Spontaneous, Life-Threatening Hemorrhagic Cardiac Tamponade Secondary to Rivaroxaban

Hemopericardium in the setting of direct oral anticoagulant use: An updated systematic review

BACKGROUND

Spontaneous hemopericardium, associated with direct oral anticoagulant (DOAC) use, is one of the uncommon complications with high morbidity that has not been extensively studied We aimed to determine demographic characteristics, clinical features, lab evaluation, management, and outcomes of the studies focusing on hemopericardium as a DOAC use.

METHODS

PubMed, Web of Science, Google Scholar, and CINAHL databases were searched for relevant articles using MeSH key-words and imported into referencing/review software. The data regarding demographics, clinical characteristics, cardiac investigations, and management were analyzed in IBM Statistics SPSS 21. t-Test and Chi-square test were used. A P score of <0.05 was considered statistically significant.

RESULTS

After literature search, a total of 41 articles were selected for analysis. The mean age of the patients was 70.09 ± 11.06 years (p < 0.05); the majority of them were males (58.5%). Most of the patients presented with shortness of breath (75.2%) and had more than 3 co-morbid conditions (43.9%). The most frequently used anticoagulant was rivaroxaban (15/41; 36.6%); the common indication being arrhythmia (78.0%). CYP4503A4/P-Gp inhibitors (22.2%) were commonly used by the patients. Majority of the cases had a favorable outcome (95.1%). Pericardial tamponade was noted in 31/41 cases. Pericardiocentesis was performed in 37/41 cases.

CONCLUSIONS

Hemopericardium from DOAC use has a favorable outcome but requires urgent pericardiocentesis. However, long term mortality, monitoring of DOAC activity, and drug-drug interactions have not been widely studied.

Cardiac tamponade from anticoagulant-related spontaneous haemopericardium in a patient with ischaemic cardiomyopathy and heart failure

We describe the case of an 86-year-old man with a background of severe left ventricular dysfunction and ischaemic cardiomyopathy who, having been optimised for heart failure therapy in hospital, unexpectedly deteriorated again with hypotension and progressive renal failure over the course of 2 days. Common causes of decompensation were ruled out and a bedside echocardiogram unexpectedly diagnosed new pericardial effusion with tamponade physiology. The patient underwent urgent pericardiocentesis and 890 mL of haemorrhagic fluid was drained. Common causes for haemopericardium were ruled out, and the spontaneous haemopericardium was thought to be related to introduction of rivaroxaban anticoagulation. The patient made a full recovery and was well 2 months following discharge. This case highlights the challenges of diagnosing cardiac tamponade in the presence of more common disorders that share similar non-specific clinical features. In addition, this case adds to growing evidence that therapy with direct oral anticoagulants can be complicated by spontaneous haemopericardium, especially when coadministered with other agents that affect clotting, renal dysfunction and cytochrome P3A5 inhibitors.

A Review of the Incidence Diagnosis and Treatment of Spontaneous Hemorrhage in Patients Treated with Direct Oral Anticoagulants

Anticoagulation carries a tremendous therapeutic advantage in reducing morbidity and mortality with venous thromboembolism and atrial fibrillation. For over six decades, traditional anticoagulants like low molecular weight heparin and vitamin K antagonists like warfarin have been used to achieve therapeutic anticoagulation. In the past decade, multiple new direct oral anticoagulants have emerged and been approved for clinical use. Since their introduction, direct oral anticoagulants have changed the landscape of anticoagulants. With increasing indications and use in various patients, they have become the mainstay of treatment in venous thromboembolic diseases. The safety profile of direct oral anticoagulants is better or at least similar to warfarin, but several recent reports are focusing on spontaneous hemorrhages with direct oral anticoagulants. This narrative review aims to summarize the incidence of spontaneous hemorrhage in patients treated with direct oral anticoagulants and also offers practical management strategies for clinicians when patients receiving direct oral anticoagulants present with bleeding complications.

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

Background

Cardiac tamponade is a potentially fatal complication after catheter ablation of ventricular arrhythmias. It often happens during or shortly after the procedure and needs urgent treatment. Here, we present a very incredible case about delayed cardiac tamponade after ablation of premature ventricular complexes.

Case presentation

A 66-year-old woman who underwent successful catheter ablation of right ventricular outflow tract origin premature ventricular complexes. Nineteen days after ablation, the patient experienced sudden syncope. Upon arriving at our hospital, she was “confused and shock”. Transthoracic echocardiography revealed hemorrhagic cardiac tamponade, which was considered due to a delayed tiny perforation in the heart induced by the previous ablation. Following an emergent pericardiocentesis to drain a 200 mL hemorrhagic effusion, the patient’s hemodynamics improved significantly. The patient was discharged after a 2-week hospitalization for investigating other probable causes with negative results. No signs of pericardial effusion recurred in a follow-up time of 12 months.

Conclusion

This case report demonstrated, for the first time, that very late post-procedural cardiac tamponade might occur after catheter ablation of ventricular arrhythmias, even without antithrombotic treatment.

Fatal acute haemopericardium associated with rivaroxaban in a patient with non-valvular atrial fibrillation

An 82-year-old female was admitted with chest pain and non-specific T wave changes on her ECG. After 72 hours of conservative management she deteriorated with non-specific symptoms including nausea and a single episode of vomiting. Abdominal and Chest X-rays were unremarkable, blood tests showed worsening Acute Kidney Injury (AKI) on Chronic Kidney Disease (CKD); and raised C-Reactive Protein (CRP) with no obvious symptoms or focus of infection. She rapidly deteriorated going into asystole cardiac arrest and attempts at resuscitation failed. Post-mortem examination suggested the most likely cause of death was acute spontaneous Haemopericardium due to Rivaroxaban therapy which she was on for non-valvular Atrial Fibrillation (AF). We believe that this might be the first reported mortality with Rivaroxaban-associated spontaneous haemopericardium in the UK.

Hemorrhagic Cardiac Tamponade Associated with Apixaban: A Case Report and Systematic Review of Literature

BACKGROUND

Hemorrhagic cardiac tamponade (HCT) is characterized by rapid accumulation of blood in the pericardium causing hemodynamic collapse. We report a case of HCT due to Apixaban use in a patient with renal cell carcinoma, supplemented with a systematic review of pericardial tamponade associated with the use of direct oral anticoagulants (DOACs).

CASE REPORT

A 62-year-old African American male with a history of metastatic renal cell carcinoma presented with dyspnea while taking Apixaban. He was diagnosed with pericardial tamponade and 800 ml of hemorrhagic effusion was drained. The pericardial fluid analysis was negative for malignancy and suggestive of HCT. He had a complicated hospital course and died several days later.

METHODS

We searched MEDLINE, EMBASE and other sources for published cases of pericardial tamponade associated with DOACs. Our outcomes of interest included patient characteristics, risk factors, timing from the start of anticoagulation to tamponade, treatment and mortality. Simple descriptive statistics using percentages for categorical variables were used to describe the included cases.

RESULTS

A total of 26 cases were included in the final systematic review after searching MEDLINE, EMBASE and other sources. The mean age was 70 years (range 43-88) with 19 (73%) males. Twelve cases (46%) were associated with Rivaroxaban, 9 (37%) with Dabigatran and 5(19%) with Apixaban. Sixteen cases had elevated INR and 15 had elevated creatinine. Only 2 patients died but 24 had to undergo pericardiocentesis.

CONCLUSION

Cardiac tamponade is rarely associated with DOACs and elderly male patients with renal and coagulation abnormalities appear to have the highest risk.

A Rare Case of Spontaneous Cardiac Tamponade Induced by Concomitant Use of Rivaroxaban and Amiodarone

Rivaroxaban is a direct oral anticoagulant (DOAC) approved as an important alternative to warfarin in patients with nonvalvular atrial fibrillation. We report the case of an 87-year-old man with past medical history of nonvalvular atrial fibrillation on rivaroxaban and recently started amiodarone for pulseless ventricular tachycardia who presented to our hospital with intermittent chest pain and was diagnosed with spontaneous hemopericardium causing cardiac tamponade. The culprit drugs were discontinued, and the patient was treated with emergent pericardiocentesis. Both rivaroxaban and amiodarone are substrates for the CYP3A4 hepatic pathway, and concomitant use can result in increased plasma rivaroxaban levels causing an increased propensity to bleeding. While most physicians are cognizant of the need for renal dosing of rivaroxaban, this article aims to increase awareness of its interactions with drugs that are also metabolized through the same hepatic CYP450 pathway.

Hemorrhagic cardiac tamponade complicated by acute type A aortic dissection: A case report with critical care ultrasound findings

RATIONALE

Acute type A aortic dissection (AAAD) is a potentially fatal clinical crisis. Hemorrhagic cardiac tamponade due to the rupture of an ascending aortic root dissection is extremely dangerous and often lacks timely clinical evidence. We report sudden death in a patient diagnosed with AAAD and in whom critical care ultrasound highly indicated hemorrhagic cardiac tamponade.

PRESENTING CONCERNS

A 75-year-old man was admitted to our emergency department with a complaint of chest pain for 8 hours. Computed tomography angiography findings indicated AAAD with a wide range of lesions. During the preoperative preparation process, he suddenly lost consciousness with a pulseless femoral artery.Diagnoses: Cardiopulmonary resuscitation was initiated and critical care ultrasound revealed hemorrhagic cardiac tamponade, strongly indicating the rupture of an ascending aortic root dissection.

INTERVENTIONS

However, family members refused further surgical interventions.

OUTCOMES

The etiology could not be reversed and the patient died.

LESSONS

Critical care ultrasound is an important skill that intensivists should master for fast screening of life-threatening complications in patients with AAAD.

Novel antidotes for target specific oral anticoagulants

Target specific oral anticoagulants (dabigatran, rivaroxaban, apixaban, and edoxaban) are changing the landscape of anticoagulation. The major drawback is the absence of an effective antidote for severe bleedings and/or prior to procedures. Currently there are a few promising antidotes undergoing clinical trials. This review summarized the latest development in idarucizumab, andexanet alpha and PER977.