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Delayed cardiac tamponade: A rare but life-threatening complication of catheter ablation
YAJEM-56299; No of Pages 3 American Journal of Emergency Medicine xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Delayed cardiac tamponade: A rare but life-threatening complication of catheter ablation Elizabeth Yetter, MD, Jared Brazg, MD ⁎, Diane Del Valle, Laura Mulvey, MD, Eitan Dickman, MD Maimonides Medical Center, 4802 Tenth Ave., Brooklyn, NY 11217, United States
a r t i c l e
i n f o
Article history: Received 28 August 2016 Received in revised form 15 November 2016 Accepted 16 November 2016 Available online xxxx Keywords: Cardiac tamponade Pericardiocentesis Echocardiography Cather ablation New oral anticoagulants
a b s t r a c t Delayed cardiac tamponade (DCT) is a rare and life-threatening complication of catheter ablation performed as a treatment of atrial fibrillation, with few cases described in the medical literature. We present the case of a 57 year-old man presenting with DCT 61 days following a catheter ablation procedure. To the best of our knowledge, this is the most delayed case of cardiac tamponade (CT) following catheter ablation described in the literature. We also discuss the importance of point of care ultrasound (POCUS) in the diagnosis and treatment of CT. Emergency physicians must maintain a high index of suspicion in making the diagnosis of CT as patients may present with vague symptoms such as neck or back pain, shortness of breath, fatigue, dizziness, or altered mental status, often without chest pain. Common risk factors for CT include cancer, renal failure, pericarditis, cardiac surgery, myocardial rupture, trauma, and retrograde aortic dissection. In addition, although rare, both catheter ablation and use of anticoagulation carry risks of developing CT. A worldwide survey of medical centers performing catheter ablation found CT as a complication in less than 2% of cases [1]. Some proposed mechanisms of DCT include small pericardial hemorrhages following post-procedural anticoagulation or rupture of the sealed ablation-induced left atrial wall [2]. Clinical examination and electrocardiography may be helpful. However, the criterion standard for diagnosing CT is echocardiography [3]. © 2016 Elsevier Inc. All rights reserved.
1. Case report A 57 year-old male with a past medical history of hypertension and atrial fibrillation (AF) presented to the Emergency Department (ED) via EMS after a syncopal episode at the beach. The patient had undergone a catheter ablation for AF at an outside hospital 61 days prior and had been taking rivaroxaban since the procedure. On arrival to the ED, the patient complained of dizziness, dyspnea, and neck pain that had started while he was swimming in the ocean. Initial vitals were a blood pressure of 73/62 mm Hg, respiratory rate of 22, pulse of 96, and oxygen saturation of 95% while breathing ambient air. Physical examination was notable for an ill appearing man, who was diaphoretic with JVD, normal heart sounds, clear lungs, a soft and nontender abdomen, and who had no edema. Capillary refill was delayed. The patient remained hypotensive despite receiving 2 l of intravenous fluids, and after vomiting and progressively worsening mental status, the patient was intubated for airway protection.
⁎ Corresponding author. E-mail address: [email protected] (J. Brazg).
An EKG revealed sinus tachycardia. Bedside echocardiography showed a large pericardial effusion causing early diastolic right ventricular collapse (Fig. 1) and a diagnosis of cardiac tamponade was made. With a blood pressure of 50/25, emergent pericardiocentesis was performed under ultrasound guidance (Fig. 2) and approximately 400 cm3 of bloody fluid was aspirated. The patient's blood pressure stabilized to 163/88 with minimal effusion visualized around the heart (Fig. 3). The patient then went into cardiac arrest, was defibrillated twice, with 2 min of CPR followed by ROSC. The patient was taken to the operating room where a large clot estimated at one liter was removed (Fig. 4), and an additional 500 cm3 of blood evacuated. He was discharged one week later with full neurologic recovery. Rivaroxaban was discontinued.
2. Discussion In our review of the literature, only one other case report was found citing tamponade occurring at greater than 30 days following an ablation [4], with the vast majority of cases occurring within a few days. Ultimately, point-of-care echocardiography led to the diagnosis and timely pericardiocentesis prior to transfer to the operating room for definitive treatment.
http://dx.doi.org/10.1016/j.ajem.2016.11.041 0735-6757/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Yetter E, et al, Delayed cardiac tamponade: A rare but life-threatening complication of catheter ablation, American Journal of Emergency Medicine (2016), http://dx.doi.org/10.1016/j.ajem.2016.11.041
2
E. Yetter et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx
Fig. 1. Star indicating large effusion causing early diastolic right ventricular collapse.
DCT is a rare and life threatening complication of catheter ablation and anticoagulation. As such, emergency physicians must maintain a high index of suspicion in order to make the diagnosis. As the prognosis of cardiac tamponade varies on the corresponding etiology and how quickly it can be treated, management should be prompt and aggressive with pericardiocentesis being the treatment of choice [3]. POCUS may be used by emergency physicians for the diagnosis of potentially life threatening cardiac conditions such as tamponade, aortic dissection, or cardiac wall hypokinesis [5]. Classic echocardiographic findings of cardiac tamponade are right ventricular collapse during diastole or right atrial collapse during systole. Furthermore, in tamponade, the IVC is dilated and does not vary during respiration. A collapsing IVC during inspiration may effectively rule out tamponade [6].
Fig. 2. Arrow indicating confirmation of correct catheter placement during pericardiocentesis.
Fig. 3. Star indicating small effusion remaining following pericardiocentesis.
3. Why should an emergency physician be aware of this? Approximately 5.6 million American adults have AF [7]. Catheter ablation has proven to be an effective treatment for AF and is increasingly being offered as a curative therapy [8]. It is standard procedure to place a patient on anticoagulation for two months after ablation, after which the need for anticoagulation is reassessed [9]. Considering that both ablation and anticoagulation increase the risk of cardiac tamponade, EM physicians should have a high index of suspicion for patients presenting with the aforementioned symptoms even if several weeks have passed since the procedure. In addition, the importance of point-of-care echocardiography to diagnose cardiac tamponade cannot be overstated as this imaging modality leads to prompt diagnosis and helps confirm correct wire and catheter placement during pericardiocentesis.
Fig. 4. Coagulated blood removed from pericardium in the operating room.
Please cite this article as: Yetter E, et al, Delayed cardiac tamponade: A rare but life-threatening complication of catheter ablation, American Journal of Emergency Medicine (2016), http://dx.doi.org/10.1016/j.ajem.2016.11.041
E. Yetter et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx
References [1] Cappato R, Calkins H, Chen SA, et al. Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circ Arrhythm Electrophysiol 2010;3(1):32–8. http://dx.doi.org/10.1161/CIRCEP.109.859116. [2] Lambert T, Steinwender C, Leisch F, Hofmann R. Cardiac tamponade following pericarditis 18 days after catheter ablation of atrial fibrillation. Clin Res Cardiol 2010;99(9): 595–7. http://dx.doi.org/10.1007/s00392-010-0174-2. [3] McGinley A, Gribbin G. A delayed diagnosis of cardiac tamponade. BMJ Case Rep 2013. http://dx.doi.org/10.1136/bcr-2012-007255. [4] Kitamura T, Fukamizu S, Sakurada H, Hiraoka M. Development of delayed tamponade 55 days after catheter ablation for atrial fibrillation with a new oral anticoagulant. J Interv Card Electrophysiol 2014;41(2):135. http://dx.doi.org/10.1077/s10840-014-9926-7. [5] Labovitz AJ, Noble VE, Bierig M, et al. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and
[6]
[7]
[8]
[9]
3
American College of Emergency Physicians. J Am Soc Echocardiogr 2010;23(12): 1225–30. http://dx.doi.org/10.1016/j.echo.2010.10.005. Peterson D, Arntfield RT. Critical care ultrasonography. In: Marconi E, Mallemat H, Mattu A, editors. Critical Care emergencies, an issue of emergency medicine clinics of North America. Philadelphia, PA: Elsevier; 2014. p. 912. Castell B. Heart failure patients fare better with catheter ablation than amiodarone. American College of Cardiology. (http://www.acc.org/about-acc/press-releases/ 2015/03/16/11/26/heart-failure-patients-fare-better-with-catheter-ablation-thanamiodarone, accessed 25 July 2016). Fisher J, Spinelli M, Mookherjee D, Krumerman A, Palma E. Atrial fibrillation ablation: reaching the mainstream. Pacing Clin Electrophysiol 2006;29:523–37. http://dx.doi. org/10.1016/j.ajem.2015.03.015. Jacobs V, May HT, Bair TL, et al. The impact of risk score (CHADS2 versus CHA2DS2VASc) on long-term outcomes after atrial fibrillation ablation. Heart Rhythm 2015; 12(4):681–6. http://dx.doi.org/10.1016/j.hrthm.2014.12.034.
Please cite this article as: Yetter E, et al, Delayed cardiac tamponade: A rare but life-threatening complication of catheter ablation, American Journal of Emergency Medicine (2016), http://dx.doi.org/10.1016/j.ajem.2016.11.041
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Delayed cardiac tamponade: A rare but life-threatening complication of catheter ablation Elizabeth Yetter, MD, Jared Brazg, MD ⁎, Diane Del Valle, Laura Mulvey, MD, Eitan Dickman, MD Maimonides Medical Center, 4802 Tenth Ave., Brooklyn, NY 11217, United States
a r t i c l e
i n f o
Article history: Received 28 August 2016 Received in revised form 15 November 2016 Accepted 16 November 2016 Available online xxxx Keywords: Cardiac tamponade Pericardiocentesis Echocardiography Cather ablation New oral anticoagulants
a b s t r a c t Delayed cardiac tamponade (DCT) is a rare and life-threatening complication of catheter ablation performed as a treatment of atrial fibrillation, with few cases described in the medical literature. We present the case of a 57 year-old man presenting with DCT 61 days following a catheter ablation procedure. To the best of our knowledge, this is the most delayed case of cardiac tamponade (CT) following catheter ablation described in the literature. We also discuss the importance of point of care ultrasound (POCUS) in the diagnosis and treatment of CT. Emergency physicians must maintain a high index of suspicion in making the diagnosis of CT as patients may present with vague symptoms such as neck or back pain, shortness of breath, fatigue, dizziness, or altered mental status, often without chest pain. Common risk factors for CT include cancer, renal failure, pericarditis, cardiac surgery, myocardial rupture, trauma, and retrograde aortic dissection. In addition, although rare, both catheter ablation and use of anticoagulation carry risks of developing CT. A worldwide survey of medical centers performing catheter ablation found CT as a complication in less than 2% of cases [1]. Some proposed mechanisms of DCT include small pericardial hemorrhages following post-procedural anticoagulation or rupture of the sealed ablation-induced left atrial wall [2]. Clinical examination and electrocardiography may be helpful. However, the criterion standard for diagnosing CT is echocardiography [3]. © 2016 Elsevier Inc. All rights reserved.
1. Case report A 57 year-old male with a past medical history of hypertension and atrial fibrillation (AF) presented to the Emergency Department (ED) via EMS after a syncopal episode at the beach. The patient had undergone a catheter ablation for AF at an outside hospital 61 days prior and had been taking rivaroxaban since the procedure. On arrival to the ED, the patient complained of dizziness, dyspnea, and neck pain that had started while he was swimming in the ocean. Initial vitals were a blood pressure of 73/62 mm Hg, respiratory rate of 22, pulse of 96, and oxygen saturation of 95% while breathing ambient air. Physical examination was notable for an ill appearing man, who was diaphoretic with JVD, normal heart sounds, clear lungs, a soft and nontender abdomen, and who had no edema. Capillary refill was delayed. The patient remained hypotensive despite receiving 2 l of intravenous fluids, and after vomiting and progressively worsening mental status, the patient was intubated for airway protection.
⁎ Corresponding author. E-mail address: [email protected] (J. Brazg).
An EKG revealed sinus tachycardia. Bedside echocardiography showed a large pericardial effusion causing early diastolic right ventricular collapse (Fig. 1) and a diagnosis of cardiac tamponade was made. With a blood pressure of 50/25, emergent pericardiocentesis was performed under ultrasound guidance (Fig. 2) and approximately 400 cm3 of bloody fluid was aspirated. The patient's blood pressure stabilized to 163/88 with minimal effusion visualized around the heart (Fig. 3). The patient then went into cardiac arrest, was defibrillated twice, with 2 min of CPR followed by ROSC. The patient was taken to the operating room where a large clot estimated at one liter was removed (Fig. 4), and an additional 500 cm3 of blood evacuated. He was discharged one week later with full neurologic recovery. Rivaroxaban was discontinued.
2. Discussion In our review of the literature, only one other case report was found citing tamponade occurring at greater than 30 days following an ablation [4], with the vast majority of cases occurring within a few days. Ultimately, point-of-care echocardiography led to the diagnosis and timely pericardiocentesis prior to transfer to the operating room for definitive treatment.
http://dx.doi.org/10.1016/j.ajem.2016.11.041 0735-6757/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Yetter E, et al, Delayed cardiac tamponade: A rare but life-threatening complication of catheter ablation, American Journal of Emergency Medicine (2016), http://dx.doi.org/10.1016/j.ajem.2016.11.041
2
E. Yetter et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx
Fig. 1. Star indicating large effusion causing early diastolic right ventricular collapse.
DCT is a rare and life threatening complication of catheter ablation and anticoagulation. As such, emergency physicians must maintain a high index of suspicion in order to make the diagnosis. As the prognosis of cardiac tamponade varies on the corresponding etiology and how quickly it can be treated, management should be prompt and aggressive with pericardiocentesis being the treatment of choice [3]. POCUS may be used by emergency physicians for the diagnosis of potentially life threatening cardiac conditions such as tamponade, aortic dissection, or cardiac wall hypokinesis [5]. Classic echocardiographic findings of cardiac tamponade are right ventricular collapse during diastole or right atrial collapse during systole. Furthermore, in tamponade, the IVC is dilated and does not vary during respiration. A collapsing IVC during inspiration may effectively rule out tamponade [6].
Fig. 2. Arrow indicating confirmation of correct catheter placement during pericardiocentesis.
Fig. 3. Star indicating small effusion remaining following pericardiocentesis.
3. Why should an emergency physician be aware of this? Approximately 5.6 million American adults have AF [7]. Catheter ablation has proven to be an effective treatment for AF and is increasingly being offered as a curative therapy [8]. It is standard procedure to place a patient on anticoagulation for two months after ablation, after which the need for anticoagulation is reassessed [9]. Considering that both ablation and anticoagulation increase the risk of cardiac tamponade, EM physicians should have a high index of suspicion for patients presenting with the aforementioned symptoms even if several weeks have passed since the procedure. In addition, the importance of point-of-care echocardiography to diagnose cardiac tamponade cannot be overstated as this imaging modality leads to prompt diagnosis and helps confirm correct wire and catheter placement during pericardiocentesis.
Fig. 4. Coagulated blood removed from pericardium in the operating room.
Please cite this article as: Yetter E, et al, Delayed cardiac tamponade: A rare but life-threatening complication of catheter ablation, American Journal of Emergency Medicine (2016), http://dx.doi.org/10.1016/j.ajem.2016.11.041
E. Yetter et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx
References [1] Cappato R, Calkins H, Chen SA, et al. Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circ Arrhythm Electrophysiol 2010;3(1):32–8. http://dx.doi.org/10.1161/CIRCEP.109.859116. [2] Lambert T, Steinwender C, Leisch F, Hofmann R. Cardiac tamponade following pericarditis 18 days after catheter ablation of atrial fibrillation. Clin Res Cardiol 2010;99(9): 595–7. http://dx.doi.org/10.1007/s00392-010-0174-2. [3] McGinley A, Gribbin G. A delayed diagnosis of cardiac tamponade. BMJ Case Rep 2013. http://dx.doi.org/10.1136/bcr-2012-007255. [4] Kitamura T, Fukamizu S, Sakurada H, Hiraoka M. Development of delayed tamponade 55 days after catheter ablation for atrial fibrillation with a new oral anticoagulant. J Interv Card Electrophysiol 2014;41(2):135. http://dx.doi.org/10.1077/s10840-014-9926-7. [5] Labovitz AJ, Noble VE, Bierig M, et al. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and
[6]
[7]
[8]
[9]
3
American College of Emergency Physicians. J Am Soc Echocardiogr 2010;23(12): 1225–30. http://dx.doi.org/10.1016/j.echo.2010.10.005. Peterson D, Arntfield RT. Critical care ultrasonography. In: Marconi E, Mallemat H, Mattu A, editors. Critical Care emergencies, an issue of emergency medicine clinics of North America. Philadelphia, PA: Elsevier; 2014. p. 912. Castell B. Heart failure patients fare better with catheter ablation than amiodarone. American College of Cardiology. (http://www.acc.org/about-acc/press-releases/ 2015/03/16/11/26/heart-failure-patients-fare-better-with-catheter-ablation-thanamiodarone, accessed 25 July 2016). Fisher J, Spinelli M, Mookherjee D, Krumerman A, Palma E. Atrial fibrillation ablation: reaching the mainstream. Pacing Clin Electrophysiol 2006;29:523–37. http://dx.doi. org/10.1016/j.ajem.2015.03.015. Jacobs V, May HT, Bair TL, et al. The impact of risk score (CHADS2 versus CHA2DS2VASc) on long-term outcomes after atrial fibrillation ablation. Heart Rhythm 2015; 12(4):681–6. http://dx.doi.org/10.1016/j.hrthm.2014.12.034.
Please cite this article as: Yetter E, et al, Delayed cardiac tamponade: A rare but life-threatening complication of catheter ablation, American Journal of Emergency Medicine (2016), http://dx.doi.org/10.1016/j.ajem.2016.11.041