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   Table of Contents      
CASE REPORT
Year : 2018  |  Volume : 4  |  Issue : 3  |  Page : 152-154

Intractable Chylothorax Following Mitral Valve Replacement in an Adult


Department of Cardiothoracic and Vascular Surgery, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, Delhi University, New Delhi, India

Date of Web Publication31-Dec-2018

Correspondence Address:
Dr. Arindam Roy
Room No. 04, New Resident Doctors Hostel (NRDH), New Delhi 110002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_46_18

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  Abstract 


Chylothorax after an open-heart surgery has previously been mentioned in the literature. We report this association in a young female post-mitral valve replacement surgery due to abnormal lymphatic channels. Medical management was conducted for 4 weeks. On failure of the conservative treatment, she underwent pleurectomy with suture ligation of the thymic gland remnants and pericardium for the chylothorax, which resolved following the redo surgery. This rare incidental variation in lymphatic drainage was responsible for refractory chylothorax, which otherwise could have been managed medically.

Keywords: Chylothorax, lymphangiography, mitral valve replacement, thoracic duct


How to cite this article:
Jain A, Roy A, Jenasamant SS, Jawarkar M, Minhas HS. Intractable Chylothorax Following Mitral Valve Replacement in an Adult. MAMC J Med Sci 2018;4:152-4

How to cite this URL:
Jain A, Roy A, Jenasamant SS, Jawarkar M, Minhas HS. Intractable Chylothorax Following Mitral Valve Replacement in an Adult. MAMC J Med Sci [serial online] 2018 [cited 2019 Jan 16];4:152-4. Available from: http://www.mamcjms.in/text.asp?2018/4/3/152/249031




  Introduction Top


Chylothorax following mitral valve replacement (MVR) requiring surgical intervention is rare.[1] Here we present this complication in an adult due to variation in thoracic duct anatomy.


  Case Report Top


A 35-year-old woman presented with progressive breathlessness for the past 6 years. Clinical examination revealed a diastolic murmur with a loud first heart sound. On echocardiography, a severe mitral stenosis of rheumatic etiology was present. The mitral valve area was 0.8 cm2. The right ventricular systolic pressure was 38 mmHg with a mean gradient of 12 mmHg. The Wilkins score was more than 8. She underwent an uneventful MVR surgery via median sternotomy, using a 29-mm Medtronic Open Pivot™ Heart Valve (Medtronic Inc., Minneapolis, Minnesota, USA). No chylous fluid was noted following the dissection of thymic tissue and pericardial fat. A pair of mediastinal and right intercostal drain was placed. The mediastinal drains were removed on postoperative day (POD) 2. The right drain output was more than 50 ml, hence not removed. POD 3 and 4 revealed an increase in the right drain output with change to milky white–colored fluid on POD 5. The drain output was >400 ml and continued to increase with a maximum output of 1200 ml/day. Chest X-ray [[Figure 1]] revealed pleural collection on the right side. A bedside test was performed using ether and equal volume of the drain fluid.[2] The milky white fluid gradually dissolved. Examination of the pleural fluid confirmed triglyceride levels of 1200 mg/dl, cholesterol of 8.2 mmol/l, total proteins 3.2 gm/dl, and presence of chylomicrons. Microscopic examination revealed total leukocyte count (TLC) to be 350 cells/mm3 with 95% lymphocytes filled with fatty vacuoles. A postoperative echocardiography revealed a 7-mm pericardial collection anterior to the right ventricle with normal functioning mitral valve prosthesis and good left ventricular function. She was started on a diet of high protein and low fat with medium chain triglyceride oil.[3] The drainage continued exhausting 500 to 1000 ml/day for a week. She was then kept nil orally, and the total parenteral nutrition was started. Hydration and electrolytes were maintained with intravenous fluids. After 14 days of unsuccessful dietary modification, she was started on injection octreotide at 100 μg three times a day. She had lost 8 kg of weight during this period. There was no hemodynamic deterioration. After 3 weeks of failed therapy, a lymphangiography using lipiodol (8 ml) was performed via right inguinal lymph node. It showed atresia of the thoracic duct beginning at the level of cisterna chyli [[Figure 2]]. There was a diffuse extravasation of contrast with no specific site of leakage. A contrast-enhanced computed tomography thorax [[Figure 3]] revealed the extravasation of lymphangiographic contrast into the mediastinum at the level of carina with caudal migration posterior to left atrium. The patient was kept on a fat diet the night before surgery. Nasogastric feeding with fat was also given[4] at the time of surgery. Surgical re-exploration revealed no obvious leak. All the fatty tissues overlying the pericardium including the thymus were tied using polypropylene 4-0 sutures and right parietal pleurectomy was performed. Pericardial edges were also suture ligated.[4] The pleural drain output ceased following the surgery. Chest tube was removed on POD 4. The subsequent chest X-rays were normal. She is in regular follow-up and asymptomatic for last 6 months.
Figure 1 Chest X-ray revealing right pleural collection (white arrow) and drain (black arrow)

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Figure 2 Flouroscopic image demonstrating complete occlusion of caudal lymphatic flow at the level of upper abdomen (solid arrow) with lymphatic streaks in the mediastinum (Arrow marked 2) and dye leakage in left upper mediastinum (white arrow)

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Figure 3 Axial image of contrast computed tomography of the chest showing contrast extravasation into the mediastinum posteriorly to left atrium (white arrow)

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  Discussion Top


The incidence of chylothorax ranges from 0.25% to 0.5% after cardiovascular surgery.[1] Variation in anatomy of the thoracic duct, injury to anomalous lymphatic channels at the perithymic tissues, the use of electrocautery rather than sutures for hemostasis, and application of tapes around the cavae are some of the important causes. Although often a single channel, the thoracic duct is found to have multiple channels in 40% of cases, with significant variations.[5] There were multiple lymphatics in our patient starting from the cisterna chyli extending into the mediastinum and draining into the left internal jugular and subclavian vein.

Kawasaki et al.[3] studied the effectiveness of therapeutic lymphangiography on refractory chylothorax. Lipiodol by its inflammatory and granulomatous reaction is suggested as one of the mechanisms. Successful healing was achieved in nine out of 14 patients (64.2%), and a 100% success rate was achieved in the minor and undetectable leak group. A median time of 9 days (6–29) was required for the evaluation of cessation of drainage.In difficult cases when the chyle leakage cannot be identified or chylothorax cannot be identified, pleural decortication or pleurodesis is the only option.[6] To date, there have been no randomized controlled clinical trials to provide evidence for the best management of chylothorax. An addition of lymphangiography to the preceding medical management of refractory chylothorax is therapeutic and diagnostic. We could detect the presence of multiple abnormal lymphatic channels in our patient, which was a rare finding and the cause of chylothorax. If the medical management fails, aggressive surgical therapy should be considered.

Financial support and sponsorship

Nil.

Informed consent

Informed consent was taken from all individuals included in the study.

Conflicts of interest

There are no conflicts of interest.

Ethical approval

All procedures performed in the study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.



 
  References Top

1.
Zaidenstein R, Cohen N, Dishi V, Alon I, Golik A, Modai D. Chylothorax following median sternotomy. Clin Cardiol 1996;19:910-2.  Back to cited text no. 1
    
2.
Sarkar BK, Bhattacharya S, Sarkar UN. Post operative chylothorax after cardiac surgery: A rare presentation. IJTCVS 2006;22:150-2.  Back to cited text no. 2
    
3.
Kawasaki R, Sugimoto K, Fujii M, Miyamoto N, Okada T, Yamaguchi M et al. Therapeutic effectiveness of diagnostic lymphangiography for refractory postoperative chylothorax and chylous ascites: Correlation with radiologic findings and preceding medical treatment. AJR Am J Roentgenol 2013;201:659-66.  Back to cited text no. 3
    
4.
Likaj E, Kacani A, Dumani S, Dibra L. Chylopericardium after mitral valve repair for rheumatic valve disease treated with surgery. Med Arch 2014;68:67-8.  Back to cited text no. 4
    
5.
Phang K, Bowman M, Phillips A, Windsor J. Review of thoracic duct anatomical variations and clinical implications. Clin Anat 2014;27:637-44.  Back to cited text no. 5
    
6.
Nair SK, Petko M, Hayward MP. Aetiology and management of chylothorax in adults. Eur J Cardiothorac Surg 2007;32:362-9.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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