Periprocedural Management of Cardiac Tamponade During Catheter Ablation for AF Under Uninterrupted DOAC and Warfarin

Abstract Objectives This was a retrospective analysis of a registry of patients who underwent catheter ablation for atrial fibrillation (AF) under uninterrupted direct oral anticoagulant (DOAC) and warfarin administration. Background Uninterrupted DOAC used during catheter ablation for AF causes a life-threatening bleeding risk of cardiac tamponade. Methods Of 3,149 catheter ablation procedures for AF with uninterrupted oral anticoagulants used in 2,406 patients in 3 institutions, DOAC and warfarin were administered in 1,896 and 1,253 procedures, respectively. Among them, cardiac tamponade requiring pericardiocentesis and surgical intervention occurred in 13 (0.7%) and 11 (0.9%) procedures in the DOAC and warfarin groups, respectively. In this study, the outcomes between these 2 groups were compared. Results The total blood volumes drained after pericardiocentesis was 300 (190 to 715) ml and 300 (200 to 380) ml in the DOAC and warfarin groups, respectively (p = 0.697). Approximately two-thirds of patients (9 in the DOAC group and 7 in the warfarin group) recovered with only pericardiocentesis and protamine infusion (including vitamin K in the warfarin group) in both groups. Two patients in the DOAC group underwent surgical intervention but recovered uneventfully, whereas none of the patients taking warfarin required surgical intervention. DOAC and warfarin were successfully resumed 2.0 (2.0 to 5.0) days and 4.0 (2.0 to 5.5) days after tamponade in all patients without an increase in effusion (p = 0.102). Conclusions Managing cardiac tamponade under uninterrupted DOAC administration was feasible. Early intensive treatment resulted in hemostasis in most patients. However, surgical intervention was required in some cases refractory to the initial treatment.