Abstract 4142349: Multidisciplinary Approach to Definitive Management of Chylopericardium with Percutaneous Thoracic Duct Embolization

Background: Conservative management of chylopericardium with pericardiocentesis, TPN, and octreotide has a high rate of recurrence. On the other hand, surgical management is invasive and can also result in treatment failure as well. Percutaneous approach has rarely been studied in this population. Case: A 26-year-old female was admitted for recurrent idiopathic chylopericardium after failing management with pericardiocentesis. On presentation, echocardiogram demonstrated a 5.4 cm pericardial effusion without hemodynamic compromise. Fluid studies showed turbid white fluid with a triglyceride level of 1,622 mg/dL. A pericardial window was performed, and patient was started on octreotide with fat-free diet. However, high chylous output continued for one week. After multidisciplinary discussion with cardiology, thoracic surgery, radiology, and interventional radiology, a nuclear medicine lymphangiogram was completed. This demonstrated a focal area of intense tracer activity at the level of pulmonary trunk. Subsequent lymphangiogram showed dilated lymphatic channels with reflux and stasis in this area. The thoracic duct was successfully embolized. Chylous output significantly decreased, and patient was discharged. An echo at one month follow-up showed complete resolution of pericardial effusion. Discussion: Although the clinical presentation was consistent with chylopericardium, management was complicated after patient failed treatment with several approaches. At this stage, invasive surgery to ligate the thoracic duct versus continued drainage in the outpatient setting was being considered. A collaborative approach guided the right imaging modality and therapeutic intervention to definitively manage chylopericardium efficiently without significant morbidity. Furthermore, it suggested that percutaneous thoracic duct embolization may be a viable treatment option for recurrent idiopathic chylopericardium refractory to conventional management. Conclusion: A multidisciplinary approach with nuclear medicine testing and percutaneous intervention can be an effective approach to certain cases of idiopathic chylopericardium.