Review of chylopericardium

Pericardial fenestration and thoracic duct ligation for treatment of chylopericardium as first symptom of underlying generalized lymphatic anomaly: a case report

INTRODUCTION

Chylopericardium represents a rare condition of chyle accumulation within the pericardial sac, caused by abnormal thoracic duct anatomy or prolonged increased pressure. Nothing by mouth (NPO) policy and total parenteral nutrition (TPN), even in combination with pericardial drainage, render only a temporary solution. Surgical intervention with thoracic duct ligation and creation of a pericardial window is believed to be the most effective treatment.

CASE PRESENTATION

An 18-year-old male was referred with a persisting idiopathic chylopericardium for five months. Various drainages and conservative treatment failed. To more permanently treat the chylopericardium, we created a pericardial window and ligated the thoracic duct by right-sided uniportal video-assisted thoracoscopic surgery. Postoperative NPO and TPN for 1 week were initiated, followed by medium-chain-triglycerides diet for 1 week. Clinical improvement occurred and the chest drain was removed two weeks after surgery. Magnetic resonance imaging of the whole body showed multiple cystic lesions in spleen and skeleton compatible with generalized lymphatic anomaly (GLA), proven by the anatomopathological examination of the thoracic duct and lung biopsy. Sirolimus was initiated for further treatment.

CONCLUSION

In this case of idiopathic chylopericardium, we successfully performed thoracoscopic thoracic duct ligation and creation of a pericardial window, diagnosing a GLA.

Dynamic Contrast-Enhanced Magnetic Resonance Lymphangiography for Diagnosis and Treatment of Chylopericardium After Cardiac Transplantation

Chylopericardium is a rare complication after cardiac transplantation. We report a case of a 69-year-old woman with persistent chylopericardium after a heart transplantation due to Chagas disease. Failure of conservative treatment led to dynamic contrast-enhanced magnetic resonance lymphangiography and percutaneous radiologic intervention of the lymphatic leakage and symptoms resolution.

Case report: Chylopericardium secondary to dialysis catheter related jugular venous thrombosis in two dogs receiving long-term hemodialysis

Chylopericardium is a rare entity in veterinary medicine. In this report we document the development of chylopericardium in two dogs undergoing chronic hemodialysis. An 11-year-old female spayed Labrador retriever (Case 1) presented with acute coughing and lethargy 2 months following initial dialysis catheter placement and initiation of dialysis therapy for severe azotemia. Echocardiography demonstrated severe pericardial effusion and cardiac tamponade. Pericardial fluid analysis was consistent with chylous effusion. The dog underwent a subtotal pericardiectomy with thoracic duct ligation, and a PleuralPort™ was placed. The patient continued to receive outpatient hemodialysis therapy after pericardiectomy for several months until she died acutely at home. A 4-year-old male neutered Doberman (Case 2) was being treated for 2 months with outpatient hemodialysis for management of chronic kidney disease. On presentation for the 17th hemodialysis treatment, the patient had increased respiratory rate. Echocardiography demonstrated pleural and pericardial effusions, and fluid analysis in both cavities was consistent with chylous effusion. Use of tissue plasminogen activator (TPA), clot removal and replacement of the catheter was attempted; however pleural and pericardial effusion continued. The patient was euthanized after 25 hemodialysis sessions as owners elected not to pursue more procedures. In both cases, the cause of the chylopericardium was suspected to be secondary to catheter-associated thrombosis and/or stenosis based on multiple imaging modalities. Despite use of rivaroxaban and clopidogrel concurrently in each case, the chylous effusion persisted. This case report describes clinical details of a rare complication of long-term indwelling dialysis catheters in two dogs.

Chylopericardium following esophagectomy: a case report and systematic review

BACKGROUND

Chylopericardium is a rare condition characterized by the accumulation of chyle in the pericardial space. It is most commonly caused by thoracic duct injury. Chylopericardium following esophagectomy is extremely rare but can cause life-threatening complications. This report presents a case of chylopericardium post-esophagectomy, resulting in cardiac tamponade and cardiac arrest. A systematic literature review was also conducted to facilitate the understanding of this rare condition.

CASE PRESENTATION

A 41-year-old male was admitted to our hospital with intermediate to highly differentiated squamous cell carcinoma of the mid-thoracic esophagus (clinical T4NxM0). He underwent thoracoscopic-laparoscopic esophagectomy with cervical anastomosis. On postoperative day 1, patient had a cardiac arrest secondary to cardiac tamponade, requiring emergency ultrasound-guided drainage. The drained fluid was initially serous but became chylous after the administration of enteral nutritional emulsion. As a result of significant daily pericardial drainage, patient subsequently underwent thoracic duct ligation. The amount of drainage was substantially reduced post-thoracic duct ligation. Over a period of 2 years and 7 months, patient recovered well and tolerated full oral diet. A comprehensive literature review was conducted and 4 reported cases were identified. Among these cases, three patients developed pericardial tamponade secondary to chylopericardium post-esophagectomy.

CONCLUSION

Chylopericardium is a rare but serious complication post-esophagectomy. Prompt echocardiography and thorough pericardial fluid analysis are crucial for diagnosis. Thoracic duct ligation has been shown to be an effective management approach for this condition.

Primary idiopathic chylopericardium managed by uniportal VATS

Chylopericardium is very rarely encountered in clinical practice. The common causes are post cardiac or thoracic surgery and neoplasms of the mediastinum. Most of the time, no cause is attributed and it is labelled as primary idiopathic chylopericardium. Conservative management is usually not successful and definitive surgery is required. The recommended surgery is creation of a pericardio-pleural window and thoracic duct ligation. We demonstrate that this procedure can be easily accomplished by uniportal video-assisted thoracic surgery (U-VATS).

Postoperative constrictive pericarditis caused rupture of lymphatic collaterals: a rare etiology of chylothorax

BACKGROUND

Chylothorax after cardiovascular surgery is primarily caused by direct injury to the thoracic duct or its branches, and occurs in early postoperative period. In the present case, we describe a rare case of chylothorax manifesting three months after surgery secondary to constrictive pericarditis.

CASE PRESENTATION

A 71-year-old man underwent mitral valve replacement, tricuspid valve annuloplasty, and the maze procedure. He developed acute perioperative myocardial infarction on postoperative day one due to plaque rupture in the left anterior descending artery and underwent percutaneous coronary intervention. Although the patient was discharged on postoperative day 36, he required readmission on postoperative day 83 because of right side chylothorax associated with constrictive pericarditis. Lymphangiography revealed thoracic duct interruption and development of lymphatic collateral vessels via the right hilum. Single-photon emission computed tomography revealed abnormal tracer accumulation in the right hilum, suggesting a lymphatic leakage site. A catheter study indicated biventricular dip and plateau patterns with a reduced cardiac index (1.6 L/min/m2) and elevated central venous pressure (18 mmHg). Conservative treatment for chylothorax, including a low-fat diet and continuous drainage with chest tube, was unsuccessful. Drainage of chyle at approximately 500 mL/day continued. On hospitalization day 50, complete pericardiectomy via median sternotomy was performed because the patient's cardiac function deteriorated. The central venous pressure dramatically decreased, and the chylothorax gradually subsided. There was no recurrence of symptoms 1 year postoperatively.

CONCLUSIONS

Chylothorax associated with constrictive pericarditis subsequent to cardiac surgery is extremely rare. Although conservative management failed, the present case was successfully treated via pericardiectomy alone and did not require any additional precedures, such as thoracic duct ligation via a right thoracotomy.

Chylous pericardial effusion with cardiac tamponade in a child treated with imatinib

Chylous pericardial effusions are extremely rare outside of thoracic and cardiac surgery patients. We report the case of an 8-year-old girl with history of recurrent benign giant cell granulomas who developed a large chylous pericardial effusion with cardiac tamponade soon after beginning therapy with imatinib. In this article, we discuss the presentation, diagnosis, and management and review the published literature of this rarely reported side effect of this medication.

Isolated primary chylopericardium: A rare case report and literature review

Introduction

Primary chylopericardium is an extremely rare disease with no previous reported case in Indonesia. It may be caused by an abnormality of lymphatic drainage in the thoracic region.

Case presentation

We report the case of a 19-year-old female who presented with a chief complaint of shortness of breath and fluid accumulation in her pericardial sac. Screening for autoimmune disease, tuberculosis, and malignancy all came back negative. Lymphoscintigraphy showed suspected leakage or obstruction of lymph at the supradiaphragmatic level. The patient was diagnosed with primary chylopericardium. In a span of 1 year, she had undergone 3 pericardiocentesis procedures and declined surgical treatment. On her fourth pericardiocentesis, the cardiologists were unable to remove fluid from the pericardial sac. Thoracic duct ligation and pericardial window were eventually performed and a total of 850 ml of chylous fluid was removed. At 6 months postoperation patient showed no signs and symptoms of pericardial effusion and was in good condition.

Discussion

Constrictive pericarditis can occur as a complication of chronic inflammation in the pericardium due to the presence of chylopericardium and a history of multiple pericardiocenteses. However, there are no reports regarding the exact duration of chylopericardium that will lead to constrictive pericarditis. Difficulty in pericardiocentesis might be an early sign of scarring in the pericardium.

Conclusion

Delayed surgical treatment of chylopericardium increases the risk of constrictive pericarditis and significantly reduces the patient's quality of life due to recurrent symptoms and hospitalizations.

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This is the first case of isolated primary chylopericardium reported in Indonesia.

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Surgery should be performed in patients with recurrent effusion.

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Delayed surgical treatment increases the risk of constrictive pericarditis.

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It also reduces the patient's QoL due to recurrent symptoms and hospitalizations.