Management and Outcomes of Cardiac Tamponade During Atrial Fibrillation Ablation in the Presence of Therapeutic Anticoagulation With Warfarin

Study Questions:

What are the outcomes among patients with and without a therapeutic international normalized ratio (INR) who developed cardiac tamponade (CT) as a complication of radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF)?

Methods:

The subjects of this retrospective study were 40 consecutive patients who developed CT during RFCA of AF at three centers. The authors divided the patients into two groups: RFCA performed with INR <2 (group 1) and INR ≥2 (group 2). There were 23 patients in group 1 and 17 patients in group 2. Comparisons between the two groups were performed using the Student t-test for continuous variables and the Fisher exact test for categorical variables. The duration of pericardial drainage and the length of hospital stay were compared using the Wilcoxon signed-rank test.

Results:

Baseline clinical and procedure characteristics were not different between the two groups. Heparin was reversed by protamine in 83% and 94% of patients (p = 0.37), and warfarin was reversed by fresh frozen plasma or factor VIIa in 17% and 35% of patients (p = 0.27) in groups 1 and 2, respectively. All patients were successfully treated by percutaneous drainage, and none required surgical intervention. There were no significant differences in the amount of initial pericardial drainage (523 ± 349 ml vs. 409 ± 157 ml, p = 0.22) or the duration of drainage (p = 0.14) between the two groups. All patients survived to hospital discharge. Median length of hospital stay was 2 days longer in group 1 (p < 0.01).

Conclusions:

The authors concluded that CT is not more severe or difficult to manage in the presence of therapeutic anticoagulation with warfarin in patients undergoing RFCA of AF.

Perspective:

This study reports that the severity of CT was not affected by whether or not the INR was in the therapeutic range. Moreover, the length of hospital stay appeared to be shorter in patients undergoing RFCA with a therapeutic INR. Overall, the data suggest that the continuation of warfarin through the RFCA procedure to maintain a therapeutic INR is a safe strategy, but prompt recognition and management of CT during left atrial ablation is critical.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Dyslipidemia, Pericardial Disease, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Lipid Metabolism, Novel Agents

Keywords: Blood Coagulation, Heart Conduction System, Warfarin, Protamines, Heparin, Atrial Fibrillation, Factor VIIa, Catheter Ablation, Cardiac Tamponade


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