Chylopericardium after cardiac surgery requiring thoracic duct ligation: a case report

Chylopericardium, the accumulation of chyle within the pericardial space, is a rare complication of cardiothoracic surgery. We report a 63-year-old woman who developed chylopericardium about 7 weeks after left ventricular aneurysmectomy and coronary artery bypass grafting. She presented with dyspnoea and abdominal pain. Chest computed tomography showed a large pericardial effusion with right-chamber compression. Emergency pericardial drainage yielded 1000 mL of milky fluid with a triglyceride concentration of 535 mg/dL and a lymphocytic predominance. The pericardial fluid culture grew Staphylococcus epidermidis from a single sample; blood cultures were negative, and vancomycin was continued for 4 weeks, although contamination could not be excluded. Doppler ultrasound showed thrombosis at the left jugulo-subclavian junction, where the Thoracic duct drains, and anticoagulation was started. Oral intake was suspended and total parenteral nutrition was given. Drainage fell and turned citrine, then became chylous again at low volume once an oral diet was reintroduced. Thoracic duct ligation and a pleuropericardial window, performed thoracoscopically, achieved definitive control, and the effusion had resolved completely by 5 months. This case shows that a low-volume chylous relapse can indicate the need for surgical ligation once conservative measures have been tried.