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• W4304144900 abstract "SESSION TITLE: Shedding Light on the PleuraSESSION TYPE: Case ReportsPRESENTED ON: 10/19/2022 11:15 am - 12:15 pmINTRODUCTION: Heart failure is a rare cause of chylothorax and chylous ascites, especially when presenting concomitantly. In the literature, only four cases have been reported to our knowledge. This case study aims to highlight the unique presentation, diagnosis, and pathophysiology of chylothorax and chylous ascites.CASE PRESENTATION: A 71-year-old male with a history of heart failure with ejection fraction of 15%, coronary artery disease, atrial fibrillation, and obstructive sleep apnea presented with dyspnea, orthopnea, and lower extremity edema. On physical examination, he had bibasilar crackles, abdominal distension, and 3+ pitting edema. Chest X-ray revealed a moderate left-sided pleural effusion. Abdominal imaging revealed moderate ascites, liver cysts (which appeared benign), no evidence of cirrhosis, and normal spleen and pancreas. He had a left-sided thoracentesis and paracentesis where 900ml and 1000ml of milky fluid were removed. Pleural fluid triglyceride was 276mg/dL and peritoneal fluid triglyceride was 486mg/dL, confirming the respective diagnoses (see fluid characteristics in Table 1).DISCUSSION: Chylothorax and chylous ascites are defined as fluid triglyceride levels exceeding 110mg/dL in the pleural space and 200mg/dL in the peritoneal space, respectively [1]. Two mechanisms by which heart failure causes chylothorax and chylous ascites have been proposed. First, heart failure is associated with high venous pressures that lead to increased production of abdominal lymph via enhanced capillary filtration. The flow of lymph in the thoracic duct can increase by up to 12-fold the normal rate, but the rigidity of the venolymphatic junction in the neck restrains lymphatic flow [2]. Second, high pressure in the left subclavian vein reduces lymphatic drainage, causing lymphatic venous collaterals to form; these collaterals, however, are ineffective and cannot handle the normal lymph flow resulting in leakage of chyle into the spaces [3].Our patient's right heart catheterization showed elevated right-sided pressures signifying pulmonary hypertension due to left-sided heart disease (Table 2). We deduced that our patient's elevated right-sided pressures caused reduced lymphatic drainage at the left subclavian vein, with resultant collateral formation and leakage of chyle into the pleural and peritoneal space.CONCLUSIONS: This case presents a unique perspective wherein both chylothorax and chylous ascites were concomitantly present. It is unclear which pathologic process occurred first and the exact pathophysiology is unknown. Clinicians should be aware that heart failure, though rare, can present with chylothorax and chylous ascites.Reference #1: Cakmak AH, Yenidunya G, Karadag B, Ongen Z. Development of chylothorax and chylous ascites in a patient with congestive heart failure. Turk Kardiyol Dern Ars 2011; 39(6):496-498.Reference #2: Dumont AE, Clauss RH, Reed GE, Tice DA. Lymph drainage in patients with congestive heart failure. Comparison with findings in hepatic cirrhosis. N Engl J Med 1963;269:949-52.Reference #3: Wilkinson P, Pinto B, Senior JR. Reversible protein losing enteropathy with intestinal lymphangiectasia secondary to chronic constrictive pericarditis. N Engl J Med 1965; 173: 1178–1181.DISCLOSURES: No relevant relationships by David BecnelNo relevant relationships by Siraphob ChansangavejNo relevant relationships by Jacqueline ChoaNo relevant relationships by Sandra OkoliNo relevant relationships by Adrian Francis Sarita SESSION TITLE: Shedding Light on the Pleura SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm INTRODUCTION: Heart failure is a rare cause of chylothorax and chylous ascites, especially when presenting concomitantly. In the literature, only four cases have been reported to our knowledge. This case study aims to highlight the unique presentation, diagnosis, and pathophysiology of chylothorax and chylous ascites. CASE PRESENTATION: A 71-year-old male with a history of heart failure with ejection fraction of 15%, coronary artery disease, atrial fibrillation, and obstructive sleep apnea presented with dyspnea, orthopnea, and lower extremity edema. On physical examination, he had bibasilar crackles, abdominal distension, and 3+ pitting edema. Chest X-ray revealed a moderate left-sided pleural effusion. Abdominal imaging revealed moderate ascites, liver cysts (which appeared benign), no evidence of cirrhosis, and normal spleen and pancreas. He had a left-sided thoracentesis and paracentesis where 900ml and 1000ml of milky fluid were removed. Pleural fluid triglyceride was 276mg/dL and peritoneal fluid triglyceride was 486mg/dL, confirming the respective diagnoses (see fluid characteristics in Table 1). DISCUSSION: Chylothorax and chylous ascites are defined as fluid triglyceride levels exceeding 110mg/dL in the pleural space and 200mg/dL in the peritoneal space, respectively [1]. Two mechanisms by which heart failure causes chylothorax and chylous ascites have been proposed. First, heart failure is associated with high venous pressures that lead to increased production of abdominal lymph via enhanced capillary filtration. The flow of lymph in the thoracic duct can increase by up to 12-fold the normal rate, but the rigidity of the venolymphatic junction in the neck restrains lymphatic flow [2]. Second, high pressure in the left subclavian vein reduces lymphatic drainage, causing lymphatic venous collaterals to form; these collaterals, however, are ineffective and cannot handle the normal lymph flow resulting in leakage of chyle into the spaces [3]. Our patient's right heart catheterization showed elevated right-sided pressures signifying pulmonary hypertension due to left-sided heart disease (Table 2). We deduced that our patient's elevated right-sided pressures caused reduced lymphatic drainage at the left subclavian vein, with resultant collateral formation and leakage of chyle into the pleural and peritoneal space. CONCLUSIONS: This case presents a unique perspective wherein both chylothorax and chylous ascites were concomitantly present. It is unclear which pathologic process occurred first and the exact pathophysiology is unknown. Clinicians should be aware that heart failure, though rare, can present with chylothorax and chylous ascites. Reference #1: Cakmak AH, Yenidunya G, Karadag B, Ongen Z. Development of chylothorax and chylous ascites in a patient with congestive heart failure. Turk Kardiyol Dern Ars 2011; 39(6):496-498. Reference #2: Dumont AE, Clauss RH, Reed GE, Tice DA. Lymph drainage in patients with congestive heart failure. Comparison with findings in hepatic cirrhosis. N Engl J Med 1963;269:949-52. Reference #3: Wilkinson P, Pinto B, Senior JR. Reversible protein losing enteropathy with intestinal lymphangiectasia secondary to chronic constrictive pericarditis. N Engl J Med 1965; 173: 1178–1181. DISCLOSURES: No relevant relationships by David Becnel No relevant relationships by Siraphob Chansangavej No relevant relationships by Jacqueline Choa No relevant relationships by Sandra Okoli No relevant relationships by Adrian Francis Sarita" @default.
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• W4304144900 title "TRANSUDATIVE CHYLOTHORAX AND CHYLOUS ASCITES IN ADVANCED HEART FAILURE" @default.
• W4304144900 doi "https://doi.org/10.1016/j.chest.2022.08.1194" @default.
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