Fatal Delayed Cardiac Tamponade Following Atrial Fibrillation Ablation: A Case Report

Catheter ablation procedure for symptomatic atrial fibrillation is an established treatment. Cardiac tamponade is one of the several complications associated with atrial fibrillation ablation. We present the case of a 60-year-old male with a past medical history of end-stage renal disease (ESRD) on hemodialysis, hypotension on midodrine, atrial fibrillation status post-ablation a week prior, and a cerebrovascular accident who presented to the emergency department with complaints of weakness, nausea, vomiting, confusion and some syncopal episodes for the past few days. He denied chest pain, dyspnea, and a history of alcohol use. On arrival at the emergency department, the patient was hypotensive and tachycardic. Laboratory evaluation revealed elevated liver enzymes and troponins. The electrocardiogram revealed sinus tachycardia. Chest X-ray showed low lung volumes with a left retrocardiac opacity and cardiomegaly. Given the patient's hypotension requiring vasopressor support, elevated troponins, and a recent cardiac procedure, an echocardiogram was done, and it revealed a large posterior pericardial effusion adjacent to the left ventricle. Tamponade was suspected and the patient was taken for an emergent pericardial window. Intraoperatively, a perforation of the right ventricle was found with a large area of surrounding necrotic and ischemic tissue. There was a significant hemorrhage with the opening of the pericardium, which could not be controlled due to the large area of non-viable cardiac tissue. The patient went into cardiac arrest with pulseless electrical activity. Open cardiac massage was performed but the return of spontaneous circulation could not be achieved and the patient was declared deceased. Pericardial effusion with tamponade is the complication of cardiac ablation associated with the highest mortality. An echocardiogram is a fast and reliable way to confirm the diagnosis of a tamponade. Delayed cardiac tamponade should always remain a differential diagnosis when a patient has recently undergone an ablation procedure given the potential fatality.