Management and Outcome of Periprocedural Cardiac Perforation and Tamponade with Radiofrequency Catheter Ablation of Cardiac Arrhythmias: A Single Medium-Volume Center Experience

Predictors of morbidity and in-hospital mortality following procedure-related cardiac tamponade

Background

Cardiac tamponade (CT) can be a complication following invasive cardiac procedures. We assessed CT following common cardiac electrophysiology (EP) procedures to facilitate risk prediction of associated morbidity and in-hospital mortality.

Methods

Patients who underwent various EP procedures in the cardiac catheterization lab (ablations and device implantations) were identified using the International Classification of Diseases, Ninth and Tenth Edition, Clinical Modification (ICD-9-CM and ICD-10-CM, respectively) from the Nationwide Inpatient Sample (NIS) database. Patient demographics, presence of comorbidities, CT-related events, and in-hospital death were also abstracted from the NIS database.

Results

The frequency of CT-related events in patients with EP intervention from 2010 to 2017 ranged from 3.4% to 7.0%. In-hospital mortality related to CT-related events was found to be 2.2%. Increasing age was the only predictor of higher mortality in atrial fibrillation (AF) ablation and cardiac resynchronization therapy (CRT) groups (OR [95% CI]: AF ablation = 11.15 [1.70-73.34], p = .01; CRT = 1.41 [1.05-1.90], p = .02).

Conclusions

In the real-world setting, CT-related events in EP procedures were found to be 3.4%-7.0% with in-hospital mortality of 2.2%. Older patients undergoing AF ablation were found to have higher mortality.

Cardiac tamponade

Cardiac tamponade is a medical emergency caused by the progressive accumulation of pericardial fluid (effusion), blood, pus or air in the pericardium, compressing the heart chambers and leading to haemodynamic compromise, circulatory shock, cardiac arrest and death. Pericardial diseases of any aetiology as well as complications of interventional and surgical procedures or chest trauma can cause cardiac tamponade. Tamponade can be precipitated in patients with pericardial effusion by dehydration or exposure to certain medications, particularly vasodilators or intravenous diuretics. Key clinical findings in patients with cardiac tamponade are hypotension, increased jugular venous pressure and distant heart sounds (Beck triad). Dyspnoea can progress to orthopnoea (with no rales on lung auscultation) accompanied by weakness, fatigue, tachycardia and oliguria. In tamponade caused by acute pericarditis, the patient can experience fever and typical chest pain increasing on inspiration and radiating to the trapezius ridge. Generally, cardiac tamponade is a clinical diagnosis that can be confirmed using various imaging modalities, principally echocardiography. Cardiac tamponade is preferably resolved by echocardiography-guided pericardiocentesis. In patients who have recently undergone cardiac surgery and in those with neoplastic infiltration, effusive-constrictive pericarditis, or loculated effusions, fluoroscopic guidance can increase the feasibility and safety of the procedure. Surgical management is indicated in patients with aortic dissection, chest trauma, bleeding or purulent infection that cannot be controlled percutaneously. After pericardiocentesis or pericardiotomy, NSAIDs and colchicine can be considered to prevent recurrence and effusive-constrictive pericarditis.

Pulsed field ablation using focal contact force-sensing catheters for treatment of atrial fibrillation: acute and 90-day invasive remapping results

AIMS

Pulsed field ablation (PFA) has emerged as a promising alternative to thermal ablation for treatment of atrial fibrillation (AF). We report performance and safety using the CENTAURI™ System (Galvanize Therapeutics) with three commercial, focal ablation catheters.

METHODS AND RESULTS

ECLIPSE AF (NCT04523545) was a prospective, single-arm, multi-centre study evaluating safety and acute and chronic pulmonary vein isolation (PVI) durability using the CENTAURI System in conjunction with the TactiCath SE, StablePoint, and ThermoCool ST ablation catheters. Patients with paroxysmal or persistent AF were treated at two centres. Patients were analysed in five cohorts based upon ablation settings, catheter, and mapping system. Pulsed field ablation was performed in 82 patients (74% male, 42 paroxysmal AF). Pulmonary vein isolation was achieved in 100% of pulmonary veins (322/322) with first-pass isolation in 92.2% (297/322). There were four serious adverse events of interest (three vascular access complications and one lacunar stroke). Eighty patients (98%) underwent invasive remapping. Pulsed field ablation development Cohorts 1 and 2 showed a per-patient isolation rate of 38% and 26% and a per-PV isolation rate of 47% and 53%, respectively. Optimized PFA Cohorts 3-5 showed a per-patient isolation rate of 60%, 73%, and 81% and a per-PV isolation rate of 84%, 90%, and 92%, respectively.

CONCLUSION

ECLIPSE AF demonstrated that optimized PFA using the CENTAURI System with three commercial, contact force-sensing, solid-tip focal ablation catheters resulted in transmural lesion formation and high proportion of durable PVI with a favourable safety profile, thus providing a viable treatment option for AF that integrates with contemporary focal ablation workflows.

Direct autotransfusion in the management of acute pericardial tamponade during catheter ablation for atrial fibrillation: An imperfect but practical method

Background

Acute pericardial tamponade (APT) is one of the most serious complications of catheter ablation for atrial fibrillation (AF-CA). Direct autotransfusion (DAT) is a method of reinjecting pericardial blood directly into patients through vein access without a cell-salvage system. Data regarding DAT for APT are rare and provide limited information. Our present study aims to further investigate the safety and feasibility of DAT in the management of APT during the AF-CA procedure.

Methods and results

We retrospectively reviewed 73 cases of APT in the perioperative period of AF-CA from January 2014 to October 2021 at our institution, among whom 46 were treated with DAT. All included patients successfully received emergency pericardiocentesis through subxiphoid access guided by X-ray. Larger volumes of aspirated pericardial blood (658.4 ± 545.2 vs. 521.2 ± 464.9 ml), higher rates of bridging anticoagulation (67.4 vs. 37.0%), and surgical repair (6 vs. 0) were observed in patients with DAT than without. Moreover, patients with DAT were less likely to complete AF-CA procedures (32/46 vs. 25/27) and had a lower incidence of APT first presented in the ward (delayed presentation) (8/46 vs. 9/27). There was no difference in major adverse events (death/disseminated intravascular coagulation/multiple organ dysfunction syndrome and clinical thrombosis) (0/0/1/0 vs. 1/0/0/0), other potential DAT-related complications (fever/infection and deep venous thrombosis) (8/5/2 vs. 5/3/1), and length of hospital stay (11.4 ± 11.6 vs. 8.3 ± 4.7 d) between two groups.

Conclusion

DAT could be a feasible and safe method to deal with APT during AF-CA procedure.

Management of massive hemopericardium in the electrophysiology laboratory: The double long sheath technique

AIM

to describe a simple and useful technique for acute management of massive hemopericardium inside the Electrophysiology (EP) laboratory METHODS AND RESULTS: five patients from a single center experience were identified, all with blood loss above 1000 milliliters (mL) after initial pericardiocenthesis. Using two long 8.5F transseptal sheaths inside the pericardium space, with continuous negative pressure, allowed the complete cessation of bleeding or hemodynamic maintenance until definitive surgical repair in all patients CONCLUSION: The use of two long sheaths for blood drainage, instead of conventional pericardiocenthesis, might be helpful to manage massive hemopericardium inside EP lab, avoiding urgent cardiac surgery or maintaining clinical stability until surgical staff is available. This article is protected by copyright. All rights reserved.

Acute Cardiac Tamponade as a Complication of Pulmonary Vein Isolation Ablation

Perioperative acute cardiac tamponade associated with perforation from pulmonary vein isolation (PVI) and radiofrequency catheter ablation (RFCA) for the treatment of refractory atrial fibrillation (AF) is rare. If not identified early and managed promptly, it can lead to decreased ejection fraction, hypotension, and ultimately death. We report a case of acute tamponade that was diagnosed and successfully managed following PVI and RFCA. A 49-year-old woman with a past medical history of paroxysmal AF and sick sinus syndrome presented to our hospital with intermittent episodes of palpitations and recurrent episodes of syncope. Given the drug-refractory AF, our patient underwent PVI and RFCA. A loop recorder was implanted for recurrent episodes of syncope, which revealed that she had sick sinus syndrome. During the current visit, transthoracic ECG revealed mild tricuspid regurgitation and trace pericardial effusion. Her left ventricle (LV) ejection fraction was 60%. A CT angiography of the pulmonary vessels and the aorta showed no evidence of pulmonary embolism, aortic aneurysm, or aortic dissection. However, there was an enlarged heart size and small bilateral pleural effusions. During a second PVI and RFCA, while in the operating room, the patient became hypotensive. A transesophageal echocardiogram (TEE) showed diastolic volume reduction in the right atrium and right ventricular and pericardial effusion. Intravenous (IV) resuscitation with lactated Ringer's solution and saline solution was rapidly given to the patient while performing percutaneous pericardiocentesis. In addition, packed red blood cells were transfused into the patient, and phenylephrine was given IV. There was 400 mL of blood drained from the pericardial sac, confirming the presence of acute cardiac tamponade. Following the pericardiocentesis, the patient became normotensive. A drainage tube was inserted into the pericardial space, which drained a total of 250 mL of sanguineous fluid over the next 48 hours after the procedure, after which it was removed without signs of persistent bleeding, and the patient was discharged. We conclude that her previous PVI and RFCA, and the anatomical distortion that might have resulted from her enlarged heart size, may have predisposed her to perforation and thus acute cardiac tamponade in this PVI and RFCA. Although perforation leading cardiac tamponade is rare during PVI and RFCA, the future focus when performing this procedure should be to (i) have a high index of suspicion for acute cardiac tamponade, (ii) use TEE and intracardiac echocardiography for early detection, and (iii) promptly manage the acute cardiac tamponade with pericardiocentesis, while giving IV fluid resuscitation and positive inotropes to hemodynamically stabilize the patient.

Surgical Strategies for Cardiac Perforation After Catheter Ablation or Electrophysiology Study

Catheter ablation is a treatment modality which has been increasingly used for cardiac arrhythmias. However, it is not complication-free, and cardiac perforation is one of its most life-threatening complications. As surgery is usually not the first-line treatment for this emergent episode, there were only very few sporadic surgical reports in the literature. This systemic review primarily aims to collect different surgical approaches for catheter-induced cardiac perforation to help surgeons manage this kind of uncommon and critical patients. Of the 452 initially screened articles, 22 studies (38 patients) were included in the systemic review. Of all the included patients, 84% (32/38) were found to have pericardial effusion acutely following catheter-related procedures, and 16% (6/38) experienced delayed-onset episodes. Regarding the surgical procedures, four patients underwent removal of clots only, eight patients underwent suture repair of the left ventricle (LV), nine patients underwent suture repair of the right ventricle (RV), five patients underwent suture repair of the LA, and four patients underwent sutureless repair of the LV and pulmonary vein (LV 1, RV 1, pulmonary vein 1). In addition to repair of perforation sites, the concomitant combined procedures included repair of intercostal vessels (complication of pericardiocentesis) for one patient, cryoablation for two patients, and maze procedure for one patient. For cardiac perforation following catheter ablation or electrophysiology study, although the majority of the patients are treated with pericardiocentesis and medical management at first, cardiovascular surgeons have to prepare to take over if the bleeding is persistent or if the cardiac tamponade is not relieved.

A case report: Amplatzer occluder device closure of an iatrogenic ventricular septal defect following radiofrequency ablation

Background

Interventricular septal perforation is an extremely rare complication of radiofrequency ablation (RFA), with an incidence of 1%. The most common mechanism is a ‘steam pop’, which can be described as ‘mini-explosions’ of gas bubbles. Data for percutaneous repair of cardiac perforations due to RFA are limited.

Case summary

A 78-year-old female patient was referred to our department for the treatment of two iatrogenic ventricular septal defects (VSDs) following radiofrequency ablation (RFA) of premature ventricular contractions. One week post-ablation, chest pain and progressive dyspnoea occurred. Transthoracic echocardiography detected a VSD, diameter 10 mm. Hence, iatrogenic, RFA-related myocardial injury was considered the most likely cause of VSD, and the patient was referred to our tertiary care centre for surgical repair. Cardiovascular magnetic resonance (CMR) imaging demonstrated border-zone oedema of the VSD only and confirmed the absence of necrotic tissue boundaries, and the patient was deemed suitable for percutaneous device closure. Laevocardiography identified an additional, smaller muscular defect that cannot be explained by analysing the Carto-Map. Both defects could be successfully closed percutaneously using two Amplatzer VSD occluder devices.

Discussion

In conclusion, this case demonstrates a successful percutaneous closure of a VSD resulting from RFA using an Amplatzer septal occluder device. CMR might improve tissue characterization of the VSD borders and support the decision if to opt for interventional or surgical closure.

Increasing role of cardiac surgeons in managing cardiac perforations during ever-expanding percutaneous interventions: a mini-review

Iatrogenic cardiac injury is a catastrophic event and its management should be emergent. Cardiac surgeons need to be aware of basics related to the catheter-based intervention techniques and their outcomes. This mini-review discusses cardiac perforations and role of surgical team during catheter-based interventions.

Surgical intervention for cardiac tamponade during atrial fibrillation ablation: who and when?-a single-center experience

INTRODUCTION

The critical decision between conservative therapy and surgical intervention to manage cardiac tamponade (CT) during atrial fibrillation (AF) ablation remains empirical. The aim of the study was to summarize the experience in management of CT during AF ablation to derive a proper management pathway.

METHODS

All patients with CT who underwent catheter ablation for AF in our center from 2013 to 2019 were included.

RESULTS

In total of 4887 patients, 32 (0.65%) patients occurred CT and received pericardiocentesis and immediate reversal of anticoagulation. All the CT patients were classified into three groups: rapid and uncontrollable bleeding who needed urgent surgical intervention (4/32), continuous bleeding (14/32), once pericardiocentesis, and no further bleeding (14/32). In the continuous bleeding group, the drainage volume in the first hour after pericardiocentesis was statistically related to surgical repair (p = 0.04) with a cutoff point of 970 ml (AUC 0.84, sensitivity 71.4%, specificity 100%, p = 0.04). During surgical repair, most of perforation sites were detected at superior anterior wall of left atrium close to right or left superior pulmonary vein antrum. No patient died of CT in our cohort.

CONCLUSIONS

Only a small proportion of patients with CT required surgical intervention during AF ablation. When pericardiocentesis was performed, if a drainage volume was more than 1000 ml in the first hour or bleeding was accelerated after an hour of observation, emergency surgical repair should be recommended.

Pericardial tamponade as a complication of invasive cardiac procedures: a review of the literature

Cardiac tamponade (CT) is a rare but often life-threatening complication after invasive cardiac procedures. Some procedures favor CT. Furthermore, the incidence depends on patients’ comorbidities, sex and age and operators’ skills. In this paper we review studies and meta-analyses concerning the rate of iatrogenic CT. We define the risk factors of CT and show concise characteristics for each invasive cardiac procedure separately. According to our analysis CT occurs especially after procedures requiring transseptal puncture or perioperative anticoagulation. The overall rate of CT after such procedures varies among published studies from 0.089% to 4.8%. For this purpose we searched the PubMed database for clinical studies published up to December 2018. We included only those studies in which a defined minimum of procedures were performed (1000 for atrial fibrillation ablation, 6000 for percutaneous coronary intervention, 900 for permanent heart rhythm devices, 90 for left atrial appendage closure, 300 for transcatheter aortic valve implantation and percutaneous mitral valve repair with the Mitra-Clip system). The search was structured around the key words and variants of these terms. In addition, secondary source documents were identified by manual review of reference lists, review articles and guidelines. The search was limited to humans and adults (18+ years).

An abnormal left ventricular-atrial perforation after radiofrequency catheter ablation: a case report

Background

Cardiac radiofrequency ablation is a popular treatment for arrhythmias. However, it does have some complications, some of which are severe, even fatally. And there were limited reports on cardiac internal perforation after radiofrequency catheter ablation (RFCA) that required a surgical repair.

Case presentation

A 47-year-old male was admitted to our hospital due to chest congestion for 4 months. He received a radiofrequency catheter ablation (RFCA) 9 months prior to admission. On admission, an echocardiogram showed an abnormal perforation between the left ventricle and the left atrium with moderate mitral valve regurgitation. We therefore performed a mitral valve replacement (MVR) and fixed the abnormal atrial-ventricular breakage via median sternotomy.

Conclusions

Cardiac perforation is a severe complication of cardiac RFCA, operators should be extremely cautious to minimize radiofrequency associated perforations. Such a challenging and complex procedure should be deliberately considered by doctors and patients before implementation.

Acute Procedural Complications of Cryoballoon Ablation: A Comprehensive Review

Catheter ablation is increasingly performed for treatment of atrial fibrillation (AF). Balloon based procedures have been developed aiming at safer, easier and more effective treatment as compared to point to point ablation. In the present review article, we aimed to discuss acute procedural complications of cryoballoon ablation.

Clinical characteristics and prognosis of cardiac tamponade patients: 5‑year experience at a tertiary center

BACKGROUND

Cardiac tamponade (CT) is characterized by compression of the cardiac chambers due to pericardial fluid accumulation. The etiology and prognosis may vary in different regions, and thus patient series from various regions can be useful for exploring the etiological and prognostic disparities. The aim of this study was to determine the clinical characteristics of patients with imminent CT, to evaluate the diagnostic performance of biochemical, microbiologic, and pathologic laboratory analysis, and to ascertain the prognosis of CT patients.

METHODS

We enrolled all patients with imminent CT who underwent percutaneous pericardiocentesis between July 2012 and December 2017 in this retrospective study. The patients were classified into three etiology groups: (a) malignancy (MRCT); (b) iatrogenic/mechanical complication of myocardial infarction (IMCT); and (c) other causes (OCT). Clinical information, laboratory findings, and survival data were recorded.

RESULTS

In total, 186 pericardiocentesis procedures were performed on 153 consecutive patients with CT. The median follow-up was 137 days (range: 1-1937). The MRCT group had the highest mortality rate (79%) in 12 months, while the OCT group had the lowest rate (27%). We determined that increased age, higher serum urea levels, and malignancy-related CT were independent predictors of mortality. The mortality rates of the MRCT and IMCT groups were similar, with both of them being significantly higher than the rate of the OCT group. In all, 15 patients were diagnosed with a new malignancy via pericardial fluid cytology.

CONCLUSION

Patients in the MRCT and IMCT groups had a poor prognosis. The presence of malignancy was found to be the most powerful predictor of mortality in CT patients.

Catheter Ablation of Atrial Fibrillation: An Overview for Clinicians

Catheter ablation (CA) of atrial fibrillation (AF) is currently one of the most commonly performed electrophysiology procedures. Ablation of paroxysmal AF is based on the elimination of triggers by pulmonary vein isolation (PVI), while different strategies for additional AF substrate modification on top of PVI have been proposed for ablation of persistent AF. Nowadays, various technologies for AF ablation are available. The radiofrequency point-by-point ablation navigated by electro-anatomical mapping system and cryo-balloon technology are comparable in terms of the efficacy and safety of the PVI procedure. Long-term success of AF ablation including multiple procedures varies from 50 to 80%. Arrhythmia recurrences commonly occur, mostly due to PV reconnection. The recurrences are particularly common in patients with non-paroxysmal AF, dilated left atrium and the "early recurrence" of AF within the first 2-3 post-procedural months. In addition, this complex procedure can be accompanied by serious complications, such as cardiac tamponade, stroke, atrio-esophageal fistula and PV stenosis. Therefore, CA represents a second-line treatment option after a trial of antiarrhythmic drug(s). Good candidates for the procedure are relatively younger patients with symptomatic and frequent episodes of AF, with no significant structural heart disease and no significant left atrial enlargement. Randomized trials demonstrated the superiority of ablation compared to antiarrhythmic drugs in terms of improving the quality of life and symptoms in AF patients. However, nonrandomized studies reported additional clinical benefits from ablation over drug therapy in selected AF patients, such as the reduction of the mortality and stroke rates and the recovery of tachyarrhythmia-induced cardiomyopathy. Future research should enable the creation of more durable ablative lesions and the selection of the optimal lesion set in each patient according to the degree of atrial remodeling. This could provide better long-term CA success and expand indications for the procedure, especially among the patients with non-paroxysmal AF.

Assessment of a novel transdermal selective β1-blocker, the bisoprolol patch, for treating frequent premature ventricular contractions in patients without structural heart disease

BACKGROUND

The autonomic nervous system involves the genesis of premature ventricular contractions (PVCs). Previous studies demonstrated that heart rate (HR) dependency of idiopathic PVCs has different autonomic mechanisms. Recently, the bisoprolol patch, a novel transdermal β1-blocker formulation containing bisoprolol, became clinically available. We examined the efficacy of the bisoprolol patch for treating frequent PVCs in patients without structural heart disease (SHD) regarding the HR dependency of PVCs.

METHODS

This prospective study included 44 consecutive patients without SHD (25 men, mean age, 63.6±12.3 years) with PVC counts≥3000 beats as measured by 24-hour Holter electrocardiograms (ECGs). PVCs were divided into positive HR-dependent PVCs (P-PVCs) and non-positive HR-dependent PVCs (NP-PVCs) based on the relationship between the hourly PVC density and hourly mean HR. A bisoprolol patch was administered once daily at a dose of 4mg. The 24-hour Holter ECGs were performed before and 1 month after the initiation of the therapy.

RESULTS

In 44 patients, there were 24 P-PVCs and 20 NP-PVCs. The bisoprolol patch reduced the PVC count significantly (from 16,563±10,056 to 7892±8817 beats/24hours, p<0.001) in the P-PVC group, while the PVC count did not change significantly (from 16,409±9571 to 13,476±12,191beats/24hours, p=0.34) in the NP-PVC group. Moreover, in the P-PVC group, the patients with mean HRs ≥80 beats/minute had a significantly higher percent improvement in the PVC count than those with mean HRs <80 beats/minute (p=0.0080). The bisoprolol patch resulted in a significant reduction in the PVC count from baseline during each time period for the changes within a 24-hour period in the P-PVC group.

CONCLUSIONS

The transdermal bisoprolol patch was effective for a PVC reduction in patients with P-PVCs, particularly in those with faster mean HRs. Furthermore, it demonstrated a stable PVC-reducing effect during the 24-hour period in the P-PVC group.