Education: Cardiovascular Imaging

Case Report - Imaging

Extensive pulmonary artery embolisation and pulmonary hypertension caused by cardiac hydatid cyst rupture

Dr Jason Harmer, June 2022


Figure 1
Transthoracic echocardiogram: apical 4 chamber view. Intracardiac hydatid cyst.

Apical attachment of a large hydatid cyst to the wall of the RV. The RV chamber is dilated and hypokinetic and the septum is dyskinetic. The distal portion of the hydatid cyst is mobile. The RA is severely dilated and the interatrial septum is displaced due to pressure overload. The tricuspid annulus appears dilated.

Figure 2
Transthoracic echocardiogram: parasternal short axis view. Intracardiac hydatid cyst.

There is a large mass (hydatid cyst) in the RV that appears to be fixed to parts of the interventricular septum. Motion of the interventricular septum is abnormal, in part due to attachment of the mass and from raised pressures in the right heart. Interventricular septal flattening is a sign of raised right heart pressures. This patient has known moderate to severe pulmonary hypertension as a consequence of dissemination of hydatid disease to the lung and pulmonary thromboembolism.

Figure 3
CT pulmonary angiogram: coronal view. Multiple hydatid masses within the pulmonary vasculature.

Multiple lobulated areas within the pulmonary vasculature from extensive dissemination of hydatid disease originating from the RV.

Abbrev. 
CT = computed tomography; RV = right ventricle; LV = left ventricle; RA = right atrium.
Figure 4
CT pulmonary angiogram: axial view.

There is a dense mass within the RV chamber due to a hydatid cyst. There is reduced RV blood filling in diastole due to the space occupying mass.  The interventricular septal wall is clearly demarcated and the mass appears to encroach on the septal wall at two points. The RV is enlarged and occupies the apex of the heart. The sternum has been divided in two parts from a previous stenotomy (with incomplete surgical resection of the mass, leading to regrowth). There is a cavitating lesion in the posterior aspect of the left lung.

Background

This case is a rare example of cardiac hydatidosis found in a patient in rural NSW, Australia. He was a middle-aged man who initially presented with a ruptured right ventricular hydatid cyst causing an anaphylactoid-like reaction, pulmonary emboli and widespread dissemination of hydatid echinococcus throughout the lung. He survived the cyst rupture and underwent cardiac surgery, but had incomplete resection and experienced progressive cardiopulmonary hydatidosis despite ongoing antihelminthic therapy. He had an array of cardiopulmonary sequelae over his lifespan, including worsening pulmonary hypertension and right heart failure, as well as bone marrow suppression and neutropenic sepsis. This case highlights rare clinical manifestations of cardiac hydatidosis and potential complications of its treatment.

Hydatidosis is caused by ingestion of larvae from the Echinococcus granulosus tapeworm from contaminated food or water supply or by direct contact with infected animals. Hydatid cysts commonly affect the liver or lung; however, cardiac involvement can occur in rare cases (i.e. <2% of all cases of hydatidosis).

To read more about this case report in BMJ published August 2021:  Dind A, Harmer JA, Hansen PS, et al. 2021. Extensive pulmonary artery embolisation caused by cardiac hydatid cyst rupture. BMJ Journals: Case Reports. http://dx.doi.org/10.1136/bcr-2020-240521

CSANZ 2020: R T Hall Lecture

Dr Paul Ridker, Director, Center For Cardiovascular Disease Prevention
Brigham and Women’s Hospital

RT Hall Lecture:  100 years from C-reactive protein to anti-cytokine therapy for atherosclerosis: A history of discovery

(Click above link to view)

Biography

Over the past 25 years, Dr. Paul Ridker has been collaboratively responsible for elucidating the critical role of inflammation in the detection, prevention, and treatment of cardiovascular diseases. Best known for his pioneering population biology work on inflammatory biomarkers such as high-sensitivity CRP and interleukin-6, the first demonstrations of the anti-inflammatory effects of statins, the guideline changing JUPITER trial in 2008, and ultimately through the CANTOS interleukin-1b inhibition trial in 2017. 

Dr. Ridker’s work has led to a fundamental shift in our understanding of atherosclerosis and to the first proof that targeted anti-cytokine therapies can lower cardiovascular event rates in the absence of lipid lowering. Insights from his group that the magnitude of inflammation inhibition directly relates to the magnitude of clinical benefit has spawned a novel class of cardiovascular therapeutics, led to the clinical recognition that “residual inflammatory risk” is a separate and distinct entity from “residual cholesterol risk”, and opened an entirely novel approach to the treatment of inflammatory lung cancers. 

Spanning the fields of epidemiology, vascular biology, population genetics, public health, preventive medicine, and clinical trials, Dr. Ridker’s career-long focus on inflammatory mechanisms of disease has advanced a controversial concept into a proven clinical intervention. Few clinical investigators have had as much translational influence at the bench, the bedside, and on guidelines for the prevention and treatment of cardiovascular disease.

CSANZ 2020: Kempson Maddox Lecture by Prof Karlheinz Peter

Prof Karlheinz Peter, Deputy Director, Baker Heart and Diabetes Institute

Kempson Maddox Lecture : Prevention and treatment of myocardial infarction – pitfalls of the past, present challenges and future opportunities
(Click above link to view)
Biography

Prof Karlheinz Peter is an interventional cardiologist at the Alfred Hospital and a basic scientist and Deputy Director at the Baker Heart and Diabetes Institute. He is Professor of Medicine and Immunology at Monash University, honorary Professor at La Trobe University, and he holds an NHMRC principal research fellowship. Prof Peter has been working for many years and continues to work as an interventional cardiologist, including previously as the head of the cardiac catheter laboratory at the University of Freiburg, Germany. He did his postdoctoral training at Johns Hopkins University, Baltimore and at Scripps Research Foundation, La Jolla, USA. He did most of his clinical training at the University of Heidelberg, Germany.

His research is focused on the cellular mechanisms of coronary artery disease and its consequences, myocardial infarction (MI), encompassing the role of platelets, coagulation and inflammation in atherosclerosis, as well as the mechanisms leading to the rupture of atherosclerotic plaques. Together with Dr Chen he developed a unique mouse model of plaque instability/rupture that closely reflects human plaque instability. He has developed novel biomarker (proteomic and microRNA) approaches and molecular imaging strategies using MRI, ultrasound, CT and PET towards the localisation of thrombi, inflammatory reactions and vulnerable, rupture-prone plaques and the identification of patients at risk of MI. 

One of his primary research interests is the development of new “intelligent” drugs for patients with MI. He has developed human single-chain antibody drugs that demonstrate highly promising properties with high anti-platelet, anticoagulant and fibrinolytic efficacy but reduced side effects, particularly bleeding complications. With his clinical background, his knowledge in pharmacology and his expertise in biotechnological methods, Prof Peter is uniquely placed for translational research. His work is the basis of several patent applications covering diagnostic tests/imaging for the detection of thrombi, vulnerable plaques and inflammatory reactions and site-directed therapy.

CSANZ 2020: Gaston Bauer Lecture

Prof Vlado Perkovic, Dean, UNSW Medicine, University of New South Wales

Gaston Bauer Lecture: Mitigating the excess cardiovascular risk associated with chronic kidney disease

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Biography

Vlado Perkovic has recently stepped down from the Executive Director role at The George Institute, Australia to take up the role of Dean with the Faculty of Medicine at UNSW Sydney from October 2019. He is Staff Specialist in Nephrology at the Royal North Shore Hospital. Vlado’s research focus is in clinical trials and epidemiology, in particular in preventing the progression of kidney disease and its complications. He leads several international clinical trials, and has been involved in developing Australian and global treatment guidelines. He has played a central role in the development of an affordable dialysis system, which was a Eureka Prize finalist in 2017. Vlado is the President of the Association of Australian Medical Research Institute and is on the Board of the Australian Clinical Trials Alliance. He is Chair of the International Society of Nephrology Advancing Clinical Trials (ISN-ACT) group; and is a Fellow of the Royal Australasian College of Physicians, and the Australian Academy of Health and Medical Sciences. He serves on the Editorial Boards of a number of leading specialist and general journals, including the Journal of the American Society of Nephrology, Circulation, and the New England Journal of Medicine.

CSANZ 2020: Leaders in Paediatric and Congenital Cardiology Lecture

Mrs Kirsten Finucane, Chief Surgeon, Paediatric and Congenital Cardiac Service at Starship Children’s Hospital / Auckland District Health Board

Leaders in Paediatric and Congenital Cardiology Lecture :
A lifetime with a repaired heart – stories of survival and hope for the future.  
Click above link to view
 
Biography

Kirsten Finucane is the Chief Surgeon of the Paediatric and Congenital Cardiac Service at Starship Hospital in Auckland. She trained at Green Lane Hospital under the direction of Mr Alan Kerr, then in Birmingham Children’s Hospital in the UK with Mr Bill Brawn. Kirsten returned to New Zealand in 1996 and her initial project was to develop the paediatric service into a specialised unit, moving from Green Lane to Starship in 2003. 

This unit now performs around 400 bypasses per year including the full range of neonatal surgery, transplants and complex adult congenital cases. Areas of interest include valve repairs for children and teenagers with rheumatic heart disease, cerebral protection in the context of neonatal cardiac surgery, a modified maze technique for adult patients undergoing Fontan Conversion and improving the cardiac surgical service to children in the Pacific Islands.
 

CSANZ 2020: Cardiovascular Nursing Lecture

Prof Robyn Clark, Professor Acute Care and Cardiovascular Research at Flinders University

Cardiovascular Nursing Lecture :  Is ACCESS a risk factor for cardiovascular disease?

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Biography

Prof Robyn Clark is a senior clinician and mid-career researcher; she holds qualifications as a Registered Nurse, Registered Midwife and Critical Care Nurse, a Master’s degree in Education and a PhD. Prof Clark is a Heart Foundation Future Leader Fellow (2016-2019), a Fellow of the Royal College of Nursing, Fellow of the American Heart Association and Life Member of the Australian College of Critical Care Nurses. Prof Clark was the inaugural recipient of a National Institute of Clinical Studies (NICS-NHMRC) PhD scholarship supported by the National Heart Foundation for researching telemonitored heart failure management in rural and remote Australia She completed a NHMRC Australian Training Fellowship at the Queensland University of Technology in 2013 after which she commenced her appointment at Flinders University in as Prof of Acute Care and Cardiovascular Research. Prof Clark currently holds adjunct appointments at the University of South Australia, Queensland University of Technology and the South Australian Health and Medical Research Institute (SAHMRI). Prof Robyn Clark is internationally-recognized for her research into the most effective management of patients with heart failure and cardiovascular disease. Prof Clark’s research program can be summarized under the overall theme of increasing ACCESS to evidence-based care for underserviced and disadvantaged populations. Prof Clark’s program of research has three streams: stream one focuses upon improving access the heart failure and cardiovascular disease services for patients and communities especially in rural and remote Australia. This suite of research is recognized for its innovative methods, particularly its emphasis on geographical epidemiological analysis using GIS. The second stream involves the use of information technology to bridge the gap between cardiac specialist centers and populations with limited access to cardiology services or to patients with low health literacy. This suite of research includes the evaluation of telehealth, apps and avatars as tools to deliver education and secondary interventions for heart failure and cardiac rehabilitation. The third theme is centred on improving access for patients with cardiotoxicity after cancer treatment to appropriate cardiac rehabilitation and secondary prevention. Prof Clark has a strong background in epidemiology and linked data analysis and in the last 4 years has been working with cancer researchers in investigate the epidemiology and patient outcome of heart failure after cancer treatment. All of these streams underpin a cohesive research strategy that aims to build capacity in cardiovascular care supported by technology outside of metropolitan hospitals.

CSANZ 2020: Victor Chang Memorial Lecture

Assoc Prof Julie Mundy, Cardiothoracic Surgeon, Princess Alexandra Hospital

Victor Chang Memorial Lecture: The changing face of cardiac surgery

(Click above link to view)

Biography

A/Prof Julie Mundy graduated in medicine from the University of Queensland in 1982. She trained in general surgery at the Princess Alexandra Hospital followed by cardiothoracic surgery training in Sydney at St. Vincent’s Hospital in adult cardiothoracic surgery and heart-lung transplantation. Further training was obtained in thoracic surgery at The Royal Prince Alfred Hospital and paediatric cardiac surgery at the Royal Children’s Hospital at Camperdown.

After completing her cardiothoracic surgical training in Australia and gaining some overseas experience in Glasgow, Assoc Prof Mundy returned to St. Vincent’s Hospital, Sydney in 1993 as a cardiothoracic and heart-lung transplant surgeon. In 1999 she commenced as the Director of Cardiothoracic Surgery at the Princess Alexandra Hospital and established this new unit. She is actively involved with RACS activities as a Councillor and for the last 4 years has held the executive position of Treasurer.

Her main interests are surgical education, having been involved extensively with trainees of all levels from basic through to advanced training, for over 25 years. She has held the positions of Chair, Surgical Science and Clinical Exam Committee as well as Senior Examiner in Cardiothoracic Surgery for the Fellowship Examination. Her other surgical interest areas are blood usage minimisation, perioperative assessment and optimisation and heart failure surgery.

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