Asian Cardiovasc Thorac Ann 2008;16:e21-e22
© 2008 Asia Publishing EXchange Ltd
Chylous Pericardial Effusion after Aortic Valve Replacement
Salim S Chaloob, MBChB,
Michael Brown, FRACP,
Robert G Stuklis, FRACS
Department of Cardiothoracic Surgery, Royal Adelaide Hospital, Adelaide, Australia
For reprint information contact: Robert G Stuklis, FRACS, Tel: 61 8 8222 5296, Fax: 61 8 8222 5962, Email: rstuklis{at}health.sa.gov.au, Department of Cardiothoracic Surgery, Level 4, East Wing, Royal Adelaide Hospital, North Terrace, Adelaide 5000, South Australia.
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ABSTRACT
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Chylous pericardial effusion after open-heart surgery is a rare complication. We report a case of chylous pericardial effusion following aortic valve replacement, which presented as cardiac tamponade, and its subsequent management.
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INTRODUCTION
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Chylopericardium is a rare condition that may be primary or more commonly secondary to injury to lymphatic vessels such as the thoracic duct. Significant leakage of chyle causes serious nutritional, metabolic and immunologic abnormalities. In addition, cardiac complications such as cardiac tamponade can occur and since chyle appears to be a pericardial irritant, acute pericarditis or chronic constriction can also develop. Without treatment, chylopericardium is associated with a high mortality rate.1
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CASE REPORT
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A 50-year-old man with stenotic bicuspid aortic valve disease underwent elective aortic valve replacement due to worsening symptoms. He was discharged uneventfully 5 days following implantation of a 27 mm Medtronic Advantage mechanical valve. He presented 2 weeks later with atrial fibrillation and shock. A transthoracic echocardiogram showed a large global pericardial effusion with tamponade. He underwent emergency pericardiocentesis using transthoracic echocardiography and 1,500 mL of milky fluid was removed. A pericardial drainage tube was left in place and continued to drain around 300–600 mL/day. The pericardial fluid was analysed and showed chylomicrons with elevated triglycerides consistent with chylous fluid. Microbiological studies were negative. Serial echocardiography over 2 weeks showed persistence of the pericardial effusion. Since drainage continued, surgical reintervention was required. After induction of anaesthesia the sternal wound was reopened without incident. Cream was given down a nasogastric tube at this time. Careful scrutiny of the mediastinum revealed diffused chylous ooze from the divided thymic lobes. Both lobes were oversewn with a running 3/0 Prolene suture. Pericardial drains were placed and were removed day 4 postoperatively and the patient was discharged home in stable condition on day 6 postoperatively. Clinical and echocardiographic follow up at 4 weeks showed no recurrence of pericardial fluid.
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DISCUSSION
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Thomas and McGoon reported the first case of a chylous pericardial effusion following cardiac surgery.2 The most common causes are trauma (blunt or penetrating), thoracic or cardiac surgery (especially for congenital heart disease) and congenital lymphangiomatosis. Thymus gland injury is reported mainly in pediatric literature as a cause of chylous pericardial effusion, because the thymus gland involutes after adolescence. This particular complication becomes rare in the adult population, with most of the literature consisting of single case reports. These include chylopericardium after aortic valvotomy, repair of tetralogy of Fallot and coronary artery bypass graft surgery.3–5 Other documented rare causes of secondary chylopericardium include radiotherapy, subclavian vein thrombosis, infection, particularly tuberculous, mediastinal neoplasms, especially lymphoma.1 Chyle is an alkaline, milky, odourless fluid consisting of lymph and emulsified fats, which is formed in the small intestine during the digestion of fats. Chyle contains greater than 30 g·L–1 of protein, 4 to 40 g·L–1 of lipid (mostly triglyceride), and cells that consist primarily of lymphocytes and provides 200 kcal·L–1.6 The diagnosis is usually confirmed by a triglyceride level of 110 mg·dl–1 or greater, the presence of chylomicrons in the drainage, a positive Sudan stain or if needed a lipoprotein electrophoresis.7 Contrast-enhanced computerized tomography together with lymphangiography can be used to help identify an injury or blockage of the thoracic duct. Scintigraphy after the oral administration of I-131 triolein has been used to establish the diagnosis in primary chylopericardium.
Conservative and expectant management has been the mainstay of treatment with few reports of surgery. Total parenteral nutrition with complete cessation of all oral intake, somatostatin, medium-chain triglyceride diets, percutaneous injection of sclerotic agent in to the cisterna chyli and thoracic duct ligation have been attempted to treat different clinical scenarios. It is usually considered if conservative therapy does not reduce pericardial drainage after 7 to 14 days.8 There is no widely accepted daily drainage volume of chyle that indicates the need for surgical treatment, although significant nutritional loss is one criterion. Surgical therapy consists of ligation of the thoracic duct and tributary lymphatics and pericardiotomy or pericardiectomy.
Previous authors have mentioned thymus gland injury being the cause for most chylous pericardial effusions, mainly in the paediatric population.6 We are one of the few groups to report this complication in an adult with its subsequent management. Early definitive surgical treatment (ligation of thymus) is a feasible option, which shortens the hospital stay. This was carried out successfully in our patient.
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REFERENCES
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- Valentine VG, Raffin TA. The management of chylothorax. Chest 1992;102:586–91.[Medline]
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- Lee Y, Lee WK, Doromal N, Ganepola GA, Hutchinson J 3rd. Cardiac tamponade resulting from massive chylopericardium after an aorta-coronary bypass operation. J Thorac Cardiovasc Surg 1987;94:449–50.[Abstract]
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- Wurnig PN, Hollaus PH, Ohtsuka T, Flege JB, Wolf RK. Thoracoscopic direct clipping of the thoracic duct for chylopericardium and chylothorax. Ann Thorac Surg 2000;70(5):1662.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
