Iranian Heart Journal

Iranian Heart Journal

Midodrine: A Golden Therapeutic Sword for High-Output Chylothorax

Document Type : Case Report

Authors
ABU TALHA
Ibrahim Hossain
Nurul Akhtar Hasan
National Heart Foundation Hospital & Research Institute, Dhaka, Bangladesh.
Abstract
Chylothorax, a significant complication after congenital heart surgery, adversely impacts children’s health and can lead to various morbidities, including nutritional deficiencies, prolonged ICU stays, extended hospitalizations, and an increased risk of mortality. Initial management of this condition involves nutritional strategies, such as providing gut rest and implementing a diet based on medium-chain triglycerides and low fat. Pharmacological options and surgical interventions are subsequently considered for refractory cases. This report describes a child who developed high-output chylous effusion following open-heart surgery for the correction of congenital heart disease. This effusion was successfully managed using chest drainage, nutritional intervention, and pharmacotherapy with midodrine. We hope the observations from this case report will help interventionists optimize chylothorax management and consider midodrine as a therapeutic option and a potential area of research for managing high-output chylothorax, before resorting to surgical intervention. (Iranian Heart Journal 2025; 26(3): 92-98)
Keywords
Chylothorax
Midodrine
High-output chylous effusion
  1. Samanidis G, Kourelis G, Bounta S, Kanakis M. Postoperative Chylothorax in Neonates and Infants after Congenital Heart Disease Surgery—Current Aspects in Diagnosis and Treatment. Nutrients 2022:14:1803.
  2. Mery CM, Moffett BS, Khan MS, Zhang W, Guzmán-Pruneda FA, Fraser CD, et al. Incidence and treatment of chylothorax after cardiac surgery in children: Analysis of a large multi-institution database. J Thorac Cardiovasc Surg 2014; 147: 678–86.
  3. Buckley JR, Graham EM, Gaies M, Alten JA, Cooper D, Costello JM, Domnina Y, Klugman D, Pasquali SK, Donohue JE, et al. Clinical epidemiology and centre variation in chylothorax rates after cardiac surgery in children: A report from the Pediatric Cardiac Critical Care Consortium. Cardiol Young 2017; 27:1678–85.
  4. Savla JJ, Itkin M, Rossano JW, Dori Y. Postoperative chylothorax in patients with congenital heart disease. J Am Coll Cardiol 2017; 69: 2410–22.
  5. Dori Y, Keller MS, Fogel MA, et al. MRI of lymphatic abnormalities after functional single-ventricle palliation surgery. Am J Roentgenol 2014; 203:426–31.
  6. Dori Y, Keller MS, Rome JJ, et al. Percutaneous lymphatic embolization of abnormal pulmonary lymphatic flow as treatment of plastic bronchitis in patients with congenital heart disease. Circulation 2016; 22:1160–70.
  7. Kreutzer J, Kreutzer C. Lymphodynamics in Congenital Heart Disease: The Forgotten Circulation. JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 2017; 69(19):2423-7.
  8. Maldonado F, Hawkins FJ, Daniels CE, Doerr CH, Decker PA, Ryu JH. Pleural fluid characteristics of chylothorax. Mayo Clin Proc. 2009; 84:129–33.
  9. Rocha G, Arnet V, Soares P, Gomes AC, Costa S, Guerra P, Casanova J, Azevedo I. Chylothorax in the neonate-A stepwise approach algorithm. Pediatr Pulmonol 2021;56: 3093–105.
  10. Justice L, Buckley J R, Floh A, Horsley M, Alten, J, Anand V, Schwartz S M. Nutrition Considerations in the Pediatric Cardiac Intensive Care Unit Patient. World J Pediatr Congenit Heart Surg. 2018; 9:333–43.
  11. Chan EH, Russell JL, William WG, Van Arsdell GS, Coles JG, McCrindle BW. Postoperative Chylothorax After Cardiothoracic Surgery in Children. Ann Thorac Surg 2005; 80 (5): 1864-70.
  12. Takahashi Y, Kinoshita Y, Kobayashi T, Arai Y, Ohyama T, Yokota N, Saito K, Sugai Y, Takano S. Management of refractory chylothorax in the neonatal intensive care unit: A 22-year experience. Pediatr Int 2021; 64: e15043.
  13. Clark M E, Woo R K, Johnson S M. Thoracoscopic pleural clipping for the management of congenital chylothorax. Pediatr Surg Int 2015; 31: 1133–37.
  14. Ahmed M A. Post-Operative Chylothorax in Children Undergoing Congenital Heart Surgery. Cureus 2021;13: e13811.
  15. Roca CM, García M J, Pedro V, Gómez Y, Herranz I M. Midodrine in refractory chylothorax after pediatric cardiac surgery: A case report. European journal of clinical pharmacy 2016; 18: 414-41.
  16. Patel D, Rahmanian M, Iqbal J, Scheinin S, Lee J, Seethamraju H. Midodrine: Breaking The New Ground In The Treatment Of Chylothorax. J chest 2019; 08:257.
  17. Shin YR, Lee H, Park YH, Park H.K. Chylothorax after Surgery for Congenital Cardiac Disease: A Prevention and Management Protocol. Korean J Thorac Cardiovasc Surg 2020; 53: 41–48.
  18. Lawati T T, Jamie A A, Mufarraji N A. Central line associated sepsis in children receiving parenteral nutrition in Oman. Journal of Infection and Public Health 2017; 10(6): 829-32.
  19. Tamaoka S, Osada A, Kin T, Arimitsu T, Hida M. Midodrine, an Oral Alpha-1 Adrenoreceptor Agonist, Successfully Treated Refractory Congenital Chylous Pleural Effusion and Ascites in a Neonate. Chest 2021; 159 (4):e189-e191.
Iranian Heart Journal
Volume 26, Issue 3
Summer 2025
Pages 92-98