Iatrogenic Pericardial Effusion and Tamponade in the Percutaneous Intracardiac Intervention Era

Abstract

The number, specific type, and complexity of percutaneous intracardiac procedures continue to evolve. Many of these procedures require left atrial access using transseptal techniques. These approaches carry with them the potential for pericardial effusion (PE) and cardiac tamponade, particularly in the setting when intraprocedural anticoagulation is being administered. PEs and even cardiac tamponade have been documented with both diagnostic as well as therapeutic procedures. When the effusion is a complication of an intracardiac procedure, it is usually the result of a cardiac perforation. The presentation depends on several factors including the structure that is perforated, the device that caused the perforation, the baseline hemodynamic status of the patient, and the level of anticoagulation present. The incidence has varied substantially although it has been recorded with essentially all intracardiac procedures, both diagnostic and therapeutic on both the right and left side of the heart. Prompt recognition is essential so that prevention of the transition from effusion to tamponade can be attempted (e.g., by reversing anticoagulation) or the hemodynamic collapse can either be averted or treated. Clinical, radiologic, and echocardiographic assessment are each important. Pericardiocentesis can be life-saving and is a core competency for all laboratories performing invasive cardiac procedures. Systems of care must include the knowledge base, equipment, and expert echocardiographic and interventional personnel. Collaboration with noninvasive colleagues and training interventionalists who perform intracardiac interventions, both electrophysiologists and interventional cardiologists, should be required as part of every invasive program.

Contemporary evaluation of the causes of cardiac tamponade: Acute and long-term outcomes

“…This finding contrasts with previous clinical studies, which reported malignant diseases as the most common cause of pericardial tamponade, reaching 30-60% of cases [6][7][8][9][10][11]. This shift in tamponade etiology is apparently due to the increase in recent years in the overall number and in the complexity of percutaneous intra-cardiac procedures, as well as the introduction of interventional techniques such as trans-catheter valve replacement and catheter ablation for atrial fibrillation, all reported to be possibly complicated by cardiac tamponade [12][13][14][15].…”

Acute Cardiac Tamponade after Left Sided Premature Ventricular Contraction Ablation

“…The risk of tamponade in a right chamber perforation is more dangerous in patients on anticoagulation therapy or with pulmonary hypertension. 6 The RV transmural thickness is 4 mm and is associated with a lower incidence of iatrogenic perforation with electrophysiology catheters. Perforation of the thicker wall (circa 10 mm) at the LV site, is less frequent.…”

“…the burned myocardium lesion, occasionally it is necessary to initiate urgent surgical hemostasis. 6 The prevalence of pericardial effusion is influenced by the location of the PVC/ablation site. RVOT and left atrial ablations present a higher percentage of tamponade because of anatomical factors.…”

“…However, the higher left ventricular pressure increases the tamponade risk especially in anticoagulated patients. 6 In order to prevent complications associated with interventional procedures, certain safety maneuvers should be strictly followed, such as using irrigated-type catheters, contact force catheters when possible, and ensuring invasive arterial blood pressure monitoring during the …”

“…The occurrence rate of cardiac tamponade at different PVC locations is similar and overall it is the highest with epicardial PVCs (4.2%). 6,7 Standard indications associated with a high success rate are: patients undergoing ablation for PVCs with typical indications such as frequent palpitation lasting longer than one year, monomorphic PVC, outflow tract location, >5000 PVC/24 hours on Holter-monitoring, without structural heart diseases or cardiac ischaemic history.…”