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cardio.cardiac-tamponade.chylopericardium.v1

Cardiac tamponade — chylopericardium (chylous pericardial effusion)

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Phase E variant of cardio.cardiac-tamponade.core.v1 — narrowed to chylopericardium (chylous pericardial effusion) characterized by milky pericardial fluid with triglycerides >500 mg/dL, pericardial-to-serum TG ratio >1, chylomicrons on lipoprotein electrophoresis, and cholesterol-to-TG ratio <1. Etiologies: PRIMARY (idiopathic, presumed congenital thoracic-duct anomaly, younger patients) vs SECONDARY (post-cardiothoracic surgery thoracic-duct injury — leading modern cause; mediastinal lymphoma — leading neoplastic cause; TB with mediastinal lymphadenitis; penetrating thoracic trauma; subclavian vein thrombosis with thoracic-duct outflow obstruction; LAM/lymphangiomatosis; mediastinal radiation). Treatment ladder per Akamatsu Ann Thorac Surg 1994 PMID 8311605 and Riquet EJCTS 1996: Step 1 pericardiocentesis if tamponade physiology (ESC 2015 Class I); Step 2 conservative MCT (medium-chain triglyceride) low-fat diet (MCTs absorbed directly into portal vein bypassing thoracic duct) ± TPN × 4-6 wk (~50-70% resolve); Step 3 octreotide 50-200 µg SC TID for non-responders after 1-2 wk MCT diet (somatostatin analog reduces thoracic-duct flow per Markham Pediatr Cardiol 2013); Step 4 surgical thoracic-duct ligation (open or VATS per Chen J Cardiothorac Surg 2014) + pericardial window if conservative fails 4-6 wk (preceded by lymphoscintigraphy/lymphangiography for anatomy definition); Step 5 pericardiectomy if constrictive sequelae develop (rare); Step 6 treat underlying cause (lymphoma chemotherapy per oncology, TB ATT per CDC/ATS/IDSA, anticoagulation for thrombosis). Severity triggers cover tamponade physiology requiring emergent drainage, conservative management failure requiring surgical ligation, lymphoma-confirmed etiology requiring oncology, TB-confirmed etiology requiring anti-TB therapy, constrictive pericarditis development. Sister-differentiated from malignant tamponade (lymphoma overlap), post-procedural tamponade (post-cardiothoracic surgery overlap), and TB pericarditis (TB lymphadenitis overlap). Manifest pointer reuses cardio.cardiac-tamponade.core.v1 manifest. Design-brief pointer reuses parent (chylopericardium-specific differences documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute (Phase E wave 25).

Entry points (6)

  • imaging
    Pericardial effusion with milky/opalescent fluid on pericardiocentesis aspirate — chylopericardium until proven otherwise (Akamatsu Ann Thorac Surg 1994 PMID 8311605; ESC 2015 §Specific Etiologies)
    pericardial_effusion_with_milky_aspirate_on_pericardiocentesis
  • lab_abnormality
    Pericardial fluid triglycerides >500 mg/dL with chylomicrons on lipoprotein electrophoresis (pericardial > serum TG ratio >1) (Akamatsu PMID 8311605; Imazio JAMA 2015 PMID 26461998)
    pericardial_fluid_triglycerides_gt_500_mg_dl_with_chylomicrons
  • history
    Post-cardiothoracic surgery (CABG, transplant, congenital repair) with new pericardial effusion within 30 days — high suspicion for thoracic-duct injury chylopericardium (Kshettry Ann Thorac Surg 1996; Riquet EJCTS 1996)
    post_cardiothoracic_surgery_with_new_pericardial_effusion_within_30d
  • imaging
    Mediastinal mass on CT/MRI with pericardial effusion → lymphoma-related chylopericardium concern (Imazio JACC 2020 PMID 32919577; Lyon EHJ 2022 PMID 35993161)
    mediastinal_mass_with_pericardial_effusion_lymphoma_concern
  • symptom
    Idiopathic pericardial effusion in younger patient with chylous fluid features — primary chylopericardium (congenital thoracic-duct anomaly; Yokota JTCVS 1989; Iyer Pediatr Cardiol 2008)
    idiopathic_pericardial_effusion_with_chylous_features_younger_patient
  • history
    TB with mediastinal lymphadenopathy OR penetrating thoracic trauma with chylous effusion (Cherian Indian J Tuberc 2018; ESC 2015)
    tb_or_thoracic_trauma_with_chylous_effusion

Required inputs (10)

  • agerequired
    demographic • used at CONTEXT
    Primary idiopathic chylopericardium more common in younger patients; secondary causes (post-surgical, lymphoma, TB) span all ages (Akamatsu PMID 8311605; Yokota 1989)
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension is part of Beck triad in tamponade physiology; chylous effusions may accumulate slowly with preserved BP until late (ESC 2015)
  • hrrequired
    vital • used at CONTEXT
    Compensatory tachycardia in tamponade (ESC 2015)
  • jvprequired
    vital • used at INITIAL_WORKUP
    JVD prominent in tamponade (Beck triad); chylous accumulation may be insidious (ESC 2015)
  • echorequired
    imaging • used at INITIAL_WORKUP
    TTE for effusion size + tamponade physiology + RV/RA collapse + IVC plethora (ESC 2015 Class I)
  • chest_ct_mrirequired
    imaging • used at INITIAL_WORKUP
    Chest CT/MRI for mediastinal mass (lymphoma), thoracic-duct anatomy, post-surgical anatomy, lymphadenopathy (TB), pleural effusion (chylothorax often co-existent) (Imazio JAMA 2015 PMID 26461998)
  • pericardial_fluid_triglyceridesrequired
    lab • used at INITIAL_WORKUP
    Pericardial fluid triglycerides >500 mg/dL diagnostic; pericardial-to-serum TG ratio >1; cholesterol-to-TG ratio <1; chylomicrons on lipoprotein electrophoresis confirm (Akamatsu PMID 8311605)
  • pericardial_fluid_cytology_chemistry_culturerequired
    lab • used at INITIAL_WORKUP
    Pericardial fluid analysis: cytology (lymphoma), gram stain + culture, AFB + Xpert MTB/RIF (TB), cell count + differential (lymphocyte-predominant in chylous), chemistry, ADA (TB) (ESC 2015)
  • recent_cardiothoracic_surgery_or_trauma_or_lymphoma_or_tb_historyrequired
    history • used at CONTEXT
    Etiology drives differential and treatment: post-surgical (thoracic-duct injury), lymphoma (mass infiltration), TB (mediastinal lymphadenopathy), trauma (penetrating injury), idiopathic (congenital), LAM (lymphatic disorder) (Akamatsu PMID 8311605; Imazio JACC 2020)
  • creatininerequired
    lab • used at CONTEXT
    Renal function for diuretic + drug dosing + contrast for imaging; KDIGO 2026 race-free eGFR (Inker NEJM 2021)

12-phase flow (9)

  1. 1FRAME
    Chylopericardium — chylous pericardial effusion characterized by milky fluid with TG >500 mg/dL and chylomicrons; primary (idiopathic congenital thoracic-duct anomaly) or secondary (post-cardiothoracic surgery, lymphoma, TB, trauma, LAM, radiation); treatment ladder MCT diet → octreotide → surgical ligation → pericardiectomy (ESC 2015 §Specific Etiologies; Akamatsu Ann Thorac Surg 1994 PMID 8311605)
    inputs: recent_cardiothoracic_surgery_or_trauma_or_lymphoma_or_tb_history
    advance: chylopericardium clinical context confirmed
  2. 2ENTRY
    Recognize patient with milky pericardial fluid on aspirate OR pericardial effusion in high-risk context (post-cardiac surgery <30d, mediastinal mass, TB, trauma); initial pericardiocentesis often diagnostic (Akamatsu PMID 8311605)
    inputs: age
    advance: chylous fluid character or high-risk context identified
  3. 3CONTEXT
    Document etiology evaluation: recent cardiothoracic surgery (thoracic-duct injury at operative site), mediastinal lymphoma history (mass effect/infiltration), TB exposure (mediastinal lymphadenopathy), penetrating trauma, prior radiation (lymphatic injury), LAM/lymphatic disorders, subclavian vein thrombosis, primary idiopathic (younger patient, no etiology found) (Akamatsu PMID 8311605; Imazio JACC 2020 PMID 32919577)
    inputs: recent_cardiothoracic_surgery_or_trauma_or_lymphoma_or_tb_history, creatinine
    advance: etiology framework + comorbidity context captured
  4. 4RED_FLAGS
    Tamponade physiology in chylopericardium — emergent drainage; rapid accumulation if active thoracic-duct leak; concurrent chylothorax from same lymphatic injury can cause respiratory compromise; lymphoma-related may have associated SVC syndrome (ESC 2015; Imazio JACC 2020)
    inputs: sbp, hr, jvp
    advance: tamponade physiology + airway compromise screened → drainage prepared
  5. 5INITIAL_WORKUP
    TTE (effusion size + tamponade physiology), chest CT/MRI (mediastinal mass + thoracic-duct anatomy + co-existent chylothorax), pericardial fluid analysis (TG >500 + chylomicrons + cytology + cultures + ADA), CBC + BMP + LFTs + lipid panel + LDH + tumor markers, lymphoscintigraphy/lymphangiography for thoracic-duct leak localization (especially pre-surgical), TB workup if indicated (Akamatsu PMID 8311605; Imazio JAMA 2015 PMID 26461998)
    inputs: echo, chest_ct_mri, pericardial_fluid_triglycerides, pericardial_fluid_cytology_chemistry_culture
    actions: panel.cardiac, panel.cbc
    advance: fluid analysis + imaging confirm chylopericardium + etiology identified
  6. 6DIFFERENTIAL
    Differentiate: primary idiopathic chylopericardium vs secondary (post-cardiac-surgery thoracic-duct injury — leading modern cause; lymphoma — leading neoplastic cause; TB — endemic regions; trauma; LAM/lymphangiomatosis; radiation; subclavian vein thrombosis); ALSO differentiate from cholesterol pericarditis (high cholesterol, low TG) and pseudo-chylous effusion (high cholesterol crystals, no chylomicrons) (Akamatsu PMID 8311605; Imazio JAMA 2015)
    advance: etiology identified — drives treatment cascade
  7. 7TREATMENT
    Step 1 pericardiocentesis if tamponade physiology (ESC 2015 Class I); Step 2 conservative MCT diet (medium-chain triglycerides bypass thoracic duct) ± TPN × 4-6 wk (~50-70% resolve); Step 3 octreotide 50-200 µg SC TID for non-responders after 1-2 wk MCT diet (somatostatin analog reduces thoracic-duct flow per Markham Pediatr Cardiol 2013); Step 4 surgical thoracic-duct ligation (open or VATS) + pericardial window if conservative fails 4-6 wk (Riquet EJCTS 1996; Chen J Cardiothorac Surg 2014); Step 5 pericardiectomy if constrictive sequelae develop; Step 6 treat underlying cause (lymphoma chemotherapy, TB ATT, thrombosis anticoagulation, LAM sirolimus) (Akamatsu PMID 8311605; Lyon EHJ 2022)
    advance: treatment ladder activated — MCT diet → octreotide → surgical → pericardiectomy as needed
  8. 8DISPOSITION
    Inpatient admission for pericardiocentesis + initial conservative management; cardiothoracic surgery referral if conservative fails or surgical etiology; oncology if lymphoma; ID if TB; multidisciplinary coordination (cardiology + cardiothoracic + nutrition + oncology/ID as applicable; ESC 2015)
    advance: multidisciplinary disposition confirmed
  9. 9MONITORING
    Re-accumulation surveillance (echo q12-24h initially then weekly during conservative management); pericardial fluid output if drain in place (target <50 mL/24h × 24h before removal); nutritional adequacy on MCT diet (weekly weight, albumin, prealbumin, lymphocyte count); long-term constriction surveillance post-recovery (echo at 1, 3, 6, 12 mo)
    advance: stable + surveillance plan documented