Cardiac tamponade in patients treated with direct oral anticoagulants

Background: Direct oral anticoagulants (DOACs) have become the treatment of choice for patients with non-valvular atrial fibrillation. However, bleeding risk remains significant even in the DOACs era. In the current study, we report a single-center experience with 8 patients who presented with Hemorrhagic cardiac tamponade while treated with DOACs.

Methods: Included were patients treated with DOACs who were admitted with pericardial tamponade in the Cardiac Unit of the Meir hospital during 2018-2020.

Results: The eight patients had a mean age of 83.6±2.8 and included six males. Atrial fibrillation was the indication for anticoagulation in all cases. DOACs included apixaban ( 5 patients), dabigatran (2 patients), and rivaroxaban (1 patient). Urgent pericardiocentesis via a subxiphoid approach under echocardiography guidance was successfully performed in 7patients. One patient was treated with urgent surgical drainage with a pericardial window. Reversal of anticoagulation using prothrombin concentrate complex and Idarucizumab was given prior to the procedure to 3 patients treated with apixaban and one patient treated with dabigatran, respectively. One patient who was initially treated with an urgent pericardiocentesis underwent pericardial window surgery due to re-accumulation of blood in the pericardium later during hospitalization. The pericardial fluid analysis demonstrated hemopericardium in all cases. Cytology tests were negative for malignant cells in all cases. Discharge diagnoses regarding the cause of hemopericardium included pericarditis (3 patients) and idiopathic (5 patients). Medical therapy included non-steroidal anti-inflammatory drugs (1 patient), colchicine (3 patients), and steroids (2 patients). None of the patients died during hospitalization.

Conclusion: Hemorrhagic cardiac tamponade is a rare complication of DOACs. Our study reports a good short-term prognosis following pericardiocentesis.