Asian Cardiovasc Thorac Ann 2006;14:e63-e64
© 2006 Asia Publishing EXchange Ltd
Chylothorax After Aortic Valve Replacement
Mehmet U Ergenoglu, MD,
Ilhan Sanisoglu, MD,
Ertan Sagbas, MD,
Resit Yaman, MD,
Mustafa Guden, MD,
Belhhan Akpinar, MD
Department of Cardiovascular Surgery, Florence Nightingale Hospital, Istanbul, Turkey
For reprint information contact: Mehmet U Ergenoglu, MD Tel: 90 212 224 4950 Ext. 4173 Fax: 90 212 225 8396 Email: mergenoglu{at}yahoo.com, Department of Cardiovascular Surgery, Florence Nightingale Hospital, Abide-i Hurriyet Cad., No: 290, Caglayan, Sisli, Istanbul 80290, Turkey.
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ABSTRACT
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A 71-year-old-man was diagnosed with chylothorax after aortic valve replacement. He was treated with a low-fat diet and pleural drainage with thoracentesis. The pleural effusion completely resolved by the 14th postoperative day.
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INTRODUCTION
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Chylothorax is the accumulation within the pleural cavity of chylous fluid containing high amounts of fat. Chyle is formed from lymphatic fluid enriched with fat secreted by intestinal cells, and is transported through the thoracic duct into the venous circulation. Chylothorax after open heart surgery is an uncommon but serious problem with an incidence of 0.25% to 0.5%.1,2 It is particularly rare after aortic valve replacement with intact pleural spaces.
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CASE REPORT
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A 71-year-old-man presented with pulmonary edema. Past medical history included congestive heart failure, hypertension, pulmonary emboli due to deep vein thrombosis, and paroxysmal atrial fibrillation. He had also undergone an appendectomy. Under general anesthesia, a central venous catheter was placed via the right jugular vein, and aortic valve replacement was performed with a Hancock II 25-mm bioprosthesis (Medtronic, Inc., Minneapolis, MN, USA) without opening either pleura. Postoperatively, left pleural effusion was diagnosed on the 4th day during routine chest radiography. Physical examination showed dyspnea and decreased breath sounds at the left hemithorax. Vital signs and other systems were normal. Diagnostic thoracentesis revealed chyloid milky fluid. Biochemical analysis of tapped fluid determined 4,957 mg·dL–1 of triglyceride. On the basis of the biochemical analysis and macroscopic appearance of the fluid, a diagnosis of left chylothorax was made. Conservative treatment with a low-fat diet, and pleural drainage with thoracentesis were undertaken; 750 mL of milky fluid was drained without any complication. The chest radiograph after drainage is shown in Figure 1
. After being on the low-fat diet, follow-up chest radiography indicated resolution of the pleural effusion. The patient was discharged on the 14th postoperative day with complete resolution of the pleural effusion (Figure 2).
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DISCUSSION
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Chylothorax after coronary artery bypass has been reported in at least 17 cases.1 It usually results from injury to the left internal mammary artery lymphatics during dissection or from injury to the parasternal nodes. Congenital malformations, reoperation, and the use of electrocautery are the other risk factors for chylothorax.3,4 Injury to the thoracic duct during insertion of a central venous catheter is another possible cause of chylothorax. However, this was not the cause in our case. The differential diagnosis must be made from Dressler’s syndrome, congestive heart failure, pulmonary embolism, and para-pneumonic effusion. Pulmonary embolism can evoke effusions, such as chylothorax or hemothorax, by altering the normal fluid transport mechanism.5 In our case, with macroscopically intact pleural spaces and an absence of thoracic duct injury, pulmonary embolism can be considered for the development of chylothorax.
There are two treatment options for chylothorax: conservative and surgical. Half of the patients respond to conservative treatment including pleural drainage and with enteral low-fat formula, or enteric gut rest with total parenteral nutrition. However, surgical treatment is recommended for either excessive drainage (> 10 mL·kg·1 per day) or prolonged drainage (up to 3 to 4 weeks). This includes chemical pleurodesis, thoracic duct ligation through thoracoscopy, and a pleuroperitoneal shunt.
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REFERENCES
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- Brancaccio G, Prifti E, Cricco AM, Totaro M, Antonazzo A, Miraldi F. Chylothorax: a complication after internal thoracic artery harvesting. Ital Heart J 2001;2:559–62.[Medline]
- Joyce LD, Lindsay WG, Nicoloff DM. Chylothorax after median sternotomy for intrapericardial cardiac surgery. J Thorac Cardiovasc Surg 1976;71:476–80.[Abstract]
- Weber DO, Mastro PD, Yarnoz MD. Chylothorax after myocardial revascularization with internal mammary graft. Ann Thorac Surg 1981;32:499–2.[Abstract]
- Kshettry VR, Rebello R. Chylothorax after coronary artery bypass grafting.Thorax 1982;37:954.[Free Full Text]
- Noone KE. Pleural effusions and diseases of the pleura. Vet Clin North Am Small Anim Pract 1985;15:1069–84.[Medline]
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ABSTRACT
INTRODUCTION
