Surgery for Cardiac Hydatid Cyst of the Interventricular Septum

Introduction 

This clinical case reports a hydatid cyst of the interventricular septum that was surgically treated under cardiopulmonary bypass using Barrett’s technique. 

Case Presentation 

The authors report the case of a male child weighing 26Kg, with no family history of hydatid disease. Clinical examination revealed hepatomegaly. The chest X-ray (frontal view) was normal. The electrocardiogram demonstrated an irregular heart rhythm, right bundle branch block (RBBB), and P wave abnormalities.The transthoracic echocardiogram showed a cystic lesion in the basal portion of the interventricular septum, bulging toward the right side, with no hemodynamic impact on the mitral or tricuspid valve function. Hydatid serology tested positive. 

The chest CT scan revealed a well-circumscribed cystic lesion involving the interventricular septum and extending to the left ventricular wall. The lesion was oval in shape, with a thickened, duplicated-appearing wall. It appeared spontaneously hypodense, with homogeneous fluid density, and showed no enhancement after contrast administration. Its dimensions were 27 × 25 × 29 mm. 
 
In the liver, there was a large cystic lesion straddling hepatic segments VII and VIII, measuring 72 × 67 mm in maximal transverse dimensions and extending over 61 mm in craniocaudal length. The lesion was also spontaneously hypodense, of homogeneous fluid density, and demonstrated no enhancement following contrast administration. 

The conclusion of the CT scan indicated two uncomplicated hydatid cysts involving the liver and interventricular septum, corresponding to Stage I (Gharbi classification) and CE1 (WHO classification). 

Surgical Strategy 

Based on this presentation, the authors decided to pursue the following strategy: 

1. Surgical treatment of the hydatid cyst of the interventricular septum. 

2. Adjunctive medical therapy with albendazole. 

3. Surgical treatment of the hepatic hydatid cyst. 

After establishing cardiopulmonary bypass with aorto-bicaval cannulation, followed by aortic cross-clamping, cardioplegia administration, and left heart venting, cardiac arrest was achieved. 

Surgical Steps  

A right atrial incision was performed parallel to the atrioventricular groove. Through the tricuspid orifice, the tricuspid valve was retracted to expose the interventricular septum, where a bulging area consistent with a hydatid cyst was clearly visualized. Careful inspection confirmed a well-encapsulated cystic lesion protruding toward the right ventricular inflow tract through the septal wall. The surrounding field was protected using Ganz packs in scolicidal solution to prevent contamination of adjacent cardiac structures. The Barrett technique was utilized, which involves prior aspiration of the cyst contents before excising the hydatid membrane. The cyst was punctured at the highest point with a trocar, avoiding any extravasation of the hydatid fluid, and allowing for the retrieval of 10 cc of “rock water,” which is characteristic of the hydatid cyst. Complete evacuation of the hydatid fluid was necessary to flatten the hydatid cyst. An enlargement of the puncture orifice was performed, and the germinative (proligerous) membrane was then gently dissected and completely extracted in one piece using forceps, preferably of the Duval type, to avoid rupture or dissemination. Care was taken to resect the entire shell flush with the septal muscle. A scolicidal solution (20 percent hypertonic saline) was instilled into the cyst cavity to inactivate protoscoleces. The bottom of the cyst cavity was then wiped with a dry and a Betadine-soaked compress. A partial perikystectomy was performed, followed by the obliteration of the residual cavity and repair of the interventricular septum. The residual cavity was thoroughly irrigated with additional hypertonic saline to ensure sterility and minimize recurrence risk. The residual cavity was then obliterated using a synthetic patch that was tailored to cover the entire septal defect. The patch was secured using a double continuous suture technique with 4-0 polypropylene to ensure tight sealing of the residual space and collapse of the cyst cavity walls. This technique allowed for effective capitonnage, reducing the risk of dead space formation, residual cavity infection, or pseudoaneurysm. Particular care was taken to avoid injury to the conduction system during suture placement. The patient was weaned from cardiopulmonary bypass after 43 minutes and experienced 20 minutes of aortic clamping without difficulty.  In the immediate postoperative period, spontaneous sinus rhythm recovery was noted, replacing the preexisting irregular rhythm. 

Outcomes 

Following the operation, treatment with albendazole was initiated in the postoperative period. After a hospital stay of seven days, the patient was discharged and referred to a digestive surgery consultation for the treatment of the hepatic hydatid cyst. 

References

1. Yildiz M, et al. Multiple hydatid cysts of che interventricular septum. Anatol J Cardiol. 2020.
2. Tuncer E, et al. Large cardiac hydatid cyst in the interventricular septum. Tex Heart Inst J. 2011.
3. Abdelaziz A, et al. Multimodality imaging of an interventricular septum hydatid cyst. Egypt Heart J. 2021
4. Lichter I, et al. Surgery of Pulmonary Rydatid cyst - the Barrett technique.Thorax. 1972

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