A novel therapeutic strategy for the management of idiopathic chylopericardium and chylothorax

Primary chylopericardium: A case report and literature review

Primary chylopericardium (CP) is a rare clinical condition in which chylous fluid containing high concentrations of triglyceride accumulates in the pericardial cavity. The present study reports a case of CP that was successfully treated by reconstruction surgery of thoracic duct. To improve the ability to diagnosis and treat this rare disease, the current study also systematically extracted 104 reported cases of primary or idiopathic CP from the past 60 years (January 1950 to December of 2015), and reviewed the clinical manifestation, etiology, diagnosis and treatment of these cases. The age at diagnosis varied between 6 weeks and 79 years with a mean age of 27.95±16.50 years. Asymptomatic patients accounted for 39.42% of cases, while the most common initial symptoms were dyspnea (44.23%) and coughing (10.58%). Jugular venous distention and distant heart sound was identified in 23 (22.12%) and 34 cases (32.69%), respectively. Cardiomegaly in X-ray scans was detected in the majority of patients (93.27%). In addition, lymphoscintigraphy and lymphangiography were helpful in identifying the source of chyle. Regarding the etiology, idiopathic cases accounted for 35.56% of the included cases in the present study. The most important cause of primary CP was abnormal connection or accumulation of lymph fluid in the pericardium (37.50%). Conservative therapy included low-fat or medium-chain triglyceride diet, as well as total parenteral nutrition. The majority of patients (71.2%) required surgery for definitive therapy, and thoracic duct ligation was the most preferred surgical procedure, performed in 44.23% of cases. Follow-up was reported in 64 cases, and all patients survived during the mean follow-up period of 12 months. Therefore, it is suggested that surgical management is the most successful treatment method and is associated with a favorable prognosis.

[Diagnostics and therapy of pericarditis and pericardial effusion]

This article describes the diagnostics, differential diagnostics, multimodal imaging, medicinal and invasive diagnostic therapy of acute and chronic pericarditis, constrictive pericarditis, pericardial effusion and cardiac tamponade under etiological aspects and on the basis of the guidelines of the European Society of Cardiology (ESC). The starting point of the decision tree is the symptomatic patient with echocardiographic evidence of pericardial effusion. The principle feature of the diagnostics is the etiopathogenetic allocation of the pericardial disease which influences the clinical picture, course therapy and prognosis. Infectious pericarditis (e.g. viral, bacterial and tuberculous) is differentiated from sterile autoreactive pericarditis and from neoplastic pericardial effusion by the cytology of the effusion and immunohistological and molecular investigations of the pericardial and epicardial biopsies. Pericardioscopy plays an important role in the recognition of suspicious areas. In many cases intrapericardial administration of cisplatin for neoplastic pericardial effusion and instillation of triamcinolone for autoreactive pericarditis prevent recurrence just as a treatment of several months with colchicine.

Chylopericardium in adults: a literature review over the past decade (1996-2006)

OBJECTIVES

We present a systematic overview of the literature on reported cases of chylous pericardial effusion in adults over the past 10 years, assessing clinical presentation, etiology, diagnosis, and treatment.

METHODS

We conducted an evidence-based literature review searching for all reported adult cases of chylopericardium in the past 10 years (January 1996-December 2006).

RESULTS

A total of 33 reported cases of chylopericardium were identified through a systematic literature search. There was no gender bias in the incidence of chylous pericardial effusion. Age at diagnosis varied from 18 to 68 years with a mean +/- standard deviation of 36.78 +/- 14.71 years. Time from symptom onset to diagnosis was variable (ranging from acute presentation to several years). The most common reported etiology was idiopathic. The diagnosis was made by pericardiocentesis in all patients. A search for secondary causes included computed tomography of the chest, lymphoscintigraphy, and lymphangiography along with radioactive oral (131)I-triolein. Conservative therapy was prescribed in 28 patients and failed in 16, in whom subsequent surgery was necessary. Overall, 21 patients underwent various types of surgery. Thoracic duct ligation with creation of a pericardial window was the most common surgical procedure.

CONCLUSION

Chylopericardium is a rare entity. The fluid appearance, triglyceride content, cytologic characteristics, and negative cultures are crucial to make the correct diagnosis. Treatment is dependent on the etiology. Surgical management is the most successful. Conservative therapy is reserved for patients with idiopathic chylopericardium, those with an untreatable etiology, those considered at high risk for surgical treatment, or those with a predictably short lifespan.

An interesting cause of chylopericardium after open heart surgery: a lymphatic channel

Chylopericardium is a very rare complication after open heart surgery that is performed by median sternotomy. It is defined as uncontrollable chylous fluid loss, and may lead to hypoproteinemia, malnutrition, and immune deficiency; hence, overall increases postoperative morbidity. In this report, we present a case in which chylopericardium developed after coronary artery bypass grafting. The patient has been successfully treated; however, postoperative course was majorly complicated with the consequences of chylous fluid loss. Interestingly, the cause of the drainage was a lymphatic channel in the mediastinum. To the best of our knowledge, this is the first report in the literature in which a lymphatic channel has been demonstrated sporadically in the mediastinum as a cause of chylopericardium following open heart surgery in the adulthood.