Unplugging the Drain: Treatment of a Rare Late Complication of Cardiac Resynchronization Therapy

Central vein thrombosis (CVT) is a rare cause of chylothorax. We report a patient with chylothorax secondary to CVT, despite being on anticoagulation, who was successfully treated with balloon angioplasty of the occluded vein. A 65-year-old male presented with shortness of breath of one-month duration. He had end-stage heart failure and was on milrinone infusion. Physical exam was consistent with elevated central venous pressure. Chest x-ray showed a large left-sided pleural effusion. Right heart catheterization (RHC) showed normal right atrial pressure and normal pulmonary capillary wedge pressure. Diagnostic thoracentesis was consistent with chylothorax. A venogram revealed bilateral brachiocephalic vein occlusion. The right brachiocephalic vein was recanalized by angioplasty, which led to resolution of pleural effusion. Our case not only highlights the identification of a rare complication of a common device (i.e., cardiac resynchronization therapy defibrillator) used in heart failure patients but also highlights the treatment for this rare but reversible complication.