Dabigatran-Induced Spontaneous Hemopericardium and Cardiac Tamponade

Abstract

1 Hemopericardium has rarely been described in association with the use of oral anticoagulants, including the novel oral anticoagulant agents. We report a case of spontaneous hemopericardium during dabigatran therapy and its reversal with use of the antibody fragment idarucizumab. To our knowledge, this is only the second report of dabigatran-induced spontaneous hemopericardium in the absence of predisposing factors. Case ReportIn April 2016, an 87-year-old man with well-controlled hypertension and dyslipidemia was admitted to the hospital with worsening dyspnea on exertion. Two months earlier, he had been prescribed dabigatran (150 mg, twice daily) and metoprolol as therapy for AF of unknown duration. A transthoracic echocardiogram (TTE) at that time had shown nothing notable. He subsequently developed progressive edema, renal insufficiency, hypotension, and tachycardia. His medications included dabigatran, furosemide, metolazone, and metoprolol.His vital signs upon admission were as follows: blood pressure, 90/50 mmHg; heart rate, 112 beats/min; respiratory rate, 18 breaths/min; and oxygen saturation, 95% on room air. His body weight was 81.6 kg (body mass index, 25.83 kg/m 2 ). He had jugular venous distention with a positive Kussmaul sign and bilateral, pitting lowerextremity edema. No other cardiac or respiratory findings were noteworthy.Laboratory test results included new anemia (hemoglobin, 9.7 g/dL) and acute kidney injury (increase in creatinine, from 1.0 to 1.9 mg/dL). The estimated creatinine clearance (CrCl) was 33 mL/min. Results of coagulation studies were normal. An electrocardiogram revealed AF with a ventricular rate of 110 beats/min and new low voltage in all leads (Fig. 1). A TTE showed a large pericardial effusion with tamponade physiology and diastolic compression of the right ventricle ( Fig. 2A), a severely dilated inferior vena cava without inspiratory collapse (Fig. 2B), and respiratory variation at the tricuspid inflow with >25% increase during inspiration (Fig. 2C). Idarucizumab was administered, after which emergency pericardiocentesis yielded 750 cc of hemorrhagic pericardial fluid. Fluid samples evaluated by gram stain, culture, and cytology were negative. The patient reported immediate resolution of his symptoms. Serial TTEs revealed no reaccumulation of fluid (Fig. 3). The patient was discharged from the hospital in stable condition, without the need for anticoagulation. Case ReportsQurat-ul-ain Jelani, MD Ram Gordon, MD Adam Schussheim, MD

Delayed cardiac tamponade following catheter ablation of frequent premature ventricular complexes: a case report

“…In addition, many patients with RVOT arrhythmias, previously identified as having normal cardiac structure by TTE, may in fact have latent early-stage cardiomyopathy in minute regions [ 4 ], which is also a potential risk factor for perforation. Cardiac tamponade secondary to warfarin or new oral anticoagulants has been sporadically reported [ 5 – 8 ]. According to case reports, it seems that spontaneous pericardial hemorrhages were prone to occur in patients with high-risk factors for bleeding, including advanced age, chronic kidney disease, and malignancy.…”

<p>Dabigatran must be used carefully: literature review and recommendations for management of adverse events</p>

“…As with any anticoagulant drug, various types of hemorrhage are common adverse events. Of the cases we reviewed, seven patients developed severe hemorrhage,5–11 including three cases of fatal gastrointestinal hemorrhage 8–10. Major bleeding was reported to occur in a dose-dependent manner, and this was reported in fewer than 3% of patients during a trial comparing dabigatran with other anticoagulants 28,29.…”

“…A lower pH is associated with dyspepsia and plays a part in the increased risk of gastrointestinal bleeding 28. Spontaneous hemopericardium,5 spontaneous hemothorax6 and hemorrhagic cystitis7 occurred separately in three patients. Major bleeding in these anatomic areas is uncommon and has rarely been reported, but it should be documented.…”

“…Among the patients with adverse events that we reviewed (except for a 20-year-old patient with a dabigatran-induced exanthema), the mean age was 76 (range, 52–90) years 5–27. Regardless of whether adverse events are associated with age, more clinical trials are needed to ascertain the relationship between age, dose, and adverse effects to better guide management.…”

“…Although patients taking dabigatran have fewer life-threatening hemorrhages, the prevalence of gastrointestinal bleeding was significantly higher than in those who used warfarin 3. An increasing prevalence of adverse events has been reported,5–27 some of them quite serious. Therefore, we searched and reviewed the literature on dabigatran with regard to adverse events (Figure 1).…”