Frequency and predictors of post-operative pericardial effusion requiring drainage following percutaneous epicardial access in the electrophysiology laboratory

Abstract

Purpose: Percutaneous pericardial access is increasingly performed for mapping and ablation. Pericardial fat irritation, disruption of intrapericardial vessels, inadvertent right ventricular entry and periprocedural anticoagulation may predispose towards pericardial effusion but post-operative pericardial drains are associated with pain and pericarditis. While intra-procedural fluid accumulation is managed with existing epicardial access, post-procedural development of pericardial effusion following drain removal requires a separate invasive procedure with inherent risks. We sought to identify the frequency and predictors of pericardial effusion following epicardial sheath removal. Methods: All patients who underwent attempted epicardial access as part of an electrophysiology procedure were included in this retrospective study. Baseline clinical and echocardiography characteristics were collected. Patients who developed pericardial effusion requiring a separate pericardiocentesis following ablation were identified and compared to those who did not develop this complication. Results: Between 1/2004 and 12/2011, 116 pericardial access attempts were made in 107 consecutive patients (94.4% successful). Of these, 9 (7.8%) patients developed post-operative pericardial effusion requiring repeat access and drainage, an average of 1 day post-operatively. Patients with post-operative effusion tended to be younger (42.2 vs 51.8 years, P=0.05), and have a higher ejection fraction (EF, 55.6% vs. 44.6% P=0.03). There was no difference in gender (44.4 vs. 32.7% female), BMI (mean 29.3 vs. 29.4), inferior (vs. anterior) access (77.8 vs. 61.5%), peri-operative heparin use, and epicardial mapping only vs. epicardial mapping and ablation (44.4 vs. 56.1%) in patients with and without pericardial effusion (P>0.05). Three percent of patients with EF <55% had a pericardial effusion, vs. 18% with EF≥55%, P=0.02. Conclusion: Pericardial effusion requiring repeat access and drainage occurred in 7.8% of patients shortly after epicardial mapping/ablation procedures, and was more common in younger patients with normal ejection fraction. This may be due to increased trauma risk with vigorous ventricular contraction, and suggests that pericardial drains are best left in place post-procedure in young patients with ejection fraction of 50-55%.