CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 4, May 2013
AFRICA
e7
Case Report
Delayed chylopericardium as a rare complication after
combined mitral valve and coronary artery bypass
surgery
BILGEHAN SAVAS OZ, GOKHAN ARSLAN, SUAT DOGANCI, ERKAN KAYA, KUBILAY KARABACAK,
FARUK CINGOZ, MEHMET ARSLAN
Abstract
Chylopericardium is a rare complication of cardiac surgery
that is performed from a midline sternotomy. Here we
present a case of a 61-year-old male patient with late-onset
postoperative chylopericardium following combined coro-
nary artery bypass grafting and mitral valve surgery, and the
applied treatment modality.
Keywords:
cardiac surgery, chylopericardium, late onset
Submitted 12/11/12, accepted 17/4/13
Cardiovasc
J Afr
2013;
24
: e7–e9
DOI: 10.5830/CVJA-2013-026
Chylopericardium is a rare but life-threatening complication
that occurs as a result of collection of chylous liquid in the
pericardial cavity. The aetiology may be both congenital and
acquired. Chylous collection following cardiac surgery may
cause nutritional imbalance and infection. In this case report, we
present the first case of late chylopericardium after combined
coronary artery bypass surgery and mitral valve replacement and
we discuss the administered therapy.
Case report
A 61-year-old male patient was admitted to our cardiology
clinic with symptoms of dyspnoea, palpitations and fatigue over
a six-month period. After his physical examination, coronary
angiogram and echocardiographic evaluation, coronary artery
lesions and mitral valve disease were detected. Transthoracic
echocardiography revealed a serious mitral regurgitation (grade
4) with mild aortic and tricuspid regurgitation. The ejection
fraction was 60%.
The patient was prepared for mitral valve replacement and
coronary artery bypass grafting surgery. A central venous
catheter through the right internal jugular vein was placed and
the patient was monitored from the right radial artery after the
application of standard open-heart surgical anaesthesia.
A median sternotomy was performed. The two pleural
spaces remained intact. The thymus was divided medially using
electrocauterisation without extracting the gland. The superior
and inferior vena cavae were snared with tapes. Following the
cross-clamping of the aorta, isothermic blood cardioplegia was
used for myocardial protection. The mitral valve was replaced
with a 25-mm St Jude bileaflet mechanical prosthesis and the
posterior leaflet was preserved. After performing bypass between
the left anterior descending artery and saphenous vein graft,
the operation was accomplished successfully and then only one
drainage tube was put into the mediastinal space. The patient
could be extubated within six hours of arrival in the cardiac ICU.
On his first day, 400 ml total of haemorrhagic drainage was
obtained from the mediastinal drain. There was no intra-operative
complication and the patient made an uneventful post-operative
recovery. He was discharged on the seventh post-operative day, at
which time he was doing well and the chest X-ray did not show
any signs of cardiomegaly.
The patient re-presented on the 17th postoperative day with
symptoms of dyspnoea and palpitations. He was in apparent
distress. His heart rate was 120 beats/min, blood pressure was
90/47 mmHg, temperature was 37.0°C, and his jugular venous
pressure was elevated. No pulsus paradoxus was detected. The
liver was 2 cm enlarged. Bilateral (
+
1) pretibial oedema was
present. Auscultation revealed a grade 2/6 systolic ejection
murmur at the right upper sternal border, a distant S1 and S2,
and no gallops or rubs.
Laboratory results included a white blood cell count of 9.3
×
10
9
/l. An electrocardiogram revealed sinus tachycardia. A chest
X-ray showed signs of cardiomegaly (Fig. 1). An echocardiogram
showed a normally functioning prosthetic mitral valve and a
large circumferential pericardial effusion (8 cm) with diastolic
right ventricular collapse.
He underwent emergency pericardiocentesis using
transthoracic echocardiography and 1 300 ml of milky, yellowish
fluid was removed. The pericardial fluid was analysed and
showed chylomicrons with elevated triglyceride levels, consistent
with chylous fluid. Microbiological studies were negative. A
24-F drain was positioned in the pericardial space.
Department of Cardiovascular Surgery, Gulhane Military
Medical Academy, Ankara, Turkey
BİLGEHAN SAVAS OZ, MD,
GOKHAN ARSLAN, MD
SUAT DOGANCİ, MD
ERKAN KAYA, MD
KUBİLAY KARABACAK,MD
FARUK CİNGOZ, MD
MEHMET ARSLAN, MD
