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Pericardial Perforation…

Preparing for Emergency

Rachael Taggart, RN,BSN,

CCRN

Cleveland Clinic

Electrophysiology Laboratory

Objectives

• Discuss care of the EP patient when

complications, specifically pericardial

perforation, occur in the lab

• Describe procedural readiness for complex

ablations

• Describe case studies relevant to

pericardial perforation (pictures)

There is no conflict of interest on the part of the presenter.

There is no conflict of

interest on the part of the

presenter

Ablation Complications

• Vascular Access: Hematoma, AV Fistula,

retroperitoneal bleed, infection, clots

• Airway/Sedation: Emergent intubation, nasal airway

trauma

• Fluid volume overload

• Foley insertion

• Pericardial effusion/tamponade/perforation---Open

Chest

• Stroke

• Rhythm disturbance

• Pulmonary vein stenosis (PVI)

• Atrio-esophageal fistula

• Skin issues

• Pleural effusion

What is it?

Accumulation of fluid or blood in the pericardial sac around

the heart. It causes the heart to become compressed and

blood flow to be restricted, leading to hemodynamic

compromise. Cardiac tamponade is life threatening and

always fatal if undetected and untreated.

Text taken from Cleveland Clinic Learning Center

Cardiac Tamponade Module, image from quizlet.com

How Often Does it

Happen? In year 2013……

PVAI 811 (6, or 0.74%)

VT ablations 87 with EF greater than or equal to 50% (1, or

1.15%)

429 PPM (1, or 0.23%, initial implant)

380 ICDs (1, or 0.26%, initial implant)

From 2009-2013……

1,117 lead extractions with leads in place greater than 1 year

(1.6%, death or intrathoracic bleeding)

Taken from Cleveland Clinic Heart and Vascular

Outcomes book 2013

What does it look like with our tools?

A Rare (but cool)

Fluoroscopy Shot

Early Signs and

Symptoms

• Anxiety, restlessness

• Faintness, lightheadedness

• Fatigue/Pallor

• Feelings of impending doom

• Cool, clammy extremities Taken from Cleveland Clinic Learning Center Cardiac

Tamponade Module

Classic Signs and Symptoms

Beck’s Triad

• Hypotension (defined as SBP <90)

• Increased jugular venous pressure

• Distant/muffled heart sounds

Taken from Cleveland Clinic Learning

Center Cardiac Tamponade Module

Other Key Clues… • Narrowing Pulse Pressure

• Sharp/stabbing pain in the

chest

• Tachypnea/dyspnea

• Tachycardia

• Pericardial friction rub

Taken from Cleveland Clinic Learning Center Cardiac

Tamponade Module

• Decreased hematocrit

• Pulsus parodoxus

• Electrical alternans

• Decreased urine output

Taken from Cleveland Clinic Learning Center

Cardiac Tamponade Module

Why it Can Happen in The EP Lab

• Placement of EP catheters, use of wires, transeptal needle

• Use of radiofrequency energy and ablation catheter (steam pops)

• Anti-coagulation is unavoidable when working in the left side of the

heart

• Takes technique and experience to work on breathing person and a

beating heart with only two-dimensional aids of fluoroscopy and

mapping system

• Anatomical variations

• Patient population with other comorbidities

Right atrium to left atrium Tenting the septum

Bubbles in the left atrium

Ablation

catheter

Ablation

lesion

So…what exactly is “ablation”???

What can we do about it?

Pictures from Merit Medical

website:

http://www.merit.com/product

s/media.aspx?type=brochure

&id=185229

What do we do in lab to be ready for

anything?

CBC, BMP within thirty days for outpatients, usually night before for

inpatients

Four units PRBCs on call for extractions or per physician request for

complex ablations

Stop anti-coagulation for three days (device implants), one week

(device extractions), day before with newer anticoagulants (factor Xa

inhibitors), will usually take Coumadin night before for PVIs/left

sided atrial flutters-- Not stopped because risk of stroke outweighs

risk of bleeding

Current Type and Screen for pretty much all EP procedures with

limited exceptions

BLOOD RELATED

SAFETY RELATED

Vital signs with pain assessment every five minutes, more often if

needed

Two 20 gauge IVs for left-sided cases

Anesthesia team interview prior to start of case for all procedures

(exception for non-ICU pacemaker implants)

CT consult for all patients with leads in place greater than 5 years

that require extraction

Routine use of irrigated ablation catheters or cryo ablation if near

fragile structures

EMERGENCY RELATED

Pericardiocentesis trays, emergency medication boxes,

echo machines in all labs

Sub-xiphoid and bilateral groins prepped ahead of time in

anticipation of need

Ventilator circuits and anesthesia machines in all room

and ready

Emergency balloon dilatation catheter on hand for SVC

tears, perforation cart from cath lab

Intra-cardiac echo at physician’s disposal for assistance

with viewing cardiac structures

Two open chest carts present and stocked at all

times

Multiple red “crash carts” present and stocked at all

times in pre-designated locations

Annual open chest inservices

Experienced RN hiring

EMERGENCY RELATED CONT’D

QUESTIONS???