An autopsy case of urinary bladder carcinoma with pulmonary infarction and subacute cor pulmonale caused by tumor embolization

Pulmonary tumor embolism is a common finding at autopsy but is difficult to diagnose clinically antemortem. We report an autopsy case of urinary bladder carcinoma associated with tumor emboli of the pulmonary arteries and subsequent pulmonary infarctions. An eighty-six-year-old man with bloody sputum showed multiple infiltrates on chest X-ray and multiple pleural based parenchymal lesions with truncated apex on computed tomography. The patient had a history of radiation therapy against urinary bladder carcinoma two years earlier. Transitional type carcinoma cells were identified from a urine sample obtained on admission. Three weeks later, the patient developed subacute cor pulmonale and died in severe respiratory distress. Postmortem examination revealed primary carcinoma of the urinary bladder. Multiple tumor emboli of pulmonary arteries and subsequent pulmonary infarctions were visible microscopically. There was a large amount of effusion in both the pleural and the abdominal space. The heart contained focal scarring and mild right ventricular hypertrophy and there was congestion of the lungs, liver, kidneys and spleen. Pulmonary tumor embolization may present at any stage of the patient's illness but rarely causes subsequent pulmonary infarctions. Cytologic examination of blood samples obtained from Swan-Ganz catheters may be useful in the diagnosis of tumor embolization.     

Chronic pulmonary thromboendarterectomy complicated by antithrombin III deficiency and antiphospholipid syndrome

Pulmonary thromboendarterectomy was performed on two patients with chronic pulmonary thromboembolism showing thrombotic tendency. Patient 1 was a 25-year-old male with the disease complicated by congenital antithrombin III deficiency. Patient 2 was a 21-year-old male with the disease complicated by antiphospholipid syndrome. Both patients were admitted to the center upon showing dyspnea. Lung perfusion scintigraphy revealed multiple defects in the right and left lungs. Pulmonary arteriography showed occlusion and stenosis from lobar to segmental arteries. Cardiac catheterization showed marked pulmonary hypertension. Pulmonary angioscopy confirmed the presence of organized thrombi while an intravascular ultrasound revealed a thickening of the pulmonary arterial walls in both lungs. After the insertion of an inferior vena cava filter in each patient, surgery was performed. Following a median sternotomy, a cardiopulmonary bypass was utilized to induce deep hypothermia at a pharyngeal temperature of 16 degrees C, after which a thromboendarterectomy of the bilateral pulmonary arteries was performed under intermittent circulatory arrest. A large amount of organized thrombi was extracted from these arteries. After surgery, both patients showed good postoperative outcome with improved blood flow in both lungs, reduced pulmonary arterial pressure and increased cardiac output.     

Fibrosing mediastinitis causing pulmonary arterial hypertension without pulmonary venous hypertension. Clinical and necropsy observations

Clinical and morphologic observations are described in two patients with severe pulmonary arterial hypertension without pulmonary venous hypertension from fibrosing mediastinitis. In one patient, both main pulmonary arteries and one major pulmonary vein were severely narrowed by dense fibrous tissue; in the second patient, only the right main pulmonary artery was severely narrowed. Both patients had normal intrapulmonary arteries and normal pulmonary parenchyma. Of nine previously described necropsy patients with pulmonary hypertension due to fibrosing mediastinitis, seven had severe narrowing of multiple large pulmonary veins and in six of them the pulmonary hypertension was entirely due to pulmonary venous obstruction. In one other patient, the pulmonary hypertension was due to obstruction of one main pulmonary artery and several large pulmonary veins. Each of these seven previously described patients had severe changes in the small intrapulmonary arteries. Of the other two previously described patients with pulmonary hypertension from fibrosing mediastinitis, one had severe narrowing of only the main right pulmonary artery, and the other, of both main pulmonary arteries. Thus, although pulmonary arterial hypertension in patients with fibrosing mediastinitis is usually due to obstruction of multiple large pulmonary veins and to severe secondary changes in small intrapulmonary arteries, fibrosing mediastinitis can cause severe pulmonary hypertension by obstructing the right or both main pulmonary arteries.     

Asymmetric distribution of the pulmonary blood flow between the right and left lungs in d-transposition of the great arteries

Pulmonary angiograms, radionuclide lung images and chest roentgenograms were evaluated regarding the incidence, magnitude and natural evolution of maldistribution of the pulmonary blood flow between the lungs in 63 patients with dextrotransposition of the great arteries. Approximately half of these patients had some degree of greater perfusion of the right relative to the left lung. A significant correlation was demonstrated between the incidence of this maldistribution of blood flow and the angulation between the main and the right pulmonary arteries. For any given angulation between these vessels, additional pulmonary stenosis increased the incidence of disparity in perfusion. Our observations suggest the following developmental mechanisms: The maldistribution in flow results from the abnormal rightward inclination of the main pulmonary artery in the transposition malformation which straightens the flow axis from the main to the right pulmonary artery. Under these circumstances the momentum of the blood in the main pulmonary artery carries the blood preferentially into the right pulmonary artery. This momentum is increased when there is stenosis of the left ventricular outflow tract. Consequent differences in the mechanical properties of the two pulmonary vascular beds can increase this maldistribution. The disparity in perfusion between the lungs is not present in newborns with d-transposition, appears to be progressive in severity and in time may result in almost complete cessation of effective perfusion of the left lung. The effect of the Mustard operation on this abnormality of flow is discussed.     

Maternal serum inhibin A can predict pre-eclampsia

A 60-year-old male patient was urgently admitted to the hospital with chest pain, anemia and shock. The echocardiographic examination revealed myocardial tamponade and, unexpectedly, a mobile mass in the right atrium, prolapsing in the right ventricle which was indicative of myxoma. The patient underwent pericardiocentesis which showed the presence of blood. Cardiac surgery was then performed to remove the tumor which was found to originate in the right atrial appendage. There were some adhesions between the atrial appendage and the anterior wall of the right ventricle. The tamponade was due to a trauma of some small pericardial arteries in the adhesion area. The presence of tamponade and right atrial myxoma, is the peculiar finding of the reported case.     

Density and localization of calcium channels of the L-type in human pulmonary artery

The pharmacological profile and the anatomical localization of Ca2+ channels of the L-type were investigated in the human pulmonary artery to identify possible mechanisms involved in the regulation of the pulmonary vascular tone. Analysis was performed on slide-mounted frozen sections of human pulmonary artery using radioligand binding assay techniques associated with light microscope autoradiography. [3H]-Nicardipine was used as ligand. Human renal and right coronary arteries also were used as systemic reference arteries. Binding of [3H]-nicardipine to sections of human pulmonary artery was time-, temperature- and concentration-dependent, saturable and reversible. In the human pulmonary artery, the apparent equilibrium dissociation constant (Kd) was 0.12+/-0.02 nM and the maximum density of binding sites (Bmax) was 38.15+/-2.25 fmol/mg tissue. Kd values were 0.3+/-0.01 nM and 0.5+/-0.02 in the human renal artery and right coronary artery respectively. Bmax values were 248+/-16 fmol/mg tissue and 173+/-9.5 fmol/mg tissue in the human renal artery and right coronary artery respectively. The pharmacological profile of [3H]-nicardipine binding to sections of human pulmonary artery was consistent with the labeling of Ca2+ channels of the L-type. It was similar in the pulmonary artery and in the human renal and right coronary arteries. Light microscope autoradiography revealed a high density of [3H]-nicardipine binding sites within smooth muscle of the tunica media of human pulmonary artery as well as of human renal and right coronary arteries. A lower accumulation of the radioligand occurred in the tunica adventitia. No specific binding was noticeable in the tunica intima. Our data suggest that human pulmonary artery expresses Ca2+ channels of the L-type sensitive to dihydropyridines. These sites have similar affinity and lower density than those expressed by systemic arteries. The presence of Ca2+ channels of the L-type in human pulmonary artery suggests that their pharmacological manipulation may be considered in the treatment of pulmonary hypertension.     

A case of racemose hemangioma of the right bronchial artery and intercostal to pulmonary arterial anastomosis]

We reported a case of racemose hemangioma of the bronchial artery and intercostal to pulmonary arterial anastomosis. A 67-year-old woman was admitted because of repeated hemoptysis. Bronchoscopic examination revealed a torous lesion of the right B7 bronchus. Intercostal angiography demonstrated communications between right dilated, meandered intercostal arteries and right pulmonary artery. Bronchial angiography showed dilatation and convolution of the right bronchial artery. Angiographic embolization of the right bronchial artery and the right intercostal artery was underwent. There was no recurrence of hemoptysis one year after the embolization procedure. We think that angiographic embolization is an effective method of treatment of hemoptysis due to racemose hemangioma of the bronchial artery and intercostal to pulmonary arterial anastomosis.     

Anatomic correction of transposition of the great vessels

We present a new approach for anatomic correction of transposition of the great arteries. The two coronary arteries, with a piece of the aortic wall attached, are transposed to the posterior artery. The two aortic openings are closed with a patch. The aorta and pulmonary artery are transected, contraposed, ant then anastomosed. The interventricular septal defect is closed with a patch, through a right ventriculotomy approach, because the right ventricle is no longer part of the systemic circulation. Two patients, aged 3 months and 40 days weighing 4,200 and 3,700 grams, respectively, were operated upon with deep hypothermia and total circulatory arrest. There was good recovery from the operation, with normal cardiocirculatory conditions. Renal failure developed in the first patient, and she died on the third postoperative day. During this time the cardiocirculatory conditions were good. The second patient made an uneventful recovery. Hemodynamic studies 20 days after the operation showed complete correction of the malformation. Five and one-half months after the operation, he weighs 7,500 grams, and his development is very good. We believe that this operation will be reproducible by most cardiovascular septal defect and pulmonary hypertension.     

Provoked enuresis-like episodes in healthy children 7 to 12 years old

A 15-year-old boy with tetralogy of Fallot and pulmonary atresia without central pulmonary arteries who was successfully treated using a staged approach is presented. The first stage consisted of the creation of central pulmonary arteries. In the second stage, the continuity between the right ventricle and the pulmonary arteries was established with closure of the ventricular septal defect. Some patients previously considered to be unsuitable candidates for correction may be successfully repaired using this approach.     

Fetal branch pulmonary arterial vascular impedance during the second half of pregnancy

OBJECTIVE: Our purpose was to establish normal physiologic parameters in the fetal proximal and distal branch pulmonary arterial vascular impedance during the second half of pregnancy and to analyze relationships between proximal and distal pulmonary arterial blood velocity waveforms. STUDY DESIGN: In this cross-sectional study 100 uncomplicated singleton pregnancies were studied by pulsed color Doppler techniques between 18 and 41 weeks of gestation (median 30 weeks). Both right and left proximal (immediately after the bifurcation of the main pulmonary artery) and distal (beyond the first bifurcation of the branch pulmonary artery) pulmonary artery blood velocity waveforms were recorded and pulsatility index values were calculated. Peak systolic velocities and time-to-peak-velocity intervals were measured. Time-to-peak-velocity intervals were also analyzed at the level of aortic and pulmonary valves and at the ductus arteriosus. Right and left pulmonary artery diameters and right lung length were measured. RESULTS: In both right and left proximal and distal pulmonary arteries pulsatility index values decreased (p < 0.0001) and the peak systolic velocities (p < 0.003) and time-to-peak-velocity intervals (p < 0.0001) increased during the second half of pregnancy. In the proximal pulmonary arteries the pulsatility index values decreased linearly until 34 to 35 weeks of gestation and in the distal pulmonary arteries until 31 weeks of gestation. Thereafter they remained unchanged. In pulmonary arteries time-to-peak-velocity intervals were shorter (p < 0.01) than at the pulmonary valve level. There were no significant differences between the right or left pulmonary arteries in the pulsatility index values, peak systolic velocities, time-to-peak-velocity intervals, or pulmonary artery diameters. In the proximal pulmonary arteries the pulsatility index values (p < 0.02) and peak systolic velocities (p < 0.0001) were higher and time-to-peak-velocity intervals (p < 0.0001) were longer than in the distal pulmonary arteries. There was a 2.5-fold increase in pulmonary artery diameters and right lung length. CONCLUSIONS: Fetal branch pulmonary arterial vascular impedance decreases significantly during the second half of pregnancy. The linear decrease in vascular impedance during the second trimester and in the beginning of the third trimester may be related to the growth of the lung and the increase in the number of resistance vessels. During the latter part of the third trimester pulmonary vascular impedance does not decrease further.     

Contractile properties of intralobar pulmonary arteries and veins in the fetal lamb model of congenital diaphragmatic hernia

BACKGROUND/PURPOSE: Pulmonary hypertension plays a significant role in the pathophysiology of congenital diaphragmatic hernia (CDH). Although there has been an intensive research effort directed at mediators that may cause pulmonary vasoconstriction, no single agent has been identified. The authors hypothesize that there may be an alteration in the cGMP-nitric oxide (NO) pathway of vasodilatation contributing to the pulmonary hypertension observed in CDH. The purpose of these studies is to begin to elucidate vasoactive properties of pulmonary vessels with particular attention to the cGMP-NO pathway of vasodilatation in fetal lambs with CDH. METHODS: Fourth-generation pulmonary arteries and pulmonary veins were dissected from both right and left lungs of eight, 139-day gestational fetuses with surgically created CDH. Vessels were studied with standard isolated tissue bath techniques. Experiments examined basal release of NO in endothelium-intact PVs and PAs of both right and left lungs by measuring the contractile force of vessels constricted with norepinephrine (NE) in the presence and absence of the nitric oxide synthase (NOS) inhibitor N(omega)-nitro-L-arginine (L-NA). Concentration-response curves to the vasodilating agents zaprinast and A23187 were also obtained in vessels contracted by NE. RESULTS: Left and right pulmonary artery responses to NE are enhanced over those of historic controls. Pretreatment of left pulmonary arteries with L-NA enhances the vasoconstrictor response to NE, whereas right PAs show no increased response. Relaxation responses to A23187 and zaprinast, in both left and right pulmonary arteries were not different from control lambs. Relaxation responses of both left and right pulmonary veins to A23187 and zaprinast are blunted compared with controls. This blunting is significantly more in left pulmonary veins than right. Further, right but not left pulmonary veins display enhanced vasoconstrictive response to NE after L-NA pretreatment. CONCLUSIONS: The NO-cGMP pathway of vasodilatation is abnormal in the near term, fetal lamb with CDH. These abnormalities were most apparent in pulmonary veins and may reflect abnormal NOS activity or content between left and right lungs of the fetal lamb with CDH. Pulmonary arteries from CDH lambs have basal and stimulated NO release equal to that of historic controls but appear to be hypersensitive to exogenous vasoconstrictors.     

Right ventricular obstruction in aortic dissection: a mechanism of hemodynamic collapse

The main and right pulmonary arteries may be compressed by the false lumen of a type I aortic dissection. We report a 73-year-old women with a dissection of the aorta in whom echocardiographic examination revealed acute pulmonary arterial compression causing right ventricular failure and hemodynamic collapse.     

Extending the concept of the autograft for complete repair of transposition of the great arteries with ventricular septal defect and left ventricular outflow tract obstruction: a report of ten cases of a modified procedure

BACKGROUND: In most cases of transposition of the great arteries with ventricular septal defect and left ventricular outflow tract obstruction, a Lecompte procedure (réparation à l'étage ventriculaire) is possible without interposition of a conduit between the right ventricle and pulmonary artery. However, the anterior location of the pulmonary arteries after the Lecompte maneuver may be a potential cause for right ventricular outflow obstruction, which continues to be reported in 5% to 25% of cases. We have used a tubular segment of aortic autograft to connect the pulmonary artery, left in the orthotopic posterior position (without the Lecompte maneuver), to the right ventricle in 10 consecutive patients with transposition, ventricular septal defect, and left ventricular outflow tract obstruction. METHODS: Ten consecutive patients aged 2 months to 11 years (mean 32 months) have undergone a modified Lecompte operation. Eight had severe pulmonary stenosis, two had pulmonary atresia, and four had a restrictive ventricular septal defect at the time of the operation. Two had multiple ventricular septal defects. Seven had undergone one (n = 5) or two (n = 2) previous modified Blalock-Taussig shunts. All patients underwent a total correction with left ventricular-aortic intraventricular connection (four needed a ventricular septal defect enlargement), connection between the right ventricle and pulmonary arteries with a tubular segment of autograft aorta, without the Lecompte maneuver (anterior location of the bifurcation of the pulmonary arteries) on the right (n = 6) or the left (n = 4) of the aorta. No valvular device was used for the right ventricular outflow repair. RESULTS: No early or late deaths occurred. One patient with multiple ventricular septal defects needed an early (2 weeks) reoperation for a residual muscular ventricular septal defect. All patients are currently in New York Heart. Association class I, without medications, in sinus rhythm, at a mean follow-up of 30 months. Late results up to 3.6 years show no calcification on the chest roentgenogram, and at the most recent echocardiogram, right ventricular pressures were low (25 to 40 mm Hg, mean 33 mm Hg) and no significant gradient (over 10 mm Hg) was found between the right ventricle and pulmonary arteries. Left and right ventricular function was satisfactory. CONCLUSION: This modification of the Lecompte operation using a segment of autograft allows an excellent early and late result, with no danger of compression of anteriorly placed pulmonary arteries, no significant right ventricular outflow obstruction, and normal appearance of the tubular autograft. In view of laboratory and clinical evidence, normal growth of the autograft can be anticipated. It allows an elective correction of transposition, ventricular septal defect, and left ventricular outflow tract obstruction without a previous Blalock-Taussig shunt (three patients) and correction at a young age (three patients younger than 1 year).     

A large vertebrobasilar junction aneurysm grown at the proximal end of basilar artery fenestration--usefulness of balloon occlusion test with 99mTc-HMPAO SPECT under induced hypotension and consideration in therapeutic strategies

A 48-year-old lady suffered a transient loss of consciousness. CT and MRI revealed a large vascular lesion compressing the left lower pons. Angiography revealed a large aneurysm at vertebro-basilar junction, dome of which projected anteriorly and left to midline. Her previous vertebral angiogram taken 10 years ago when she suffered a subarachnoid hemorrhage from the left MCA aneurysm, had showed a fenestration of lower basilar artery without apparent aneurysm. Bilateral super-selective vertebral angiograms revealed that the aneurysm arose at the proximal end of the fenestration, and vertebrobasilar junction was incorporated into the aneurysm indicating broad neck aneurysm. The left posterior communicating artery was well developed. Balloon test occlusion (BTO) of bilateral vertebral artery was performed under normotension and induced hypotension. 99mHM-PAO SPECT was used to examine cerebral blood flow (CBF) during hypotensive BTO. The patient tolerated the test and CBF imaging showed insignificant sight decrease in bilateral cerebellar hemispheres. Exploration of the aneurysm was carried out by the right far lateral suboccipital approach. Bilateral vertebral arteries and the right segment of the basilar artery fenestration were identified. Neck clipping of the aneurysm with reconstruction of the parent vessels were tried with fenestrate clip. However, narrow operative field and large dome of the aneurysm made it hard to identify the left segment of the fenestration. Neck clipping was given up and clipping of bilateral vertebral arteries were performed distal to posterior inferior cerebellar artery with three body clippings. The patient showed moderate postoperative left lower nerve palsy, which was gradually improved in several weeks. Follow-up angiography revealed no opacification of the aneurysm.(ABSTRACT TRUNCATED AT 250 WORDS)     

V/Q mismatch without pulmonary emboli in children with histoplasmosis

In two children with histoplasmosis pulmonary perfusion and ventilation studies revealed mismatched abnormalities characterized by almost unilaterally absent perfusion but normal ventilation in the right lung. Chest roentgenograms demonstrated right hilar enlargement and pulmonary contrast angiograms revealed narrowing of the right pulmonary arteries by extrinsic fibrotic granulomata but no pulmonary emboli were present. Fibrosing mediastinitis due to histoplasmosis was found by mediastinoscopic examination in one of the patients. Non-embolic causes of V/Q mismatch lung imaging are discussed briefly, and the correlation with clinical findings is stressed for the diagnosis of pulmonary emboli.     

Moyamoya disease associated with pulmonary sarcoidosis--case report

A 61-year-old female presented with a unique case of moyamoya disease associated with pulmonary sarcoidosis. She was admitted for sudden onset of left temporalgia with episode of numbness on face, tongue, and upper extremity on the right side. The next morning, she had symptoms of Gerstmann syndrome and her ability to speak was disturbed. Her medical history included radical resection of lung cancer on the right side. She had no symptoms of pulmonary sarcoidosis. Neuroimaging showed an infarction in the left occipital lobe. Angiography showed occlusions of the bilateral internal carotid arteries at the supraclinoid portions. Subsequently, a left superficial temporal artery-middle cerebral artery anastomosis with encephalo-myo-synangiosis was performed. Ninety-three days after admission, she suddenly developed dyspnea which resulted in death 3 hours later. Autopsy findings showed typical epithelioid granulomas of sarcoid type in the lymph nodes of the peribronchus, lung, and liver. Thrombotic emboli were found in the bilateral pulmonary arteries, and marked fibrous intimal thickening in the bilateral internal carotid arteries. Immunological reaction with inflammatory events may cause pathological changes in patients with moyamoya disease or sarcoidosis. The co-incidence in this case suggests that some common inflammatory events may be involved in the pathogenesis of these diseases.     

Single coronary artery arising from the right coronary sinus. Report of two cases

The authors report two cases of single coronary artery arising from the right coronary sinus. Both patients had angina with reversible myocardial ischaemia on exercise Thallium scintigraphy. Coronary angiography showed single coronary artery arising from the right coronary sinus in both cases with severe stenosis of the right coronary artery in the first and occlusion of the right coronary artery in the second patient. Both underwent surgical revascularisation with a good result. Single coronary artery is a rare congenital abnormality (approximately 0.36 per 1,000) diagnosed at autopsy until 1963, and thereafter at coronary angiography. A review of the literature shows that an equal number of single coronary arteries arise from the right as from the left coronary sinus: there does not seem to be an increased risk of complication when a branch runs between the aorta and pulmonary artery. On the other hand, single coronary arteries arising from the right coronary sinus seem to be more commonly associated with atherosclerosis than a network with two coronary arteries, but when the lesions are proximal, the risk is high. Revascularisation is indicated only when myocardial ischaemia has been documented.     

Bilateral pulmonary artery aneurysms in a patient with Behcet syndrome: evaluation with radionuclide angiography and V/Q lung scanning

The case of a 14-year-old girl with Behcet syndrome is described. Besides painful and recurrent oral ulcerations, the patient had a cough and intermittent hemoptysis. The initial chest roentgenogram revealed bilateral parahilar opacities. CT and MRI scans of the thorax showed bilateral thrombosing aneurysms of the pulmonary arteries. Pulmonary blood flow imaging was performed after technegas ventilation lung scanning and Tc-99m MAA injection using a first-pass radionuclide angiography procedure. Altered blood flow in the left pulmonary artery was shown. Bilateral and well-defined ventilation/perfusion mismatched areas suggested a high probability of pulmonary embolism. Little additional information was obtained on subsequent contrast pulmonary angiography. The high incidence of pulmonary artery hypertension and associated vascular injury risk makes pulmonary angiography an unsafe procedure in patients with pulmonary Behcet syndrome. The need for pulmonary angiography could be obviated in such cases with the use of high-precision MRI and ventilation/perfusion lung scanning, including radionuclide pulmonary angiography.     

Fatal outcome of an hepatic adenoma following short term oral contraceptive use

In this case report, it is emphasized that duration of exposure to an oral contraceptive is not of prime importance. The patient was a 30-year-old woman complaining of sudden onset of severe epigastric pain which radiated to the right upper abdomen and the right shoulder. She had been using anovulatory pills for 18 months. A mass was felt in the right upper abdomen. The white cell count was 21,000/cu mm. Acute cholecystitis was the original diagnosis. In the next 4 days the bilirubin rose to 2.9 mg% and the alkaline phosphatase to 23.1 KA units. At laparotomy the gallbladder was found to be normal. Hepatomegaly was noted. A liver biopsy was taken. Subsequently a liver scan showed a large defect in the right lobe of the liver. Selective angiography of the right hepatic artery showed a large vascular mass. The diagnosis was changed to hepatic adenoma with secondary hemorrhage. Before further surgery the patient suffered a cardiorespiratory arrest and died. At autopsy a hepatic adenoma was found in the right lobe. A large embolus was found blocking the pulmonary arteries. The embolus was considered the cause of the sudden death.     

Bilateral hydatid cyst of pulmonary arteries: MR and CT findings

The location of hydatid cysts inside pulmonary arteries has been reported only on rare occasions in the literature and is caused, in the majority of cases, by embolization due to the rupture of hydatid cysts located in the heart; more rarely, hematogenous dissemination from a hepatic focus is the cause. We report a case of a 44-year-old patient with hydatid cysts located in both the right and left pulmonary arteries, whose first clinical reference was hemoptysis. The patient had undergone surgery because of a hepatic hydatid cyst 5 months previously. The importance of this case lies in the infrequent bilateral location in both pulmonary arteries and in the absence of intracardiac hydatid cysts.