Ann Thorac Surg 2006;82:1892-1894
© 2006 The Society of Thoracic Surgeons
Case Reports
Chylous Pericardial Effusion After Minimally Invasive Mitral Valve Repair
Girish Mood, MD,
Mustaphasahim Shaaraoui, MD,
Raghavendra Allareddy, MD,
Derek Smith, MD,
Leonardo Rodriguez, MD,
Donald Hammer, MD,
Vidyasagar Kalahasti, MD*
Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
Accepted for publication February 13, 2006.
* Address correspondence to Dr Kalahasti, Department of Cardiovascular Medicine, Desk F-15, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195. (Email: kalahav{at}ccf.org).
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Abstract
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We would like to report the first case of chylous pericardial effusion after thymus gland injury in a middle-aged patient who underwent minimally invasive mitral valve surgery, and outline the surgical approach to manage this condition.
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Introduction
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Chylous pericardial effusion after open-heart surgery is a rare complication with an incidence of 0.2% to 1.0% [1]. Thomas and McGoon [2] reported the first case of chylous pericardial effusion after cardiac surgery, and Grinberg and colleagues [3] reported the first case of chylopericardium after mitral valve replacement. There have also been case reports after aortopulmonary surgeries [4] and aortic valve replacement [5]. We would like to describe one of the first cases of chylous pericardial effusion after minimally invasive mitral valve repair at our institution.
A 34-year-old Caucasian man with a history of mitral valve prolapse since the age of 12, it was discovered during a school physical, was referred to our center for mitral valve surgery. He had worsening symptoms secondary to severe mitral regurgitation and enlarged cardiac diameters on surveillance echocardiogram.
A minimally invasive thoracotomy was performed after obtaining venous access through the right internal jugular vein. The operative findings were both ruptured and elongated chordae to the middle scallop of the posterior leaflet and a small patent foramen ovale. The mitral valve was approached by a combined superior and transseptal incision. The middle scallop was excised and a sliding repair was completed. A 34-mm Cosgrove-Edwards (Edwards Life Sciences LLC, Irvine, CA) annuloplasty band was placed. The surgical procedure was uneventful. The patient was monitored in the intensive care unit for 24 hours and was then transferred to the step-down unit in a stable condition.
He remained hemodynamically stable during the postoperative period. Routine transthoracic echocardiogram on postoperative day 4 showed moderate, circumferential organized pericardial effusion with early signs of cardiac tamponade. He was observed for a day, and a repeat transthoracic echocardiogram was done that showed a large circumferential pericardial effusion consistent with pre-tamponade physiology (Figs 1, 2).
He underwent pericardiocentesis under transthoracic echocardiogram guidance and 550 cc of milky fluid was removed. A pericardial drainage tube was left in place, and after overnight observation the drainage tube was removed. The pericardial fluid analysis showed chylomicrons and elevated triglycerides. Microbiology studies were negative. He was closely monitored for the next 72 hours with a medium-chain triglyceride diet. Despite this, a repeat transthoracic echocardiogram showed increasing pericardial effusion but no signs of tamponade.
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Fig 1. Transthoracic echocardiographic scan in the subcostal view showing large circumferential pericardial effusion with diastolic collapse of the right ventricle.
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Fig 2. Another transthoracic echocardiographic scan in the subcostal view showing large circumferential pericardial effusion with diastolic collapse of the right ventricle.
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A lymphangiogram was performed using ethiodol contrast showed the thoracic duct being opacified with a normal caliber. Initially there was no extravasation of contrast material outside of the lymphatic system; however on delayed imaging it was apparent that there were extravasated droplets of contrast in the superior and anterior mediastinum at the expected location of the thymus gland. A decision was made to re-explore to identify and surgically repair the defect.
The patient was given a fat-rich diet (ie, dairy cream and ice cream) the night before the operation, and he was reopened the following day. He also received cream in the operating room through a nasogastric tube. Initially the mediastinum was normal in appearance; however on continued scrutiny some lymphatic leakage was seen in the left aspect of the previously ligated thymus, which was concordant with the data obtained by the lymphangiogram. This was ligated and sealed with Coseal (Baxter Healthcare Corporation, Freemont, CA). There was no further lymphatic leak noted after observation for 30 minutes. The incision was then closed and the patient was kept in the intensive care unit for observation.
A transthoracic echocardiogram repeated the next day showed trivial pericardial effusion. He was discharged home in stable condition and was seen by his local cardiologist with a repeat echocardiogram, which showed no recurrence of pericardial effusion since the 3-month prior discharge.
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Comment
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Chyle is an alkaline, milky, odorless 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 of protein, 4 to 40 g/L of lipid (mostly triglyceride), and cells that consist primarily of lymphocytes and provide 200 kcal/L. Nutrition therapy plays a major role in the conservative treatment of chyle leaks, which carries a risk for leukopenia and malnutrition. Previously reported causes for chyle leakage are venous thrombosis of the major neck veins as seen in the Behçet's syndrome [6], superior vena cava syndrome, thoracic duct obstruction, abnormal connection between the lymphatic system and the pericardium [7], and lymphangiectasia of the pericardium [8]. Gland injury being the cause for chylous pericardium has been reported mainly in the pediatric population, as thymus gland atrophies start showing changes after puberty.
The diagnosis is usually confirmed by a triglyceride level of 110 mg/dL or greater, the presence of chylomicrons in the drainage, a positive Sudan stain, or if needed a lipoprotein electrophoresis. Conservative and expectant management has been the mainstay during these years with few reports of surgical approach [2, 3, 5]. Total parental nutrition with complete cessation of all oral intake, somatostatin, medium-chain triglyceride diets, percutaneous injection of sclerotic agents into the cisterna chyli, and thoracic duct ligation have been attempted to treat different clinical scenarios. Time required for complete recovery has varied from days to months in these situations [5]. If patient were to be treated with conservative treatment then he would be kept without oral feeding and he would have continued protein loss through the chylous leak. With early intervention this would be prevented enhancing recovery from the original surgical procedure.
Previous case reports and literature have mentioned thymus gland injury being the cause for chylous pericardial effusion, mainly in the pediatric population. We believe that this is the first case report showing thymus gland injury as the cause for chylous pericardial effusion, especially after minimally invasive mitral valve repair. As the thymus gland atrophies after puberty, this particular complication has not been reported in the middle-aged or adult population. We believe that this is also the first report of the use of lymphangiogram in identifying the chylous leak and performing surgery to correct the defect. This approach led to the quick recovery of the patient within a few days. This is in contrary to older practices outlined by Pitol and colleagues [1]. During this period the albumin level of the patient remained unchanged, and he had expectant recovery from the surgical procedure.
In conclusion we report that the thymus gland injury resulting in chylous pericardial effusion can be seen in the adult population. Early definitive surgical treatment is a feasible option, which shortens the hospital stay and minimizes the complications related to chylous leak, especially protein malnutrition and reduced immunity.
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References
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- Pitol R, Pederiva JR, Pasin F, Vitola D. Isolated chylopericardium after cardiac surgery Arq Bras Cardiol 2004;82(4):384-389.[Medline]
- Thomas Jr CS, McGoon DC. Isolated massive chylopericardium following cardiopulmonary bypass J Thorac Cardiovasc Surg 1971;61(6):945-948.[Medline]
- Grinberg M, Tarasoutchi F, Pomerantzeff PM, et al. Chylopericardium. A complication following mitral valve replacementA case report. Arq Bras Cardiol 1985;45(4):263-266.[Medline]
- Hawker RE, Cartmill TB, Celermajer JM, Bowdler JD. Chylous pericardial effusion complicating aorta-right pulmonary artery anastomosis J Thorac Cardiovasc Surg 1972;63(3):491-494.[Medline]
- Kansu E, Fraimow W, Smullens SN. Isolated massive chylopericardiumComplication of open heart surgery for aortic valve replacement. Chest 1977;71(3):408-410.[Abstract/Free Full Text]
- Coplu L, Emri S, Selcuk ZT, et al. Life threatening chylous pleural and pericardial effusion in a patient with Behcet's syndrome Thorax 1992;47(1):64-65.[Abstract/Free Full Text]
- Kannagi T, Osakada G, Wakabayashi A, Kawai C, Matsuda M, Miki S. Primary chylopericardium Chest 1982;81(1):105-108.[Abstract/Free Full Text]
- Musemeche CA, Riveron FA, Backer CL, Zales VR, Idriss FS. Massive primary chylopericardium: a case report J Pediatr Surg 1990;25(8):840-842.[Medline]
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Abstract
Introduction
