Clinical Predictors of Rescue Duration in Acute Pericardial Tamponade in Atrial Fibrillation Ablation

Pericardial tamponade during atrial fibrillation (AF) ablation is a life-threatening event, yet optimal rescue strategies remain uncertain. This study explored factors influencing rescue duration and long-term outcomes, focusing on the timing of protamine reversal.

Among 3544 consecutive AF ablations (March 2021-April 2025), ten patients who developed acute tamponade were retrospectively analyzed. The primary endpoint was rescue duration, defined as the time from tamponade recognition to patient departure from the electrophysiology (EP) laboratory. Secondary endpoint was a composite of recurrent tamponade, stroke, cardiac rehospitalisation, and all-cause death during follow-up. All patients received protamine and were stratified by median time to further assess its association with rescue duration.

Protamine administration time correlated positively with rescue duration (Spearman ρ = +0.65, p = 0.043) and remained shorter in the early-use group than in the delay-use group (90 [44-130] vs. 140 [120-172.5] min, directional p = 0.048). Lower BMI correlated with longer rescue duration (Spearman ρ = -0.72, p = 0.019), and non-paroxysmal AF tended to prolong stabilization. During follow-up, patients with and without secondary endpoint events showed no significant differences in protamine timing, baseline characteristics, AF pattern, or comorbidities.

Protamine reversal should be considered promptly once pericardial effusion is recognized, as earlier administration may shorten the rescue process and facilitate earlier departure from the EP laboratory without compromising long-term safety. Lower BMI and non-paroxysmal AF were associated with longer rescue durations, suggesting both patient and arrhythmia characteristics may influence rescue complexity.