Chylomediastinum after cardiac surgery through median sternotomy: A case report

Background: Chylous discharge can rarely occur after cardiac surgery through a median sternotomy. Conservative or surgical treatment might be chosen based on the amount of the discharge. Methods: We report the case of a patient who developed chylomediastinum after aortic valve replacement through a median sternotomy. A 79-year-old woman underwent aortic valve replacement through a median sternotomy for aortic valve stenosis. The thymus exhibited fatty degeneration and was divided with ligation at the mid-portion of the body without separation between the right and left lobes. Results: On the second postoperative day, 100mL of milky fluid was observed from the drainage tube of the retrosternal space after oral intake. We diagnosed the patient with chylomediastinum based on the characteristic appearance of the fluid and the relationship between the oral intake and the event. The drainage and low-fat total parenteral nutrition were continued for 1 week, leading to complete disappearance of the chylous discharge. Conclusion: Gentle and minimal exploration is required during venous snaring and thymus division for cardiac surgery through a median sternotomy, and minor chylomediastinum could be cured conservatively.

Direct cannulation of arch vessels for total arch replacement

Objectives: To observe the efficiency and safety of direct and indirect three arch vessels’ cannulation for bilateral antegrade cerebral perfusion during total arch replacement. Methods: Between 2002 and 2014, 130 patients underwent total arch replacement with direct and 66 patients with indirect cannulation for antegrade cerebral perfusion under moderate hypothermia. Patients were assigned to the direct cannulation group based on the condition of the aortic arch vessels. Demographics and concomitant surgeries were similar in the two groups. Patient characteristics, surgical and haemodynamic measurements, and postoperative neurologic findings were observed. Results: Aortic cross-clamping (120 ± 42 vs 139 ± 65 min; p = 0.032) and cardiopulmonary bypass (178 ± 57 vs 206 ± 71 min; p = 0.025) times were lower in the direct cannulation group. There were no differences in overall hospital mortality (4% vs 6%; p = 0.87), selective antegrade cerebral perfusion time (91 ± 52 vs 100 ± 65 min; p = 0.185), and incidence of neurologic deficit (3% vs 9%; p = 0.07). Indirect cannulation led to more frequent re-exploration for bleeding (5% vs 13%; p = 0.0356). There was no difference in midterm survival (log-rank p = 0.103; mean follow-up times: 4.74 years (direct cannulation), 5.50 years (indirect cannulation)). Conclusion: Direct cannulation during mild systemic hypothermia yields excellent outcomes while reducing time and rate of reoperation for bleeding and can be used in total arch replacement without increasing morbidity and mortality.