rivaroxaban and Cardiac-Tamponade

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 57year-old man presenting with DCT 61days 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].

Topics: Anticoagulants; Atrial Fibrillation; Cardiac Tamponade; Catheter Ablation; Emergency Medicine; Humans; Male; Middle Aged; Pericardiocentesis; Rivaroxaban; Syncope; Time Factors; Treatment Outcome; Ultrasonography, Interventional

Topics: Aged; Atrial Fibrillation; Cardiac Tamponade; Factor Xa Inhibitors; Hemorrhage; Humans; Kidney Failure, Chronic; Male; Rivaroxaban

We describe the case of an 86-year-old man with a background of severe left ventricular dysfunction and ischaemic cardiomyopathy who, having been optimised for heart failure therapy in hospital, unexpectedly deteriorated again with hypotension and progressive renal failure over the course of 2 days. Common causes of decompensation were ruled out and a bedside echocardiogram unexpectedly diagnosed new pericardial effusion with tamponade physiology. The patient underwent urgent pericardiocentesis and 890 mL of haemorrhagic fluid was drained. Common causes for haemopericardium were ruled out, and the spontaneous haemopericardium was thought to be related to introduction of rivaroxaban anticoagulation. The patient made a full recovery and was well 2 months following discharge. This case highlights the challenges of diagnosing cardiac tamponade in the presence of more common disorders that share similar non-specific clinical features. In addition, this case adds to growing evidence that therapy with direct oral anticoagulants can be complicated by spontaneous haemopericardium, especially when coadministered with other agents that affect clotting, renal dysfunction and cytochrome P3A5 inhibitors.

Topics: Acute Kidney Injury; Aged, 80 and over; Anticoagulants; Cardiac Tamponade; Cytochrome P-450 CYP3A Inhibitors; Diagnosis, Differential; Drainage; Echocardiography; Heart Failure; Humans; Hypotension; Male; Myocardial Ischemia; Pericardial Effusion; Rivaroxaban; Ventricular Dysfunction, Left

Rivaroxaban is an oral anticoagulant approved for prevention of stroke, as well as for the treatment and prevention of venous thromboembolic disease. Hemopericardium is a serious complication of anticoagulant use, which has been reported with oral vitamin-K antagonists and newer oral anticoagulants. At the time of this report, to my knowledge, there are no published reports of hemorrhagic effusion leading to tamponade associated with a Factor Xa Inhibitor. I report a case of hemopericardium with associated tamponade in a patient who developed pericarditis while being treated with Rivaroxaban. The case highlights an important adverse effect of a newer anticoagulant, as well as the particular dangers of medication co-administration in the elderly.

Topics: Aged, 80 and over; Anticoagulants; Cardiac Tamponade; Factor Xa Inhibitors; Humans; Male; Morpholines; Pericarditis; Rivaroxaban; Thiophenes

Topics: Aged; Atrial Fibrillation; Cardiac Tamponade; Catheter Ablation; Echocardiography, Doppler; Follow-Up Studies; Humans; Male; Morpholines; Pericardiocentesis; Pleural Effusion; Postoperative Complications; Rare Diseases; Rivaroxaban; Thiophenes; Time Factors; Treatment Outcome