Case Report
Introduction
Orthotopic heart transplantation (OHT) is an accepted method of end stage heart failure treatment.1) Among the main OHT indications are cardiomyopathies and ischemic heart disease (ischemic cardiomyopathy). While pericar- dial bleeding and/or effusion is fairly common in cardiac surgery, the isolated chylopericardium is an extreme rarity, but still a potential cause of postoperative cardiac tampon- ade. In the vast majority of cases, the cause of chyloperi- cardium remains undiscovered. The surgical dissection in cardiac surgery is remote from the thoracic duct and the risk of its direct injury is relatively low. Riquet et al.
reported in a study of 90 cadaver hearts, that the lymphatic drainage from the heart is variable, and lymphatic vessels originating from the heart connect with the thoracic duct in 8.9%.2) Chylus is collected from the heart by the right and left efferent lymphatic trunks, and it is postulated that their damage may be causative for some chyloipericardium cases after cardiac surgery.2) Also, small lymphatic vessel injury, high venous pressure, venous thrombosis and increased lymphatic vessels permeability were mentioned as arguable chylopericardium culprits.3)
To the best of our knowledge there are only three reports of chylopericardium complicating the postoperative course after OHT.4–6) Here we present a case of a 59-year-old man who underwent OHT and suffered from chylopericardium resulting in cardiac tamponade in the postoperative course.
We discuss the successful invasive therapeutic approach with use of absorbable fibrin sealant patch.
Case Report
A 59-year-old male patient with ischemic cardiomyopa- thy and end stage heart failure, a non-smoker with a history of implantable cardioverter-defibrillator (ICD) implantation
Life-Threatening Cardiac Tamponade Secondary to Chylopericardium Following Orthotopic Heart Transplantation—A Case Report
Karol Wierzbicki, MD, PhD,1 Piotr Mazur, MD,1,2 Piotr We˛grzyn, MD, PhD,2 and Bogusław Kapelak, MD, PhD1,2
Chylopericardium is a rare complication in cardiac surgery, and an extremely rare occur- rence in patients following orthotopic heart transplantation (OHT), which, however, can lead to cardiac tamponade. Here we present a case of a 59-year-old man who underwent OHT and suffered from chylopericardium resulting in cardiac tamponade late in the post- operative course, despite the initially uneventful early postoperative period (decreasing blood drainage was observed directly after the procedure, and the drains were safely removed). After the diagnosis of chylopericardium was made, the conservative treatment was initiated, which turned out to be insufficient, and eventually invasive approach for the recurrence of tamponade secondary to chylopericardium was required. We discuss the available therapeutic options for chylopericardium and demonstrate the successful invasive therapeutic approach with use of the absorbable fibrin sealant patch.
Keywords: chylopericardium, chylorrhea, orthotopic heart transplantation, fibrin sealant patch
1Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
2Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland
Received: July 20, 2015; Accepted: September 2, 2015
Corresponding author: Piotr Mazur, MD. Institute of Cardiology, Jagiellonian University Medical College, 80 Pradnicka St., 31-202 Krakow, Poland
Email: piotr.k.mazur@gmail.com
©2015 The Editorial Committee of Annals of Thoracic and Cardiovascular Surgery. All rights reserved.
264 Ann Thorac Cardiovasc Surg Vol. 22, No. 4 (2016)
Ann Thorac Cardiovasc Surg 2016; 22: 264–266 Online November 6, 2015
doi: 10.5761/atcs.cr.15-00233
Chylopericardium after Heart Transplantation Treated with Fibrin Sealant Patch
underwent urgent OHT in our Institution in February 2015.
The donor was a 49-year-old women, who died after a major stroke. The biatrial approach was employed (total ischemic time: 160 min; local donor). Concomitantly, the ICD with electrodes were explanted. The pericardial and substernal chest-tubes were placed, and the early postoperative course was uneventful. Decreasing blood drainage was observed, and the drains were removed on postoperative day (POD) 5. The immunosuppression (with tacrolimus, mycofeno- late mofetil, steroids and thymoglobulin) was initiated, and until POD 10 the daily routine echocardiographic exam- inations revealed recovering ventricular function and a fluid-free pericardium. On POD 10, routine endomyocar- dial biopsy was performed, and acute allograft rejection was excluded. On POD 14, the patient experienced increas- ing dyspnea, and the clinical signs of cardiac tamponade were observed. The tamponade was confirmed echocardio- graphically, and a pericardial drain was placed surgically through a 3 cm subxiphoid incision (500 ml of milky fluid was obtained). The diagnosis of chylopericardium was based on macroscopic fluid appearance and high triglyceride content (3.30 mmol/l; the neoplastic markers were negative).
Conservative treatment was initiated – total chyloperi- cardium drainage time was 35 days, and the maximal chy- lus volume was observed on POD 18 (800 ml/d). On POD 18, total parenteral nutrition was initiated, which resulted in drainage volume decrease to 200–300 ml/d. On POD 40, a repeat endomyocardial biopsy was performed, excluding acute allograft rejection. On the following days, the drainage volume decreased gradually and echocardi- ography revealed fluid collection in the pericardium. On POD 46 the signs of cardiac tamponade were observed again, and a redo-sternotomy was necessary (500 ml of chylus obtained). The site of chylorrhea origin could not be directly identified. The anterior superior mediastinum was patched with absorbable fibrin sealant patch (Tacho- Sil, Baxter Healthcare, Deerfield, IL) and the chest was closed. No chylorrhea was observed subsequently, and the pericardial drain could be removed after 2 days. Enteral nutrition was re-initiated, and the patient was discharged on POD 61. Follow-up echocargiography on POD 75 revealed minimal pericardial effusion and left ventricular ejection fraction of 65%. Subsequent follow-up visits were uneventful.
Discussion
We report for the first time the successful implementa- tion of absorbable fibrin sealant patch in the treatment of
chylopericardium complicating OHT. The chylopericar- dium is a rare complication in cardiac surgery, and very few cases after OHT were reported. In our Institution the reported case is the first among 554 OHTs to date, giving the incidence of 0.18% among OHT recepients, which is comparable to that reported in literature (0.12%–0.22%
for all cardiosurgical operations3); however, if all types of cardiac operations were considered, the incidence would be extremely low, as the reported case is the first ever to occur in our Institution – a high volume cardiac center performing over 2000 operations in cardiopulmonary by-pass a year since 1979).
Chylopericardium can develop into a life-threatening cardiac tamponade.7) The therapeutic approach must be judicious, particularly in the OHT recipients cohort, as they are extremely vulnerable to infectious complications.
Generally, in chylopericardium complicating cardiosurgi- cal procedures, the conservative strategy is the treatment of the first choice, which is successful in most cases.3) The chylopericardium treatment strategies in OHT patients reported in literature comprised pericardiocentesis, medi- cal and nutritional (medium-chain triglicerides rich diet) management,4) pericardial window5,6) and thoracoscopic right-sided duct ligation with partial pericardiectomy.6,8) Of other medical interventions, somatostatin9) or oct- reotide (somatostatin analogue, an agent decreasing portal vein system pressure and chyle flow10)) administration were put forward in the literature, both in the treatment of chylothorax and chylopericardium after cardiac proce- dures, however, this strategy was never used in an OHT recipient. In patients with pericardial effusions secondary to malignancy, topical use of minocycline to induce adhe- sions was proposed as a treatment option.11) This therapy (also never used in an OHT recipient) was shown to be highly effective, however, it is frequently associated with severe chest pain, and can potentially cause constrictive pericarditis. It must also be highlighted that OHT recipi- ents receive high doses of steroids, and the efficiency of adhesion generation would probably be decreased.
Because of the early postoperative period after OHT and reservations regarding possible complications, the conservative treatment was initially preferred (pericardial drainage and parenteral nutrition). After the prolonged drainage failure and the second episode of cardiac com- promise, a full re-do sternotomy was performed with intention to identify the origin of chylorrhea. It is gener- ally accepted that the injury to thoracic duct would result in chylothorax, rather than chylopericardium,3) and because the OHT is a purely intrapericardial procedure
Ann Thorac Cardiovasc Surg Vol. 22, No. 4 (2016) 265
Wierzbicki K, et al.
(excluding pacemaker removal), damage to the thoracic duct, which is located near the descending aorta, was ana- tomically rather unlikely. Rose et al and reported small lymphatic leaks in the thymic tissues or periaortic fat as a source of chylorrhea, identified during reoperation in a patient with chylopericardium.12) In our patient, the site could not be found (Sudan III dye could be given orally to facilitate the visual identification). The intuitive place- ment of TachoSil in the superior anterior mediastinum proved sufficient and definitively resolved the chyloperi- cardium. The anterior superior mediastinum is frequently involved in chylopericardium development, especially in pediatric patients, in whom the thymus is rich in lymphatic tissue.3) Furthermore, the right and left efferent lymphatic trunks, draining chylus from the heart, ascend in the prox- imity of the ascending aorta and pulmonary trunk,2) and their transsection might be inevitable during OHT.
The employment of the fibrin sealant patch in the most suspicious area allowed to avoid the classical invasive methods of chylorrhea management, including thoracic duct ligation or anastomosis to innominate vein, or tho- racic duct obliteration, along with their potential conse- quences. It must however be acknowledged that repeated sternotomy was necessary, which is a major limitation, of the method used.
Conclusions
In conclusion, chylopericardium resulting in tampon- ade, as a complication of OHT, can be successfully and definitely treated with absorbable fibrin sealant patch during re-do sternotomy.
Acknowledgments
This study was funded by a grant of the Jagiellonian University Medical College (No. K/ZDS/004595 to K.W.).
Disclosure Statement
None declared.
References
1) McMurray JJ, Adamopoulos S, Anker SD, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology.
Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 2012;
14: 803-69.
2) Riquet M, Le Pimpec Barthes F, Souilamas R, et al.
Thoracic duct tributaries from intrathoracic organs.
Ann Thorac Surg 2002; 73: 892-8; discussion 898-9.
3) Kan CD, Wang JN, Wu JM, et al. Isolated chyloperi- cardium after intrapericardial procedures: possible role of inadvertent right efferent lymphatic trunk injury.
Tex Heart Inst J 2007; 34: 82-7.
4) Jackson E, Khan A, Yonan N. Persistent medical man- agement of chylopericardium following orthotopic heart transplant. J Surg Case Rep 2010; 2010: 8.
5) Mailander L, Van Meter C, Ventura H, et al. Chyloperi- cardium after orthotopic heart transplantation. J Heart Lung Transplant 1992; 11: 587-90.
6) Gelsomino S, Morelli A, Porreca L, et al. Video- assisted thoracoscopic surgery for primary chyloperi- cardium after orthotopic heart transplantation. J Heart Lung Transplant 2002; 21: 701-5.
7) Bakay C, Wijers TS. Treatment of cardiac tampon- ade due to isolated chylopericardium following open heart surgery. J Cardiovasc Surg (Torino) 1984; 25:
249-51.
8) Furrer M, Hopf M, Ris HB. Isolated primary chyloperi- cardium: treatment by thoracoscopic thoracic duct liga- tion and pericardial fenestration. J Thorac Cardiovasc Surg 1996; 112: 1120-1.
9) Kelly RF, Shumway SJ. Conservative management of postoperative chylothorax using somatostatin. Ann Thorac Surg 2000; 69: 1944-5.
10) Szabados E, Toth K, Mezosi E. Use of octreotide in the treatment of chylopericardium. Heart Lung 2011;
40: 574-5.
11) Lashevsky I, Ben Yosef R, Rinkevich D, et al. Intrap- ericardial minocycline sclerosis for malignant pericar- dial effusion. Chest 1996; 109: 1452-4.
12) Rose DM, Colvin SB, Danilowicz D, et al. Cardiac tamponade secondary to chylopericardium following cardiac surgery: case report and review of the literature.
Ann Thorac Surg 1982; 34: 333-6.
266 Ann Thorac Cardiovasc Surg Vol. 22, No. 4 (2016)
