Chylothorax after Surgery for Congenital Cardiac Disease: A Prevention and Management Protocol

Shin, Yu Rim; Lee, Ha; Park, Young-Hwan; Park, Han Ki

doi:10.5090/kjtcs.2020.53.2.41

Cited by 19 publications

(28 citation statements)

References 14 publications

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“…21 Shin et al have reported their incidence of 5% after BCPS surgery. 20 We had a fairly low incidence of chylothorax (2%) in our series, of which more than half required thoracic duct ligation.…”

Section: Resultsmentioning

confidence: 64%

“…Chylothorax after congenital heart surgery has been reported ranging from 2 to 5%. 20,21 Although the incidence per se of this complication is low, it can lead to serious complications such as malnutrition, infection, and immunosuppression causing greater morbidity and mortality following pediatric cardiac surgery. 21 Shin et al have reported their incidence of 5% after BCPS surgery.…”

Section: Resultsmentioning

confidence: 99%

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In Hospital Outcomes after Bidirectional Cavopulmonary Anastomosis: 18 Year Experience from a Single Center

et al. 2020

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Background: Bidirectional cavopulmonary shunt (BCPS) is used for the interim palliation of a variety of cyanotic cardiac lesions. It is a standard palliative step for patients with functionally univentricular hearts in hope of achieving Fontan completion. At our center, first case of BCPS was performed on February 7, 2002. Here, we share our experience with BCPS over last 18 years. Methods: This is a retrospective analysis of all patients undergoing BCPS from February 2002 to July 2019. Patients who underwent BCPS as a part of one-and-half ventricular repair for Ebstein’s anomaly were excluded. Baseline, intraoperative, and postoperative variables were collected from hospital records. Results: A total of 326 patients with mean age of 5.7±5.8 years (median 3.5 years; range: 1.5 months-32 years) underwent BCPS over last 18 years. Majority (61%) were males. Double outlet right ventricle (DORV) was the most common primary cardiac lesion (30%) followed by tricuspid atresia (23%). Mean ICU stay was 3.9±4.8 days, with hospital stay of 7.8±5.9 days. In-hospital mortality was 15%. Patients who died had low body weight (11.8±10.7 kg vs 16.0±11.6 kg; p=0.019), and longer cardiopulmonary bypass time (101±64 min vs 76±42 min; p=0.001). Oxygen saturation improved significantly at the time of discharge (79.2±9.5% vs 68.6±13.7%; p=0.000). Conclusion: This is the first report of its kind to analyze the outcomes of BCPS in our center. We have discussed the evolution of BCPS surgery in our center and presented our outcomes. Our in-hospital mortality remains high, and we need to strive towards reducing the mortality.

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Section: Resultsmentioning

confidence: 64%

Section: Resultsmentioning

confidence: 99%

In Hospital Outcomes after Bidirectional Cavopulmonary Anastomosis: 18 Year Experience from a Single Center

et al. 2020

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“…While low-fat diets have become a part of chylothorax management for many, there is no data to demonstrate low-fat diets or nothing per os are bene cial. Studies, particularly in those with congenital heart disease, have not been done randomizing patients with chylothorax to a low-fat diet or normal fat diet and comparing the two groups [10,17,18]. Data for low-fat diets comes from case reports and retrospective reviews which cannot differentiate the effect of time versus the effect of the low-fat diet.…”

Section: Discussionmentioning

confidence: 99%

“…Various clinical management protocols have been described. While many of these have been associated with a decrease in chest tube duration and hospital length of stay, speci c components of the protocol mediating these improvements have not been delineated [10][11][12].…”

Section: Introductionmentioning

confidence: 99%

Objective lessons from a chylothorax protocol: identifying specific mediators of chest tube duration

Loomba¹,

Heenan²,

Ogden³

et al. 2022

Preprint

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Background Chylothorax after pediatric cardiothoracic surgery is associated with increased morbidity and resource utilization. There is limited data on optimal management of chylothorax as well as effectiveness of individual components of previously reported management protocols. A chylothorax clinical management protocol was implemented at Advocate Children’s Hospital as a quality improvement initiative with the primary objective of determining the association of protocol implementation with chest tube duration. Secondary objectives were to determine the association of individual protocol elements with chest tube duration. Methods The clinical management protocol was developed by a multidisciplinary work group after reviewing internal practice patterns as well as published data. Patient data was compared 21 months before and 21 months after implementation of the protocol in April 2019. Data collected included patient demographics, chest tube duration, and medical and dietary interventions such as use of steroids and low fat diet. Outcomes analyzed included death, surgery, duration of chest tube, and hospital length of stay. Results A total of 15 and 27 patients were analyzed before and after protocol implementation respectively. There was no significant difference in demographic data. Protocol adherence was 96%. Methylprednisolone was used exclusively after protocol implementation. Patients tended to receive lower maximum doses of furosemide and chlorothiazide after protocol implementation. Multivariable analysis showed that duration of chest tube after onset of chylous output decreased by 3 days after protocol implementation. A cutoff of 10 mL/kg per 24 hours of chest tube output was shown to predict high volume chest tube output above the median. Conclusion A chylothorax management protocol was associated with a 3-day decrease in chest tube output in pediatric cardiac patients. Review of the protocol components demonstrates that a 5-day course of steroids may be beneficial while a low-fat diet may not. This initiative demonstrates how a quality improvement initiative can be successfully utilized in the clinical setting and provide not only protocol level data but also component-specific data.

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“… 1 – 3 The characteristics of postoperative chylous effusion fluid include lymphocytic predominance and high triglyceride count. 4 , 5 Secondary chylothoraces result in significant morbidities, including prolonged ventilator dependence, intensive care stays, malnutrition, prolonged parenteral nutritional support, hypoalbuminemia, lymphopenia, immunodeficiency, electrolyte abnormalities, nosocomial infections, and death. 6 – 8 Despite severe morbidities and mortality, little is known about the causes of postoperative chylothorax.…”

Section: Introductionmentioning

confidence: 99%

Lymphatic Endothelial Cell Defects in Congenital Cardiac Patients With Postoperative Chylothorax

Shakoor

Muley

et al. 2021

Journal of Vascular Anomalies

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Objectives: Chylothorax following cardiac surgery for congenital cardiac anomalies is a complication associated with severe morbidities and mortality. We hypothesize that there are intrinsic defects in the lymphatics of congenital cardiac patients. Methods: Postsurgical chylothorax lymphatic endothelial cells (pcLECs) (n = 10) were isolated from the chylous fluid from congenital cardiac defect patients, and characterized by fluorescent-activated cell sorting, immunofluorescent staining, and quantitative RT-PCR. Results were compared to normal human dermal lymphatic endothelial cells (HdLECs). pcLECs (n = 3) and HdLECs were xenografted into immunocompromised mice. Implants and postoperative chylothorax patient’s pulmonary tissues were characterized by immunostaining for lymphatic endothelial proteins. Results: pcLECs expressed endothelial markers VECADHERIN, CD31, VEGFR2, lymphatic endothelial markers PROX1, podoplanin, VEGFR3, and progenitor endothelial markers CD90 and CD146. However, pcLECs had key differences relative to HdLECs, including altered expression and mislocalization of junctional proteins (VECADHERIN and CD31), and essential endothelial proteins, VEGFR2, VEGFR3, and PROX1. When xenografted in mice, pcLECs formed dilated lymphatic channels with poor cell–cell association. Similar to congenital lymphatic anomalies, the pulmonary lymphatics were dilated in a patient who developed postoperative chylothorax after cardiac surgery. Conclusions: Recent studies have shown that some postoperative chylothoraces in congenital cardiac anomalies are associated with anatomical lymphatic defects. We found that pcLECs have defects in expression and localization of proteins necessary to maintain lymphatic specification and function. This pcLEC phenotype is similar to that observed in lymphatic endothelial cells from congenital lymphatic anomalies. Co-existence of lymphatic anomalies should be considered as a feature of congenital cardiac anomalies.

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Chylothorax after Surgery for Congenital Cardiac Disease: A Prevention and Management Protocol

Cited by 19 publications

References 14 publications

In Hospital Outcomes after Bidirectional Cavopulmonary Anastomosis: 18 Year Experience from a Single Center

In Hospital Outcomes after Bidirectional Cavopulmonary Anastomosis: 18 Year Experience from a Single Center

Objective lessons from a chylothorax protocol: identifying specific mediators of chest tube duration

Lymphatic Endothelial Cell Defects in Congenital Cardiac Patients With Postoperative Chylothorax

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