title: Management of Periprocedural and Early Pericardial Effusions With Tamponade Following Ablation of Atrial Fibrillation With Uninterrupted Factor Xa Inhibitors: A Case Series.
abstract: BACKGROUND
  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.
  
  
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.|Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
authors.forename: Carola
authors.initials: C
authors.lastname: Gianni
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.|Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.|Department of Biomedical Engineering, University of Texas, Austin, Texas, USA.|Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy.
authors.forename: Luigi
authors.initials: L
authors.lastname: DI Biase
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.
authors.forename: Sanghamitra
authors.initials: S
authors.lastname: Mohanty
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.
authors.forename: Chintan
authors.initials: C
authors.lastname: Trivedi
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.
authors.forename: Rong
authors.initials: R
authors.lastname: Bai
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.
authors.forename: Amin
authors.initials: A
authors.lastname: Al-Ahmad
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.
authors.forename: J David
authors.initials: JD
authors.lastname: Burkhardt
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.
authors.forename: G Joseph
authors.initials: GJ
authors.lastname: Gallinghouse
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.|Department of Biomedical Engineering, University of Texas, Austin, Texas, USA.
authors.forename: Rodney P
authors.initials: RP
authors.lastname: Horton
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.
authors.forename: Javier E
authors.initials: JE
authors.lastname: Sanchez
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.
authors.forename: Patrick M
authors.initials: PM
authors.lastname: Hranitzky
authors.affiliation: Division of Cardiovascular Diseases, University of Kansas Medical Center, Kansas City, Kansas, USA.
authors.forename: Dhanunjaya
authors.initials: D
authors.lastname: Lakkireddy
authors.affiliation: Division of Electrophysiology, Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Moussa C
authors.initials: MC
authors.lastname: Mansour
authors.affiliation: Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Pasquale
authors.initials: P
authors.lastname: Santangeli
authors.affiliation: Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Erica S
authors.initials: ES
authors.lastname: Zado
authors.affiliation: Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Francis E
authors.initials: FE
authors.lastname: Marchlinski
authors.affiliation: Electrophysiology and Arrhythmia Services, California Pacific Medical Center, San Francisco, California, USA.
authors.forename: Salwa
authors.initials: S
authors.lastname: Beheiry
authors.affiliation: Electrophysiology and Arrhythmia Services, California Pacific Medical Center, San Francisco, California, USA.
authors.forename: Steven C
authors.initials: SC
authors.lastname: Hao
authors.affiliation: Interventional Electrophysiology, Scripps Clinic, La Jolla, California, USA.
authors.forename: Linda
authors.initials: L
authors.lastname: Couts
authors.affiliation: Interventional Electrophysiology, Scripps Clinic, La Jolla, California, USA.
authors.forename: Douglas
authors.initials: D
authors.lastname: Gibson
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.|Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.|Department of Biomedical Engineering, University of Texas, Austin, Texas, USA.|Electrophysiology and Arrhythmia Services, California Pacific Medical Center, San Francisco, California, USA.|Interventional Electrophysiology, Scripps Clinic, La Jolla, California, USA.|MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.|Division of Cardiology, Stanford University, Stanford, California, USA.|Dell Medical School, University of Texas, Austin, Texas, USA.
authors.forename: Andrea
authors.initials: A
authors.lastname: Natale
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage; D001281:Atrial Fibrillation / Q000150:complications / Q000601:surgery*; D021721:Balloon Occlusion / Q000379:methods*; D017115:Catheter Ablation / Q000009:adverse effects*; D003430:Cross-Sectional Studies; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D065427:Factor Xa Inhibitors / Q000008:administration & dosage*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010490:Pericardial Effusion / Q000209:etiology / Q000517:prevention & control*; D011183:Postoperative Complications / Q000517:prevention & control; D011292:Premedication / Q000379:methods; D011379:Prognosis; D013923:Thromboembolism / Q000209:etiology / Q000517:prevention & control*; D016896:Treatment Outcome; D014481:United States
chemical_list: D000925:Anticoagulants; D065427:Factor Xa Inhibitors
keywords: 4-factor prothrombin complex concentrate; apixaban; atrial fibrillation ablation; factor Xa inhibitors; pericardial tamponade; rivaroxaban; uninterrupted anticoagulation