Semptomatik dev bir parakardiyak kist hidatik olgusu

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Introduction
The diagnosis of paracardiac masses is one of the
mostly encountered difficulties in clinical practice.
Such patients are frequently misdiagnosed as dyspnea of
pulmonary origin unless a detailed examination is performed. Pericardial cyst is the most common benign
paracardiac mass lesion, and typically located along the
right cardiophrenic angle. Slowly enlarging echinococcal cysts generally remain asymptomatic until their
expanding size or their space-occupying effect elicits
symptoms in an involved organ. The liver and lungs are
the most common sites of these cysts. Since a period of
years elapses before cysts enlarge sufficiently to cause
symptoms, they may be discovered incidentally on a
routine x-ray or ultrasonographic study.
In this case report, we present a case of paracardiac
mass, which had been followed as obstructive lung disease until echocardiography revealed and computerized tomography (CT) confirmed the presence of a cystic structure just adjacent to the right and left atria. The
importance of imaging techniques in such cases is also
discussed.
Case Report
A 57-year-old man had admitted to the pulmonologist because of exertional dyspnea, cough, and positional chest pain. His history revealed that he had been
treated for chronic obstructive pulmonary disease for 15
years. He denied systemic diseases including hypertension, diabetes mellitus or previous chest trauma. The
chest pain was not suggestive of angina pectoris and not
associated with exertion. The chest roentgenogram and
standard surface ECG were normal. The patient was
* GATF Kardiyoloji AD
**GATF Kalp Damar Cerrahisi AD
Ayrý basým isteði: Dr. Mehmet Yokuþoðlu, GATF Kardiyoloji AD, Etlik
06018, Ankara
E-mail: myokusoglu@gata.edu.tr
Makalenin geliþ tarihi: 26.03.2007
Kabul tarihi: 14.05.2007
OLGU SUNUMU/CASE REPORT Gülhane Týp Dergisi 2008; 50: 50-52
© Gülhane Askeri Týp Akademisi 2008
Summary
Diagnosis of paracardiac masses is problematic in clinical
practice, and they may remain asymptomatic for a long
period. We herein report a case of mass posterior to the
heart in a 57-year-old male. Computed tomography examination showed a thin-walled cystic mass containing liquid,
suggesting a relationship with pericardium at first. Further
examination with transthoracic and transesophageal
echocardiography revealed that paracardiac mass did not
have any relationship with heart structure. The patient
underwent thoracic surgery and the pathologic examination
revealed that the mass was an echinococcus cyst.
Key words: Computed tomography, cyst hydatid, echocardiography, giant paracardiac mass
Özet
Semptomatik dev bir parakardiyak kist hidatik olgusu
Parakardiyak kitlelerin tanýsý klinik uygulamada problem
olmaktadýr ve bu kitleler çok uzun süre asemptomatik
olarak kalabilir. Bu olgu sunumunda 57 yaþýnda erkek hastada kalbin posteriyorundaki bir kitleyi sunuyoruz. Bilgisayarlý
tomografik incelemede ilk bakýþta perikardla iliþkili
olduðunu düþündüren ince duvarlý, mayi içeren kistik kitle
saptandý. Transtorasik ve transözefageal ekokardiyografik
incelemelerde parakardiyak kitlenin kalp yapýlarý ile iliþkisi
olmadýðý görüldü. Torasik cerrahiye verilen hastanýn patolojik deðerlendirmesi kitlenin ekinokok kisti olduðunu ortaya
koydu.
Anahtar kelimeler: Bilgisayarlý tomografi, kist hidatik,
ekokardiyografi, dev parakardiyak kitleCilt 50 · Sayý 1 · Gülhane TD Paracardiac cyst hydatidis · 51
referred to cardiologist for further evaluation. His physical examination was normal except for 1/6 grade systolic murmur best heard at mesocardium. The patient
underwent echocardiographic examination in order to
evaluate cardiac functions. On apical four chamber
view a mass was visualized totally adjacent to the left
and right atria (9x12 cm) (Figure 1), and on subcostal
view, a smooth paracardiac mass adjacent to the left atrium was noticed (Figure 2). Cardiac structures and
functions were assessed normal. Thoracic CT revealed
a cystic mass occupying the aortapulmonary window
(Figure 3). There were no signs of aortic aneurysm,
hemothorax or pneumomediastinum. Subsequent
serologic tests for hydatidosis (indirect hemagglutination tests) were positive for echinococcus granulosus
with marked eosinophilia. The patient underwent
surgery. The patient was prepared for the operation and
after median sternotomy an inverse Y shaped pericardiectomy was done, and a 7x6x11 cm cyst was seen
on the right and left atrial walls of the heart. With a surgical blade the calcified pericystic layer was incised and
cyst content was taken away completely with a large
injector having a wide needle. After the aspiration of all
fluid content NaCl 20% solution was injected into the
cyst. Five minutes later this solution was aspirated
through the same place at one time. With a gentle cut,
the incision line in pericystic layer was extended without harming the cyst pouch. The cyst pouch was taken
out by forceps. The cavity was washed out again and left
open. After the operation albendazol therapy was continued in the intensive care unit. The patient was discharged from the hospital on the 5th postoperative day
with the same medication and pathologic examination
confirmed that the mass was an echinococcus cyst.
Discussion
Benign paracardiac masses might be originated from
lung, lymph node, pleura, pericardium or vascular
structures. Pericardial cyst is the most common benign
paracardiac mass lesion (1).
Paracardiac masses may alter the cardiac contour on
roentgenograms of the chest so as to mimic configurations associated with cardiac disease. Although many
uncommon locations have been reported, the disease is
rarely present in mediastinum. Large mediastinal
hydatid cyst may compress the vital organs and produces pressure symptoms. These symptoms are similar
to those of the other mediastinal cystic lesions.
Differentiations may be impossible even with sophisticated radiological imaging techniques (2). EchocardioFigure 1. Apical four chamber view of transthoracic echocardiography. LV; left ventricle, LA; left atrium, RV; right ventricle,
RA; right atrium
Figure 2. Subcostal view of transthoracic echocardiography. LV;
left ventricle, LA; left atrium
Figure 3. Computed tomography of the patient. LV; left ventricle, RV; right ventricle, RA; right atrium, Ao; Aorta52 · Mart 2008 · Gülhane TD Köz et al.
graphy and CT allow visualization of the paracardiac
masses. CT is less precise in defining highly mobile
structures, more expensive and difficult to perform in
patients with orthopnea. However, identification of a
pericardial cyst on CT is a simple task based on its wellcircumscribed nature, its fluid attenuation and its relationship to the pericardium. Echocardiography is easy
to perform and gives real time images. In addition, it
may provide information about the structural and functional effects of paracardiac masses on heart. However,
localization and nature of the mass may limit this
advantage, such as, if anteriorly localized, mass may
hamper the image. Solid and air-filled lesion may prevent structural relation between mass and heart. On this
occasion, transesophageal echocardiography may surpass this limitation. Visualization of mediastinal and
thoracic structures adjacent to the heart is difficult by
echocardiography (3). In addition, it often fails to provide a complete view of the mass and involved structures to aid in its full definition. Consequently, magnetic resonance imaging, CT and echocardiography are
diagnostic modalities in evaluating the paracardiac
masses adjacent to the heart with different accuracy (3-6).
In conclusion, the present case is important for considering the paracardiac mass by transthoracic echocardiography and transesophageal echocardiography imaging according to structural and functional hemodynamic nature.