American Journal of Emergency Medicine 35 (2017) 803.e1–803.

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American Journal of Emergency Medicine

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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 a b s t r a c t

Article history: Delayed cardiac tamponade (DCT) is a rare and life-threatening complication of catheter ablation performed as a
Received 28 August 2016 treatment of atrial fibrillation, with few cases described in the medical literature. We present the case of a
Received in revised form 15 November 2016 57 year-old man presenting with DCT 61 days following a catheter ablation procedure. To the best of our knowl-
Accepted 16 November 2016
edge, this is the most delayed case of cardiac tamponade (CT) following catheter ablation described in the liter-
ature. We also discuss the importance of point of care ultrasound (POCUS) in the diagnosis and treatment of CT.
Keywords:
Cardiac tamponade
Emergency physicians must maintain a high index of suspicion in making the diagnosis of CT as patients may
Pericardiocentesis present with vague symptoms such as neck or back pain, shortness of breath, fatigue, dizziness, or altered mental
Echocardiography status, often without chest pain.
Cather ablation Common risk factors for CT include cancer, renal failure, pericarditis, cardiac surgery, myocardial rupture, trauma,
New oral anticoagulants 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 hemor-
rhages 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 An EKG revealed sinus tachycardia. Bedside echocardiography

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. Ini-
tial 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 di-
aphoretic with JVD, normal heart sounds, clear lungs, a soft and non-
tender abdomen, and who had no edema. Capillary refill was delayed.
The patient remained hypotensive despite receiving 2 l of intrave-
nous fluids, and after vomiting and progressively worsening mental sta-
tus, the patient was intubated for airway protection.
diaphoretic function
⁎ Corresponding author.
E-mail address: jbrazg@maimonidesmed.org (J. Brazg).
showed a large pericardial effusion causing early diastolic right ventric-
ular collapse (Fig. 1) and a diagnosis of cardiac tamponade was made.
With a blood pressure of 50/25, emergent pericardiocentesis was per-
formed under ultrasound guidance (Fig. 2) and approximately 400
cm3 of bloody fluid was aspirated. The patient's blood pressure stabi-
lized 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 re-
moved (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 abla-
tion [4], with the vast majority of cases occurring within a few days. Ul-
timately, point-of-care echocardiography led to the diagnosis and
timely pericardiocentesis prior to transfer to the operating room for de-
finitive treatment.

http://dx.doi.org/10.1016/j.ajem.2016.11.041
0735-6757/© 2016 Elsevier Inc. All rights reserved.
803.e2 E. Yetter et al. / American Journal of Emergency Medicine 35 (2017) 803.e1–803.e3
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 dias-
tole 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 ab-
lation 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 ab-
lation 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 echo-
cardiography to diagnose cardiac tamponade cannot be overstated as
this imaging modality leads to prompt diagnosis and helps confirm cor-
rect wire and catheter placement during pericardiocentesis.
Fig. 4. Coagulated blood removed from pericardium in the operating room.
 E. Yetter et al. / American Journal of Emergency Medicine 35 (2017) 803.e1–803.e3
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