Department of Cardiology, Hospital Israelita Albert Einstein, Albert Einstein Av. 627, São Paulo, Brazil.
Heart Institute (InCor), University of São Paulo Medical School, Dr Eneas de Carvalho Aguiar Street 44, São Paulo, Brazil.
BMC Cardiovasc Disord. 2020 Oct 31;20(1):469. doi: 10.1186/s12872-020-01755-z.
Candida prosthetic endocarditis is associated with high mortality rates and valve replacement surgery, together with antifungal treatment, play a major role in eradicating the fungal infection. Valve reoperations in these scenarios may be relatively common due to the high infection relapse rates and, in some cases, heart transplantation may be an imposing therapy for infection resolution and for the heart failure related to the myocardial reoperation injury. Among the many postoperative complications related to heart transplantation, chylopericardium is a rare but challenging example.
We report the case of a 55-year-old man who was admitted to our hospital with a 1-month history of progressive dyspnea and fatigue. His past medical history included four open-heart surgeries for aortic and mitral valve replacement due to recurrent Candida parapsilosis infective endocarditis. Transthoracic echocardiogram showed a markedly reduced left ventricular systolic function and normofunctioning bioprosthetic valves. An inotropic dependency condition led to heart transplantation surgery. In the early postoperative period, a persistent chylous fluid started to drain from the pericardial tube, compatible with the diagnosis of chylopericardium. The lack of clinical response to total parenteral nutrition and intravenous infusion of octreotide imposed the need of interventional radiology with diagnostic lymphography through cisterna chyli puncture and thoracic duct catheterization, confirming the presence of a lymphatic fistula. A successful treatment outcome was achieved with percutaneous thoracic duct embolization using coils and n-butyl-cyanoacrilate glue, possibiliting hospital discharge.
Fungal endocarditis requires combined treatment (surgical and antimicrobial) for eradication. Valve replacement, while necessary, may lead to severe ventricular deterioration and heart transplantation may be the only viable therapeutic solution. Among the several postoperative complications of heart transplantation, chylopericardium is an uncommon and defiant example. Advances in interventional radiology like the percutaneous embolization allow a less invasive and highly efficient approach for this complication.
念珠菌性人工心脏瓣膜心内膜炎与高死亡率和瓣膜置换手术相关，抗真菌治疗与瓣膜置换手术一起在消除真菌感染方面发挥着重要作用。由于感染复发率高，在这些情况下瓣膜再次手术可能相对常见，在某些情况下，心脏移植可能是一种强制性的治疗方法，既能解决感染，又能解决与心肌再手术损伤相关的心衰。在与心脏移植相关的众多术后并发症中，乳糜性心包积液是一种罕见但具有挑战性的病例。
我们报告了一例 55 岁男性病例，他因进行性呼吸困难和疲劳入院，病史包括因反复念珠菌属假丝酵母感染性心内膜炎而行 4 次开胸主动脉瓣和二尖瓣置换术。经胸超声心动图显示左心室收缩功能明显降低，生物瓣功能正常。由于存在正性肌力依赖状态，故行心脏移植手术。术后早期，心包引流管开始持续引流乳糜液，符合乳糜性心包积液的诊断。由于完全胃肠外营养和静脉注射奥曲肽治疗均无临床反应，故需行介入放射学诊断性淋巴造影术，通过经腔静脉穿刺和胸导管置管术证实存在淋巴管瘘。经皮胸导管栓塞术使用弹簧圈和 n-丁基氰基丙烯酸酯胶成功治疗，患者得以出院。
真菌感染性心内膜炎需要联合（手术和抗菌）治疗以根除感染。瓣膜置换虽然必要，但可能导致严重的心室恶化，心脏移植可能是唯一可行的治疗方法。在心脏移植的多种术后并发症中，乳糜性心包积液是一种罕见但具有挑战性的病例。介入放射学的进步，如经皮栓塞术，为这种并发症提供了一种微创且高效的治疗方法。
