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9UDC: 616.36-002.951.21
ECHINOCOCCOSIS OF THE PERICARDIUM (CASE FROM PRACTICE)
I.H. Bebezov, A.A. Rakimbaev, M.K. Dzhundubaev, D.B. Toktosunova, E.D. Seitahunova, R.S. Kalieva, A.K. Turgunov
Research Institute for Heart Surgery and Organ Transplantation, Bishkek, Kyrgyz Republic
Abstract
Echinococcosis is a parasitic disease widespread in many countries of the world and continues to remain a serious medical and national economic problem. The article presents a rare case of a giant echinococcal cyst localized in the pericardial cavity with invasion into the left ventricular myocardium and causing compression ofthe left heart, as well as surgical intervention aimed at its complete removal. Key words: echinococcosis of the pericardium, echocardiography, computed tomography.
УДК 616.36-002.951.21
ПЕРИКАРДИУМДУН ЭХИНОКОККОЗИ (ПРАКТИКАДАН УЧУР)
И.Х. Бебезов, А.А. Ракимбаев, М.К. Джундубаев, Д.Б. Токтосунова, E. Д. Сейтахунова, Р. Калиева, А.К. Тургунов
ЖYрeк хирургиясы жана органдарды трансплантациялоо илимий - изилдее институту, Бишкек шаары, Кыргыз Республикасы
Аннотация
Эхинококкоз - паразитардык оору, дYйнвнYн квптвгвн елкелерунде кецири таралган жана олуттуу медициналык жана экономикалык квйгвй бойдон калууда. Макалада перикардиалдык квцдвйдв локализацияланган жана сол карынчанын миокардына кирип, сол журвктун кысылышына алып келген ири эхинококк кистасынын сейрек учуру келтирилген, ошондой эле аны толугу менен алып салууга багытталган хирургиялык кийлигишYY.
Негизги свздвр: перикардиалдык эхинококкоз, эхокардиография, компьютердик томография.
Address for Correspondence: Candidate of Medical Sciences, Associate Professor I.H. Bebezov
tel.:+996 555 99 99 83
УДК 616.36-002.951.21
ЭХИНОКОККОЗ ПЕРИКАРДА (СЛУЧАЙ ИЗ ПРАКТИКИ)
И.Х. Бебезов, А.А. Ракимбаев, М.К. Джундубаев, Д.Б. Токтосунова, Э.Д. Сейтахунова, Р.С. Калиева, А.К. Тургунов
Научно-исследовательский институт хирургии сердца и трансплантации органов, Бишкек, Кыргызская Республика
Аннотация
Эхинококкоз - паразитарное заболевание, распространенное во многих странах мира и продолжает оставаться серьезной медицинской и народно-хозяйственной проблемой. В статье приведен редкий случай гигантской эхинококковой кисты, локализованной в полости перикарда с прорастанием в миокард левого желудочка и вызывающей сдавление левых отделов сердца, а так же хирургическое вмешательство, направленное на полное ее удаление.
Ключевые слова: эхинококкоз перикарда, эхокардиография, компьютерная томография.
Introduction
Echinococcosis in the Kyrgyz Republic is a hyperendemic pathology and is widespread both in its northern part, where the population is traditionally engaged in cattle breeding, and in the southern part, where the most of the population is engaged in field work. Along with the widespread prevalence of echinococcosis of the liver, lungs, echinococcosis of the heart and pericardium is often found [1].
Cardiopericardial echinococcosis, as a disease, has long attracted the attention of doctors, since it often served as the cause of sudden death of patients. Nowadays, interest in this localization of parasitic cysts has increased even more, since the possibilities of surgical treatment of these patients have increased. The first indications of heart damage by echinococcus are available in May (1639). 200 years later, Smith described in detail the sudden death of a woman in whom an autopsy revealed a large echinococcal bladder that filled the right ventricle so that the passage of blood into the pulmonary artery was blocked. Among Russian authors, N. Kashin first described 2 cases of the location of echinococcal cysts in the walls of the heart in 1862. [5, 10].
Despite the fact that historians of medicine attribute the first attempts at surgical treatment of parasitic cysts to Hippocrates, there is still no consensus among experts in choosing the optimal
strategy for treating cardiac echinococcosis. There are reports of positive results of conservative treatment with albendazole.
Other authors reduce the field of application of chemotherapy without surgery only to patients with inoperable options or those who refused surgery [4]. Still others perform heart surgery after a course of chemotherapy [3]. Still others believe that treatment with albendazole before surgery is deadly and absolutely contraindicated due to the softening of the parasite wall during treatment and the multiply increasing risk of cyst rupture [2.8]. Finally, the fifth note the low effectiveness of chemotherapy even after the removal of hydatids [6, 11].
Clinically, cardiopericardial echinococcosis is diagnosed very rarely, more often it is an unexpected finding, as any clinical signs appear, reflecting the degree of involvement of various structures of the heart by the pathological process. Late diagnosis can lead to such formidable complications as: cardiac tamponade with rupture of an echinococcal cyst, which leads to sudden death, various cardiac arrhythmias, dissemination of echinococcal cysts by blood flow [2].
We diagnosed a secondary form of large echinococcosis, localized in the pericardial cavity with invasion into the left ventricular myocardium and causing compression of the left ventricle of the heart.
Description of the clinical case.
Patient K.O., 57 years old, was in hospital at the Department of Acquired Heart Diseases of NIIKHSTO since 23.11.2018. until 17.12.2018 The patient complained of shortness of breath and palpitations at rest, aggravated by insignificant physical exertion, suffocation and a feeling of lack of air in a horizontal position, heaviness and pain in the right hypochondrium, general weakness.
From the anamnesis of life: social conditions are satisfactory. he is engaged in animal husbandry of small and large livestock. From the anamnesis of the disease: in 2002 he underwent surgery to remove an echinococcal cyst of the lower lobe of the right lung. The postoperative period was smooth, was discharged with an improvement in general condition and well-being. The deterioration of the condition began to be noted since February 2018,
when the above complaints appeared. It was examined at the place of residence, where a significant increase in the shadow of the heart to the left due to the left ventricle is determined on the chest x-ray. KTI = 61%. Received treatment at the place of residence, there is no effect from the medication. The patient was referred to NIIKHSTO for an EchoCG study, where a large cystic formation was found between the pericardial layers with invasion into the myocardium of both ventricles and their compression. The size of the cystic formation was 15.0x7.0 cm. Aimed at computed tomography (CT) of the chest organs, where a volumetric formation of the pericardium (echinococcal cyst of the pericardium?) was detected. Additional features: the heart is displaced to the left and up.
Figure 1. X-ray CT data: volumetric formation behind the apex of the left ventricle, heterogeneous fluid density, with a thick capsule up to 5 mm, with the presence of internal septa, size 140x100x90 mm, leads to deformation of the left ventricle.
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Figure 2. Anterior X-ray CT data.
Laboratory data: UAC: Hb - 136 g / l, erythrocytes - 4.4 x 10 A 12 / l, CP - 0.92, Ht-40.8%, platelets - 215 x 10 a 9 / l, leukocytes - 5, 2 x10 a 9 / l, ESR - 19 mm / h, p / i - 3%, s / i - 58%, eosinophils -2%, lymphocytes - 34%, monocytes -3%. SSK: ACT 9 sec., PV - 13 sec., PTI - 100%, INR-1.0, fibrinogen A - 4218 mg / l, APTT - 44 sec. Creatinine - 66.4 mmol / L, total bilirubin - 8.4 mmol / L. OAM: straw-yellow color, beats. weight 1016, protein - neg., leukocytes 1-2-1 in FOV.
On November 27, 2018 at the Research Institute of Heart Surgery and Organ Transplantation, an operation was performed in a planned manner - echinococcectomy from the pericardial cavity under conditions of artificial circulation (IC). On surgery: median longitudinal sternotomy. On the left lateral surface, a formation is visualized, tightly adhering to the anterior - lateral surface of the heart, which squeezes the apex of the left ventricle and partly of the right ventricle, with a
longitudinal size of about 10.0 cm. The formation is tightly soldered to the pericardium. The anterior surface of the formation is partially released, the lateral surface is intimately fused with the myocardium of the right ventricle. When trying to further isolate the formation, hypotension is noted. Taking into account the unstable hemodynamics of the patient, it was decided to carry out further manipulation in the conditions of IC. The entrance to the IC was unremarkable, hemodynamics were stable. A fibrous capsule was opened on the beating heart, and about 1.0 liters of echinococcal cysts with sizes from 0.5 to 4.0 cm were evacuated. The cavity of the fibrous capsule reaches the posterior wall of the pericardium, with a volume of more than 1.0 liters. The fibrous capsule is excised as much as possible. End of IC. Control for hemostasis. Drainage of the pericardial cavity and anterior mediastinum. Layer-by-layer wound closure.
Figure 3. Echinococcal cyst of the pericardial cavity.
Pic. 4. Echinococcal cyst
of the pericardial cavity Pic- 5* Echinococcal cyst
The postoperative period was uneventful. He was transferred to the CPPS department for further treatment and observation. Was discharged with improvement in general condition and well-being. At this time, the patient is registered with a cardiologist and surgeon at the place of residence.
In the clinical picture of uncomplicated echinococcosis, there are no specific symptoms, based on which a reliable diagnosis could be established. In areas endemic for the disease, the detection of cystic lesions of organs by ultrasound examination should be considered from the standpoint of the possible presence of a parasitic disease, which requires the use of a set of diagnostic measures to confirm the disease.[1]
In the diagnosis of cardiac echinococcosis, the main place is occupied by instrumental research methods (chest x-ray, echocardiography, computed tomography). The combination of echocardiography, CT and serological reactions (ELISA) allows in 86-91% of cases to establish the correct diagnosis of the disease. [2]
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