Invited commentary

Abstract

This is another helpful paper from the Toronto Hospital for Sick Children. Postoperative pericardial and pleural effusions are not uncommon, especially in postoperative patients with certain congenital heart diagnoses. Conditions that result in elevated right atrial or superior vena caval pressures not infrequently have pericardial and pleural effusions postoperatively, and it is not surprising that the large database from Toronto confirms prior findings that those same patients are the ones more likely to experience chylous effusions. The authors also remind us that the increased lymphatic permeability associated with the lymphatic dysplasia contributes to chylous effusions (7 of 16 chylopericardium patients had Trisomy 21). Although the reported overall incidence of chylous pericardium is low, a full 15% of symptomatic postoperative pericardial effusions that required drainage were chylous in nature. Not surprisingly, 15% of the patients with an associated chylous pleural effusion had chylous pericardial effusions.In this series only 2 patients, once their diagnosis of chylous pericardial effusion was established could be treated with diet alteration alone, most requiring pericardial drainage by means of a tube or a pericardial window. Only 3 thoracic duct ligations were done, and all were associated with chylous pleural and pericardial drainage. It is important to note that in the authors’ experience, failure to respond to aspirin or anti-inflammatory medical treatment for pericardial effusion occurred in 8 of the 16 patients and raised the suspicion that the effusion was, in fact, chylous. The findings of this study support the observations of many that patients with both pleural and pericardial effusions postoperatively should be suspected of having chylous effusions, especially if the postoperative courses have been associated with elevated pressures in the superior vena cava or right atrium. If the patient is a child with Trisomy-21, the titer of suspicion should be much higher. This is another helpful paper from the Toronto Hospital for Sick Children. Postoperative pericardial and pleural effusions are not uncommon, especially in postoperative patients with certain congenital heart diagnoses. Conditions that result in elevated right atrial or superior vena caval pressures not infrequently have pericardial and pleural effusions postoperatively, and it is not surprising that the large database from Toronto confirms prior findings that those same patients are the ones more likely to experience chylous effusions. The authors also remind us that the increased lymphatic permeability associated with the lymphatic dysplasia contributes to chylous effusions (7 of 16 chylopericardium patients had Trisomy 21). Although the reported overall incidence of chylous pericardium is low, a full 15% of symptomatic postoperative pericardial effusions that required drainage were chylous in nature. Not surprisingly, 15% of the patients with an associated chylous pleural effusion had chylous pericardial effusions. In this series only 2 patients, once their diagnosis of chylous pericardial effusion was established could be treated with diet alteration alone, most requiring pericardial drainage by means of a tube or a pericardial window. Only 3 thoracic duct ligations were done, and all were associated with chylous pleural and pericardial drainage. It is important to note that in the authors’ experience, failure to respond to aspirin or anti-inflammatory medical treatment for pericardial effusion occurred in 8 of the 16 patients and raised the suspicion that the effusion was, in fact, chylous. The findings of this study support the observations of many that patients with both pleural and pericardial effusions postoperatively should be suspected of having chylous effusions, especially if the postoperative courses have been associated with elevated pressures in the superior vena cava or right atrium. If the patient is a child with Trisomy-21, the titer of suspicion should be much higher.