Abstract
Chylothorax is a rare but serious complication in children who undergo heart surgery. Its pathogenesis is poorly understood, and invasive surgical treatments are considered only after conservative management fails. Current diagnostic imaging techniques, which could aid decision making for earlier surgical intervention, are difficult to apply. Herein, we deployed near-infrared fluorescence (NIRF) lymphatic imaging to allow the visualization of abnormal lymphatic drainage in an infant with postoperative chylothorax to guide the choice of surgical management. A 5-week-old male infant, who developed chylothoraces after undergoing Norwood surgery for hypoplastic left heart syndrome, was intradermally administered trace doses of indocyanine green in both feet and the left hand. NIRF imaging was then performed at the bedside to visualize lymphatic drainage patterns. Imaging results indicated impeded lymphatic drainage from the feet toward the trunk with no fluorescence in the chest indicating no leakage of peripheral lymph at the thoracic duct. Instead, lymph drainage occurred from the axilla directly into the pleural cavity. As a result of imaging, left pleurodesis was performed to stop the pleural effusion with the result of temporary decrease of left chest tube drainage. Although additional studies are required to understand normal and abnormal lymphatic drainage patterns in infants, we showed the potential of using NIRF lymphatic imaging at the bedside to visualize the lymphatic drainage pathway to guide therapy. Timely management of chylothorax may be improved by using NIRF imaging to understand lymphatic drainage pathways.
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References
Adams KE, Rasmussen JC, Darne C, Tan I-C, Aldrich MB, Marshall MV et al (2010) Direct evidence of lymphatic function improvement after advanced pneumatic compression device treatment of lymphedema. Biomed Opt Express 1(1):114–125
Biewer E, Zürn C, Arnold R, Glöckler M, Schulte-Mönting J, Schlensak C et al (2010) Chylothorax after surgery on congenital heart disease in newborns and infants—Risk factors and efficacy of MCT-diet. J Cardiothorac Surg 5(1):1–7
Burrows PE, Gonzalez-Garay ML, Rasmussen JC, Aldrich MB, Guilliod R, Maus EA et al (2013) Lymphatic abnormalities are associated with RASA1 gene mutations in mouse and man. Proc Natl Acad Sci U S A 110(21):8621–8626
Chan EH, Russell JL, Williams WG, Van Arsdell GS, Coles JG, McCrindle BW (2005) Postoperative chylothorax after cardiothoracic surgery in children. Ann Thorac Surg 80(5):1864–1870
Hematti H, Mehran RJ (2011) Anatomy of the thoracic duct. Thorac Surg Clin 21(2):229–238
Matsuo S, Takahashi G, Konishi A, Sai S (2013) Management of refractory chylothorax after pediatric cardiovascular surgery. Pediatr Cardiol 34(5):1094–1099
Mihara M, Seki Y, Hara H, Iida T, Oka A, Kikuchi K et al (2013) Predictive lymphatic mapping: a method for mapping lymphatic channels in patients with advanced unilateral lymphedema using indocyanine green lymphography. Ann Plast Surg 72(6):706–710
Milonakis M, Chatzis AC, Giannopoulos NM, Contrafouris C, Bobos D, Kirvassilis GV et al (2009) Etiology and management of chylothorax following pediatric heart surgery. J Card Surg 24(4):369–373
Okitsu T, Tsuji T, Fujii T, Mihara M, Hara H, Kisu I et al (2012) Natural history of lymph pumping pressure after pelvic lymphadenectomy. Lymphology 45(4):165–176
Pego-Fernandes PM, Nascimbem MB, Ranzani OT, Shimoda MS, Monteiro R, Jatene FB (2011) Video-assisted thoracoscopy as an option in the surgical treatment of chylothorax after cardiac surgery in children. J Bras Pneumol 37(1):28–35
Rasmussen JC, Tan IC, Marshall MV, Fife CE, Sevick-Muraca EM (2009) Lymphatic imaging in humans with near-infrared fluorescence. Curr Opin Biotechnol 20(1):74–82
Rasmussen JC, Tan IC, Marshall MV, Adams KE, Kwon S, Fife CE et al (2010) Human lymphatic architecture and dynamic transport imaged using near-infrared fluorescence. Transl Oncol 3(6):362–372
Sevick-Muraca EM, Sharma R, Rasmussen JC, Marshall MV, Wendt JA, Pham HQ et al (2008) Imaging of lymph flow in breast cancer patients after microdose administration of a near-infrared fluorophore: feasibility study. Radiology 246(3):734–741
Sevick-Muraca EM, Kwon S, Rasmussen JC (2014) Emerging lymphatic imaging technologies for mouse and man. J Clin Invest 124(3):905–914
Shibasaki J, Hara H, Mihara M, Adachi S, Uchida Y, Itani Y (2014) Evaluation of lymphatic dysplasia in patients with congenital pleural effusion and ascites using indocyanine green lymphography. J Pediatr 164(5):1116–1120e1
Soto-Martinez M, Massie J (2009) Chylothorax: diagnosis and management in children. Paediatr Respir Rev 10(4):199–207
Tan IC, Maus EA, Rasmussen JC, Marshall MV, Adams KE, Fife CE et al (2011) Assessment of lymphatic contractile function after manual lymphatic drainage using near-infrared fluorescence imaging. Arch Phys Med Rehabil 92(5):756–764 e751
Zuluaga MT (2012) Chylothorax after surgery for congenital heart disease. Curr Opin Pediatr 24(3):291–294
Acknowledgments
This study was supported in parts by National Institutes of Health Grant Nos. R01 HL092923 and U54 CA136404.
Conflict of interest
E. M. Sevick-Muraca declares financial interest in the NIRF Imaging, Inc., a company seeking to commercialize NIRF lymphatic imaging. I–C Tan, J. C. Rasmussen, and E. M. Sevick-Muraca also are inventors on patents and patent applications concerning the technology presented herein.
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Tan, IC., Balaguru, D., Rasmussen, J.C. et al. Investigational Lymphatic Imaging at the Bedside in a Pediatric Postoperative Chylothorax Patient. Pediatr Cardiol 35, 1295–1300 (2014). https://doi.org/10.1007/s00246-014-0946-y
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DOI: https://doi.org/10.1007/s00246-014-0946-y