Our patient experienced the dramatic natural history of candida prosthetic endocarditis, characterized by high morbidity mainly related to elevated recurrence rate (around 36%) despite combined treatment (valve replacement and long-term antifungal therapy) [1]. Candida prosthetic endocarditis is a rare entity, corresponding up to 3.4% of valvar prosthetic endocarditis, with a high mortality rate (up to 50% in a 5-year period) [3]. Interestingly, the patient did not have any risk factors related to fungal endocarditis such as immunosuppression, parenteral nutrition and intravenous drug use. In fact, the source of the fungal infection has not been identified in this case. From an etiological perspective, Candida albicans is the most frequently involved agent [4]. Despite valve replacement surgery, a 6-week in-hospital antifungal treatment with intravenous liposomal amphotericin-B and a year of continuous suppressive antifungal therapy with oral fluconazole the patient had prosthetic endocarditis recurrence 3-years later by the same agent: Candida parapsilosis. Concerning the factors related to this therapeutic failure and recurrence of the infection, it is possible that a longer period of postoperative suppressive antifungal therapy (> 1 year), as described in some case series, could prevent this relapse [3, 4].

After 4 open-heart cardiac surgeries, an inexorable complication arose for our patient: severe systolic left ventricular dysfunction. In a retrospective study, Ataka et al. found that up to 2/3 of patients with second/third valvar reoperation had a significant loss of ventricular function (around 25%), possibly related to ischemic/reperfusion injury in the previous operations [2]. Regarding this case, serial echocardiographic evaluation documented a progressive worsening of left ventricular function (up to 25%) associated with secondary pulmonary artery hypertension, without concomitant prosthetic valve dysfunction. Recurrent hospital admissions for decompensating heart failure requiring inotropic support have become frequent, despite pharmacological treatment optimization. Even the implementation of cardiac resynchronization therapy has not been able to mitigate symptoms and hospitalizations. In view of this poor evolution, the patient was referred for heart transplantation evaluation.

Taylor et al. found that about 4% of patients undergoing heart transplantation had their cardiomyopathy related to a valvular pathology, representing a small proportion when compared to other etiologies such as ischemic or dilated cardiomyopathy [6]. The reasons for this low prevalence can be justified by the possibility of surgical correction (repair or valve replacement) in most of the valve diseases, with heart transplantation restricted to those subgroups considered inoperable or at high surgical risk. One of the major concerns related to heart transplantation for patients with valvular cardiomyopathy is the association with increased pulmonary vascular resistance, especially in mitral valve disease. This finding may impair the immediate postoperative period with right ventricular failure and hemodynamic deterioration.

After successful orthotopic heart transplantation, our patient was diagnosed with chylopericardium in the early postoperative period. Chylopericardium is a rare condition with variable clinical presentation, involving the development of a lymphatic fistula to the pericardium [7]. The most common etiologies are idiopathic (56%), after valve replacement surgery (9%), coronary artery bypass grafting (6%) and heart transplantation (3%) [7]. It is very likely that during the heart transplantation, the dissection of multiple adhesions related to previous redo operations has caused an accidental injury to the thoracic duct, culminating in the installation of the chylopericardium. Confirmatory testing requires a total triglycerides concentration at the pericardium effusion > 500 mg/dL, cholesterol/triglyceride ratio < 1.0, predominance of lymphocytic cells and negative cultures [7]. Conservative treatment may be successful in up to 50% of patients and recommended for patients with daily pericardium drainage less than 1000 mL. Low-fat adapted diets, rich in medium chain triglycerides, or even total parenteral nutrition are the main therapeutic strategies [7]. Surgical treatment usually consists of thoracic duct ligation [8]. However, the anatomical identification of the thoracic duct represents a major difficulty issue during surgery, leading to the development of less invasive therapies as percutaneous embolization [9]. The approach to the thoracic duct can be performed by anterograde access (via cisterna chyli puncture or direct thoracic duct catheterization) or by retrograde route through direct thoracic duct ostium catheterization into the subclavian vein [10, 11]. Embolization is usually performed by using liquid agents and/or micro coils with technical and clinical success rates up to 79% and 72%, respectively [12, 13]. In this case, our interventional radiology team selected the retrograde access for embolization. A second complementary embolization was performed three days later, via cisterna chyli direct puncture, with a successful fistula repair. A literature review identified four reported cases of chylopericardium after heart transplantation: in two cases, conservative treatment warranted clinical success; in the other cases, after an initial conservative treatment, surgical intervention was required for definitive resolution [12‐15]. This is the first case report of thoracic duct embolization for chylopericardium treatment after heart transplantation. This technique can be effective and a less morbid alternative to open heart surgery.

Regarding the patient’s perspective, it is worth highlighting the strength that has always motivated him during the many intercurrences experienced. Despite some disappointments and moments of uncertainty, he has never lost confidence in the medical team. His willingness and cooperation were crucial for the positive outcomes achieved.

From an educational point of view, this case report brings some relevant conclusions: (1) fungal endocarditis requires a strict clinical follow-up after hospital discharge with special care in implementing and maintaining antifungal suppression therapy to avoid recurrence; (2) cardiac reoperations, even when necessary, can lead to permanent ventricular dysfunction; (3) heart transplantation remains a method for definitive clinical recovery in refractory heart failure; (4) integrated multidisciplinary work in the form of heart team is essential to ensure favorable clinical outcomes in such challenging scenarios.