Development of delayed cardiac tamponade 55 days after catheter ablation for atrial fibrillation with a new oral anticoagulant

  • Takeshi Kitamura
  • Seiji Fukamizu
  • Harumizu Sakurada
  • Masayasu Hiraoka
Case Report


Atrial fibrillation Delayed cardiac tamponade New oral anticoagulant Pulmonary vein isolation Pericardial effusion Rivaroxaban 

1 Case

A 66-year-old man underwent catheter ablation for paroxysmal atrial fibrillation (AF) using an irrigation catheter, for which the 15-mg rivaroxaban (standard dose in Japan) he had been taking was discontinued. Pericardial effusion (PE) was not evident on the post-procedure intracardiac echocardiography, and rivaroxaban was re-administered. He was discharged symptom-free from the hospital 2 days later (blood pressure [BP], 118/56 mmHg; heart rate [HR], 80 bpm). He remained symptom-free at follow-up 30 days post-procedure (BP, 124/80 mmHg; HR, 70 bpm). Serum hemoglobin was unchanged at 16.6 mg/dL. He developed chest discomfort with hypotension 55 days after the procedure (BP, 104/80 mmHg; HR, 90 bpm). Transthoracic echocardiography revealed a large amount of PE, prompting a diagnosis of delayed cardiac tamponade (DCT). Emergency pericardiocentesis was performed to aspirate hemorrhagic effusion (850 mL), followed by rapid symptom improvement. Serum hemoglobin decreased to 11.9 mg/dL, necessitating a blood transfusion. Rivaroxaban was discontinued. He experienced no further signs of PE.

2 Discussion

To the best of our knowledge, this case presents the most delayed DCT occurrence in the literature [1, 2, 3]. Further, this is the first DCT case reported with the use of a new oral anticoagulant (NOAC). The global incidence of AF ablation-related cardiac tamponade is 1.31 % [2], while the global DCT incidence is 0.2 % with a 5 % mortality rate [1]. In a previous report, the independent predictors of a DCT event include excessive volume infusion, irrigation catheter use, and a procedure for paroxysmal AF, following which DCT has developed a median of 12 days (range 0.2–45 days) later [1]. The potential mechanisms of DCT include a rupture of the sealed ablation-induced left atrial wall or small pericardial hemorrhages due to the intense post-procedural anticoagulation [3]. DCT could also occur in the setting of Dressler’s syndrome where non-hemorrhagic PE accumulation develops suddenly [3]. In our case, abrupt symptom development and hemorrhagic PE are consistent with an acute process; however, the mechanism is unknown.

As NOACs have been widely used, attention must be paid to DCT signs/symptoms after AF ablation not only during the perioperative period but also during clinical follow-up.


  1. 1.
    Cappato, R., Calkins, H., Chen, S. A., Davies, W., Iesaka, Y., Kalman, J., et al. (2011). Delayed cardiac tamponade after radiofrequency catheter ablation of atrial fibrillation: a worldwide report. Journal of the American College of Cardiology, 58(25), 2696–2697.PubMedCrossRefGoogle Scholar
  2. 2.
    Cappato, R., Calkins, H., Chen, S. A., Davies, W., Iesaka, Y., Kalman, J., et al. (2010). Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circulation. Arrhythmia and Electrophysiology, 3(1), 32–38.PubMedCrossRefGoogle Scholar
  3. 3.
    Lambert, T., Steinwender, C., Leisch, F., & Hofmann, R. (2010). Cardiac tamponade following pericarditis 18 days after catheter ablation of atrial fibrillation. Clinical Research in Cardiology, 99(9), 595–597.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Takeshi Kitamura
    • 1
  • Seiji Fukamizu
    • 1
  • Harumizu Sakurada
    • 2
  • Masayasu Hiraoka
    • 3
  1. 1.Department of CardiologyTokyo Metropolitan Hiroo HospitalShibuya-kuJapan
  2. 2.Tokyo Metropolitan Health and Medical Treatment Corporation Ohkubo HospitalShinjuku-kuJapan
  3. 3.Toride Kitasohma Medical Center HospitalToride CityJapan

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