts which grow towards the adventitia usually sit between the adventitia and myocardium by dissecting these two layers. This latter group constitutes the majority of cases. They may create an inflammatory reaction causing adherent pericardium and sometimes cysts may open into the pericardial cavity. Opening the surface of the cystic area means removal of already dissected layers and will not create any additional weakening for remaining myocardial tissue. So we prefer to open all the "cysts’ tops" and remove them with all their extensions, leaving the cardiac tissues in place with the aid of scissors or scalpels. The holes are then cleared of any debris with curettage and they are left open after they are washed with polivinylprodine. We believe that all pouches, however deep they may be, should be left open. In time these pouches will be closed with secondary healing. In our series we removed large cystic masses and left the pouch open and did not observe any complication related to this strategy. If one tries to suture this cavity for closure, this might lead to tears as the ventricle starts to contract. The only mortality in our series was due to this complication [1]. We do not find it practical to fill a large pouch with biologic glue. This will create an akinetic segment and can impede the contraction of neighboring myocardial segments. Filling the space with biologic glue is akin to removing one mass and replacing this with another. This is especially true for some cysts which are not alive and do not have the ability to grow any further, yielding the surgery meaningless.
Aspiration of the ventricular cyst contents is a maneuver easing the surgical treatment. First, if there is difficulty for echocardiographic diagnosis (some cysts resemble tumor tissues under echocardiography), needle aspiration of the cystic mass content is very helpful for diagnosis. Second, if there is controversy about the existence of a communication between cyst cavity and intracardiac compartments, needle aspiration may provide clues. As a result of cardiac mass movement cystic mass also moves and cystic fluid may reveal color changes with color doppler echocardiography. Again if there is a connection between cystic mass cavity and blood, this may reveal "smoke like" stasis on echocardiography as in mitral patients with giant left atrium, resembling viable hydatic cysts containing scolexes. In this setting, if blood is aspirated into the needle, one should think of communication of cyst cavity and cardiac chambers and should than cannulate the patient and perform the operation under cross-clamp. Third, for cysts with high pressure, dissecting leaks may occur and may infect the surroundings. For this reason, first aspiration of some cyst fluid, then injecting polyvinylpyrolidone iodine into the cyst cavity will kill the living scolexes. Distension may then be reduced with aspiration easing the surgical manipulations. This strategy will also provide more safety since most operations are performed with "off-pump" technique especially if the cysts are localized laterally or inferiorly; prolonged dissection time with lifting the heart cannot be tolerated hemodynamically.
Both mebendazole or albendazole could be used during the postoperative period for medical treatment and we believe there exists no major advantage in choosing one or the other.
References
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