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.