Cardiac Tamponade Under Uninterrupted DOAC and Warfarin

Study Questions:

What are the outcomes of patients with cardiac tamponade during catheter ablation for atrial fibrillation (AF) under uninterrupted direct oral anticoagulants (DOACs) and warfarin?


This was a retrospective analysis of a Japanese three-center registry of patients who underwent catheter ablation for atrial fibrillation (AF) under uninterrupted DOACs (apixaban, dabigatran, rivaroxaban, edoxaban) or warfarin. The twice-daily DOACs were given the morning of the procedure without holding. The anticoagulants were continuously administered after the procedure.


A total of 2,406 patients underwent 3,149 catheter ablation procedures for AF with uninterrupted DOAC (1,896) and warfarin (1,253). Among the patients with pericardial bleeding, 13/16 procedures in the DOAC group and 11/21 procedures in the warfarin group required pericardiocentesis and surgery. Cardiac tamponade requiring pericardiocentesis and/or surgical intervention occurred in 13 (0.7%) in the DOAC group and 11 (0.9%) in the warfarin group. The total blood volume drained during pericardiocentesis was 300 in both groups. 9/13 patients in the DOAC group and 7/11 patients in the warfarin groups recovered with only pericardiocentesis and protamine infusion and vitamin K in the warfarin group. Blood transfusion was required for four patients in the DOAC group. Two patients in the DOAC group underwent surgical intervention; none of the patients taking warfarin required surgical intervention. DOAC and warfarin were successfully resumed 2.0 (2.0–5.0) and 4.0 (2.0–5.5) days after tamponade in all patients without an increase in effusion (p = 0.102).


Managing cardiac tamponade under uninterrupted DOAC administration resulted in hemostasis in most patients. However, surgical intervention was required in some cases.


The outcomes of the patients in the NOAC and warfarin groups did not appear much different, with the notable exception that while two patients on NOACs required surgery, none of the warfarin patients did. Warfarin patients were reversed with vitamin K, but none of the tamponade patients with DOACs received DOAC-specific reversal agents. The average amount of the evacuated blood in this series was much lower than in previous studies. All procedures in this series were done with conscious sedation and all patients were subject to continuous femoral arterial blood pressure monitoring. Early detection of signs of cardiac tamponade and intensive treatment after onset may have been essential for reducing bleeding. Widespread availability of reversal agents, which were not available for the study patients, should enhance the safety of this approach.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Pericardial Disease, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias

Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Cardiac Surgical Procedures, Cardiac Tamponade, Pericardial Effusion, Catheter Ablation, Hemorrhage, Hemostasis, Pericardiocentesis, Vitamin K, Warfarin

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