PMC9795171_01
Cardiac cyst on 2D-TTE and 3D-TTE. (A) 2D X-plane imaging showed a drop-like and echo-lucent intramural structure (star) bulging into the left ventricle from the myocardium of the left ventricular lateral wall. (B) 3D full-volume imaging: The cyst was round and unilocular, with liquid content and well-defined edges (star). (C,D) 3D zoom imaging (en-face view) from outside (C) and from inside (D) perspectives (arrow), the cyst wall looked homogeneously smooth and hyper-echogenic. Cystic sludge was hypo-echogenic.
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Transthoracic echocardiography (TTE) revealed a drop-like and echo-lucent intramural structure measuring 29 x 21 mm, bulging into the left ventricle from the myocardium of the left ventricular lateral wall and moving synchronously with the cardiac cycle (Figure 1A). The cyst was round and unilocular, with liquid content and well-defined edges; its wall looked homogeneously smooth and hyper-echogenic when seen from outside and inside (Figures 1B-D and Supplementary Videos 1-3).
Hepatic cyst and the cardiac cyst on CT and on MRI. (A) A giant hepatic cyst was seen on the abdominal CT scanner (white arrow). (B-E) An encapsulated, rounded, and fluid-attenuated non-calcified structure along the LV lateral wall (white arrow) and its spatial relationship with coronary arteries (left anterior descending, circumflex) on MDCT. (F) Cardiac cyst (black arrow) and the hepatic cyst (white arrow) were simultaneously depicted on MRI. The cardiac cyst was a single intramuscular cyst located at the anterolateral papillary muscle attached to the LV lateral free wall, protruding into the LV cavity, not enhanced by the gadolinium. Myocardial perfusion and enhancement were normal.
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CT images, the lesion looked primarily intracavitary. Contrast-enhanced MDCT of the heart showed an encapsulated, rounded and fluid-attenuated, non-calcified structure along the LV lateral wall measuring 32 mm x 24 mm, its morphologic features looked similar to that of the hepatic cyst which was shown in the Figure 2A. In computed tomographic 3D volume-rendered images, the cyst was also clearly seen not in contact with coronary arteries (Figures 2B-E). Cardiac MRI also demonstrated a single intramuscular cystic mass located at the anterolateral papillary muscle attaching to LV lateral free wall and protruding into the ventricular cavity (Figure 2F and Supplementary Video 4).
Surgical findings and Echinococcus larvae. (A,B) Echinococcus larvae (arrow) in the hepatic cyst specimen. (C) Cardiac cyst fluid that looked clear yellow was aspirated. (D) Opalescent white and smooth sphere cyst (arrow) was totally removed from the heart. (E) Cyst specimen (arrow). (F,G) Echinococcus larvae at different stages (arrow) in the cardiac cyst fluid.
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Echinococcus larvae were found in the histological specimen of the hepatic cyst wall (Figures 3A,B). The anterior papillary muscle containing the cyst was pale and swollen, and on exposure, the cyst was an opalescent white and smooth sphere containing clear yellow liquid (Figures 3C-E). The cystic fluid contained larvae at different stages that had specific morphological characteristics of Echinococcus granulosus, according to the designation of the World Health Organization and the World Organization for Animal Health (Figures 3F,G).
3D-TEE at 1-year follow-up. (A) Mitral anterior leaflet prolapse (white arrow) on a mid-esophageal two-chamber view (left panel) and the origin of the regurgitation jet with color Doppler (right panel). (B) X-plane imaging with two orthogonal views shows exactly the prolapsed scallops (white arrow). (C,D) 3D-zoom images of the mitral valve from the left atrial perspective (surgeon's en-face view) show exactly A1 (black arrow) and A2 (white arrow) prolapse (C) normal 3D gain vs. (D) true view mode.
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Cardiac MRI also demonstrated a single intramuscular cystic mass located at the anterolateral papillary muscle attaching to LV lateral free wall and protruding into the ventricular cavity (Figure 2F and Supplementary Video 4). However, the 12-month 2D-TTE revealed mild to moderate mitral regurgitation due to prolapsed A1 and A2 segments that were confirmed by 3D transesophageal echocardiography (3D-TEE) (Figures 4A-D); the prolapse was probably due to resection of the anterior papillary muscle at the time of cyst removal.