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Nazirov Feruz Gafurovich, director of "Republican Specialized Scientific-Practical Medical Center
of Surgery named after acad. V. Vakhidov" academician of the Academy of Sciences of the Republic of Uzbekistan, Government company "RSSPMCS named after acad. V. Vakhidov" G.C.
Abdumadzhidov Hamidulla Amanullaevich, Ph.D., DS. Head of the Department of cardio Surgery "RSSPMCS named after acad. V. Vakhidov" G.C.
Akbarov Mirschavkat Miralimovich, doctor of medical sciences, prof., Head of the Department of cardio Surgery "RSSPMCS named after acad. V. Vakhidov" G.C.
Buranov Khairulla Zhumabaevich, Ph.D., Head of Department of Cardiosurgery of "RSSPMCS named after acad. V. Vakhidov" G.C.
Tursunov Nasritdin Toshevich, Head of the Department of Thoracic Surgery of "RSSPMCS named after acad. V. Vakhidov" G.C.
E-mail: cs.75@mail.ru
SURGICAL TREATMENT OF COMBINED ECHINOCOCCOSIS OF HEART AND TARGET ORGANS (LUNGS, LIVER)
Abstract: In the article was reviewed results of diagnostic methods and surgical treatment of 33 patients with hydatid cyst of heart. Basic diagnostic technique was echocardiogram and Magnetic Resonance Imaging (MRI). Postoperative lethality was 9,06%. Spontaneous perforation and anaphylactic shock were observed in 6% cases. Among not fatal complication there often were observed heart rhythm disturbance.
Keywords: hydatid cyst, echinococcosis of heart, cardiopulmonary bypass, surgical treatment.
Introduction: Hydatid cyst of the heart is rare, amount- Accordingly, the aim of study was to analyze and evaluate
ing to only 2.0% of all localizations of this zooanthroponosis the results of surgical treatment of patients with combined
[1; 4; 6; 8; 10; 11]. Despite certain advances in the medical hydatid cyst of heart and target organs (lungs or liver). and surgical treatment of heart hydatid cyst, it is still remains a Material and methods: of investigation. In the center of
serious medical and social problem. A small number ofworks surgery for the period from 1986 to 2017 in 33 patients was
on the surgery of heart hydatid cyst attract attention [1-3, diagnosed combined hydatid cyst of the heart/ pericardium
10]. In the endemic areas there is a rather "high" frequency and target organs (lungs, liver). All these patients underwent
of patients with heart echinococcosis. The small number of surgical treatment. The age of the patients ranged from 7 to 64
publications and clinical observations on the diagnosis and years, an average of 26.7 ± 2.7years. The men were 15(48.2%)
surgical treatment indicates a lack of awareness of clinicians and women-16(51.7%). Diagnosis of parasitic heart disease
about the diagnostic features and the possibilities of surgical concluded by means of chest radiography, transthoracic (TT)
treatment. There is no consensus in the literature regarding the and transesophageal (TE) echocardiography (EchoCG), mul-
tactics of surgical treatment of heart hydatid cyst. The issues tislice spiral computed tomography (MSCT), and coronary
of simultaneous surgical interventions in combined hepato- angiography.
cardial and cardiopulmonary hydatid cyst remain "open". A Surgical intervention in 11 cases (35.8%) was carried out
number of researchers consider, that it's necessary to perform on pump (75.0 ± 7.6 min) and cardioplegia (45.3 ± 4.9 min)
simultaneous operations in hydatid cyst of the pericardium from sternal access. In 20(64.5%) cases with hydatid cyst of
and lungs, justifying their point of view by the location of the pericardium or combination with lungs, interventions
parasitic cysts in one anatomical cavity. performed off pump by thoracotomy access.
On pump operations included a standard connection to the circulation device (according to the aorta-vena cava scheme) and antegrade pharmaco-cold cardioplegia. After asystole, a hydatid cyst was lined with a gauze pad, puncture of the cyst cavity was performed in the most convex non-vascular part. Then, its contents were removed by external suction; then cystectomy were performed.
The residual cavity was treated with 30% solution of the sodium chloride or 80-100% solution of the glycerol. If possible, partial pericystectomy was performed. The region of cystectomy was sewn with a double-suture seam with a filament 2/0 - the first row with U-shaped seams on the gaskets, the second row with a continuous suture seam. Cysts from the interventricular septum (IS) were removed from right atrial access. In this case, after puncture and aspiration ofthe contents ofthe cyst by an "external" suction, the cavity of the cyst was opened and performed the cystectomy, the cavity was treated with anti-scleric drugs and the cavity was left widely "open" to right ventricular cavity for constant "irrigation" of the parasite cavity with blood.
In 6(19.3%) cases, hydatid cyst of heart was combined with parasitic damage of liver. Simultaneous-sequential cystectomy was performed in 4 patients. In this cases performed on pump echinococcectomy from the heart, and then from the liver through the upper-median laparotomy with the capi-tonage of the cyst bed. In 2 patients, was performed staged tactics, such as, first of all cystectomy from the heart, and then, after normalization of the general condition of patients after 2-3 weeks the next stages of the operation (from the liver). The postoperative period of patients with combined hydatid cyst of the heart and liver was relatively smooth.
In 5 (8.9%) cases performed concomitant cystectomy from the heart and the lungs. The simultaneous tactics of surgical treatment used successfully. In 20 (35.7%) cases, we observed combined lesions of the pericardium and lungs. In all of this patients were successfully operated off pump by thoracotomy, simultaneously from the lung and pericardium. Cysts of the pericardium in most cases were located extrapericardially. In another one patient, additionally to pulmonectomy (due to multifocal recurrent lung lesions) performed cystectomy from the pericardium.
In 2(3.5%) cases, there was a multifocal lesion of the heart, pericardium, lungs and mediastinum. In the process of sternotomy a clinical picture of anaphylactic shock was observed, which led to a lethal outcome. The autopsy confirmed multifocality of parasitic lesion of the thoracic organs with perforation of cysts in the heart cavity.
In the postoperative period, all patients underwent three courses of anthelmintic chemotherapy with the use of mebendazole or albendazole (10-15 mg/kg per day) with monthly intervals under the control of blood tests [1; 2; 13; 15; 16].
Results. The total postoperative mortality among observed patients were 9.06% (3 patients). In one of them, the cause of the fatality was iatrogenic damage to the anterior descending artery during removal of the parasitic cyst of the interventricular septum.
Perforation is a fatal complication, which was observed in 2(6%) patients at the stage of sternotomy. Both patients experienced perforation of the right heart tense cyst in the right ventricular cavity with the development of severe anaphylactic shock leading to a fatal outcome.
Relapse of the disease for 5 years was not detected. In the postoperative period, anthelmintic therapy was performed according to the recommendations.
Among the non-fatal complications, the most frequently encountered ventricular arrhythmias, which was noted in 6(18.1%). Heart failure in 5(15.1%) patients and one of them had pneumopathy. The abdominal and pleural complications have not been revealed.
The volume and functional parameters of the heart were not changed. There was no accumulation of fluid or suppuration of the residual cavity. Dynamical changes showed a decrease in the residual cavity.
Discussion. Echinococcosis of the heart is a rare parasitic lesion whose frequency of occurrence, according to different authors, does not exceed 2% [1; 3; 6; 13; 14]. More often observed in young people, mostly male [2; 5; 11]. In our study group, the average age of patients is 26.7 ± 2.7 years, which again indicates the high incidence among young people.
In the world literature there are data that patients with echinococcosis of the heart are hospitalized in hospitals with a clinic for coronary blood flow disturbances [1; 4; 10]. In our study, in 22.7% of cases in the preoperative period, myocardial ischemia was detected on the ECG, the signs ofwhich disappeared after the operation. According to the literature, in 7-15% of cases, spontaneous perforation of the cyst into the cavity of the pericardium or into the heart cavity is observed with the development of anaphylactic shock [2; 13; 17]. Some authors describe cases of perforation of cysts during cardiopulmonary resuscitation. In our study, 2(6.4%) patients died due to perforation of echinococcal cysts in the heart cavity at the stages of sternotomy.
A special place in the intravital diagnosis of heart echinococcosis is with echocardiography [8; 9; 15]. We consider it advisable to conduct transesophageal EchoCG and MSCT for all patients, which allows not only to detect cystic heart formation, but also to detail topographic location, cyst size and relationship with coronary vessels [9, 14-16]. The literature describes the case of a multi-chamber echinococcosis of the heart simulating a picture of the polycystic myxoma of the left atrium. Only intraoperatively the authors managed
to establish a clinical diagnosis: echinococcosis of the heart [12]. Echocardiography also plays an important role in postoperative monitoring of patients and for the timely diagnosis of relapse of illness [8; 9].
Echinococcosis of the heart is an intracardiac infection, the treatment ofwhich is carried out according to all the rules of purulent-septic surgery. These operations required the development of a new optimal surgical tactic, since an ideal cystectomy involving the complete removal of a cyst with a fibrous capsule is unacceptable in heart surgery. According to the world literature, surgical treatment is the method of choice for heart echinococcosis [3; 4; 6; 11; 14; 16].
When choosing surgical tactics, a number of authors prefer operations on the "working" heart from thoracotomy access, especially with pericardial echinococcosis [2]. Carrying out the operation on the "beating" heart, to remove the echinococcal cyst is associated with a number of complications, such as dissemination of the contents of the cyst, the possibility of accidentally taking nearby coronary vessels into the suture during the cardiac cycle, the perforation of the body during the treatment of the parasite bed, risk of aeroemboli and also non-radical removal with a high risk of recurrence of the disease.
When analyzing the literature, it is established that one in six patients dies from bleeding during surgical treatment, especially if the latter is not performed on pump. Therefore, some authors, fearing the occurrence of a number of complications (bleeding, rupture of the myocardium, etc.), consider it expedient to perform cystectomy from the heart in conditions of IR and KP [3, 4, 6, 11, 12, 14, 16]. We also consider it expedient and justified to fulfill the EE under conditions of infrared and KP on an "immobilized" heart.
Concerning the number of cystectomy from the heart, it should be noted that the experience of a single team of authors does not exceed 2-3 observations. In this respect, only a few
authors, such as Shevchenko Yu.L. (2006), Bouraoui H. et al. (2005), Orhan G. et al (2008), Kabbani S. S. et al. (2007) have experience of cystectomy from the heart in 5-19 patients. The largest clinical material is the experience of Thameur H. et al. (2001) from Tunisia, who described 45 patients with heart echinococcosis.
Unfortunately, there is no single point of view regarding the tactics of surgical treatment of the combined echinococcosis of the heart and target organs. So, many sources report the phased removal of echinococcal cysts first from the target organ, after a short period of time - from the heart. In contrast, Kabbani S. S. et al. (2007) in their 8 observations the first stage of cystectomy was performed from the heart, after 3-6 months from the liver or lungs.
The current level of development of cardioanesthesiology and cardiac surgery allows for successful simultaneous operations. According to N. O. Travin [2], simultaneous operations of the hydatid cyst of the pericardium and lungs are possible, because the cysts are in one anatomical cavity. The results of our studies indicate that simultaneous operation is suitable, even when the parasitic cyst is located simultaneously in different anatomical cavities (thoracic and abdominal). Hospital lethality after surgical treatment ranges from 5 to 20%.
Conclusions
Transthoracic echocardiography is a screening method for diagnosing hydatid cyst of the heart.
Surgical treatment is the method of choice for heart hy-datid cyst.
It is advisable to fill the echinococcectomy from the heart in conditions of artificial circulation and cardioplegia.
In case of hepatocardial, cardiopulmonary and pericardial pulmonary hydatid cyst, one-stage - sequential echinococcectomy is possible.
Perforation of the echinococcal cyst is a fatal complication.
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