Chylopericardium as a Rare Entity Following Orthotopic Heart Transplantation

Introduction Chylopericardium is a rare complication following orthotopic heart transplant (OHT). Chylous pericardial effusions are characterized by an accumulation of lymph and emulsified fats in the pericardial sac that has a milky appearance with triglyceride levels in high concentration. Ongoing leakage of chyle in the pericardial space can have detrimental effects on nutrition, metabolism, and the immune system. We report one of the first cases of chylopericardium following orthotopic heart transplant that was successfully treated with thoracic duct embolization. Case Report A 37 year old male with dilated nonischemic cardiomyopathy on home milrinone presented for OHT. The operation was uncomplicated with a bicaval anastomosis and allograft ischemic time of 178 minutes. The early postoperative course was complicated by 2R acute cellular rejection, for which he was treated with pulse steroids with good effect. The post-biopsy echocardiogram revealed a large circumferential pericardial effusion with fibrinous strands and evidence of tamponade. He was taken for pericardiocentesis where 1.2 liters of pink milky fluid were removed, with improvement in pericardial pressure from 14 mmHg to 0 mmHg. Pericardial fluid triglycerides resulted at 1645 mg/dL consistent with chylous fluid. Unfortunately, the effusion reaccumulated in less than 24 hours suggestive of thoracic duct injury. He was taken for pericardial window and placed on a low-fat lymphatic diet. Subsequent lymphangiogram confirmed thoracic duct injury, for which successful coil embolization of the thoracic duct was performed. He was restarted on a regular diet and follow up echocardiogram showed normal graft function and no further reaccumulation of the effusion. He convalesced well and his post-transplant course was unremarkable on a standard maintenance immunosuppression regimen. Summary Chylopericardium may occur rarely as a complication of cardiothoracic surgery, trauma, malignancy, infection, or congenital abnormalities. Conservative management with dietary modification has resulted in only variable success while surgery (ligation of the thoracic duct and pericardial window) can carry higher risks due to its invasive nature. We report a case of chylopericardium following orthotopic heart transplant that was successfully managed with a percutaneous option of thoracic duct embolization.