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J Thorac Cardiovasc Surg 1994;108:388-389
© 1994 Mosby, Inc.

LETTERS TO THE EDITOR

Chylopericardium complicating pericardiocentesis for acute idiopathic pericardial effusion

University Department of Medicine
Withington Hospital, Nell lane
Manchester M20 8LR, England

To the Editor:

We wish to report what we believe to be the first case of chylopericardium complicating pericardiocentesis for acute idiopathic pericardial effusion.

In April 1992 a healthy 22-year-old woman was admitted on an emergency basis with a 5-day history of progressive breathlessness after an episode of pericardial pain that had resolved spontaneously. On examination she had signs of cardiac tamponade. A chest radiograph confirmed massive cardiomegaly but normal lung fields. An electrocardiogram recorded small voltage complexes with QRS alternans. Echocardiography confirmed a massive pericardial effusion and was used to guide the insertion of a pigtail catheter into the pericardial cavity via a subxiphoid approach and the Seldinger technique. This catheter was sutured into position, and 1.8 L of a hemorrhagic effusion was aspirated. The fluid was negative to malignant, viral, bacterial, and autoimmune screens.

The patient's progress was monitored by daily echocardiograms and repeated aspirations. By the fourth day the character of the fluid had changed from serosanguineous to chylous, and chylopericardium was diagnosed biochemically. Computed axial tomography of the chest and abdomen showed no abnormalities, and the pigtail catheter was withdrawn 1 inch, but with no resolution of the drainage. By day 7, 7.1 L of fluid had been collected and the patient had become profoundly lymphopenic. Therefore she was referred to the regional cardiothoracic center for further management.

With the patient under general anesthesia, the sternum was exposed by a transverse submammary incision and opened through a median sternotomy. A large lymphatic vessel 5 mm in diameter coursing up over the anterior pericardial wall had been pierced by the pigtail catheter, and chyle was seen to be leaking freely into the pericardial cavity. The anomalous lymphatic channel was sealed by oversewing, and biopsy of the pericardium showed inflammatory changes only. One year after her initial illness she remains well.

Pericardiocentesis has been in use for more than a century, and the routine use of echocardiography in the past 20 years has helped to establish it as a safe and effective procedure in the diagnosis and treatment of pericardial effusion. However, it still carries a greater risk of complication than cardiac catheterization. ¹ Patients undergoing pericardiocentesis for cardiac tamponade have a major complication rate of 7%. ² In our case accidental perforation of an anomalous lymphatic channel on the anterior pericardium by the pigtail catheter resulted in iatrogenic chylopericardium. More usually, secondary chylopericardium results from damage to the thoracic duct during cardiothoracic operations, ³ but obstruction of the duct by mediastinal masses, radiation fibrosis, and subclavian thrombosis may cause it.

Surgical treatment of chylopericardium involves ligation of the thoracic duct above the diaphragm and formation of a pericardial window, although in this case simple oversewing of the leaking vessel was all that was required. In patients unsuitable for surgical treatment, a medium-chain triglyceride diet or parenteral nutrition supplemented by tube drainage may suffice. ⁴ Long-term follow-up is suggested, because a case of constrictive pericarditis complicating chylopericardium has been described. ⁵

We thank Mr. T. Hooper (consultant cardiothoracic surgeon) for his help in the management of this case.

References

1. Krikorian JG, Hancock EW. Pericardiocentesis. Am J Med 1978;65:808-14.[Medline]
   
2. Guberman BA, Fowler NO, Engel PJ, et al. Cardiac tamponade in medical patients. Circulation 1981;64:633-40.[Abstract/Free Full Text]
   
3. Rose DM, Colvin SB, Danilowicz D, Isom OW. Cardiac tamponade secondary to chylopericardium following surgery: case report and review of literature. Ann Thorac Surg 1982;34:333-6.[Abstract]
   
4. Miller SU, Pruett HJ, Long A. Fatal chylopericardium caused by hamartomatous lymphangiomatosis. Am J Med 1959;26:951.[Medline]
   
5. Morishita Y, Taira A, Furoi A, Arima S, Tanaka H. Constrictive pericarditis secondary to primary chylopericardium. Am Heart J 1985;109:373-5.[Medline]
   

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