Case Presentation
A 68-year-old woman presented to a health care center with a clinical manifestation of a slow-growing and painless lump on the right side of the cervical region over several weeks. She had no cardiac symptoms. History-taking revealed working in a sheep-farming area in her twenties. Past medical and surgical history included hypertension and hepatic hydatidectomy two years ago.
Clinical examination through ultrasound imaging revealed a 47mm×75 mm cervical cyst expanded to superior mediastinum with neither inflammatory response nor spasm of the cervical muscles. The cervical cyst consisted of a bilayer membrane with several membrane-attached scolices, indicating an active hydatid cyst (cystic echinococcosis type 1, CE1). The lesion was lateral to the common carotid artery and posterior to the internal jugular vein with no cervical lymphadenopathy. Besides, the abdominal ultrasound examination showed multiple active, recurrent hepatic cysts in both the right and left lobes (stage 1), encompassing all liver segments. There was no evidence of biliary dilatation as well.
In the transthoracic echocardiographic (TTE), a bulging and well-defined echo-lucent cystic mass in the interventricular septum measuring 33×42 mm was detected (figure 1). A slight compression effect was present on the right ventricle (RV) cavity. The LV size and LV outflow tract (LVOT) were normal, with a mild systolic dysfunction (eye-ball estimation of LV ejection fraction = 45-5%). The valvular functions were normal, with no pericardial effusion. Other echocardiographic findings were unremarkable. The hydatid serology was positive, in which the enzyme-linked immunosorbent assay (ELISA)-based qualitative assessment of E. granulosus IgG antibodies confirmed the echinococcosis. Finally, the patient underwent cardiac surgery using cardiopulmonary bypass (CPB) for cystectomy to minimize the risk of spillage of cyst contents. The CPB technique was established by cannula inserting into the ascending aorta, superior vena cava (SVC), and inferior vena cava (IVC) after the routine median sternotomy. Following the cold cardioplegia, the established hypothermia was recorded at 32 °C. The outlines of the isolated cardiac cyst seemed to be complete and clear. Conservative procedures were further performed to sterilize and evacuate the cyst contents. The RV cavity was entered, and the cyst was exposed carefully. Thereafter, ten milliliters of its contents were aspirated. An equal amount of hypertonic saline (NS 20%) was injected into the cyst, and after several minutes, the exposed cyst was evacuated completely (figure 2). Following successful excision and secured hemostasis, the cyst specimen, containing 8 ml colorless turbid fluid, was sent to the histopathological examination, which further vouched for the diagnosis of a hydatid cyst (figure 3).