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J Thorac Cardiovasc Surg 1997;114:299-300
© 1997 Mosby, Inc.

LETTERS TO THE EDITOR

Isolated primary chylopericardium

Department of Thoracic/Cardiovascular Surgery
University of Bern
Inselspital
Bern CH-3010, Switzerland

Reply to the Editor:

Yüksel and associates have addressed some interesting points concerning the treatment of isolated primary chylopericardium. Although percutaneous pericardial drainage combined with a medium-chain triglyceride diet is recommended as the initial approach, ¹ we did not follow this conservative strategy in our patient because of the rapid recurrence of pericardial fluid accumulation with development of cardiac tamponade within 14 days after echocardiographically guided pericardiocentesis. The patient was then referred to our surgical department, and pericardial fenestration with ligation of the lymphatic duct was chosen as a straightforward procedure. Pericardial evacuation was strongly indicated in any case, and repeated pericardiocentesis and dietary treatment were not attempted because of the high probability of recurrence ² in the case of such rapid development of pericardial effusion. We believe that the minimally invasive approach as described in our brief report ³ is simple, efficient, and cost effective. Conservative attempts should be restricted to children or patients at high risk with slow progression of chylopericardium.

Unlike chylothorax, chylopericardium should not result in visible leakage of the thoracic duct. Therefore intraoperative attempts at duct visualization seems nonessential. We favor "mass ligation," as recommended by Murphy and Piper, ⁴ allowing a complete interruption of all possible lymphatic vessels, especially in the case of double or triple ducts at this level. ⁵ For this technique the right-sided approach is more appropriate and is preferred by most authors. ⁶

In our patient the minimal amount of loculated pericardial fluid was on the right side and hardly visible on echocardiographic follow-up after 1 month. We do not believe that this fluid is related to the size of the pericardial window, as suggested by Yüksel and coauthors, because we had performed a partial pericardiectomy of 7 x 5 cm on the right side. In our experience, the extent of pericardial fenestration on the left is also limited by the inherent possibility of heart herniation through the pericardium. Long-term follow-up was not suggested in our report, but we can update our case report now by an uneventual radiologic and clinical 2-year follow-up.

12/8/82355

References

1. Chan BK, Murphy MC, Rodgers BM. Management of chylopericardium. J Pediatr Surg 1990;25:1185-9.[Medline]
   
2. Akamatsu H, Aman J, Sakamoto T, Suzuki A. Primary chylopericardium. Ann Thorac Surg 1994;58:262-6.[Abstract]
   
3. Furrer M, Hopf M, Ris HB. Isolated primary chylopericardium: treatment by thoracoscopic thoracic duct ligation and pericardial fenestration. J Thorac Cardiovasc Surg 1996;112:1120-1.[Free Full Text]
   
4. Murphy TO, Piper CA. Surgical management of chylothorax. Ann Surg 1977;43:719.
   
5. Anson BJ. An atlas of anatomy. Philadelphia: WB Saunders; 1950.
   
6. Shields TW. Management of chylothorax. In: General thoracic surgery. 4th ed. Malvern: Williams & Wilkins; 1994. pp. 719-20.
   

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Markus Furrer Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Furrer, M. Search for Related Content PubMed Articles by Furrer, M.