Carola Gianni1,2, Luigi DI Biase1,3,4,5, Sanghamitra Mohanty1, Chintan Trivedi1, Rong Bai1, Amin Al-Ahmad1, J David Burkhardt1, G Joseph Gallinghouse1, Rodney P Horton1,4, Javier E Sanchez1, Patrick M Hranitzky1, Dhanunjaya Lakkireddy6, Moussa C Mansour7, Pasquale Santangeli8, Erica S Zado8, Francis E Marchlinski8, Salwa Beheiry9, Steven C Hao9, Linda Couts10, Douglas Gibson10, Andrea Natale1,3,4,9,10,11,12,13. 1. Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA. 2. Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy. 3. Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA. 4. Department of Biomedical Engineering, University of Texas, Austin, Texas, USA. 5. Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy. 6. Division of Cardiovascular Diseases, University of Kansas Medical Center, Kansas City, Kansas, USA. 7. Division of Electrophysiology, Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts, USA. 8. Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA. 9. Electrophysiology and Arrhythmia Services, California Pacific Medical Center, San Francisco, California, USA. 10. Interventional Electrophysiology, Scripps Clinic, La Jolla, California, USA. 11. MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA. 12. Division of Cardiology, Stanford University, Stanford, California, USA. 13. Dell Medical School, University of Texas, Austin, Texas, USA.
Abstract
INTRODUCTION: Because of the absence of a dedicated reversal agent, the outcome of pericardial effusion (PE) following procedures performed with uninterrupted apixaban or rivaroxaban is unknown. We report the characteristics of PEs presenting with tamponade in patients undergoing AF ablation with uninterrupted factor Xa inhibition (FXaI) to understand their management and prognosis. METHODS AND RESULTS: We performed a multicenter cross-sectional survey in 10 centers across the United States. Patient data were obtained by chart review. In all patients the procedure was performed with uninterrupted FXaI. A total of 16 PEs requiring intervention were reported from 5 centers. Two patients were on apixaban 5 mg BD, the remaining on rivaroxaban 20 mg OD. Eleven PEs occurred in the periprocedural setting, and 5 PEs occurred from 1 to 28 days after the procedure. Pericardiocentesis and drainage were performed in all cases. Protamine and 4-factor prothrombin complex concentrate (4F-PCC) were given in all periprocedural cases. Two patients required surgery: in one case coagulation of the pericardial blood prevented effective drainage, and in the other bleeding was secondary to a steam pop-induced atrial tear. None of the postprocedural cases required FXaI reversal and the dose of rivaroxaban was temporarily reduced. No fatal outcomes or thromboembolic events were reported. CONCLUSION: Pericardiocentesis and drainage with FXaI reversal proved effective in the management of acute PEs with tamponade occurring periprocedurally in patients undergoing AF ablation with uninterrupted FXaI. Early postprocedural effusions can be treated with pericardiocentesis without the need of a reversal agent.
INTRODUCTION: Because of the absence of a dedicated reversal agent, the outcome of pericardial effusion (PE) following procedures performed with uninterrupted apixaban or rivaroxaban is unknown. We report the characteristics of PEs presenting with tamponade in patients undergoing AF ablation with uninterrupted factor Xa inhibition (FXaI) to understand their management and prognosis. METHODS AND RESULTS: We performed a multicenter cross-sectional survey in 10 centers across the United States. Patient data were obtained by chart review. In all patients the procedure was performed with uninterrupted FXaI. A total of 16 PEs requiring intervention were reported from 5 centers. Two patients were on apixaban 5 mg BD, the remaining on rivaroxaban 20 mg OD. Eleven PEs occurred in the periprocedural setting, and 5 PEs occurred from 1 to 28 days after the procedure. Pericardiocentesis and drainage were performed in all cases. Protamine and 4-factor prothrombin complex concentrate (4F-PCC) were given in all periprocedural cases. Two patients required surgery: in one case coagulation of the pericardial blood prevented effective drainage, and in the other bleeding was secondary to a steam pop-induced atrial tear. None of the postprocedural cases required FXaI reversal and the dose of rivaroxaban was temporarily reduced. No fatal outcomes or thromboembolic events were reported. CONCLUSION: Pericardiocentesis and drainage with FXaI reversal proved effective in the management of acute PEs with tamponade occurring periprocedurally in patients undergoing AF ablation with uninterrupted FXaI. Early postprocedural effusions can be treated with pericardiocentesis without the need of a reversal agent.