No. 06-1249 In the Supreme Court of the United States On Petition for a Writ of Certiorari to the Vermont Supreme Court BRIEF OF AMICI CURIAE PRODUCT LIABILITY ADVISORY COUNCIL, INC. AND U.S. CHAMBER OF COMMERCE IN SUPPORT OF PETITIONER Washington, DC 20006(202) 263-3000 1615 H Street, N.W. Washington, D.C. 20062 TABLE OF CONTENTS The Decision Below Thwarts Important
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295_298 emin aliogluTürk Kardiyol Dern Arﬂ - Arch Turk Soc Cardiol 2007;35(5):295-298 Sol ventrikül yerleﬂimli kist hidatik: Olgu sunumu Emin Alio¤lu, M.D., U¤ur Önsel Türk, M.D., ‹stemihan Tengiz, M.D., Ertu¤rul Ercan, M.D.
Department of Cardiology, Central Hospital, ‹zmir Cardiac hydatid disease is uncommon, occurring in Kardiyak hidatik hastal›¤› nadirdir ve ekinokokkosizli 0.2% to 2% of patients with echinococcal disease. A 67- tüm hastalar›n %0.2-%2’sinde görülür. Altm›ﬂ yedi ya- year-old farmer presented with fatigue, dyspnea, and ﬂ›nda bir çiftçi bitkinlik, nefes darl›¤› ve çarp›nt› yak›n- palpitations. He had no previous history of heart dis- malar›yla baﬂvurdu. Öyküsünde kalp hastal›¤› yoktu.
ease. Cardiovascular examination, electrocardiography, Kardiyovasküler muayenesi, elektrokardiyografi, gö- chest X-ray, hematologic and biochemical tests were ¤üs filmi, hematolojik ve biyokimyasal testleri normal normal. Parasitic serology was negative. Transthoracic bulundu. Parazitik serolojisi negatif idi. Transtorasik echocardiograpy showed a cyst, measuring 3.7x3.5 cm, ekokardiyografide sol ventrikülün posteroapikal bölge- in the posteroapical region of the left ventricle. Magnetic sinde 3.7x3.5 cm boyutlar›nda bir kist görüldü. Kist resonance imaging confirmed the cardiac cyst and varl›¤› magnetik rezonans görüntüleme ile do¤ruland› showed another cyst in the liver. The patient underwent ve karaci¤erde ikinci bir kiste rastland›. Hastaya me- surgery through median sternotomy and the cyst was dian sternotomiyle cerrahi uygulanarak kist ç›kar›ld›.
removed. Pathologic examination confirmed the diagno- Patolojik incelemede ekinokokkosiz tan›s› do¤ruland›.
sis of echinococcosis. Postoperatively, the patient was Ameliyat sonras›nda hastaya dört haftal›k albendazol treated with albendazole (800 mg/day) for four weeks.
tedavisi (800 mg/gün) uyguland›. Üç ayl›k takip süre- At three-month follow-up, the patient was asympto- sini hasta asemptomatik geçirdi, fonksiyonel kapasite- matic, with improved functional capacity. Two-dimen- sinde düzelme görüldü. ‹kiboyutlu transtorasik eko- sional transthoracic echocardiography showed no signs kardiyografide kist oluﬂumunu düﬂündürür bir bulgu Key words: Cardiomyopathies; echinococcosis/surgery; hydatid Anahtar sözcükler: Kardiyomiyopati; ekinokokkosiz/cerrahi, hi- Echinococcosis is a tissue infection in humans myocardium via the coronary arteries and may be caused by the larval stage of Echinococcosis gran- either confined solely to the heart or associated ulosus and E. multilocularis. Canines are the hosts with involvement of other organs. The left ven- for E. granulosus. Hydatid disease is endemic in tricular wall is the most frequent site, but the inter- cattle-raising areas of the world including ventricular septum, right ventricle, and left or right Mediterranean countries and the Middle East. The atrium may also be involved. Major complica- incidence of hydatidosis in the Turkish population tions of cardiac hydatid disease result from rupture has been reported as 1:20,000. Theoretically, of the cyst either into the heart or pericardium and echinococcosis can involve any organ, the liver death may occur subsequent to anaphylactic shock, being the most common, followed by the lungs.
cardiac tamponade, and systemic or pulmonary These two organs account for 90% of all cases.
embolization. When echinococcosis is diagnosed, Cardiac involvement is infrequent, accounting for surgery is the treatment of choice for even asymp- 0.2% to 2%. It is caused by the invasion to the tomatic cases due to the risk for cystic rupture. Received: December 8, 2006 Accepted: January 24, 2007Correspondence: Dr. Emin Alio¤lu. ‹zmir Central Hospital, 1644 Sok., No: 2/2, 35050 Bayrakl›, ‹zmir.
Tel: 0232 - 341 67 67 Fax: 0232 - 341 68 68 e-mail: email@example.com ventricle, right ventricular hydatid cysts have a high- A 67-year-old farmer complained of fatigue, dysp- nea, and palpitations. He had no previous history of Other manifestations of cardiac echinococcosis heart disease. Cardiovascular examination revealed may result from mechanical compression exerted by no abnormal findings. His electrocardiogram and the cyst on neighboring tissues, including myocardial chest radiograph, and hematologic and biochemicaltests were normal. Parasitic serology was negative.
Transthoracic two–dimensional echocardiograpyshowed a cyst, measuring 3.7x3.5 cm, localized inthe posteroapical region of the left ventricle (Fig. 1a).
Magnetic resonance imaging confirmed the cardiaccyst and showed another cyst in the liver (Fig. 1b).
Transesophageal echocardiography showed an ovoidcavitated mass with internal areas of calcification andconfirmed the absence of additional cysts in the car-diac chambers. Selective coronary angiographyrevealed no significant lesions. The patient under-went surgery through median sternotomy. Standardcardiopulmonary bypass techniques were used withmoderate hypothermia and cardioplegic arrest. Thecyst was reached via a left ventriculotomy andremoved (Fig. 2). Hypertonic saline (10% NaCl) wasused as a scolicidal agent. Pathologic examination confirmed the diagnosis of echinococcosis. Thepatient was discharged on the sixth postoperative dayand treated with albendazole (800 mg/day for 4weeks). At three-month follow-up, the patient wasasymptomatic, with improved functional capacity.
Two-dimensional transthoracic echocardiographyshowed no signs of cystic formation.
Cardiac hydatid disease is very rare, occuring inapproximately 0.2% to 2% of patients with hydatiddisease. Cardiac hydatid cysts develop in manyparts of the heart such as the left ventricle (55-71%),right ventricle (13-18%), interventricular septum (5- Figure 1. (A) Transthoracic echocardiographic apical view.
13%), right atrium (2-4%), and left atrium (8%).[5,6] (B) Magnetic resonance image showing hydatid cysts locatedin the left ventricular apex and in the liver.
Several hypotheses have been proposed for thepredilection for left ventricular location, includingdominance of the left coronary artery, better condi-tions of the left ventricular myocardial mass for par-asitic development, and different pressure regi-mens. Clinical manifestations of cardiac cysts are broad, ranging from asymptomatic patients to sudden death.
Symptoms depend on the location, size, and integrityof the cyst. Embolization, anaphylactic shock, andcardiac tamponade are the most serious and oftenlethal complications. Cysts have the potential forintracardiac or intrapericardial ruptures. Although Figure 2. Macroscopic view of the excised hydatoid material hydatid cysts are more frequently located in the left ischemia; disturbances of the cardiac rhythm; and asymptomatic patients in order to prevent rupture.
valve malfunction. Three main symptoms that suggest However, surgical intervention may result in seri- the presence of an uncomplicated cyst are chest pain, ous complications. Whether the treatment should dyspnea, and palpitations. With chest pain, the severity be medical or surgical remains controversial. It is and the site are variable, although it is often a perma- important to consider the localization, number, and nent or recurrent precordial pain. Sometimes the pain size of the cysts in choosing the treatment method.
resembles angina pectoris suggesting coronary disease, Medical therapy with albendazole results in disap- or myocardial infarction when it is severe. These palpi- pearance of extracardiac hydatid cysts in up to tations may arise from ventricular extrasystoles, parox- 48%, and reduction in size in 24%. However, the ysmal ventricular tachycardia, and conduction disor- specific efficacy of albendazole against cardiac ders that may lead to a complete atrioventricular block hydatid cysts has not been established.
with bradycardia and Adams-Stokes attack, which are Antihelmintics have been recommended in inoper- typical of the septal location of a cyst.
able cases or as adjuvant therapy when there is The diagnosis of a cardiac cyst is probable in patients with a history of echinococcosis in another Surgical approach is not recommended for peri- organ. In the absence of any diagnostic sign, routine cardial hydatid cysts. Percutaneous aspiration and investigations by specific cardiac imaging proce- instillation of ethanol or silver nitrate after pretreat- ment with albendazole (800 mg/day for 4 weeks) is Chest radiographic findings are usually reliable.
The chest X-ray may reveal localized or global deformations and calcifications of the cardiac out- 1. Salih OK, Celik SK, Topcuoglu MS, Kisacikoglu B, line. The typical image is a calsified, well-limited, Tokcan A. Surgical treatment of hydatid cysts of the and sessile lobular mass with clear edges. heart: a report of 3 cases and a review of the literature.
Nonspecific electrocardiographic abnormalities such as T-wave inversion, ST-depression, prema- 2. McManus DP, Zhang W, Li J, Bartley PB.
ture ventricular beats, incomplete or complete bun- Echinococcosis. Lancet 2003;362:1295-304.
dle branch block, and supraventricular tachycardia 3. Kardaras F, Kardara D, Tselikos D, Tsoukas A, are present in more than 80% of patients. In older Exadactylos N, Anagnostopoulou M, et al. Fifteen year patients, it is often more difficult to establish the surveillance of echinococcal heart disease from a refer- differential diagnosis between acute coronary dis- ral hospital in Greece. Eur Heart J 1996;17:1265-70.
ease and cardiac hydatid cyst disease. In young 4. Eckert J, Deplazes P. Biological, epidemiological, and patients, especially in the presence of a Q wave of clinical aspects of echinococcosis, a zoonosis of increas- necrosis the diagnosis of a cardiac hydatid cyst ing concern. Clin Microbiol Rev 2004;17:107-35.
should be considered. This Q wave is due to the 5. Sensoz Y, Ozkokeli M, Ates M, Akcar M. Right ven- electrical window formed by a transmural cyst.
tricle hydatid cyst requiring tricuspid valve excision.
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Conduction disorders may also be associated with a 6. Kunt AS, Aydin S, Demir D, Selli C, Andac MH. Left ventricle wall hydatid cyst. Kalp Damar Cer Derg Hematology may reveal eosinophilia of a varying degree. Serological tests including indirect hemag- 7. Thameur H, Abdelmoula S, Chenik S, Bey M, Ziadi glutination and latex agglutination tests are useful if M, Mestiri T, et al. Cardiopericardial hydatid cysts.
positive, but many cyst carriers will not develop an immune response. Diagnosis of cardiac hydatid 8. Bashour TT, Alali AR, Mason DT, Saalouke M.
cysts is often made using transthoracic echocardiog- Echinococcosis of the heart: clinical and echocardio- raphy. Transesophageal echocardiography provides graphic features in 19 patients. Am Heart J 1996;132: details of the cyst. Computed tomography and magnetic resonance imaging may provide valuable 9. De Paulis R, Seddio F, Colagrande L, Polisca P, Chiariello L. Cardiac echinococcosis causing coronary information, but two-dimensional echocardiography artery disease. Ann Thorac Surg 1999;67:1791-3.
10. Tengiz I. Cardiac hydatid cysts. J Card Resc 2006;1:1-5.
Surgical excision is the definitive method of 11. Charet E, Roudaut R, Lafitte S, Laffort P, Madonna F, de treatment for cardiac hydatid cysts, even for Mascarel A. Echocardiographic demonstration of rupture of intraseptal hydatid cyst. J Am Soc Echocardiogr 2000; 14. Akar R, Eryilmaz S, Yazicioglu L, Eren NT, Durdu S, Uysalel A, et al. Surgery for cardiac hydatid disease: an 12. Tufan Tükek, ﬁeref Demirel, Dursun At›lgan, Ertan Anatolian experience. Anadolu Kardiyol Derg 2003;3: Onursal, Ferruh Korkut. Kardiak kist hidatik tan› ve tedavisinde transözofageal ekokardiyografinin önemi: 15. Simeunovic D, Seferovic PM, Ristic AD, Petrovic P, iki vaka nedeni ile literatürün gözden geçirilmesi. Türk Maisch B. Pericardial cysts: incidence, clinical presen- tations and treatment. In: Seferovic PM, Spodick DH, 13. Kaplan M, Demirtas M, Cimen S, Ozler A. Cardiac Maisch B, editors. Pericardiology: comtemporary hydatid cysts with intracavitary expansion. Ann answers to continuing challenges. Belgrade: Science
LUKE NIELSON Education University of Wyoming College of Business: Marketing Major Anticipated Graduation Date: May 2013 Courses Studied: Accounting, Economics, Information Management Systems, Business Calculus Western Wyoming Community College Associate of Arts in General Studies & Certificate in Digital Design Technologies Cumulativ